TO THE EDITOR: I have intercourse ...

TO THE EDITOR: I have intercourse withed the article "Breast Cyst Aspiration," (1) in the November 15 2003 issue of American Family Physician. As a diagnostic radiologist, I've aspirated thousands of breast sacs and would like to propound a few suggestions regarding the management of cysts

I think the aspiration technique is equable simpler than the authors (1) indicate. according to cleansing the skin that will be punctur on the needle with two or three alcohol wipes, povidone-iodine swabs or sterile drapes are not necessary.

There is fairly profitable evidence (2-4) that injecting an equivalent bulk of air into the pouch after aspirating the fluid stops or markedly reduces the propensity for pouch fluid reaccumulation. Desiccation of the fluid-secreting small rooms that line the cyst interior has been propos as the mechanism. The air injection is accomplished by means of unscrewing the syringe from the needle with the needle in situ, evacuating the aspirated cyst's fluid from the syringe into a container or ordeal tube, drawing an equivalent whirl of air back into the syringe, reattaching the syringe, and injecting the air. This takes 20 inferiors and may prevent cyst return Patients will have a easily moulded mushy mass where the pouch had been, and the air resorbs during the ensuing days. Before ultrasonography was generally available in breast-imaging facilities, we would perform "pneumocystogram" mammography after injecting the air to omit the possibility of intracystic mass.

In my experience, thick gelatinous sac fluid is simply "old" fluid with high protein make easy Intracystic neoplasms are papillary cancers or papillomas, and do not have this prototype of intracystic fluid; it is generally modern or old blood resulting from spontaneous hemorrhage or local needle trauma to the friable papillary frond that appears during the aspiration procedure. I've watched numerous colloid-filled sacs completely disappear with aspiration beneath real-time ultrasound observation. It is okay to simply discard viscous fluid from sacs if it is not sanguinary Even in the case of documented intracystic papillary cancer, the sensitivity of cytologic diagnosis from the sac fluid is quite poor. In general, sac fluid cytology is seldom helpful, and may smooth force unnecessary surgical biopsies in cases where the cytology indicates "atypia."

If no fluid is obtained during the first stick, I would press physicians to stop and maintain firm influence to minimize bruising, because hematomas can complicate breast imaging by way of obscuring true masses.

Lastly, the authors (1) note that surgical referral is attract favor toed for refilling of cysts or residual mass after aspiration. Actually, breast imaging is the chiefly logical next step. A work-up would include a diagnostic mammogram following placement of a metallic marker athwart the palpable finding, and an ultrasound examination of the region using current-generation equipment. alone after a thorough imaging evaluation should the ne for tissue sampling be addressed. The radiologist usually should decide whether or not tissue diagnosis is lacked If tissue sampling is stand in want ofed it could be done with core needle biopsy at the time of the diagnostic mammogram, and all data necessary for management would be obtained during individual visit to the radiology department.

REFERENCES

(1) Lucas JH Cone DL Breast pouch aspiration. Am Fam Physician 2003;68:1983-6

(2) Ikeda DM Helvie MA, Adler DD Schwindt LA, Chang AE, Rebner M The character of fine-needle aspiration and pneumocystography in the treatment of impalpable breast pouchs AJR Am J Roentgenol 1992;158:1239-41

(3) Tabar L Pentek Z Dean PB The diagnostic and therapeutic value of breast pouch puncture and pneumocystography. Radiology 1981;141:659-63

(4) Dyreborg U Blichert-Toft M Boegh L Kiaer H Needle small hole followed by pneumocystography of palpable breast pouchs A controlled clinical trial. Acta Radiol Diagn (Stockh) 1985;26:277-81

EDITOR'S NOTE: This verbal expression was sent to the authors of "Breast pouch Aspiration," who declined to reply

DAVID R PENNE MD

Betty Ford Diagnostic Breast Center

1840 Wealthy SE

Grand Rapids, MI 49506

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