What is the recommended treatment for a simple cyst?

Management of Simple Cysts

Primary Recommendation

Asymptomatic simple cysts require no treatment or follow-up, regardless of size or location. 1, 2

Diagnostic Confirmation

Imaging Characteristics of Simple Cysts

Simple cysts must meet strict criteria to be classified as benign:

Breast simple cysts: 1

• Anechoic (completely fluid-filled)
• Well-circumscribed, round or oval shape
• Well-defined imperceptible wall
• Posterior acoustic enhancement

Hepatic simple cysts: 1

• Anechoic on ultrasound
• Hypointense on T1-weighted MRI
• Markedly hyperintense on T2-weighted MRI
• No enhancement with contrast
• No solid components, thick walls, or septa

Initial Diagnostic Approach

• Ultrasound is the first-line imaging modality for evaluating suspected simple cysts in all locations 1, 2
• If imaging characteristics are equivocal or show irregular walls, septations, or solid components, proceed to contrast-enhanced CT or MRI 3

Management Algorithm

For Asymptomatic Simple Cysts

No follow-up imaging is indicated, regardless of cyst size. 1, 2 This represents a strong recommendation with 96% consensus from the European Association for the Study of the Liver. 1

For Symptomatic Simple Cysts

When patients develop symptoms (abdominal pain, distension, early satiety, nausea):

1. Obtain ultrasound first to assess size and evaluate for complications 1, 2

2. Treatment options for confirmed symptomatic simple cysts: 1, 2, 3

   • Laparoscopic fenestration (preferred due to high success rate and low invasiveness) 3
   • Percutaneous aspiration with sclerotherapy (effective for immediate symptom relief but higher recurrence rates) 1, 2, 3

3. Treatment success is defined by symptom relief, not volume reduction 1, 2

For Complicated or Complex Cysts

These are NOT simple cysts and require different management:

Complicated cysts (low-level internal echoes but no solid components): 1

• Malignancy risk <2%
• Options: aspiration OR 6-12 month follow-up for 1-2 years
• Biopsy if increasing in size or suspicion

Complex cysts (solid components, thick walls, thick septa, intracystic masses): 1

• Malignancy risk 14-23%
• Core needle biopsy is mandatory 1

Post-Treatment Management

Routine follow-up imaging after treatment is NOT recommended (92% consensus). 1, 2 Imaging should only be performed if symptoms recur or persist.

Critical Pitfalls to Avoid

1. Do not follow asymptomatic simple cysts with serial imaging - this wastes resources and causes unnecessary patient anxiety 1, 2

2. Do not confuse complicated or complex cysts with simple cysts - any solid component, thick wall, or septation excludes the diagnosis of a simple cyst and requires tissue diagnosis 1

3. Do not perform simple aspiration without sclerotherapy - this leads to high recurrence rates 3, 4

4. Recognize hemorrhagic complications - intracystic hemorrhage resolves spontaneously and does not require treatment, but infected cysts require active management 1, 2

5. Ensure imaging quality is diagnostic - only confidently diagnosed simple cysts on high-quality ultrasound can be managed conservatively 5