I have an atypical cyst in my breast after my breast reduction surgery. Should I worry about it?

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iCliniq / Answers / Radiology / Breast Cyst / I have an atypical cyst in my breast after my breast reduction surgery. Should I worry about it?
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Q. Is it normal for an atypical cyst to form after breast reduction surgery?

Answered by
Dr. Vivek Chail
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Oct 28, 2022 and last reviewed on: Nov 22, 2022

Hello doctor,

I wanted an opinion about my ultrasound and mammogram. I had undergone breast reduction surgery approximately three years back. I had pain in my left breast that started with my period. My plastic surgeon also noticed a lot of scar tissue in this area. I went for an ultrasound and mammogram. The doctor told me she saw a mass that could possibly be a fibroadenoma and wants to do a biopsy. I had a second opinion from another radiologist who told me that he observes an atypical cyst and that there is nothing to worry about. I have attached my reports. I am very nervous and I need to have peace of mind.

Please help me.

#

Hello,

Welcome to icliniq.com.

I went through your query and understood your concern.

The images have been viewed by me (the attachments have been removed to protect the identity of the patient) and it looks like a BI-RADS 3 (breast imaging-reporting and data system) lesion and is probably benign. It might be an atypical cyst. Usually, in such cases, a six-month follow-up is suggested and chances of malignancy are less than two percent. A biopsy is usually not done unless clinically indicated.

I hope this has helped you.

Thanks and regards.

Hello doctor,

Thank you for replying.

Do you think the atypical cyst is fluid-filled or solid? Could it be a possible scar tissue or fat necrosis from my breast reduction? The primary doctor had taken these images and do not think that it is a cyst and wants to do a biopsy. I do not know what to do? Thank you.

#

Hello,

Welcome back to icliniq.com.

Areas of scar tissue and an atypical cyst are visible on the mammogram.

There is no need to worry as even if they do a biopsy, it is an official investigation and will clarify things.

I hope I helped you.

Thanks and regrads.

Thank you doctor for the reply,

Please answer the following questions:

  1. Do you think that the cyst is fluid-filled?
  2. Do you think it could be a fibroadenoma?
  3. Also, what do you mean by reactive lymph nodes? Are they enlarged?
#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

Yes, the atypical cyst might contain fluid. Fibroadenoma is less likely but cannot be completely ruled out. Coarse calcification is not worrisome. Fine calcification can be a concern. Calcification can occur after breast reduction surgery. Reactive lymph nodes mean enlargement of lymph nodes due to non-neoplastic causes. It is mildly enlarged.

Thank you doctor for the reply,

Please answer the following questions:

  1. What is your impression of the focal asymmetry on the mammogram?
  2. Is the focal asymmetry the same as the cyst seen on the ultrasound?
  3. Is there a sonographic correlation with the focal asymmetry on the mammogram?
  4. Is the focal asymmetry high-density?
  5. Does it mean anything if it is of high density?
#

Hi,

Welcome back to icliniq.com.

Thanks for writing back to us.

Focal breast asymmetry is a finding that is visualized in one projection but not in another and is due to the superimposition of normal breast tissue. It is not significant due to technical reasons and is an opacity. Focal breast asymmetry is not visualized in ultrasound scans.

Thank you doctor for the reply,

The doctor said there was a focal asymmetry on the mammogram and a cyst on the ultrasound. The doctor sent me an updated radiology report. The high-density focal asymmetry in the left outer breast is new and persistent on additional spot compression images.

  1. Is this true, and could you view the spot compression images?
  2. Was the asymmetry viewed in more than one projection on my mammogram?
  3. Is the area of asymmetry where the doctor marked “2” on the attached photos a high-density focal asymmetry? That’s the area I’m worried about the most.

Thank you.

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

The area marked two is visualized in compression images (attachments removed to protect the patient's identity). It overlaps with normal breast architecture in the other view. There is no need to worry even if there is high-density focal asymmetry as the grading is most important for a breast lesion after viewing ultrasound and mammogram. In your case, it is probably benign but needs a follow-up. A biopsy will confirm the nature of the lesion, and you can get it done if your doctor insists.

