The diagnostic value of clinical examination and imaging used as part of an age-related protocol when diagnosing male breast disease: An audit of 1141 cases from a single centre

Breast Cancer Screening in Men

Breast cancer screening has been highly successful in women in reducing mortality through early detection. In comparison, clinical detection of breast cancer remains the norm in men, and delay in diagnosis is reflected by a persistent survival disparity compared to women despite advances in modern therapy. Male breast cancer presents an interesting dilemma. While mammography is highly sensitive and specific for male breast cancer, routine screening is not justified by the overall low disease incidence. Yet there has been interest in leveraging mammography in targeted screening of men with identifiable risk factors to allow early detection, and early data may support this approach. The purpose of this article is to explore the potential utility of targeted breast cancer screening in men by examining unique clinical and biologic characteristics of male breast cancers that may lend themselves to mammographic detection. We will also discuss available evidence in screening outcomes in men and summarize recent updates in risk management recommendations in Society guidelines.

Male Breast Cancer Review. A Rare Case of Pure DCIS: Imaging Protocol, Radiomics and Management

Ductal carcinoma in situ (DCIS) of male breast is a rare lesion, often associated with invasive carcinoma. When the in situ component is present in pure form, histological grade is usually low or intermediate. Imaging is difficult as gynaecomastia is often present and can mask underlying findings. We report a rare case of pure high-grade DCIS in a young male patient, with associated intraductal papilloma and atypical ductal hyperplasia. Digital breast tomosynthesis (DBT) showed an area of architectural distortion at the union of outer quadrants of the left breast without gynaecomastia. Triple assessment suggested performing a nipple-sparing mastectomy, which revealed the presence of a focal area of high-grade DCIS of 2 mm. DCIS, even of high grade, is difficult to detect with mammography and even more rare, especially when associated with other proliferative lesions. DBT with 2D synthetic reconstruction is useful as the imaging step of a triple assessment and it should be performed in both symptomatic and asymptomatic high-risk men to differentiate between malignant and benign lesions. We propose a diagnostic model to early detect breast cancer in men, optimizing resources according to efficiency, effectiveness and economy, and look forward to radiomics as a powerful tool to help radiologists.

Outcomes of male patients attending the symptomatic breast unit: adherence to local and national imaging guidelines and effectiveness of clinical examination and imaging in detecting male breast cancer

AIM

To review outcomes of male patients attending the breast unit, evaluate effectiveness of imaging and examination in detecting breast cancer and review adherence to guidelines for male breast imaging.

MATERIALS AND METHODS

A retrospective review was undertaken of male patients attending Cambridge Breast Unit from 1 January 2015 to 31 December 2019. Patient electronic records and imaging were reviewed to establish demographics, clinical findings, imaging, biopsy, and pathology outcomes.

RESULTS

Of 1,362 male patients attending the breast unit, 1,028 (75%) had imaging performed. Biopsy was performed in 41 men (3%), with 14 cancers diagnosed (1%). Clinical examination showed 42.7% sensitivity, 99.6% specificity, 54.6% positive predictive value (PPV) and 99.4% negative predictive value (NPV) for detection of cancer. Mammogram demonstrated 84.6% sensitivity, 99.4% specificity, 69.8% PPV, and 99.8% NPV for detection of malignancy. Ultrasound demonstrated 78.6% sensitivity, 98.9% specificity, 73.3% PPV and 99.2% NPV for detection of cancer. Forty-one percent of patients <40 years and 51% < 50 years were imaged, who according to local and Royal College of Radiologists (RCR) guidelines did not require imaging based on age and clinical score.

CONCLUSION

Male patients account for a small proportion of referrals to the breast unit but generate significant workload. Imaging protocols, incorporating clinical score and age cut-off at 40 years remains robust for detecting malignancy. Clinician awareness of the imaging protocol, and close liaison with radiologists is essential to minimise additional radiology workload.

Unusual Male Breast Lesions

Most of male breast masses are benign with gynecomastia being the most common entity encountered. Primary male breast cancer accounts for less than 1% of the total number of breast cancer. Male breast can be affected by a variety of conditions affecting the female breast with less frequency due to the lack of hormonal influence and consequent glandular sub-development. Imaging features of male breast masses are quite similar to the female breast. Therefore, using the knowledge of the female breast and applying it may help in the diagnosis and management of male breast abnormalities. In this article, we aim to review a variety of unusual male breast masses. We discuss the demographics of male breast tumors, describe the diagnostic algorithm for evaluating male breast masses, and review the imaging features of rare breast masses and mimickers of male breast cancer.

