 So we'll start with the cyst talk and we're going to talk about breast cysts that aren't simple people worry about them a lot But in general, I think they worry too much because the vast majority are benign so we're going to show a lot of beautiful histology from Laszlo and other places that show why cysts look the way they do and Help you get a feeling for whether you should worry about a non-symbol cyst or not What I'm showing here is a a nice large section pathology slide and what I want to show is that I make a grayscale and video inverted So that white is black and black is white You can see that it looks a lot like the old sound and so when I show you the correlations I'm going to use a lot histologic Beautiful color pictures that I'm going to convert to grayscale and video invert so you understand why things look the way they do I have no disclosures to make Now the percentage of cysts that is not simple is higher today than it was 20 or 30 years ago The reason for that is is a combination of us using scan parameters that exceed the ability the machine to clean up the noise We've pushed our frequency so high our bandwidth so wide and Our dynamic range so wide that we're creating some haze inside the cyst But secondly with the higher frequency we have better resolution and we're seeing real Proteinaceous and or fatty debris inside the cyst that creates echoes So what is fibrocystic change? Well, I'm showing you a picture of a normal breast Tdlu terminal duct olabular unit This is the lobule in the long axis and this is the extra lobular terminal duct part So it looks like a tennis racket and this is a short axis view which would be taken 90 degrees through that Now inside this Acinus are 50 to 60 ass and I on average in Fibrocystic change what happens is the ass and I become fluid distended So I can see one two three four five six seven fluid distended or or cystically dilated ass and I and I see the extra lobular terminal duct and the inter lobular terminal duct in the center and then the normally loose gray stromal tissue Becomes abnormally white. That's the fibro part of fibrocystic change as fibrocystic change gets worse Or more progressive the ass and I enlarge The walls between some of the ass and I rupture or becoming faced so we have fewer Larger micro cysts and then ultimately if all the Walls between the ass and I rupture or a face we come up with a simple unilocular cyst which occurs because of twisting These are beautiful pictures from Lazlo for some reason. I don't have Lazlo's name on there But all of these are Lazlo large section thick section Slides, so we don't have any trouble with normal TDL use. We don't have any trouble with Simple cysts But these in-between states of micro cysts can cause us problems because the micro cysts can be too small to resolve and if you volume average a White micro white fibers tissue with black Micro cysts what you'd come up with is gray So what I did here is I just put this in Photoshop and I did a Gaussian blur So this is this image blurred and you can see that with lower resolution I can't resolve the micro cysts and this looks like a solid mural nodule an isocoic solid mural nodule and in this case I've learned you can see that it looks like there's a thick septation So what I found is that with lower-end cheaper up sound machines You can't resolve the micro cysts as well. So I don't think you miss cancers more But you have less ability with a lower-end ultrasound machine that has less a resolution You have less ability to resolve the micro cysts which are benign and Come up with a falsely suspicious appearance of a complex cystic and solid mass with either a mural nodule or a thick septation Now fibrocystic change is not just Cystic change But usually includes a mixture of benign proliferative disorders like usual duct hyperplasia apricon Metaplasia fibrosclerosis whatnot So if we go down the primarily cystic pathway, it's easier to call things benign If we if we take the bottom pathway where there's more benign proliferative things It's harder to call something benign. We come up with more false positives And again, it's usually a matter of the micro cysts are too small to resolve in some cases In other cases, they're larger and more easily to resolve. So what makes this difference? Well in general it has to do with estrogen receptors. Okay, so this is a single Tdlu and this is an estrogen stain the black and so we can see that the asinine that have estrogen receptors become Cystically dilated While those that lack the estrogen receptors don't cystically dilate and So we can get heterogeneous Tdlu's in which some of the asinine are cystically dilated enough for us to recognize as cysts But other than that and what can happen in these cases and again, these are beautiful Laszlo 3d pictures We can Resolve some of the might cysts that are large enough the micro cysts that are large enough But the ones that are too small Can make it look like a complex cystic and solid mass So one of the reasons that benign fibrocystic change can look Suspicious is uneven distribution of estrogen receptors and the suspicious part is the part that doesn't have the estrogen receptors now When the fluid has a relatively low amount of proteinaceous or fatty debris They can appear simple cystic. So these are clustered simple cystic micro cysts, but There are several reasons that we can get echoes inside the micro cysts one of these is that The fluid can be ecogenic due to a high concentration of proteinaceous debris and or Fatty debris another reason is that what creates the fluid is papillary apricon metaplasia or apricon metaplasia So if you have papillary apricon metaplasia filling micro cyst that can make them appear ecogenic and Then I on the previous slide I talked about uneven estrogen receptor So the part that doesn't have estrogen receptors can appear to be solid and the fourth reason Is micro papillary carcinoma in sight to in my experience About 99 more than 99% of all these complex micro cystic things are caused by Equigenic fluid papillary acrometaplasia on even estrogen receptors are less than 1% are caused by micro papillary carcinoma in sight to So that should be reassuring Now in the ACR by results on lexicon complicated has one connotation and it needs to be distinguished from complex And in fact in in the last version of by reds in 2013 edition 5 We took away the word complex and we made it complex cystic and solid Because people frankly couldn't remember whether complicated or complex was worse and By changing the terminology to complex cystic and solid it makes it easier to appreciate that that's a more that's a higher risk situation So complicated breast cysts are usually by reds two or three if they're multiple incidental bilateral they're by reds two if there's a dominant complicated cyst that causes a palpable abnormality or a Mammographic abnormality you might call it by reds three What makes it complicated ecogenic fluid or ecogenic debris within the fluid so diffuse low-level echoes within the cyst fluid Synthelating echoes, which are mobile