What is the diagnosis and recommended management for a patient with bilateral breast simple cysts, focal fibroadenosis in the left breast, and a small fibroadenoma in the left breast, as seen on ultrasound?

Management of Bilateral Breast Simple Cysts, Focal Fibroadenosis, and Small Fibroadenoma

For this patient with bilateral simple breast cysts, focal fibroadenosis, and a small fibroadenoma, routine breast screening is recommended without need for biopsy or surgical intervention, as all findings represent benign lesions (BI-RADS 2). 1

Diagnosis and Risk Stratification

Simple Breast Cysts (Bilateral)

• Simple cysts are definitively benign (BI-RADS 2) and carry no increased risk of subsequent breast cancer development. 1
• The cysts described in this report meet all criteria for simple cysts: well-defined, cystic appearance with appropriate acoustic characteristics. 1
• No aspiration is needed unless the patient develops persistent clinical symptoms from the cysts. 1

Small Fibroadenoma (Left Breast, 6.8 x 4.7 mm)

• This hypoechoic lesion with posterior acoustic enhancement and round shape is characteristic of a fibroadenoma. 2
• At less than 2 cm in size with benign ultrasound features, this lesion is classified as probably benign (BI-RADS 3) and does not require immediate biopsy. 1, 3
• The risk of malignancy in such lesions is less than 2%. 1

Focal Fibroadenosis (Left Breast)

• Prominent fibroglandular parenchyma representing fibroadenosis is a benign finding. 1
• This represents normal physiologic variation in breast tissue and requires no specific intervention. 1

Recommended Management Algorithm

Immediate Management

• No biopsy or surgical excision is indicated at this time. 1
• The simple cysts are benign and require no intervention unless symptomatic. 1
• The small fibroadenoma does not meet size criteria (>2 cm) for excision. 3

Follow-Up Protocol

For the small fibroadenoma specifically:

• Perform physical examination with ultrasound at 6-month intervals for 1-2 years to document stability. 1, 4
• If the lesion remains stable or decreases in size throughout the surveillance period, return to routine age-appropriate breast screening. 1, 4
• If the lesion increases in size or develops suspicious features during follow-up, proceed to core needle biopsy (not fine needle aspiration). 1, 3

For the bilateral simple cysts:

• Return to routine breast screening immediately. 1
• Therapeutic aspiration only if persistent symptoms develop. 1

When to Consider Biopsy or Excision

Absolute Indications for Core Needle Biopsy

• The fibroadenoma increases in size during the 1-2 year follow-up period. 1, 4
• Development of suspicious ultrasound features (irregular margins, heterogeneous echogenicity, posterior shadowing). 2
• Patient age >40 years with family history of breast cancer may warrant lower threshold for biopsy. 5

Indications for Surgical Excision

• Fibroadenoma grows to exceed 2 cm in size. 3
• Patient experiences significant anxiety about the mass and requests removal (this is a valid indication). 3
• Core biopsy reveals atypical features, lobular neoplasia, or other high-risk pathology. 1, 5

Critical Pitfalls to Avoid

Common Errors in Management

• Do not perform fine needle aspiration for the fibroadenoma—core needle biopsy provides superior diagnostic accuracy with better sensitivity, specificity, and histological grading. 3
• Do not aspirate simple cysts unless they are symptomatic. 1
• Do not assume that a decreasing fibroadenoma requires no follow-up; it still needs 1-2 years of monitoring to document stability. 4

Surveillance Considerations

• Ensure concordance between clinical findings and imaging throughout follow-up. 1
• If any discordance develops between imaging appearance and expected benign behavior, proceed to tissue sampling. 3
• For women age 30 or older, consider combining ultrasound with mammography during follow-up visits. 4

Special Populations

• In patients over 40 years with family history of breast cancer, maintain a lower threshold for biopsy even with benign-appearing lesions, as the risk of underestimating in situ foci within fibroadenomas exists. 5
• Complex fibroadenomas (containing cysts >3mm, sclerosing adenosis, or calcifications) carry slightly higher relative risk and may warrant closer surveillance. 5, 6