Male patients with unilateral breast symptoms: an optimal imaging approach

OBJECTIVES

To evaluate the usefulness of bilateral mammography in male patients with unilateral breast symptoms, including investigation of the diagnostic performance of unilateral and bilateral reviews and the average glandular dose (AGD) per exposure.

METHODS

Two hundred seventy-one consecutive male patients (mean age, 57 years) with unilateral breast symptoms underwent bilateral mammography. Image interpretation was performed in two ways, first with a unilateral review of the symptomatic breast and then with a bilateral review. A modified BI-RADS scale (from 1 to 5) was used. The diagnostic performance of unilateral and bilateral reviews was compared, and contralateral breast abnormalities and the AGD per exposure were recorded. We also analyzed ultrasound (US) results and compared them with mammography.

RESULTS

Of 271 male patients, 29 were pathologically diagnosed with breast cancer. There was no bilateral breast cancer. The sensitivity, specificity, positive and negative predictive values, and accuracy were 96.6%, 96.7%, 77.8%, 99.6%, and 96.7%, respectively, for unilateral review, and 96.6%, 95.9%, 73.7%, 99.6%, and 95.9% for bilateral review. Receiver operator characteristic analysis showed excellent diagnostic performance for both methods: the area under the curve (AUC) was 0.966 for unilateral review and 0.962 for bilateral review (p = 0.415). The mean AGD per exposure was 1.10 ± 0.29 mGy for symptomatic breast and 1.04 ± 0.30 mGy for contralateral breast (p < 0.001). Diagnostic performance parameters of US were not significantly different from bilateral or unilateral review of mammography.

CONCLUSION

The diagnostic performance of unilateral mammography is comparable with bilateral mammography in male patients with unilateral breast symptoms. Unilateral mammography also has the advantage of reducing radiation exposure.

KEY POINTS

• There is limited knowledge about standardized guidelines or recommendations for imaging the male breast. • Unilateral mammography for male patients with unilateral breast symptoms showed comparable diagnostic performance with bilateral mammography. • Both unilateral and bilateral mammography showed excellent diagnostic performance in the assessment of male patients with unilateral breast symptoms.

Efficiency of Imaging Modalities in Male Breast Disease: Can Ultrasound Give Additional Information for Assessment of Gynecomastia Evolution?

Objective

The purpose of this study is to present mammography and ultrasound findings of male breast lesions and to investigate the ability of diagnostic modalities in estimating the evolution of gynecomastia.

Materials and Methods

Sixty-nine male patients who admitted to Taksim and Bakirkoy Education and Research Hospitals and underwent mammography (MG) and ultrasonography (US) imaging were retrospectively evaluated. Duration of symptoms and mammographic types of gynecomastia according to Appelbaum's classifications were evaluated, besides the sonographic findings in mammographic types of gynecomastia.

Results

The distribution of 69 cases were as follows: gynecomastia 47 (68.11%), pseudogynecomastia 6 (8.69%) primary breast carcinoma 7 (10.14%), metastatic carcinoma 1 (1.4%), epidermal inclusion cyst 2 (2.8%), abscess 2 (2.8%), lipoma 2 (2.8%), pyogenic granuloma 1 (1.4%), and granulomatous lobular mastitis 1 (1.4%). Gynecomastia patients who had symptoms less than 1 year had nodular gynecomastia (34.6%) as opposed to dendritic gynecomastia (61.5%) (p<0.01) based on mammography results according to Appelbaum's classifications. In patients having symptoms for 1 to 2 years, diffuse gynecomastia (70%) had a higher rate than the dendritic type (20%). Patients having the symptoms more than 2 years had diffuse gynecomastia (57.1%) while 42.9% had dendritic gynecomastia (p<0.001). With sonographic examination patients who had symptoms less than 1 year had higher rates of dendritic gynecomastia (92.3%) than noduler type (1.9 %). Patients having symptoms for 1 to 2 years had more dentritic gynecomastia (70%) than diffuse type (30%). Patients having symptoms more than 2 years had diffuse gynecomastia (57.1%) comparable to dendritic gynecomastia (42.9 %).

Conclusion

Diagnostic imaging modalities are efficient tools for estimation of gynecomastia evolution as well as the diagnosis of other male breast diseases. There seems to be an incongruity between duration of clinical complaints and diagnostic imaging classification of gynecomastia. The use of these high resolution US findings may demonstrate an early phase fibrosis especially in patients visualized by mammography as with nodular phase.