cholesterol crystals that we'll talk more about that later Debris levels created by proteasious debris layering out on the dependent part of the cyst or Non-dependent lipid layers floating in the non-dependent part so all four of those things can give rise to benign complicated cysts a complex cystic and solid mass Is usually by reds four or five it can be by reds three again if it's multiple and bilateral What causes a complex cystic and solid appearance well mural nodules thick septations Especially isoacoo acceptations thick irregular walls and to that I would add internal vascularity Now what by reds doesn't mention is that there's still a small percentage of cysts That we mistake for solid Usually these are cysts that have ecogenic fluid so ecogenic That a complicated cyst simulates a fiber adenoma now Why do we worry about cysts? Well because these echoes inside of non-simple cysts could be caused by papillomar carcinoma But what is it usually? protein globs cholesterol crystals flat fat globules white blood cells red blood cells epithelial cells foamy macrophages individual aprican Metaplastic cells or Pam papillary aprican metaplastic cells and this is what it is in the vast majority of cases Now a pathologist can describe all these things on the left and what the pathologist Doesn't do is he doesn't get brain damage from all of this He sees all these things inside the cysts, but in his impression. He says benign fibrocystic change So what I want to talk about in the rest of this talk is how we as radiologists can do a better job of distinguishing the benign things on the left From the red things on the right suspicious things on the right now This is a nice picture from a textbook on benign breast disease by Hughes and Mansell and you can see that these are Fluids drawn from benign breast cysts and you can see that they very greatly in color What am I going to do? I'm going to make a grayscale and video invert them And now you can see that they also very greatly in opacity Now this can be very instructive because let's just say That the two cysts on the right are simple cysts They have about mid-level opacity Well, we have two cysts the second and third from the left That have higher opacity That means there has to be something inside the fluid Causing it to be more opaque. What is that? Proteinaceous debris we also have two of these fluids that are less dense than a simple cyst What does that mean? It means that there has to be something in the fluid other than just water And what would be less dense than water fat? So what we're seeing here is that Echoes inside of cyst fluid Can be caused by proteinaceous debris Or fat now Every cyst starts With some fat or some protein in it, but in general The amount of protein And the percentage of fat is so low that we don't see any echoes Here's a simple cyst Here it is on a six month follow-up five month follow-up. It still looks like a simple cyst. It's completely anechoic But at 12 months, it's a little smaller And now it's developed some echoes Why is this? If you've ever followed cysts, and we weren't following this, we were following this patient for a fibroedinoma, but Just happened to have follow-up pictures of a benign cyst About 80% of cysts are acute and resolve spontaneously, but about 20% become chronic Now in a chronic cyst that doesn't go away right away. What can happen is the water component Of the cyst contents can be resorbed through the cyst wall over time And so if you've ever followed any of these complicated cysts, you know over time they tend to become smaller and more ecogenic This is because of resorption of water But whatever protein or fat contents are inside the cyst can't be resorbed through the wall So over time these chronic cysts tend to concentrate the fat indoor Proteinaceous Contents and become more ecogenic the fluid tends to become more ecogenic so These are pictures of cysts that every pathologist in the world will just call benign fibrocystic change These are the video inverted grayscale images of those cysts And these are the ultrasound pictures that correspond We can now see Quite clearly why appearances are what they are So is there some proteinaceous debris on this simple cyst on the left? Yes But why don't we see it on ultrasound? Because the proteinaceous contents aren't Dense enough or aren't concentrated enough to create echoes Notice that we have a very thin ecogenic wall Second from the left we have a complicated cyst caused by proteinaceous debris Notice that the debris is more concentrated And higher percentage than on the left and so we get a diffused low-level ecogenicity within the cyst But we still have a thin ecogenic wall Now the third from the left is also complicated But it has a layer of aprican meta plastic cells, which is thicker and it will appear isocoic So you should have a slightly thicker less ecogenic wall And the fat contents within the cyst are also going to create echoes So we have diffused low-level echoes and we have a slightly thicker slightly less ecogenic wall Than we have for the proteinaceous debris Now on the right is papillary aprican metaplasia So this is causing irregular thickening of the wall and it's causing fat inside the cyst So we have ecogenic fluid But we have irregular ecogenic thickening of the cyst wall So what this is showing is that you know, we have a simple cyst on the left Complicated cysts in the middle and because there's ecogenic fluid Uh, we could call the right cyst complicated But because it has a regular thickening of the wall It could also be considered complex cystic and solid Now anytime we have a mixture of reassuring and less reassuring findings and also We classify by the more suspicious finding So the right one would have to be considered complex cystic and solid rather than complicated Now we have to have a systematic approach because there are just so many cysts We don't want to we don't want to biopsy any of them if we can avoid it And we certainly don't want to put a lot of them in follow-up because it'll just plug up our system I mean, what are we trying to do? We're trying to detect cancers at a stage where they're so early that Minimal treatment can cure them But what we don't want to do is plug our system with a false positive So I mentioned that part of the reason we're seeing more complicated cysts than we used to non-simple cysts than we used to Is because we've taken our scan parameters beyond their limits We've taken the frequency on so high the dynamic range so wide and the bandwidth so wide That we're creating diffuse low level echoes The other thing we can do is make sure that we're focusing right because If you don't have your focal zones at the right spot, even if you have a high quality machine And your beam is going to be a little wider and you're not going to be able to resolve these microsists Are going to volume average black microsists with white fibers tissue and make it look like solid gray stuff in the in the center of the cysts, so One of the ways that we can avoid creating artificial non-simple cysts is by using