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Imaging of the Male Breast: Beyond the Basics
Acknowledgements: Meaghan Magarik, MD PhD
Lucy B. Spalluto, MD
Assistant Professor of Radiology and Radiological Sciences
Director, Women in Radiology
Associate Director, Diversity, Equity and Inclusion
Department of Radiology and Radiological Sciences
Vanderbilt University Medical Center
Tennessee Radiological Society MeetingFebruary 25, 2018
CONFLICTS OF INTEREST:
NONE
Objectives
• Review the indications for male breast imaging
• Review normal imaging appearance of the male breast
• Illustrate common and uncommon findings in the male breast
• Briefly discuss the management of male breast pathology
Indications for Imaging
• Symptoms of gynecomastia• Palpable breast mass• Breast tenderness• Axillary adenopathy• Nipple discharge
Imaging Modalities
1st line study:
Mammography
• Useful in distinguishing benign disease from malignant, NPV 99%
• Avoid other unnecessary imaging
• Eliminate need for biopsy in benign conditions
• Identify cancer
Imaging Modalities
2nd line studies:
Ultrasound• Indications:
• Finding is outside mammographic field of view• Mammography suggests etiology other than gynecomastia
• More variable results than mammography• Lower specificity in distinguishing benign vs malignant
etiologies when compared with mammography• Gynecomastia often appears mass-like on ultrasound and can
lead to unnecessary procedures
MRI• Very few studies on the use of MRI in evaluation of the male breast
Normal Male Breast
Male Breast Development
• Mammary glands of males and females are identical at birth
Male Breast Development
• At puberty, no further development of male breast
• Testosterone causes involution and atrophy of ducts
• Transient increase in estradiol at puberty results in formation of subareolar ducts and stroma in some males resulting in gynecomastia (40-70%)
Normal male breast composition:• Mostly: skin and subcutaneous fat
• Atrophic ducts and stromal elements
• No lobules
• Neurovascular structures
• Lymphatics
• Absence of Cooper
ligaments
Male Breast Pathology
Common Findings
Benign
Gynecomastia
Abscess
Lipoma
Trauma/Post Op
Sebaceous Cyst
Malignant
Infiltrating Ductal
Carcinoma
Uncommon Findings
Benign
Angiolipoma
Myofibroblastoma
IntraductalPapilloma
Transgender Breast
Malignant
Infiltrating Lobular
Carcinoma
Metastatic Disease
DCIS
Breast Cancer Recurrence
BI-RADS 2 – Benign Findings
Male patient presents with palpable mass…
BI-RADS 2 – Benign Findings
Male patient presents with left palpable mass…
Gynecomastia
• Most common male breast disease• Caused by benign proliferation
of glandular tissues• No causal association between
gynecomastia and breast cancer
• Clinical presentation:• Unilateral or bilateral breast
pain• Most common in puberty and
senescence• Soft, rubbery, firm, mobile
mass directly under the nipple
Gynecomastia
Work-Up• Physical Exam• Diagnostic bilateral mammogram
• Central, flame-shaped retroareolarglandular tissue
• DDx: • Pseudogynecomastia• Breast carcinoma• Lipoma• Myofibroblastoma• Diabetic mastopathy• Abscess
Mammographic Patterns of Gynecomastia
• Nodular• Non-neoplastic ductal and stromal
proliferation (<1 yr of gynecomastia)• “Fan-shaped” sub areolar density, blends
into subcutaneous fat
• Dendritic (subareolar flame-shaped)• Fibrotic phase with stromal fibrosis and
dilated ducts• “Flame-shaped” sub areolar density
radiates from nipple
• Diffuse glandular• Seen in patients receiving high-dose
estrogen therapy• Heterogeneously dense breasts that
resemble female breasts
Gynecomastia
Ultrasound can appear as a hypoechoic, spiculated mass on ultrasound
• Spironolactone
• Steroids
• Marijuana
• Alcohol
• TCA Antidepressants
• Diazepam
• Exogenous estrogen
Drug-Related
• Adrenal cortical neoplasm
• Pituitary Adenoma
• Hepatocellular CarcinomaNeoplastic
• Cirrhosis
• Chronic renal failureSystemic Disease
• Physiologic
• ObesityHormonal
Causes of Gynecomastia
43 year old male presents with a painful, palpable right breast mass
BI-RADS 4
Aspiration yielded purulent material. Symptoms resolved
with antibiotic therapy.
