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The Male Breast: a Multi-Modality Pictorial Essay on the Spectrum Of The Male Breast: A Multi-modality Pictorial Essay on the Spectrum of Benign and Malignant Disease Reddy MB, Jordan SJ, Lee SS, Kuzmiak CM, Koomen MA, Langman EL UNC Department of Radiology, Chapel Hill, NC Prevalence of Male Breast Cancer Benign Findings in the Male Breast More Benign Findings in the Male Breast Malignancy in the Male Breast - Approximately 0.7% of all breast cancers occur in men8 Most breast conditions in men are benign conditions. Many of these conditions have • - The lifetime risk for breast cancer is 1 in 1,000 for men—100 times less common characteristic imaging findings that allow differentiation form malignancy. Case 2 Case 4 than in women3 - The incidence of male breast cancer has increased 26% in the past 30 years3 Characteristics of benign lesions: 35-year-old male with palpable mass on physical exam. Figure A: Faint, lucent 23-year-old male presents with a palpable lump. - Subareolar lesions that are central to the nipple mass on mammography, History of neuroblastoma at age 3 years, treated at In 2016: - Fat containing lesions deep to the palpable that time with full body radiation. - An estimated 2,600 new cases of invasive breast cancer will be diagnosed in male B marker. Final Diagnosis: Papillary carcinoma and DCIS, patients Figure B:: Mixed presumed radiation-induced malignancy - 440 men will die of breast cancer Gynecomastia echogenic oval mass consistent with a fat- - Papillary carcinoma is the second most common Gynecomastia is the most common abnormality of containing lesion. subtype of breast cancer in men, and the only type of the male breast, caused by benign proliferation of ductal breast cancer that is more common in men than in Development & Anatomy of the Male Breast & stromal tissue elements. May be unilateral or bilateral. DDX: Lipoma, women. - Age distribution: Infancy, puberty, senescence fibroadenoma - Often presents as a complex cyst. Final diagnosis: A cyst in a male should be viewed with suspicion and should prompt biopsy. The totipotential mammary glands of males and females are identical at birth and are A Fibroadenoma composed of mammary lobes that drain via lactiferous ducts into the nipple. Three Types of Gynecomastia: 1. Nodular: Acute, florid phase: Painful breast Case 5 enlargement for < 1 year. Fan-shaped or spherical More Examples of Benign Disease sub-areolar density that blends into surrounding 55-year-old male with history of left subcutaneous fat, resulting in indistinct borders Figure A: 77-year-old neck swelling for several months, with (figure A). Reversible. A B male with Alzheimer palpable masses in the left axilla and 2. Dendritic: Chronic, quiescent, fibrotic phase. Disease who presents breast . “Flame-shaped” sub-areolar density radiating from the with a left breast mass nipple into the deeper adipose tissue (figure B). of unknown etiology. Ddx: Lymphoma, metastatic disease Usually irreversible due to fibrosis. Final diagnosis – Final Diagnosis: B-cell Non-Hodgkin 3. Diffuse glandular: Usually seen in patients receiving high dose estrogen therapy. Hematoma. Lymphoma -accounts for the majority Mammographic appearance similar to heterogeneously dense female breasts (figure of breast lymphoma cases Normal adult male breasts are composed of skin, subcutaneous fat, atrophic ducts, C). Figure B: Epidermal and stromal elements. Conditions related to ductal and stromal proliferation, such as inclusion Cyst IDC, DCIS, and papillary neoplasm can occur in men. Pseudo-gynecomastia: Fatty breast enlargement – no glandular or stromal tissue Examples of Metastatic Disease (figure D) Teaching Point: Men typically do NOT get breast conditions related to lobular While gynecomastia is a benign entity, patients should be counseled to follow up with Malignancy in the Male Breast proliferation - fibroadenoma, cysts/ fibrocystic change, Phyllodes tumor, ILC, and their provider to ensure that there is no underlying cause needing clinical attention. LCIS Risk factors for male breast cancer: Advanced age, family history of breast cancer A B C D in a first degree male or female relative, BRCA2 > BRCA1, history of prior chest radiation, cryptorchidism, testicular injury, chronic exposure to estrogen or Imaging Algorithm for Male Breast Masses A conditions causing hyper-estrogenism (cirrhosis, obesity, Klinefelter Syndrome) B Figure A: Multiple Myeloma Figure B: Metastatic Melanoma There is no standardized Mean age at diagnosis is 67 (5-10 years later than the mean average in women) imaging algorithm for male Most common metastases to the breast: melanoma, non-Hodgkin lymphoma, lung breast masses. Clinical symptoms: Painless, palpable mass. May also have nipple ulceration or carcinoma, sarcoma, and carcinomas of the stomach, kidneys, prostate gland retraction, bloody nipple discharge, skin thickening, or axillary lymphadenopathy. The incidence of breast cancer is too low in male patients to Suspicious imaging findings: Unilateral, sub-areolar mass which is eccentric to Prognosis & Survival of Male Breast Cancer justify screening mammography. the nipple. Therefore all imaging in males Poor prognostic factors: Larger size of the lesion, lymphadenopathy, age >65 years is diagnostic. Case 3 Case 1 Men present at a more advanced stage due to delay in presentation/diagnosis Mammography allows • - 50% present with palpable axillary lymphadenopathy differentiation between benign 73-year-old male who presented with palpable right breast mass. - May be secondary to women being detected with screening mammography or and malignant breast disease in 21-year-old male who presented with 1 week history of a palpable left breast mass lack of public awareness about male breast cancer male patients with a high that was tender to palpation. sensitivity (92%) and specificity Staging, treatment, and survival are similar to that of women with breast cancer. (90%). If the mammogram is diagnostic References for a benign process, such as gynecomastia, no further work- up is necessary. DDx: Breast cancer until proven otherwise Teaching Point: Risk factors for Final Diagnosis: Invasive ductal carcinoma with ductal carcinoma in situ cancer will also affect the contralateral breast – Bilateral - IDC NOS is the most common subtype of male breast cancer, and makes up 85% diagnostic mammograms should Ddx: Lymph node, lipoma, fibroadenoma of breast cancers in men always be obtained. Final Diagnosis: Reactive intramammary lymph node - More likely to be ER or PR positive than in a female patient - Calcifications are less frequent and more coarse than in female breasts .
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