harmonics and spatial compounding and also carefully moving our focal zones around to make sure What we're looking at is in focus If we don't use harmonics or compounding, we probably have to scan at a lower dynamic range You know normally Current top of the line machines you can scan somewhere between 70 and 105 decibels dynamic range But if you're not using harmonics and spatial compounding, you're probably going to be stuck around 50 decibels because you're going to have too many false positives otherwise Now on the left is a complicated cyst with a fat fluid level And notice that on the right with harmonics, a lot of those Artifactual echoes are cleared out Now here on the left I have fundamental gyming on the right to have harmonics and notice that in this case I have proteanaceous debris within the cyst And because it's real stuff within the cyst harmonics actually makes it more ecogenic So when the internal echoes are artificial harmonics tends to decrease the echoes But when the internal echoes are real say by caused by proteanaceous or fatty debris Harmonics tends to increase so what we get in summary with harmonics Is a better ability to distinguish real from artificial internal echoes Uh, and we get a similar effect from spatial compounding and they achieve this effect in different ways So I'm a big believer in scanning with both spatial compounding and harmonics on Now I want to reassure you that the general rules of non-simple cysts are very reassuring the the majority of non simple breast cysts Lie within the spectrum of fibrocystic change Malignant cysts are relatively infrequent the unusual malignant breast cyst usually has the appearance of a solid nod to with liquefactive or hemorrhagic Central necrosis and it's really only in the rarest of circumstances Do we see a malignant breast cyst that I would consider to be tricky now These are populational rules So in individual cases, even though the populational rules are very reassuring You kind of have to have a systematic way of evaluating these things I mean, especially if you scan doctors wives or nurses or doctors themselves They always seem to be the exception to the rule So we have to have a systematic way of evaluating it Now we also have to have a reference standard that we can use when we're trying to develop An algorithm for dealing with these And the problem is that the reference standard for non simple breast cysts is not as good as the reference standard for solid masses I mean solid masses we do core biopsy Or surgical biopsy with histology With non simple breast cysts The traditional way of following them was either aspiration to fluid cytology Or shorted it will follow Those tended to be poor reference standards because there's too many false positives and false negatives With uh fluid cytology And use follow up a lot of these cysts go away and a lot of people don't even bother to come back So follow up tends not to be very good So the truth of the matter is we didn't really we weren't really and even surgery wasn't necessarily the best reference standard Because invariably either at surgery or in pathology The dominant palpable and or mammoreftly visible cyst was ruptured And then was misinterpreted by the pathologist as a background pyrocystic process rather than the cause for the biopsy Or histology or surgery So basically dvab That we were able to develop a meaningful algorithm for the cyst And the full algorithm that we use for cysts that aren't simple is Pretty much the same thing we use for mammography and solid breast nodules I look for suspicious findings first if I don't find suspicious findings Then I try to find definitively benign findings that are byreds too And if I can't find byreds too, then I try to call it byreds three so that I don't have to biopsy it But I could do follow up on it But if I can't make it byreds two or three, then I have to consider the whole thing suspicious and I have to biopsy it And really again, we're not reinventing the wheel. This is exactly how I deal with mammograms and solid breast masses So when we talk about looking for things that are suspicious byreds four or more These are basically the things that in byreds edition five are things that make a cyst Classifiable as complex cystic and solid mass rather than complicated That includes mural nodules irregular wall thickening thick isochroic internal septations And internal vascularity And for that I would add certain complex clustered micro-cyst because not all micro-cyst appear simple some appear to be complex so Let's talk about the septations. These are thin hypercoacceptations. They aren't they aren't suspicious. Those are byreds too This has benign fibrocystic change. And what are we actually seeing here? We're seeing a thin approximately one millimeter thick or 500 micron thick ultrasound tomographic slice through a single cystically dilated tdlu And what do I see on this image? Three cystically dilated Asini within that tdlu And what are the thin hypercoacceptations? They're simply the unruptured walls of asini. So in this particular tomographic slice I'm three seeing three cystically dilated asini with the septations representing Unruptured asiner walls This on the other hand is a thick isocoacceptation caused by papillary carcinoma So this is suspicious The thick isocoacceptation is suspicious. The thin hypercoacceptations are not suspicious Now if I take this beautiful laslow picture video inverted into gray scale You can see that I have a single cystically dilated tdlu with one two three Four residual cystically dilated asini. You can clearly see That these hypercoacceptations do indeed correspond to the unruptured Walls between different a cystically dilated asini Now if we get an irregular wall thickening or mural nodule is that complex cystic and solid? Yes Does it mean it's papillol or carcinoma? No Papillary apricot meta-plasia, which is simply part of the benign fibrocystic spectrum can easily cause Uh irregular wall thickening or mural nodule So if we look at the chicken versus egg argument, the question is what came first the mural nodule or the cyst And I think in most cases Whatever is causing the irregular wall thickening or mural nodule came first And then by a combination of secreting fluid And obstructing the duct Carefully created the cyst that means that the answer as to whether this is apricon meta-plasia Causing this complex cystic and solid appearance or whether it's a papillol or carcinoma The answer lies at the point of attachment of the mural nodule Or irregular wall thickening to the wall And so what you'll see if it's a true papillary lesion like papillol or carcinoma The thin echogenic capsule will not be present at the point of attachment And there may be a regularity or extension of the papillary lesion whether it's benign or malignant Into the duct usually toward the nipple So we can see this in real life. Here's a mural nodule We can see a beautiful thin echogenic capsule almost all the way around it But at the point where this thing arose The capsule is absent And it's growing up the duct