43 year old male presents with a painful, palpable mass
BI-RADS 4
Abscess
• Localized infection, commonly subareolar in location
• Findings: pain, swelling, nipple discharge, erythema
• Most common organisms: • Staph Aureus• Staph Epidermidis
• Mammographics Findings:• Ill-defined subareolar mass• Trabecular thickening
• Ultrasound Findings:• Incompletely circumscribed mass • Contains complex fluid• Doppler may show increased
peripheral vascularity
• Treatment:• Antibiotitcs• Percutaneous ultrasound-guided
drainage• If recurrent, may require surgical
excision of abscess and regional lactiferous ducts to prevent recurrence
Abscess
Breast mass seen on CT
A 50yo male presents with chest pain …
Breast mass seen on CT
BI-RADS 3
Breast mass seen on CT
HEMATOMA … The patient had an INR of 10.2
Follow-up left breast ultrasound one month later shows interval decrease in the size of the hematoma (red arrows).
Follow-Up Ultrasound 1 month later
Hematoma
• Benign process
• Localized collection of extravasatedblood
• Related to trauma or breast surgery
• Always ask about trauma/anti-coagulation history
• May appear as atypical mass-like lesions
• Mammographic findings:• May simulate breast cancer• Appearance is variable• Round, oval mass• May have architectural distortion• Dystrophic calcifications
• Ultrasound Findings:• Circumscribed mass• Possible internal fluid-debris level
and internal septae
• DDx:• Seroma• Contusion• Hamartoma• Fat necrosis• Intracystic carcinoma
Hematoma
Male presents with palpable mass right breast
A 72yo male presents with a painless, mobile palpable breast mass …
BI-RADS 2
Male presents with palpable mass right breast
Lipoma
• Benign tumor composed of mature fat cells
• Presents as: • soft • non-tender • mobile mass
• Treatment:• None• Do not require excision
• Mammography:• Well-encapsulated• Radiolucent, fat-density lesion
• Ultrasound Findings:• Hyperechoic, avascular• Oval Mass• Parallel orientation
• Other Fatty Breast Lesions:• Fat necrosis• Gynecomastia• Hamartoma• Intramammary lymph node
Lipoma
Male present with palpable left breast mass
A 45 yo male presents with a palpable mass …
BI-RADS 2
Male present with palpable left breast mass
Sebaceous Cyst6 months later, after spontaneous drainage of purulent material …
BI-RADS 2
Sebaceous Cyst
• Benign intradermal lesion lined by epithelial tissue
• Caused by obstruction of a sebaceous gland
• Similar to an epidermal inclusion cyst which has epidermal lining
• Treatment:• Considered a DO NOT BIOPSY
LESION• Biopsy may cause inflammatory
response • Could lead to abscess formation
if the cyst ruptures
• Mammographic Findings:• Well-circumscribed, rounded• Soft tissue density• Skin or subcutaneous soft tissue
• Ultrasound Findings:• Well-circumscribed, round or
oval, avascular hypoechoic mass• Increased through transmission• Skin or subcutaneous tissues • Possible track extending to skin
surface
• DDx:• Epidermal inclusion cyst
Sebaceous Cyst
35yo male taking estrogen hormone replacement…
BI-RADS 1
Estrogen Therapy
Imaging the Transgender Breast• Imaging Findings:
• Increase in lobular-containing breast tissue similar to natal women if taking estrogen• May develop cysts, fibroadenomas
• Spectrum of breast density• Breast density should not be referred to as gynecomastia• Proper terms include: heterogeneously dense, very dense
• May have breast implants• Implant rupture
• Screening Recommendations:• No consensus guidelines yet …• Transgender women >50 with past or current hormone use should receive annual
mammography if additional risk factors:• if estrogen and progestin use for > 5 years• body mass index > 35• family history
• Not currently recommended for transgender women not taking hormones
Estrogen Hormone Therapy
A 35yo male presents with a palpable mass …
BI-RADS 2
Male presents with right breast mass
A 35yo male presents with a palpable mass …
Male presents with right breast mass
Male presents with left breast mass
BI-RADS 4 – Biopsy was performed.
