Radiology

Ultrasound Guided Cyst Aspiration

By: Keon Mahmoudi, MD and Daniel Bradley, MD

In cases in which a breast ultrasound reveals a cystic structure, cyst aspiration may be indicated.  The following guide is meant to serve as a general overview of ultrasound-guided cyst aspiration in the breast. Ultrasound-guided breast biopsy is discussed separately.  Depending on institutional preferences and equipment used, there may be slight variations in the steps for the procedure.

Step 1: Pre-Procedure

  • Determine the best approach to target the lesion, typically via the shortest skin-to-target route. 
  • Discuss the risks, benefits, and alternatives to the procedure with the patient.
  • Obtain written and verbal consent from the patient.
  • Technologist brings the patient to the procedure room.

Step 2: Pre-Procedure Imaging

  • Technologist confirms the lesion is still visualized and saves a pre-procedure image (Figure 1). 

    Procedure: US Guided Cyst Aspiration Figure 1
    Figure 1. Grayscale sonogram shows two adjacent well-circumscribed, anechoic cysts at 12:00, 3 cm from the nipple.
  • Radiologist performs time out and confirms patient identity, procedure, and side.
  • Radiologist and technologist optimize prone/oblique patient positioning using wedges/folded blankets as needed. 

Step 3: Procedure Preparation

  • Prepare the biopsy site in the usual sterile fashion.
  • Radiologist achieves local anesthesia along the expected course of the aspiration needle using a combination of lidocaine (superficial tissues) and lidocaine with epinephrine (deep tissues).

Step 4: Breast Aspiration

  • Under sonographic guidance, radiologist manually advances the aspiration needle to the target and confirms placement of the needle tip within the cystic structure. 
  • Technologist saves an image documenting placement of the needle tip (Figure 2).
Procedure: US Guided Cyst Aspiration Figure 2
Figure 2. Grayscale sonogram shows the aspiration needle tip (black arrow) within the more posterior cystic structure.
  • Radiologist aspirates the cyst under direct sonographic guidance to document it decreases in size. If there is no aspirate, the radiologist may decide to biopsy the finding instead; please refer to the separate guide for ultrasound-guided breast biopsy.
  • Technologist saves a final image to document that the cyst has decreased in size and/or completely collapsed (Figure 3). 
Procedure: US Guided Cyst Aspiration Figure 3
Figure 3. Post-aspiration grayscale sonogram shows complete collapse of the more posterior cystic structure, indicating that the internal contents have been successfully aspirated.
  • Radiologist removes aspiration needle and achieves hemostasis with manual compression. Sterile dressing is applied. 

Step 5: Post-Aspiration

  • Patient is provided with verbal and written after care instructions and sent home.
  • Radiologist evaluates the aspirate. If the aspirate is bloody (unrelated to trauma from the procedure itself) it is packaged appropriately and sent for histological analysis. Otherwise, the aspirate can be disposed of according to institutional preferences. 

References:

  1. Hogg JP, Harris KM, Skolnick ML. "The Role of Ultrasound-guided Needle Aspiration of Breast Masses." Ultrasound Med Biol. 1988;14 Suppl 1:13-21. DOI: 10.1016/0301-5629(88)90042-7. PMID: 3055586.