toward the nipple So the answer on this mural nodule lies only at this point where the capsule is absent And where it's growing up the duct. This is clearly not apricon meta-plasia This is clearly a papilloma Or a papillary carcinoma Because there should be an intact Thin echogenic wall and the shape should be round or oval not keyhole shape. So this is a keyhole shape. So When we look at this point of attachment We don't want to see angles angular is suspicious We don't want to see loss of the capsule. We want a capsule to be present Loss of a capsule is suspicious We want an oval or circular shape. We don't want a protrusion Into ducts that would create a keyhole shape And we don't want to see an internal vascularity apricon meta-plasia no matter how vascular Virtually never incites neo vascularity So on the left is a reassuring Complexistic and solid mass caused apricon meta-plasia The apricon meta-plasia is filling about 80 percent of the cyst But it's oval shaped and all along the point of attachment. There's an intact thin echogenic capsule On the right is a hemorrhagic papilloma And what we can see is that the capsule is absent along the point of attachment on the right side And then there's extension into a couple ducts that are creating some angles and irregularity So the left is reassuring caused by apricon meta-plasia on the right is suspicious caused by a papilloma Okay shape Left is reassuring oval shape Again apricon meta-plasia filling about two-thirds of the cyst But notice the beautiful thin echogenic capsule all along the point of attachment This is very typical of benign apricon meta-plasia This is about a similar size complexistic and solid mass But we have an absent echogenic capsule along the right side where it's attached We clearly see That it's a keyhole shape that's extending out Of the oval shape or round shape And growing into a duct And when we see that in pathology, we can see the same thing here. We have an oval shaped cyst But where the papilloma is attached The thin capsule is absent And it's growing out into a duct So the answer Really lies only at the point of attachment. Why? Well, let's take away all these lines and bring pathology back All along the internal surface That's surrounded by fluid Benign malignant lesions have exactly the same shape and surface characteristics. Why is that? What determines shape and surface characteristics? Two things Number one is the resistance of the surrounding tissue to growth Of the lesion and number two is the gressiveness of growth But when you're surrounded by fluid, there's zero resistance to growth in any direction And so benign and malignant lesions grow exactly the same inside of fluid So you learn nothing by evaluating the fluid surfaces of this mass The only place you can get any diagnostic information Is the point of origin or the point of attachment to the wall So here's an eccentric wall thickening There's an absent capsule along the left side So that's suspicious And the key thing I want you to look at here is this is actually Intracistic grade 3 DCIS Notice how extensive the component is outside the cyst So in many instances what I'm telling you here is in many instances the answer is not inside the cyst But outside the cyst and the surrounding tissues So the amount of DCIS that's outside this cyst is much larger than the amount of DCIS inside the cyst and notice that The classical histology of Of grade 3 DCIS is present. These are micro lobulations An inside molecule ovulation is a calcification. Where does that occur in the necrosis in the center of the lumen? What is each of those micro lobules? It's a single grossly enlarged duct Filled with DCIS central necrosis and calcifications within the central necrosis Now the case Similar tiny neural nodule But I have an absent Thinic-Ogenic capsule along the left side where it's attached And if I look carefully I can see several enlarged ducts in the surrounding tissue. So again Intracistic DCIS The answer is not necessarily inside the cyst But in the grossly enlarged ducts and or micro lobulations in the surrounding tissue Now apricon metaplasia Unless it develops on a pre-existing papilloma, which it can But apricon metaplasia alone Is only two cells wide It gets all of its nutrients and gets rid of its all of its wastes Simply by passive diffusion through the fluid. It does not develop a vascular stalk On the other hand, intracistic papilloma and intracistic carcinoma are amongst the most vascular things in the breast So it's Often very easy to demonstrate internal vascularity within a papilloma and or carcinoma So here's a papilloma. You can see that it has a vascular stalk that's branching And this is apricon metaplasia filling a larger percentage of the cyst Then is the smaller papilloma on the right, but absolutely no demonstrable flow now What can I say about this? well, if you see Internal vascularity within a mirror or a thick septation That makes it suspicious by reds for you have to biopsia. It could be papilloma. It could be carcinoma You can't really tell but it's not just apricon metaplasia So positive Doppler is exceedingly helpful a negative Doppler Not as useful. Why because papilloma is often undergo spontaneous Infraction and hyalinization. So if you've got an infarcted hyalinized papilloma, it won't show vascular stalk Now in this case, I put the patient on her side for 10 minutes or five minutes I put her upright with a longitudinal view for five minutes And this did not shift Occasionally a fat food level can simulate an eccentric wall thickness in your mural nodule And so there are a couple ways that we can solve that that I'll talk about more later Now let's talk about clustered microsys Simple clustered microsys are by reds too. They're benign. They're just part of the fibrocystic spectrum They're caused by apricon metaplasia When we have complex cystic and solid microsys Then we have a problem Because we have to differential diagnosis of micropapillary DAV or DCIS versus papillary apicon metaplasia So these are beautiful pictures of uh from laszlo to our Uh micropapillary on the left apicon metaplasia on the right. What am I going to do? I'm going to make them grayscale video and verdom. So white is black black is white And you can say they look fairly similar and now here's the else sounds That's not very reassuring. They look very very similar So complex clustered microsys can be a diagnostic problem for us What we have to take some Comfort in Is that more than 99 out of 100 of these complex clustered microsys are going to be apricon metaplasia Less than one out of 100 are going to be papillary micropapillary DCIS Now this patient presented with a palpable up. These were palpable Uh and so on this exam it was 14 millimeters. It was called by reds three And she was asked to come back in six months Well seven weeks later she thought it was enlarging and sure enough it had gone in large from 14 to 33 millimeters Now, what did we do wrong on the first exam? We didn't put Doppler on at 10 weeks. She came back for Uh surgery And it increased to 50 