Male presents with right breast mass
• Benign hamartomatousneoplasm
• 5-17% of benign fatty tumors in the body• Very rare to see in breast
tissue
• Treatment:• Managed with follow-up
imaging• Simple excision
• Mammographic Findings:• Mixture of fat and soft-
tissue density
• Ultrasound Findings:• Well-circumscribed,
homogenous, echogenic mass
• DDx:• Hamartoma• Complicated cyst• Angiosarcoma• Atypical vascular lesion
Angiolipoma
A 66yo male presents with a palpable mass …
Male presents with palpable right breast mass.
A 66yo male presents with a palpable mass …
BI-RADS 4 – Biopsy was performed.
Male presents with palpable right breast mass.
• Rare, benign stromal tumor• Only breast lesion more
common in men than women
• Men ages 60-70• Slow-growing, unilateral,
painless, mobile mass
• Treatment:• Core biopsy• Surgical resection• Clinical surveillance
• Mammographic Findings:• Well-circumscribed• Round or oval mass
• Ultrasound Findings:• Solid, well-circumscribed• Homogenous echotexture• Hypoechoic mass
Myofibroblastoma
Male presents with left nipple discharge
Male presents with left nipple discharge
BI-RADS 4 – Biopsy was performed.
• Benign, intraductal neoplasm
• Most present in subareolarregion
• Most arise 1cm from nipple
• Increases risk of malignancy
• Symptoms:• Bloody or clear nipple
discharge
• Treatment:• Surgical excision to exclude
neoplasia or atypia
• Mammographics Findings:• Can be normal if the papilloma is
small• May see dilated ducts• Circumscribed, benign-appearing
mass• Clustered calcifications
• Ultrasound• More sensitive for detection• Well-defined solid nodule or
intra-ductal mass• Filling defect or mass outlined by
fluid• Vascular stalk
Intraductal Papilloma
Abnormal PET CT
A 68yo male with mesothelioma has a palpable mass on physical exam …
Abnormal PET CT
A 68yo male with mesothelioma has a palpable mass on physical exam …
BI-RADS 4 – Biopsy was performed
Abnormal PET CT
Malignant Mesothelioma
68 y/o male presents with right breast mass.
BI-RADS 5 – Biopsy was performed.
68 y/o male presents with right breast mass.
Invasive Mammary Carcinoma
57 y/o male presents with right breast mass.
57 y/o male presents with right breast mass.
BI-RADS 4 – Biopsy was performed
Invasive Mammary Carcinoma
Invasive Mammary Carcinoma
Gynecomastia
A 66yo male presents with a right palpable mass…
BI-RADS 4 –
66 year old male presents with palpable right breast mass.
Right mastectomy – Invasive mammary carcinoma
A 66yo male presents with a right palpable mass…
BI-RADS 4 –
9 years later same patient palpates a right axillary lymph node.
A 66yo male presents with a right palpable mass…
Intermediate Grade DCISMetastatic Recurrence in Right Axillary Lymph Node
BI-RADS 4 –
MalMale Breast Cancere Breast Cancer
• 0.7% of all breast cancers
• 0.17% of all cancers in men• Typically older men (median age =
63)
• 1:100,000 in US
• Most present at later stage due to delayed diagnosis
• Types: • Infiltrating ductal carcinoma NOS
is most common (80% of cases)• DCIS most common subtype (5% of
cases)
• Invasive papillary is most rare• Lobular carcinoma very rare (1.5%
in men vs 12% women) as lobule formation is rare in men, even those with gynecomastia
• Risk factors:• Hyperestrogenism• Testicular abnormalities• Radiation therapy to the chest• Family history• BRCA 1 or BRCA 2 mutation
• Symptoms:• Painless, hard mass• Retroareolar• Eccentric to the nipple
• Secondary signs: • Nipple or skin retraction• Nipple discharge• Axillary lymphadenopathy
Male Breast Cancer
Thank you!