LARGE SOLITARY CYSTIC LESIONS OF THE BREAST

BRUCE YOUNG, M.B., CH.B., F.R.c.s.E., F.F.R., D.M.R.D., AND

ERIC SAMUEL, M.D., F.R.c.s., F.R.c.P.E., F.F.R., D.M.R.E.

Y THE TIME A CYST HAS REACHED EASILY B palpable proportions it is tense and it feels hard. In a well-developed breast such a lesion, especially if i t lies deep, may be indis- tinguishable from a carcinoma. Fortunately such single large cysts are uncommon.2

Mammograms will clearly show the cystic nature of such lesions and thereby question the clinical diagnosis. Care, however, must be taken in concluding that such a tumor is benign as malignant intracystic papilloma and carcinoma do occur.

In our series19 4, 5 of 300 mammograms for palpable lesions of the breast we have had 3 such cases. They are of varying pathology and illustrate these points well-each case being confidently diagnosed clinically as a car- cinoma but each being clearly mainly cystic on the mammogram.

As far as we are aware, no report emphasiz- ing this aspect of mammography has been made before. Details of the cases follow.

CASE REPORTS

Case 1. E.R. The 72-year-old patient had a 5-month history of a lump in her breast. The surgeon and the radiotherapist independently reported a hard lump of about 3 cm., which was partly fixed to the skin and which was classified as a stage 1 carcinoma.

The mammogram (Fig. 1) showed a well- defined tumor of 4 cu. cm. There was no calci- fication and no halo-it had a definite taiI sweeping toward the nipple. The lump on clinical palpation was thus smaller than when seen radiologically. According to Leborgne’s law3 this would indicate a benign lesion, but the well-marked tail inclined us to the view that, although the tumor was largely cystic, a malignant lesion in its wall was highly prob- able. A simple mastectomy was done, and the

lesion was found to be a cyst measuring 4 cu. cm. In its wall was a benign papilloma (Fig. 2).

Case 2. A.E. The 79-year-old patient had a lump in her breast of unknown duration. The surgeon and the radiotherapist reported a hard irregular mass of about 4.5 cm. in diam- eter that was classified as a stage 1 carcinoma.

The mammogram showed a well-defined cystic lesion 3.x3.xZ.5 cm. with a tail on the deep aspect of the tumor, at which point the tumor outline was a little indistinct (Fig. 3). Apart from a calcified overlying artery, there was no calcification.

Although the lesion was largely cystic, an equivocal report was given because of the unfavorable discrepancy between clinical and radiological size and the tail. With the pre- vious case in mind, we favored another in- tramural papilloma. Simple mastectomy re- vealed that the tumor was largely cystic but the growth in the wall was a carcinoma. Car- cinomatous spread in the adjacent breast tis- sue was found by the pathologist.

Case 3. A.W. The 46-year-old patient had felt a lump in her breast some months earlier. The surgeon and the radiotherapist found a tumor of a little more than 3 cm. with slight skin dimpling “quite typical of carcinoma” (stage 1). A mammogram (Fig. 4) showed an oval lesion showing slight lobulation of 3 . 5 ~ 3.5~4.5 cm. There was no calcification, but the tumor was partly haloed. Double densities within the tumor shadow were noted but er- roneously thought to be artefacts. N o tail was identified. It was felt that the lesion was cystic and benign, and biopsy was suggested. Excision biopsy revealed a lobulated intra- cystic fibroadenoma (Fig. 5A). The explana- tion of the double densities, thought to be artefacts, is well shown by comparing the post- operative roentgenogram of the specimen with a photograph of the specimen itself (Fig. 5A and B).

From the Radiodiagnostic Department, The Royal Infirmary, Edinburgh 3, Scotland.

We are grateful to Mr. W. A. D. Adamson for his co-operation and for allowing us access to his clinical notes of these cases from his wards. We are grateful also to Dr. J. W. Black for the pathological reports and material.

Received for publication March 11, 1964.

DISCUSSION

Solitary cystic lesions of the breast are rare but when found may be associated with papil- loma, carcinoma, or fibroadenoma. The diffi- culties of differentiating these are illustrated

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No. 10 LARGE SOLITARY CYSTIC LESIONS OF BREAST Young & Samuel 1255

FIG. 1. Well-defined tumor with tail sweeping toward the nipple.

FIG. 2. Roentgenogram of slice of breast contain- ing tumor shown in Fig. 1. The extramural papil- loma can be seen in the wall of the cyst.

1256 CANCER October 1964 Vol. 17

FIG. 3. Well-defined tumor with tail (T). The nipple (N) is in the upper right-hand corner. Note the calcified artery (A) and skin marker (S).

~~ ~ ~_ -~ .-

FIG. 4. The oval tumor show- ing lobulation can be seen, It is partly haloed. The double den- sities within the tumor, as shown in the insert, were visi- ble in the original mammogram.

No. 10 LARGE SOLITARY CYSTIC LESIONS OF BREAST Young dr Samuel

FIG. 5. A, Cystic tumor shown in Fig. 4 has been slit open and polypoidal contents are seen. B, Mammogram of the specimen shown in Fig. 5A (mirror image). Cause of double densities observed in Fig. 4 can be seen to be due to tumor tissue within the cyst.

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in the 3 cases described. Apart from the tumor outline, valuable critical points in the differ- entiation would seem to be the identification of a tumor tail, or double densities within the cyst. The importance of giving full weight to Leborgne’s law is also well illustrated by these cases.3

Well-circumscribed carcinoma, fibroade- noma, and the dominant cyst in generalized fibrocystic disease should be easily excluded by the recognized radiological signs of these conditions.

Uncommon lesions that enter into the dif- ferential diagnosis are epidermoid cyst, en- capsulated hematoma, and tuberculoma. A galactocele is also cystic but the fatty contents

appear translucent in a mammogram and the translucent area with its clear outline can be readily recognized.3

SUMMARY

Three solitary cystic lesions of the breast with illustrative mammograms are presented.

Such cases are usually diagnosed clinically as carcinoma.

Mammography will modify such a diagnosis to a cystic lesion, but cannot always exclude cancer.

Mammography should assure excision bi- opsy and avoid an initial mastectomy. This may be of particular value in the elderly.

REFERENCES

1. BLACK, J. W.: Structure and pathology of breast in relation to mammography. In X-ray diagnosis of disease of breast; Section of Radiology. Proc. Roy. SOC. Med. 56: 767-776, 1963; 761-770.

2. CUTLER, M.: Tumours of the Breast: Their Pa- thology, Symptoms, Diagnosis and Treatment. London, England. Pitman Publishing Corporation. 1962; p. 67. 3. LEBORGNE, R. A.: The Breast in Roentgen Diag-

nosis. (Transl. by Lucy Crocker de Leborgne.) Monte- video, Uruguay. Imp. uruguaya. SA 1953; pp. 55, 186. 4. SAMUEL, E.: Soft-tissue radiology of breast. In

X-ray diagnosis of disease of breast: Section of Radi- ology. Proc. Roy. SOC. Med. 56: 767-716, 1963; 770-772. 5. YOUNG, B.: Some aspects of mammography. In

X-ray diagnosis of disease of breast: Section of Radi- ology. Proc. Roy. SOC. M e d . 56: 167-116, 1963; 772-715.