millimeters. This is micropapillary DCIS What we did wrong on the first exam is that we never turned on Doppler This was the second exam when I saw I put on the Doppler. You can see how tremendously vascular this is remember The differential is just two things papillary apricon metaplasia Versus micropapillary grade 3 DCIS That's one of the most vascular lesions in the breast If I see internal vascularity like this, it's not apricon metaplasia This is going to be very suspicious. And so had we turned on Doppler the first time we could have avoided that false negative Now one thing I have to caution you about is that The transducers firm the breast the chest walls firm the cysts are soft So if you use too much scan pressure you will uh You can create false negatives by shutting the tumor vessels off the tumor vessels don't have muscular Muscles or elastic and they're easy to compress. So here I'm just letting the weight of my arm rest on the transducer and I'm getting a false negative on the right I'm consciously lifting up on the probe so that I'm barely touching the skin. In fact, you can see there's an air bubble here I'm touching so lightly That I'm starting to lose contact, but you can see how tremendously vascular this is So if you're going to use Doppler and you want to minimize false negatives You have to use very light scan technique and I think the literature is somewhat unfair and that it hasn't emphasized this enough Now once you decide that this is a complex cystic and solid mass and that you feel that it's suspicious for a papillomar carcinoma I don't think cyst aspiration and cytology is the right thing to do. In fact, I'll tell you for sure It's not the right thing to do. I also don't think an 18 gauge corbopsy or even a 14 gauge corbopsy is the right thing to do I think for complex cystic and solid masses You need to do Histology and the best way to do that is vacuum and take the whole thing out and ask the pathologist the serial section the entire specimen So here's a complex cystic and solid mass. We considered suspicious. Here's the vacuum probe Underneath it. You can see where the aperture is by the ring down artifact And then we take everything out till we get to the front wall of the cyst and we always deploy a marker because if there's A tip of your malignancy, we're going to have to get back and excise that maybe it can be hard to find that area If you don't leave a marker behind Now there's one other thing that we might put a needle in a cyst for other than papillomar carcinoma And that's an infected cyst So what are the signs of inflammation or infection? There are three uniform iso quote quote unquote wall thickening, which I'll show you is really peri cystic A debris level, which is pus And hyperemia of the cyst wall again. It's really peri cystic hyperemia Usually we see all three of those things together So on the right is a simple cyst with a thin hypercococ wall Nothing suspicious there, but on the left we have a debris level, which is layered pus And uniform isoacroic wall thickening, which again is really peri cystic and we found in most cases represents Foamy macrophages and or Lymphocytes or plasma cells On the right again with Doppler, we get typically no flow in a benign cyst wall But we have hyperemia in the peri cystic tissues in an acutely inflamed cyst Now obviously we can get flow in the wall of a malignant nodule But one thing I found is that in a malignant nodule the blood vessels are simply passing through the wall to supply the intracystic papillary lesion And therefore the vessels tend to be oriented perpendicular to the cyst wall If it's a papilloma or carcinoma whereas When it's an inflamed cyst the vascularity is parallel to the cyst wall And usually outside the cyst in the peri cystic tissues So the orientation of the vessels can be helpful In distinguishing an inflamed cyst from A malignant cyst. Now, this is that simple cyst I showed you earlier at baseline anicoic Five months anicoic It developed echoes at seven months. Why again because fluid was resorbed and the on the fatty contents became concentrated but then At 24 months She came in with tenderness And we can see that there's a debris level which is pus and there's uniform isochoric wall thickening And there's hyperemia with the vessels parallel to the wall So what happened here is that the fat became concentrated and the fat is very inflammatory Any sort of tear or rent Of the epithelium lining the cyst wall can allow this inflammatory lipid content to come in Contact with the surrounding tissues and cause acute inflammation. So this is actually very common Now when you aspirate these cysts They aspirate completely But the peri cystic inflammation persists. So you can see this little white line Represents the two walls of the cysts completely opposed. I've taken every drop of fluid out of this But what I have is residual peri cystic wall thickening. It really represents two layers of closely opposed apricon metaplasia So when you aspirate completely an inflamed cyst Expect to see the residual thickened quote unquote wall or peri cystic inflammation I followed about a hundred of these and they go away in about two weeks So I don't bother to follow them anymore. I just expect when I get pus out of a cyst That I'm going to have this residual wall thickening at the end Now sometimes you'll get a cyst that's not acutely inflamed. It has a uniform isocoke wall thickening It's indistinguishable from an acutely inflamed cyst for the very simple reason that it represents the healed phase Of an acutely inflamed cyst So when an acutely inflamed cyst heals It heals with fibrosis So when it's acutely inflamed Foaming macrophages or lymphocytes or plasma cells In the peri cystic area create the appearance of isocoke wall thickening But when it heals, it's the fibrosis that creates it and of course These cysts won't be tender when they're no longer inflamed if they're just thick walled fibrotic cysts They won't be tender and they won't have any hyperemia Now the debris level that we see Represents pus and pus can be very viscous So if you want to see if it shifts you can put them on their side while you're looking transversely or put them upright While you're scanning longitudinally and they will shift, but it's not instantaneous. The debris is so thick and viscous That it can take five minutes to shift So you can see here when I'm scanning transversely supine The pus is layered posteriorly But when I put it on their left side even at two minutes, it's just beginning to shift three minutes a little more It isn't till five minutes That it's fully shifted to the left side of the cyst. That's somewhat of a problem And there's a shortcut we can use So here's a case of an inflamed cyst with tumor-factive pus Uh, but it look it's so tumor-factive. It looks like a mural nodule So what can I do? I could put her on her side and wait five or ten minutes for this to shift But I can do Frematus So if I put in power diopter with PRF of a thousand have the patient home It'll create orange artifact or yellow artifact in