When the diagnosis of fibrocystic change is established by ultrasonography or is practically certain because the history is classic, aspiration of a discrete mass, suggestive of a cyst, is indicated if the patient is symptomatic, the cyst obscures visualization of breast tissue on mammography and prevents adequate imaging, or if the ultrasonographic criteria are not met. In one study of a screened population, 1% of individuals developed a new cyst that resolved in more than 50% of cases (90). Aspiration may be performed with ultrasonographic guidance, but image guidance is usually not necessary if the cyst is palpable (91). FNA of a cyst is a minimally invasive procedure performed with a 21-or 22-gauge needle without local anesthesia and is not associated with significant risks or complications. There is minimal pain and little risk for infection or bleeding. Benign cyst ﬂuid is straw colored to dark green to brownish and does not need to be submitted for cytologic evaluation (6). Injection of air into the cyst cavity is reported to reduce the likelihood of cyst recurrence but generally is not performed. The patient should be reexamined at a short interval thereafter for cyst recurrence. Cysts will reoccur in 30% of patients, cause anxiety, and require repeated evaluations (84). Tissue biopsy should be performed in the presence of the following findings:
No cyst ﬂuid is obtained.
The ﬂuid is bloody.
The ﬂuid is thick.
The cyst is complex.
There is an intracystic mass.
A mass persists after aspiration.
A persistent mass is noted at any time during follow-up.
If a needle biopsy is performed and results are negative for malignancy, a suspicious mass that does not resolve over several months should be excised. Surgery should be conservative, because the primary objective is to exclude cancer. Simple mastectomy or extensive removal of breast tissue is not indicated for fibrocystic disease. Most patients do not require treatment for fibrocystic changes, just reassurance that fibrocystic change is a transient phenomenon of aging that is associated with hormonal effects on the breast glandular tissue that eventually subsides.