Thank you doctor for the reply,

Sorry for all of the questions. I am trying to convey them to my primary care doctor, who cannot view the images.

It overlaps with normal breast architecture. Are you saying that the focal asymmetry in normal breast architecture overlaps? Could it be a pseudo asymmetry? Do you think the focal asymmetry could be scar tissue from my breast reduction? When my plastic surgeon felt this area, she felt a lot of scar tissue on the outer left breast. Are you able to see scar tissue on ultrasound, and is it in the area on the ultrasound where the focal asymmetry would be?

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us. Your questions are always welcome. Mammogram interpretation is subjective at times, and that is probably the reason why you were provided with an addendum and revised report findings. In reply to your queries: Focal asymmetry itself is a pseudo lesion and not a true lesion and is due to the X-rays casting an abnormal shadow in a particular plane. Pseudo asymmetry is not a recognized term, to my knowledge. You are probably referring to focal asymmetry due to technical reasons. This is less likely in your images. The review of medical information confirms that focal asymmetry can be due to fibrocystic changes, dense stromal fibrosis, or pseudoangiomatous stromal hyperplasia. Scar tissue is fibrosis and causes focal asymmetry appearance in mammogram images. It is difficult to exactly pinpoint the focal asymmetry and scar tissue area in the ultrasound scan due to technical reasons.

Thank you doctor for the reply,

I am confused because you said focal asymmetry is not a true lesion. My question is if it is fibrosis, or could it be overlapping scar tissue? Also, for focal asymmetry, would you recommend a six-month follow-up?

Thank you.

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us. Please allow me to clarify your confusion by rephrasing my statement. Fibrocystic changes, dense stromal fibrosis, or pseudoangiomatous stromal hyperplasia are not concerning or malignant findings. Instead, these are an extension of the normal breast architecture. Therefore, I meant that any focal asymmetry is not a malignancy or cause of concern. The appearance in one plane is due to technical reasons, and it is an opacity that is not malignant and not significant. I hope the confusion due to the statements is cleared. Scar tissue formation in the breast causes fibrosis, and the scar tissue shows fibrotic changes; hence fibrotic changes are visualized in scar tissue areas.

Thank you doctor for the reply,

I did start massaging the area of the pain where the focal asymmetry is, and massaging it has slowly been helping ease some of the discomforts. I suppose massage helps scar tissue. I was unaware that scar tissue could cause pain two years after a breast reduction. When you say that “the appearance in one plane is due to technical reasons and it is an opacity,” are you referring to it appearing in only one particular plane on my actual images? Or do you mean this in a generalized way on all mammograms?

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

Scar tissue results from healing and can irritate surrounding nerves. The statement was a general one for focal asymmetry and not in particular for your images (attachments removed to protect the patient's identity).

Thank you doctor for the reply,

Please answer the following questions:

  1. Is focal asymmetry worrisome? This is where I get confused, and you said mine is not worrisome. What features does it have that allow you to know that? Please explain in medical terms, as I will also be consulting my primary care doctor.
  2. Was the focal asymmetry visualized on the previous mammogram? If not, would it make it a developing asymmetry?

Thank you.

# Hi,

Thanks for writing in to us.

In mammograms there are criteria for focal breast asymmetry and it is seen only on one projection, the borders are not convex, or the centre is not denser than the periphery. Follow up is the best recommendation.

The focal asymmetry was there previously but is prominent in the recent mammogram. This might be due to the scar tissue being more prominent with time.

Regards and thanks,

Thank you doctor for the reply,

I know you said that coarse is not worrisome, and my doctor labeled them benign and most likely a result of post-reduction.

She also said that they were amorphous and heterogenous, and when I read up on that online, everything I read said that that could be worrisome, and I started to worry. I know it goes on a case-by-case basis and also depends on other factors. Could you elaborate on my calcifications? What features make them most likely benign even if they are heterogenous and amorphous? Do post-surgical calcifications resulting from surgical trauma put you at a higher risk of malignancy, or is it totally unrelated?