the breast. Normal breast tissues will vibrate Now If this were attached to the cyst wall like a mural nodule like a papillom or carcinoma It would turn orange as well The fact that this does not turn orange on Frematus means that it's not attached and this proves conclusively This is just tumor-factive pus So what do I gain by doing this? I can save five minutes. I don't have to wait five or ten minutes for this gooey sticky pus to shift Now in that particular case I had to wait ten minutes for this to shift So in this particular case simply turn on power Doppler Frematus saved me at ten minutes Would have saved me ten minutes Now when you aspirate these inflamed cysts you either get pus or bloody pus If I just get pain pus I don't send it for Psytology or flow cytometry because I'm not worried about papillom or carcinoma All I want to know is it infected or just bland inflammation So all I need is a gram stain and a culture on that If I get bloody pus on the other hand Then I feel obligated to send it for cytology and flow cytometry So what's the point here? Well the point is I showed you all the vascularity and the pericystic tissues If you're going to aspirate a cyst That you think is inflamed put on color Doppler find the vessels find a routine that avoids the vessels so that you can get Plain pus and not bloody pus Now what percentage of these inflamed cysts is actually infected only a small percentage Most of this is bland inflammation What causes the bland inflammation to lipid contents and the cysts lipid is very inflammatory and again Only a tiny rent or tear in the epithelium can lead to severe inflammation So the vast majority of these inflamed cysts are not infected What do I do? Yeah, I cover them with dicloxacillum usually these spontaneous outpatient infected cysts are caused by staff And while I'm waiting for the 72 hour culture I give them a three day prescription to diclox and if it's if it's positive the culture is positive Then I can extend their antibiotics for seven, you know to seven or ten days But if it's negative, I'm already done So that's kind of my approach to these things now Once we decided the cyst is not suspicious for tumor and it's not inflamed Then we can look for definitively benign findings. Those things are usually things that you know in the acerbirets fifth edition Are simply things that make it a complicated cyst. So these are scintillating echoes They're being moved simply by the energy of the ultrasound beam now What I had to do to make these move in this case was I had to turn up the transmit power on the machine Basic ultrasound machines always boot up at low Transmit power as low as reasonably acceptable transmit power to minimize whatever possible adverse effects ultrasound might have So to make these move with grayscale in some cases you may have to manually turn up the power A simpler thing to do is simply turn on color or power Doppler Which supplies about 10 times the power of grayscale ultrasound. So I don't bother Any more turning up the transmit power. I just put on color or power Doppler Notice that the echoes are moving faster here than they were with grayscale ultrasound So the fact that they're moving faster also shows you the Doppler has more power Now here I'm scanning with an open box and you can see it's moving echoes. So these are scintillating echoes But notice what happens when I narrow the box. See how much faster they're moving What's the significance of that well the viscosity of fluid in the cysts can vary greatly So for the least viscous fluid just grayscale ultrasound even at low power settings may make them move As the fluid gets more viscous An open color box may make them move as fluid gets even more viscous They may not move with an open color box. You may have to narrow the color box to make them move And the last thing that supplies even more energy Than Doppler is shear wave elastography So This machine is generating about three shear waves a second So you can see that the movement appears jerky But two things about this shear wave are telling me that this is just echogenic fluid and not a hypochoric solid mass Number one is I can see the echoes being moved the scintillating echoes Um and number two, it's not transmitting shear waves no matter how viscous fluid is it won't transmit shear waves So so basically grayscale will move uh echoes It'll create scintillating echoes in very non viscous fluid Uh open color box in mildly viscous fluid narrow color box in more viscous fluid and uh Probably the best thing to do a shear wave because it'll move the most viscous fluid and give you the best distinction Of a solid versus complicated cyst with echogenic fluid Now when you aspirate these complicated cysts with internal echoes, they aspirate completely And you don't see anything unflow cytometry in And uh cytology that's suspicious But if you look on a polarized light, you'll see these birefringent cholesterol crystals So I believe that these scintillating echoes are simply cholesterol crystals You know, they're crystallized fat essentially and they're just benign. They're birefringent, too As debris, proteinaceous debris can layer in the non-dependent part of the cyst A lipid layer can layer in the non-dependent part of the cyst So protein layers posteriorly dependent part Fat layers anteriorly in the non-dependent part And just like you can make proteinaceous debris move by changing patient position You can make fat move by changing pace and position So here on the left, I'm scanning supine The fat is layered anteriorly When I put the patient upright It moves to the craniot end of the cyst So you can see an 90 degree shift in the degree in the Orientation of the fat fluid level Now these aspirate completely just like complicated cysts And in general these these are birets, too You don't need to aspirate them if you can definitively prove it's just the fat fluid level Interestingly immediately after aspiration I don't see a little white lipid layer here because the fat has become emulsified Passing through the needle So tiny micro droplets are evenly dispersed through the fluid But if I leave this upright on the desk for a few minutes a white fat layer will form on top Now we call this an acorn cyst because it looks like the cap on an acorn So here's an acorn cyst that's not caused by a fat fluid level It's actually caused by papillar aprican metaplasia And I know that because even after 10 minutes I can't get it to shift If this were a fat fluid level when I put our supine The interface between the fat and the fluid would have shifted horizontally With the fat being anteriorly and the fluid being posteriorly Now the problem with causing you know with with getting fat fluid levels to shift Is that like proteinaceous debris It can take a long time for the shift to occur So here I'm showing you a longitudinal view of a complicated cyst with a fat fluid level Filled about 70% with fat And when I put our supine immediately nothing happens At one minute it's only beginning to shift at two minutes a little more Three minutes a little