What is the recommended treatment approach for breast cysts and fibrocystic breast changes (fibroadenosis) in reproductive‑age women?

Treatment of Breast Cysts and Fibrocystic Breast Changes

Simple Breast Cysts

Simple cysts are benign and require no treatment beyond routine screening when clinical examination and ultrasound findings are concordant. 1, 2

• Simple cysts are characterized by anechoic (cystic) appearance, well-circumscribed borders, round or oval shape with well-defined imperceptible wall, and posterior acoustic enhancement 1, 2
• These cysts carry essentially no malignancy risk and are not associated with subsequent breast cancer development 2
• Therapeutic aspiration should only be considered if the patient has persistent clinical symptoms (such as pain or discomfort), but is not required for asymptomatic simple cysts 1
• After confirming the cyst is simple and clinical findings are concordant, the patient returns to routine age-appropriate breast screening 1, 2

Complicated (Non-Simple) Cysts

For complicated cysts, choose between aspiration or short-term surveillance with physical examination and ultrasound ± mammography every 6-12 months for 1-2 years. 1, 2

• Complicated cysts have most but not all elements of a simple cyst, may contain low-level echoes or intracystic debris, but do not contain solid elements, intracystic masses, thick walls, or thick septa 1, 2
• The malignancy risk is very low (<2%) 1, 2
• Aspiration may be more strongly considered in patients likely to be lost to follow-up 1
• If blood-free fluid is obtained on aspiration and the mass resolves, monitor the patient with clinical examination; if examination remains negative, return to routine screening 1
• Cytologic examination is only required if bloody fluid is obtained on aspiration 1
• If bloody fluid is obtained, place a tissue marker and perform cytologic evaluation; if cytology is positive, proceed to percutaneous vacuum-assisted biopsy or surgical excision 2
• Complicated cysts that increase in size during surveillance must be biopsied 1
• If a mass persists after aspiration, tissue biopsy is required 1

Complex Cysts

Complex cysts require tissue biopsy due to their 14-23% malignancy risk. 1, 2

• Complex cysts have both anechoic (cystic) and echogenic (solid) components, including thick walls, thick septa, and/or intracystic masses 1, 2
• Ultrasound-guided core needle biopsy is the preferred diagnostic approach 1
• If biopsy results are benign and image-concordant, perform physical examination ± ultrasound or mammogram every 6-12 months for 1-2 years to assess stability 1
• If the lesion increases in size, repeat tissue sampling 1
• If stable throughout surveillance, return to routine screening 1

Fibrocystic Breast Changes (Fibroadenosis)

Fibrocystic changes are benign and typically require no specific treatment beyond reassurance and symptom management. 3, 4

Diagnostic Approach

• For women under 30 years with palpable masses, perform ultrasound as the initial imaging modality 5
• For women 30 years and older, perform both diagnostic mammography and ultrasound 5
• Clinical examination alone is insufficient for definitive diagnosis 5

Management Strategy

• Most fibrocystic changes require only routine screening when imaging confirms benign features 5, 2
• Fibrocystic changes are predominantly found in premenopausal women due to hormonal fluctuations and typically regress during the postmenopausal period 6, 4
• For symptomatic patients with breast pain or tenderness, lifestyle modifications may provide relief 3
• Medical management with hormonal therapy (low-dose oral contraceptives or cyclic progestogen) can be considered for severe symptoms, though this is not routinely necessary 6

Important Caveats

• Any palpable mass within fibrocystic breast tissue that appears suspicious on clinical examination warrants biopsy, even if imaging is negative 5, 7
• Fibrocystic changes with atypical hyperplasia on biopsy require risk-reduction therapy according to breast cancer risk reduction guidelines 1
• Complex fibroadenomas (characterized by cysts >3 mm, sclerosing adenosis, epithelial calcifications, or papillary apocrine changes) carry a modestly increased risk of subsequent breast cancer and may warrant closer surveillance 7, 8

Follow-Up Protocol

• For lesions classified as BI-RADS 2 (benign), routine screening is appropriate 5
• For lesions classified as BI-RADS 3 (probably benign), short-interval follow-up imaging at 6 months is recommended, with continued surveillance every 6-12 months for 1-2 years 5, 2
• For lesions classified as BI-RADS 4 or 5, tissue biopsy is mandatory 5

Critical Pitfalls to Avoid

• Never accept discordance between pathology results and imaging findings; this requires repeat sampling or surgical excision 1, 7
• Do not delay biopsy of a clinically suspicious mass while awaiting imaging results 7
• Cysts cannot be reliably distinguished from solid masses by palpation alone (only 58% accuracy), so imaging is essential 5
• Never perform cytologic examination of cyst fluid unless it is bloody 1