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

Amorphous and coarse heterogeneous calcifications are suspicious or grouped as an intermediate concern. Typically benign calcifications are coarse or popcorn line, large rod-like, round or punctate, rim calcifications, and dystrophic. Fine calcifications are more of a concern for malignancy. Surgical calcifications do not put you at high risk for malignant outcomes. It is totally unrelated.

Thank you doctor for the reply,

I went to another doctor, and they only read the images and the mammogram, not the ultrasound. They want me to come in for another ultrasound and do their own. What they told me they saw on the mammogram was this:

  1. I was told that there is a 2.5 cm equal-density oval-shaped mass with irregular borders in the posterior upper outer quadrant of the left breast, located about 13 cm from the nipple. This is better seen on ML tomography image 23/71 and CC tomography spot image 19/63.
  2. I was also told that there is a 12 mm equal density asymmetry in the media aspect, located about 5 cm from the nipple. Did you see this or any ultrasound correlation?
  3. I was also told that there is a 2.5 cm focal asymmetry with associated amorphous calcifications in the lower outer quadrant of the left breast, located about 6 cm from the nipple. I am assuming this is what we discussed already, but I wanted to include it anyways.
  4. Please elaborate on those three images and re-check those areas on the mammogram, as I am really worried. I am especially worried about the first one.

Also, I have two more questions.

  1. I know you originally said coarse calcifications appear and are not worrisome, but I was told they are amorphous. What kind of calcifications do you see on the mammogram, and are those worrisome or common in post-reduction?
  2. How long does it take for a cyst to regress?
#

Hi,Welcome back to icliniq.com.

Thanks for writing to us. Many doctors prefer to do an ultrasound scan review with the mammogram. However, an ultrasound scan is an operator-dependent investigation; therefore, it is better to get an ultrasound scan from your doctor again, with mammogram images as a reference. Areas 1, 2, and 3 are visualized in the mammogram (attachment removed to protect the patient's identity), and you are right. In addition, we have discussed the left breast focal asymmetry. However, there are no immediate concerns for the above-listed areas, and follow-up is suggested. Usually, fine calcifications are something that needs urgent attention. This is because amorphous calcifications are there. However, amorphous calcification is of intermediate urgency in most cases, and follow-up is needed for confirmation. There is no definite time limit for a cyst to regress, and is a range between six months to five years in some cases. However, you must remember that cysts might persist for a long time.

Thank you doctor for the reply,

Please answer the following questions:

  1. Could you tell me what exactly areas 1 and 3 identify as on the mammogram?
  2. Are they visualized on the ultrasound?
#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

Areas 1 and 3 are probably non-malignant lesions in a mammogram (attachment removed to protect the patient's identity). The lesions are not easily identifiable on the ultrasound scan due to operator-dependent factors. The person doing the ultrasound should screen the exact areas where the opacities are found.

Thank you doctor for the reply,

Sorry, I meant areas marked one and two.

  1. Is the area marked two also identified as probably benign?
  2. Is it also not identified on the ultrasound?
  3. Are there calcifications on the right breast?
#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

From the attached images (attachments removed to protect the patient's identity), the same holds good for the area marked two. There is no significant calcification in the right breast.

Thank you doctor for the reply,

I had a follow-up ultrasound on those areas that I mentioned above. Please interpret the ultrasound. I consulted another radiologist who thinks they are fibroadenomas. Since then, I received the report from the doctor, and they want for biopsy of both breasts. Please give me your opinion and compare the previous images as well. I attached the mammogram report with the areas I mentioned in the previous question and the ultrasound targeting those areas on the mammogram. I am very scared. Do these look like fibroadenomas or post-reduction changes?

Thank you.

#

Hi,

Welcome back to icliniq.com.

Your images (attachments removed to protect the patient's identity) are reviewed, and the following are the possibilities.

Right breast: The lesion might be a fibroadenoma or an intra-mammary lymph node.