more and it is until five minutes that it shifted Is this a problem? Way big a problem Why? Because we don't see that many cysts with fluid debris levels But we see thousands and thousands of fat fluid levels Why? Because aprican cells which create cysts excrete fat into the fluid So a large percentage of benign fibrocystic cysts have fat in them Many cases the fat's not concentrated enough to see But when it does become concentrated enough to see if the patient lies still Or is in the same position for a long enough time The fat will come out of the solution layer So in somebody with severe fibrocystic change It wouldn't be unusual to see somebody with five of these on each side And if you have to wait five minutes for each of these five cysts You're talking 50 minutes just to prove that these are all fat fluid levels So there has to be a shortcut So is there a shortcut that can prevent us from waiting five minutes? There are two shortcuts Shortcut number one is to look at the shape of the interface between the Equigenic fat and the clear fluid And if it's a fat fluid level the shape is sigmoid shaped or S shaped Convex posteriorly concave anteriorly That's the classical shape of a fat fluid level in the process of shifting From one non-dependent position to another as the patient changes position This is important for sonographers because if they're efficient The patient is upright in the waiting room Or they put her on the table and if they have a work list So they can pull up the patient's information very quickly They may well have scanned the patient sooner than five minutes So sonographers are frequently going to see this sigmoid shape Now there's a second shortcut And the second shortcut is simply to use Fremadis So I have two acorn cysts side by side Remember I told you acorn cysts can be caused by aprican metaplasia Papillary aprican metaplasia or by a fat fluid level Remember that a fat fluid level is not attached so it won't transmit Fremadis But aprican metaplasia is attached so it will So when I look at the Fremadis I can see that this Supposedly thickened wall is not transmitting Fremadis Proving it's not attached proving that it's a fat a lipid layer On the other hand the one on the right is clearly transmitting Fremadis Showing clearly that this is attached I mean this is not just a fat a lipid layer It could be papillary aprican metaplasia, it could be papilloma, it could be carcinoma But what this is showing me clearly In just a few seconds without waiting five minutes Is that one of these is a complicated cyst that's Byred's 2 And one of these is a complex cyst that's Byred's 3, 4, or 5 Depending on our other evaluations that we do Now this shows shear wave again shear waves will not transmit Through fluid no matter how viscous so if we get black in the center We know that it's a complicated cyst not solid With a slight caveat you can get liquefact over hemorrhagic necrosis in say a grade 3 Triple negative cancer and you might get black in the center of the cyst there So the other caveat I would give you is that Sheer wave doesn't seem to work need neither shear wave nor strain Elastography seems to work very well with cysts smaller than a centimeter And in many cases our dilemmas that we're trying to solve this problem Smaller than one centimeter cyst so there are some limitations to to shear wave Now milk of calcium Is a complicated cyst it's just debris within the cyst But they're just a Samoma descalcations Individually these are too small to resolve with ultrasound So what we see is a cluster of dozens of tiny Samoma descalculi And we can make them shift into it, you know, just like we do on mammography This is actually the ultrasound version of a teacup So here we see a teacup on a beautiful Tabar 3d slide Here we're showing this cluster of Samoma descalculation shifting from the posterior wall While the patient's supine to the inferior wall when she's upright in the longitudinal view Now there's another cause of calcifications of an eye and cyst Called calcium oxalate crystals or wedelates And they're larger they're kind of like tiny gallstones And again we can make those shift So here I'm scanning transversely with the patient's supine I see a couple of calculi on the posterior wall of the cyst And now I've turned around her left side and even in the transverse view They've fallen over to the left side in the left lateral to cubitis position And we can actually show that in real time So here I'm just showing these calcium oxalate crystals Falling down the back wall as I rotate the patient from her back to her left side While I'm scanning transversely Now we can get clusters of Punctater amorphous calcations In microsists where we can't see classical teacups And they're suspicious mammographically But in ultrasound we can actually show clustered microsists with Dependent calcations in the posterior wall of each of the microsists And sometimes the best way to show that is a video suite So mammography can show more numerous and smaller calcifications than can ultrasound But ultrasound can sometimes be more definitively benign Cists that occur in the skin are sebaceous cysts or epidermal inclusion cysts They can lie entirely within the skin They can lie mostly subcutaneous but we can see a cloth skin wrapping around them Or they can be entirely subcutaneous but we can see the Gland neck along the hair follicle Sometimes with a whitehead or a blackhead obstructing it Notice that in all of these I've got a little gel standoff This is an ultimate near field problem Even with a matrix array probe it can be difficult To clearly demonstrate whether these are subcutaneous or of skin origin And especially the case where it's mostly subcutaneous And you need to see the gland neck to know that it's a sebaceous cyst It can be helpful to use gel standoff Notice that I've got a thicker gel standoff on the left and the right Because these hair follicles course obliquely through the skin So I need to create an angle nearly 90 degrees as close to 90 degrees To this as possible and that usually requires some healing and towing of the probe with a gel standoff But these are definitively benign Now I mentioned that about 3% of the time we can't tell whether something is cystic or solid In general fibroednomes are going to be slightly marcogenic oval shaped and parallel And complicated cysts with ecogenic fluid are going to be rounder more hypocholic and have enhanced through transmission But you know in any individual case it can be impossible to tell whether something's a complicated cyst Or a solid nodule So there's several approaches we can try to clear the artifact with harmonics and spatial compounding I showed you that earlier We can look for internal blood vessels because there's internal blood vessels. It's either an insisted papillary lesion or solid mass We can just say hey, what's the worst it could be solid and if we characterize it It'll be by reds three, but then we're obligated to do six month follow-up We can do a lastography To try to distinguish ecogenic fluid from solid We can