Treatment for Galactocele
Galactoceles are benign milk-containing cysts that require ultrasound-guided aspiration for both diagnosis and treatment, with observation alone being appropriate for asymptomatic cases. 1, 2
Initial Diagnostic Approach
Breast ultrasound is the mandatory first-line imaging modality for any lactating or postpartum woman presenting with a breast mass, as it achieves 100% sensitivity for detecting pathology and immediately differentiates benign fluid collections (galactoceles, simple cysts) from solid masses requiring further workup. 3, 1
Ultrasound can instantly identify galactoceles as fluid-filled lesions, distinguishing them from solid masses that would necessitate biopsy. 3, 1
Mammography should not be the initial study in pregnant or lactating women because increased breast density limits its diagnostic utility compared to ultrasound. 3, 1, 4
Treatment Algorithm
Asymptomatic Galactoceles
Simple observation with clinical follow-up is appropriate for asymptomatic galactoceles that are clearly benign on ultrasound (BI-RADS 2), as these lesions often resolve spontaneously after cessation of lactation. 1, 2
The key management principle is to follow up until complete resolution occurs, as galactoceles typically disappear naturally at the end of pregnancy or lactation. 2
Symptomatic Galactoceles
Ultrasound-guided aspiration serves both diagnostic and therapeutic purposes when the galactocele is symptomatic (causing pain, discomfort, or cosmetic concern). 1, 5, 6
Aspiration of milky fluid confirms the diagnosis and provides immediate symptom relief through decompression of the cyst. 6, 2
Patients should be counseled about increased bleeding risk and possible milk fistula formation during any breast procedure in lactating women. 3, 1
When Biopsy is Required
Core needle biopsy is mandatory if ultrasound shows suspicious features (irregular margins, solid components, heterogeneous echogenicity) rather than a simple fluid collection, as galactoceles can rarely coexist with malignancy. 1, 7, 2
At least 2-3 cores should be obtained if biopsy is performed, and concordance between pathology, imaging, and clinical findings must be verified. 1, 7
Discordant results mandate additional tissue sampling or surgical excision to exclude malignancy. 1, 7
Special Clinical Scenarios
Infected Galactoceles
Infected galactoceles require urgent ultrasound evaluation to distinguish them from breast abscess or inflammatory breast cancer, as all three conditions present with similar symptoms. 7, 8
Ultrasound-guided aspiration combined with antibiotics is the initial management approach for infected galactoceles. 8
Definitive surgical drainage may be required if aspiration and antibiotics fail to resolve the infection. 8
Breastfeeding can continue uninterrupted even during treatment of infected galactoceles, including in the perioperative period. 8
Complex or Atypical Presentations
Galactoceles can occur in unusual locations such as accessory axillary breast tissue and may mimic malignancy on ultrasound with irregular margins and heterogeneous echogenicity. 6
Diagnostic aspiration revealing milky fluid and resolution of the mass after aspiration confirms the diagnosis even when imaging appearance is suspicious. 6
Long-standing galactoceles can rarely show crystal formation on aspirate smears (crystallizing galactocele), but this does not change management. 5
Critical Pitfalls to Avoid
Do not assume all breast masses in lactating women are benign without proper imaging evaluation, as more than 80% are benign but pregnancy-associated breast cancer can present as a palpable mass with aggressive biology. 3, 1, 4
Do not delay imaging because the patient is breastfeeding—the transiently increased breast cancer risk during pregnancy and lactation requires prompt workup of any discrete mass. 1, 4
Do not rely solely on benign-appearing ultrasound characteristics, as pregnancy-associated breast cancer can masquerade as a benign-looking lesion with circumscribed margins and posterior acoustic enhancement. 3, 1
Do not perform biopsy before imaging, as post-biopsy changes can obscure lesion visualization and impair interpretation. 3, 1
Do not use surgical excision as first-line treatment in lactating women unless there is rapid enlargement, discordance in triple assessment, or failure of conservative management. 2, 9