Left breast: The lesion might be an area of fat necrosis or fibroadenoma. Malignancy possibility is less but cannot be completely ruled out.

Follow-up is needed for both lesions.

Thank you doctor for the reply,

I am planning to do the biopsy, but in the meantime, I am still very worried.

  1. Could you compare these ultrasound images to the mammogram?
  2. Are you sure that the right breast does not look suspicious?
  3. Could it be scar tissue?
  4. If it is a fibroadenoma, does it look like a simple fibroadenoma?
  5. Does the area on the left breast that they want to do a biopsy correspond with the focal asymmetry or calcifications they saw on the mammogram? If not, do you see this area on the ultrasound?
  6. What percent sure are you that everything is benign?
  7. Could these areas be oil cysts?
#

Hi,

Welcome back to icliniq.com.

A biopsy is the best way to proceed. I feel that the lesion in the left breast is visualized at a 3 to 4 o clock position in the ultrasound scan (attachment removed to protect the patient's identity). It is not possible to be completely confident, but I certainly feel that there is a 90 percent chance that the lesion in the right breast is not malignant. It might be a fibroadenoma or breast lymph node.

It is possible that the focal asymmetry and biopsy area are the same. I write possible because ultrasound is operator-dependent, and we need to double-confirm the probe position with a mammogram. We cannot generalize all the lesions. In the right breast, it is more than a 90 percent possibility that the lesion is benign, and in the left breast, it is more than a 75 percent chance that the lesion is benign, and it is my personal opinion. I wish all the lesions are benign. It is less likely for the lesions and cysts to be oil cysts but cannot be completely ruled out.

Thank you doctor for the reply,

Is the one on the left breast wider than the other, and does it have circumscribed margins? Are there concerning features, and if so, what? Please be as detailed as possible. Is it a good sign that it was visualized the last year and did not change? In the outer left breast, I have a lot of scar tissue.

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

From the attached images (attachments removed to protect the patient's identity), the lesion in the left breast is wider than the other and shows fairly circumscribed margins. This makes it more likely benign. In breast ultrasound, the emphasis is to grade a lesion as benign, less likely malignant, probably malignant, and high-risk malignant and provide guidance. In your case, it does not look malignant, but there is a need to follow up closely and do a biopsy if the treating doctor desires it in some cases. It is good that there are no changes in the lesion in the follow-up ultrasound scan.

Thank you doctor for the reply,

Please answer the following questions:

  1. What shape are the ones in each breast? Are they oval?
  2. Do they have posterior shadowing?
  3. Does the right one have the same features as the left one, as you described above?
  4. The cyst on the left breast was not seen on the ultrasound, but I still feel pain in the area of the cyst. The pain went away during my cycle and returned later on. Is the cyst possibly still there even though it was not seen on the ultrasound?
#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

Only the cyst-like lesion visualized in the previous scan shows posterior acoustic shadowing. The rest of the lesions do not show shadowing. In addition, there is a difference between the lesions in the right and left breast. The one in the right breast is well-circumscribed and isoechoic. The lesion in the left breast is heterogeneously hyperechoic. Sometimes it is possible that the cyst got compressed and not well visualized.

Thank you doctor for the reply,

Why did the ultrasound report state that the one on the right breast is hypoechoic? Is it not that different from isoechoic? Why does it state the one on the left breast is of mixed echogenicity? Is no posterior shadowing good or bad? Is it possible that the masses represent fibrocystic changes? My primary doctor would like to know if they are both oval-shaped.

#

Hi,

Welcome back to icliniq.com.

Thanks for writing to us.

The hypoechoic lesion in the breast means it is darker than the surrounding breast tissue, and isoechoic means it is the same as the breast tissue. Mixed echoic means it has a light and dark grey areas. Posterior acoustic shadowing usually means a higher tendency of abnormal tissue that might be suspicious for malignancy. Your masses are different in a few areas. Differential diagnoses might be fibrocystic changes. The lesion in the right breast at 5 o clock is oval, and the lesion in the left breast at 4 o clock position is fusiform.

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