attempt to aspirate it Or we can do outside get a directional that can assist the biopsy A lot of people go to attempted aspiration first thing off I don't like that because if I can't aspirate it completely then it obligates me to do an outside get a vacuum assist biopsy I prefer to use One of the other approaches Here I've turned on color Doppler. Could this have been assist? Yeah But all this internal vascularity means it's either solid mass or an insisted papillary lesion Um here. I'm using shear wave. This is transmitting shear waves. It's turning blue. This indicates this is solid In this case, there's no transmission of shear waves proving that it's assist now If you strain the lastography depending on which machine there are different ways to tell on the g e machine here I've got a trilameter blue red green layer showing that this is fluid contained And here on a phillips or senons I'm getting this bullseye appearance where i'm getting white in the center of assist That tells me that this is just assist and not solid So you have to know what type of elastography you have and which machine you have And you have to sort of figure out how that works on your particular machine There's not one set of rules that goes for every every elastography machine Now if we assume That an intermittent cystic versus solid lesion is solid It's usually round or oval Has a thin capsule and it has two transmissions so we can usually call it by reds three or two depending on whether a multiple incidental or a single dominant palpable or mammographic if it's a single dominant palpable mammographic we may call it by reds three If it's multiple bilateral incidental like during a screening outside we probably call it pirates two Now if we try to aspirate these indeterminate cystic versus solid lesions There are three possibilities and I haven't found any way to predict from the gray-skilled cell alone Which of these it's going to be it might be completely non aspiratable It might be partially aspiratable or it might be completely aspiratable Here's an indeterminate lesion Is this a complicated cyst or is it a solid nodule? I don't know. Is it a fibrinoma? Maybe Is it a papilloma completely filling assist? Maybe Is it assist completely filled with papillary epica metaplasia? Maybe Is it assist filled with proteolysis debris? Maybe Is it assist filled with lipids? Maybe Or could it even be a mixture of papillary epica metaplasia and assist filled with lipids? So this could be six different things This is just proteolysis debris. This is just fatty debris and this is completely filled with epica metaplasia So here's one that looks for all the world Like a classical fibrinoma. I put a needle in I attempt to aspirate it. It aspirates completely Now here's one that's rounder and more hypo-coic. It looks like a cyst I put a large needle in this is an 18 gauge normally I would use a 20 You can see that the tip of the needle is exactly halfway between the front wall of the cyst and the back wall I can't get anything to aspirate even with a 30 cc syringe Now, you know, that could be a solid mass. It could be a papilloma. It could be a fibrinoma It could be a triple negative cancer Or could just be papillary epica metaplasia completely filling assist One thing I can do is try to rotate the tip of the needle up and down within the cyst Because if it's a solid mass A papilloma carcinoma, I'm not going to be able to move the tip of that needle It's going to stay exactly halfway between the front and back wall So I did that I'm rotating posteriorly as hard as I can so hard that I'm indenting the pectoralis muscle But the tip of that needle is exactly halfway between the front and the back wall. This is a solid mass There's no way that this is papillary epica metaplasia Now in this case I couldn't aspirate the cyst. I've rotated the tip of the needle Anteriorly to the front wall of the cyst shown by the anterior pink arrow But now I've been able to move the tip all the way to the back So even though I can't aspirate this because it's aprican metaplasia aprican metaplasia. Remember, it's just two cells wide It's not solid. It's just little grass aisle topillary Exgressances that I can easily be torn By the needle as I rock it to front to back. So this shows that this is just aprican metaplasia Now when you aspirate these cysts with viscous fluid, I use a vacutainer system many times And I'll just change the size of the needle if I think it's very viscous I'll use a 30 cc syringe But many times the fluid's too viscous to actually show up in the glass part of the tube You have to actually look up in the cork and you'll see some green mucusy looking stuff Or white foamy looking Stuff and if you smear that You'll need to get a cellular debris or peplary to become metaplasia So basically you can turn a failed aspiration into an fna. Do I like fna in the breast? No But am I satisfied to use fna in a failed aspiration to prove that it's just aprican metaplasia? Yeah, I am So it's kind of a fallback position for me Now if all that fails we have to go to old sun vacuum biopsy and that's why Aspiration is my least favorite method. I try to use one of the other methods first And remember if we can't classify it as bioreads 2 or 3 then we have to classify it by at least bioreads 4a and we have to biopsy it Well, this is why it's important To really distinguish non-simple cysts and to have some method of evaluating This is a single field of view in a patient In whom every field of view in both breasts look this way We have four different types of non-simple cysts. We have a debris level We have Indeterminate cystic versus solid and number four. We have a fat level in number three And we have acorn cysts non mobile aprican metaplasia in cyst 2 So this is one of the reasons we have to be willing to use Multiple multiplicity to downgrade as many of these non-simple cysts to bioreads 2 as possible basically If we're doing a whole breast exam whether it's diagnostic or screening And we see multiple incidental non palpable non mammography visible lesions On mammograms we downgrade that to bioreads 2 using the rule of multiplicity We need to be able to do the same thing with ultrasound in order to Not plug up our entire breast system with a lot of benign breasts that don't really need further work up So in summary We see a larger percentage of non-simple system We used to because of better resolution and scan parameters being exceeded And the valuation is complicated and that is meant to be a play on word The reference standard was really not clear until directional vacuum assisted biopsy could remove only the part that was suspicious We did not create a new algorithm. We simply apply the same algorithm I used to mammography and solid breast nodules We use bioreads categories if it's bioreads 4 we need astrology and that means dvab If it's inflamed we need aspiration and culture but not cytology We need also our guidance to avoid getting bloody fluid And we have to downgrade As many bioreads 3s to bioreads 2 for the rule of multiplicity as is possible. Thank you