Shear-wave elastography quantitative assessment of the male breast: added value to distinguish benign and malignant palpable masses

OBJECTIVE

To evaluate the ability of shear-wave elastography (SWE) to distinguish between benign and malignant palpable masses of the adult male breast.

METHODS

Clinical examination, mammography, B-mode and Doppler ultrasound findings and SWE quantitative parameters were compared in 50 benign lesions (including 40 gynaecomastias) and 15 malignant lesions (invasive ductal carcinomas) from 65 patients who were consecutively addressed for specialized advice at our comprehensive cancer centre. Mean elasticity (El mean), maximum elasticity (El max), El mean of the surrounding fatty tissue and lesion to fat ratio (El ratio) were reported for each patient.

RESULTS

Malignant masses displayed significantly higher El mean (p < 0.0001), El max (p < 0.0001) and El ratio (p < 0.0001) compared to benign masses without overlap of values between the two groups. By adding SWE to clinical examination, mammography and ultrasound, all the lesions would have been retrospectively correctly diagnosed as benign or malignant. One false positive could have been downstaged, 14/65 undetermined masses could have been correctly reclassified as 4 malignant and 10 benign lesions, for which biopsies could have consequently been avoided.

CONCLUSION

Evaluation of male breast palpable masses by SWE demonstrates that malignant masses are significantly stiffer lesions and may improve diagnostic management when clinical examination, mammography and conventional ultrasound are doubtful. Advances in knowledge: Quantitative SWE is feasible in male breast and could be of great interest to help classify doubtful lesions after classical clinical and radiological evaluations, probably because of different anatomy and different tumours epidemiology compared with female breast.

Radiologic evaluation of lumps in the male breast

BACKGROUND

Gynecomastia has a typical appearance on mammography, and occurs frequently in men. However, imaging is often performed on men with breast lumps to exclude breast cancer, which only comprises 1% of male breast masses.

PURPOSE

To assess whether ultrasound and fine needle aspiration cytology (FNAC) are necessary investigations when mammograms show classical gynecomastia.

MATERIAL AND METHODS

We have retrospectively collected data on male patients referred for mammography during the period 2011-2013 (a total of 539 patients). All radiological images were re-read, and descriptions of ultrasound images were reviewed. Clinical information supplied with the original referrals was assessed, along with pathology and cytology reports.

RESULTS

Among the 539 male patients who underwent mammography, 483 were also examined with ultrasound, and 335 were further evaluated with FNAC. Mammograms showed gynecomastia in 350 patients, and among these subjects ultrasound was performed in 340 (97%), FNAC in 261 (75%), and core biopsies in four (1%) patients. The diagnosis gynecomastia was unchanged in all patients who underwent FNAC or biopsy. Malignant tumors were found in eight patients, six of which were invasive ductal carcinomas.

CONCLUSION

In patients with a classical appearance of gynecomastia on mammography, supplemental ultrasound, FNAC, or biopsy is superfluous and contributes to unnecessary costs.

Different Levels of CEA, CA153 and CA125 in Milk and Benign and Malignant Nipple Discharge

Background

The aim of this study was to assess the diagnostic values of three breast tumor markers (i.e., CEA, CA153 and CA125) in milk and nipple discharge in the prediction of different breast diseases diagnoses.

Methods

Three hundred thirty-six patients (96 breast cancer and 240 benign disease patients) with nipple discharge and a control group of 56 healthy parturient participants were enrolled in the present study. Nipple discharge samples were preoperatively collected from the patients, and milk was collected from the colostrum of the parturient participants. The samples were assayed for the CEA, CA153 and CA125 levels. Cutoff values were determined for the detection of breast diseases using ROC curves.

Results

The levels of CEA, CA153 and CA125 were significantly different between the nipple discharge and the milk (all ps < 0.001). In the nipple discharge, the CEA and CA153 levels in the breast cancer group were significantly greater than those in the benign group (all ps < 0.001), and cutoff values of 263.3 ng/mL and 1235.3 U/mL, respectively, were established. However, the expression of CA125 did not differ significantly between the breast cancer and benign groups.

Conclusion

Differences in the apparent expression levels of CEA, CA153 and CA125 in patients with nipple discharge and healthy persons were validated. The present data suggest that CEA and CA153 might potentially be useful in the differential diagnoses of benign tumors and breast cancer. CA125 did not seem to be useful for breast cancer detection.