Management of Extremely Painful Breast Cysts
For extremely painful breast cysts, therapeutic aspiration should be performed immediately to provide symptom relief, regardless of whether the cyst is simple or complicated. 1
Immediate Management Approach
Simple Cysts with Severe Pain
- Perform therapeutic aspiration for symptomatic relief when persistent clinical symptoms are present, even though simple cysts are benign (BI-RADS 2). 1
- Aspiration is the definitive treatment for pain relief in simple cysts that are causing significant symptoms. 1
- Cytologic examination of aspirated fluid is only required if bloody fluid is obtained—clear or straw-colored fluid can be discarded without analysis. 1, 2
Complicated Cysts with Severe Pain
- Aspiration is strongly preferred over observation when pain is severe, as it provides immediate symptom relief. 1
- The option of aspiration should be more strongly considered in patients likely to be lost to follow-up. 1
- Complicated cysts have a very low malignancy risk (<2%), making aspiration a safe first-line approach. 1
Post-Aspiration Management Algorithm
If Cyst Resolves After Aspiration
- Blood-free fluid + complete resolution: Monitor with physical examination; return to routine screening if examination remains negative. 1
- Bloody fluid + complete resolution: Place tissue marker, send fluid for cytologic evaluation, and follow with physical examination ± ultrasound/mammogram every 6-12 months for 1-2 years. 1
If Mass Persists or Recurs
- Persistent mass after aspiration: Perform tissue biopsy (core needle biopsy preferred). 1
- Recurrent mass after initial successful aspiration: Tissue biopsy is mandatory. 1
Complex Cysts Require Different Management
- Do not aspirate complex cysts—these have both cystic and solid components with malignancy risk of 14-23%. 1
- Complex cysts require immediate tissue (core needle) biopsy regardless of symptoms. 1
Critical Pitfalls to Avoid
- Never dismiss severe focal pain without intervention—while pain alone rarely indicates cancer, geographic correlation between a cyst and focal severe pain warrants drainage for both diagnostic and therapeutic purposes. 3, 4
- Do not send clear/straw-colored cyst fluid for cytology—this is unnecessary, costly, and provides no additional benefit. 1, 2
- Avoid observation as first-line management when pain is described as "extremely painful"—while observation is acceptable for asymptomatic or mildly symptomatic cysts, severe pain warrants immediate aspiration. 1
- Do not assume small cysts cannot cause pain—while some literature suggests small incidental cysts are unlikely pain sources, a cyst that correlates geographically with focal severe pain should be aspirated. 1, 3
Adjunctive Symptomatic Management
While awaiting or following aspiration, provide: