Ultrasonography of the male breast

Imaging the Male Breast: Gynecomastia, Male Breast Cancer, and Beyond

The number of men undergoing breast imaging has increased in recent years, according to some reports. Most male breast concerns are related to benign causes, most commonly gynecomastia. The range of abnormalities typically encountered in the male breast is less broad than that encountered in women, given that lobule formation rarely occurs in men. Other benign causes of male breast palpable abnormalities with characteristic imaging findings include lipomas, sebaceous or epidermal inclusion cysts, and intramammary lymph nodes. Male breast cancer (MBC) is rare, representing up to 1% of breast cancer cases, but some data indicate that its incidence is increasing. MBC demonstrates some clinical features that overlap with those of gynecomastia, including a propensity for the subareolar breast. Men with breast cancer tend to present at a later stage than do women. MBC typically has similar imaging features to those of female breast cancer, often characterized by an irregular mass that may have associated calcifications. Occasionally, however, MBC has a benign-appearing imaging phenotype, with an oval shape and circumscribed margins, and therefore most solid breast masses in men require tissue diagnosis. Histopathologic evaluation may alternatively reveal other benign breast masses found in men, including papillomas, myofibroblastomas, and hemangiomas. Radiologists must be familiar with the breadth of male breast abnormalities to meet the rising challenge of caring for these patients. ©RSNA, 2024 Supplemental material is available for this article.

Is Breast Imaging in Male Patients With Benign Lumps Necessary? A Retrospective Study to Assess Concordance Between Clinical Diagnosis and Imaging Findings

Objective

Breast imaging for male patients is a controversial topic due to the high prevalence of gynecomastia compared to male breast cancer. Worldwide, men are undergoing more breast imaging despite the low incidence of male breast cancer. Gynecomastia is a benign condition, but the anxiety it causes and unnecessary medical costs are still high.

Materials and Methods

In accordance with Royal College of Radiology guidelines, a retrospective study was performed in two cycles to determine if mammography or ultrasound should be included in the workup of male patients who were referred to a breast care unit for a lump that was deemed benign by doctors.

Results

There was 100% concordance between clinical diagnosis and imaging findings.

Conclusion

In this population imaging was not necessary in cases of probable gynecomastia and benign conditions found during a clinical assessment. Standardised patient assessment methods can improve care and ensure accurate evaluation.

Male Breast Cancer: Three Case Reports and a Literature Review

INTRODUCTION

Male breast cancer (MBC) accounts for 0.5%-1% of all breast cancers diagnosed worldwide. However, its biological characteristics can be distinguished from that of female breast cancer (FBC).

CASE REPRESENTATION

The diagnostic and treatment approaches for MBC are mainly similar to that of FBC due to the lack of male breast cancer-related studies, clinical trials, and literature. An increasing number of retrospective and prospective studies have been conducted to clarify the individualized care for MBC. Herein, we report three cases of advanced MBC to describe the diagnostic approaches, treatment process, and survival prognosis.

CONCLUSION

MBC patients had older age, later stage at first diagnosis, higher expression of hormone receptors, and poor prognosis. A literature review was conducted to determine the incidence, risk factors, disease features, diagnosis, treatment, survival, and management of MBC.

Sonographic Features of Palpable Breast and Axillary Lesions in Adult Male Patients: A Pictorial Essay

The male breast is a non-functional and rudimentary organ, but similarly to the female breast, it can be affected by various diseases. In contrast to female breast cancer, male breast cancer has a low incidence, and there is no established breast cancer screening program for male patients. Therefore, the diagnostic evaluation is usually performed in male patients with symptoms such as palpability or pain in the breasts. Furthermore, most adult male patients who visit breast clinics sometimes present with not only breast symptoms but also axillary symptoms, and both the breast and axilla are usually examined during breast ultrasonography in daily clinical practice. The purpose of this pictorial essay was to present the sonographic features of various palpable breast and axillary lesions in adult male patients.

Urgent and emergent breast lesions – A primer for the general radiologist, on‐call resident and sonographer

There are very few true breast emergencies. While infrequent, women do present to emergency departments or urgent care centres with breast-related concerns. In this case-based review, both common and uncommon urgent and emergent breast lesions are presented, emphasising ultrasound characteristics and imaging optimisation to improve accurate diagnosis and appropriate recommendations.

The ins and outs of male breast and anterior chest wall lesions from childhood to adulthood

Physiological and pathological processes arising from the breast and anterior chest wall may share similar clinical presentations because of the small volume of male breasts. Therefore, imaging is frequently required to localise and characterise the lesion and guide biopsy when radiological findings are equivocal or suspicious. Mammography or digital breast tomosynthesis (DBT) and ultrasound are the mainstays of breast imaging work-up. Other imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and positron-emission tomography (PET) can sometimes augment the investigation and aid treatment planning. This article reviews the key imaging features of a wide spectrum of benign and malignant conditions that involve the male breast and anterior chest wall across various age groups. Familiarisation with the salient radiological findings is essential for reaching an accurate diagnosis and optimising management.

Breast development in pediatric patients from birth to puberty: physiology, pathology and imaging correlation

Breast tissue undergoes a series of changes from birth to puberty. The majority of the changes are transient, related to physiological hormonal changes. Although the breast is identical in both sexes at birth, its histology and development will eventually differ. It is important for radiologists to have a basic understanding of endocrinological changes and appearance on imaging to avoid potential pitfalls, particularly on ultrasound, which is the primary modality used to evaluate the breast.

Suspicious breast lesions incidentally detected on chest computer tomography with histopathological correlation

OBJECTIVE

To evaluate incidental breast lesions on chest computed tomography with histopathological correlation. It is important for general radiologist to characterize a breast lesion as benign, indetermined, or sufficiently suspicious to warrant further work-up.

METHODS

A total of 35.000 chest CT examinations were performed between January 2016 and December 2020. 27 patients (mean age 70 years, age range 48-87 years) with incidental breast lesions were identified in this retrospective study. Two radiologists scored incidental breast lesions independently regarding their morphology, and the results were compared to histopathology which was obtained by an ultrasound-guided core needle biopsy or a surgical excision.

RESULTS

Out of 35.000 chest CT examinations, a total of 31 incidental breast lesions in 27 patients were detected. Among the 31 lesions, 23 were malignant and 8 benign. The malignant lesions included 17 carcinomas and 6 metastases (4 lymphomas and 2 melanomas). The benign lesions contained 2 hematomas, 4 fat necrosis, and 2 fibrosis lumps.

CONCLUSION

Chest computed tomography as a standard imaging technique is helpful for evaluation of suspicious breast lesions. This may ultimately influence patient management and lead to further imaging.

Imaging in gynecomastia

BACKGROUND

Gynecomastia (GM) is the benign proliferation of glandular tissue in the male breast. It is a common condition, which may occur physiologically and shows three age peaks during a male's lifespan: infancy, puberty, and senescence. An underlying pathology may be revealed in 45%-50% of adult men with GM, such as aggravating medications, systemic diseases, obesity, endocrinopathies, or malignancy.

OBJECTIVE

To discuss the role of imaging in the evaluation of GM and its contribution to therapeutic decision-making.

MATERIALS/METHODS

The current literature was reviewed through PubMed, Scopus, and CENTRAL electronic databases to identify the best available evidence concerning imaging modalities in patients with GM.

RESULTS

Most male breast lesions can be diagnosed on clinical grounds; however, in certain cases, when physical examination is inconclusive, imaging may be helpful.

DISCUSSION

The main purpose of evaluating a patient with GM is to establish the diagnosis and differentiate true GM from pseudogynecomastia, exclude breast cancer, and detect the possible cause. GM is seen in mammography as a subareolar opacity and three mammographic patterns of GM are described: nodular, dendritic, and diffuse, corresponding to florid GM of early onset, fibrous persistent GM, and GM due to exogenous estrogen administration, respectively. In ultrasound (US), florid GM is depicted as a disk-shaped, hypoechoic area underlying the areola, whereas echogenicity of the lesions increases as fibrosis develops. Data on the use of MRI in the evaluation of the male breast and GM are still limited. Imaging findings can be classified according to the BIRADS (breast imaging reporting and data system) based on their malignant potential.

CONCLUSION

Both mammography and US are sensitive and specific to diagnose GM and distinguish it from breast cancer. When clinical findings are suggestive of malignancy or imaging findings are inconclusive, a histological confirmation should be sought.

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.

A Male Patient With Breast Hamartoma: An Uncommon Finding

Mammary hamartoma is a rare type of breast tumor that is composed of the same elements as normal mammary tissue. This condition is very rare in men. In current literature, there are fewer than five case reports on male breast hamartoma. This benign pathology is under-reported because of several reasons. Since breast tumors are still considered an exclusively female diagnosis and statistically proven to be gynecomastia when arising in men, they are often overlooked. In addition to the uncommon clinical presentation in men, insufficiency of definitive pathologic and radiologic characteristics can make an accurate diagnosis a challenging task. Mammary hamartoma is a benign condition with an excellent prognosis. The following case describes a rare instance of an enlarging mammary hamartoma in a male patient, highlighting the imaging features, pathohistological findings, and clinical management.

Imaging findings and classification of the common and uncommon male breast diseases

Male breast hosts various pathological conditions just like "female breast." However, histo-anatomical diversities with female breast lead to many differences regarding the frequency and presentation of diseases, the radiologic appearance of lesions, the diagnostic algorithm, and malignity features.Radiological modalities may play an important role in evaluating male breast lesions. Although some imaging findings are non-specific, having knowledge of certain imaging characteristics and radiologic patterns is the key to reduce the number of differential diagnoses or to reach an accurate diagnosis.Male breast imaging is mostly based on physical examination and is required for the complaints of palpable mass, breast enlargement, tenderness, nipple discharge, and nipple-skin changes. The majority of the male breast lumps are benign and the most common reason is gynecomastia. Although it is difficult to exclude malignancy in some cases, gynecomastia often has distinguishable imaging features. Pseudogynecomastia is another differential diagnosis that may be confused with gynecomastia. The distinction is important for the treatment plan.Apart from gynecomastia, other male breast lesions form a highly heterogeneous group and can be classified based on "Tissue origin," "Histopathological type and behavior," and "Radiologic features" for both simplification and comprehensive understanding.This article mainly focuses on emphasizing the results of basic histo-anatomical differences of male and female breasts, classifying male breast lesions, covering the spectrum of male breast diseases, and assisting radiologists in recognizing the imaging findings, in interpreting them through a holistic approach, in making a differential diagnosis, and in being a part of proper patient management.

Galactocele of adult male breast: A cytopathologist's perspective

Galactocele, although a common cytological diagnosis in females, is not previously reported as a cause of breast enlargement in adult males. Hyperprolactinemia is the principal cause of galactocele in male breast. Besides drug induced hyperprolactinemia, other anatomical lesions of hypothalamo-pituitary region and different medical conditions like cirrhosis and chronic kidney disease are to be considered along with a full evaluation of features revealing hypogonadism in case of galactocele. Aspirated milk from the male breast is the primary clue for this detailed investigation process. Here we are presenting the first case of galactocele of the male breast due to hypogonadotropic hypogonadism with idiopathic hyperprolactinemia.

A split-body study evaluating the efficacy of a conformable surface cryolipolysis applicator for the treatment of male pseudogynecomastia

BACKGROUND

Cryolipolysis is a non-invasive method of body shaping that has been used for male pseudogynecomastia. However, traditional vacuum suction cryolipolysis requires a minimum pinchable fat layer which may not always be present in this area.

OBJECTIVE

To evaluate the efficacy and safety of a conformable surface cryolipolysis applicator for the reduction of male pseudogynecomastia.

MATERIALS AND METHODS

Ten male subjects with pseudogynecomastia received two cycles of cryolipolysis to the breast 6 weeks apart. Ultrasound was used to measure the thickness of adipose tissue.

RESULTS

Seven of 10 patients completed the study. Compared to baseline, the mean ± SD change in adipose tissue thickness was 8.12 ± 6.94 mm for the treated versus 1.03 ± 6.03 mm for the control breast at week 6 (p = 0.014), and 8.71 ± 7.04 mm for the treated vs. 2.66 ± 7.04 mm for the control breast at week 12 (P = 0.16). Four (4) of seven (57%) patients were at least slightly satisfied with the treated breast, and although subject satisfaction was higher in the treated breast, this did not reach significance (0.085). Adverse events were mild and transient.

CONCLUSION

A conformable surface cryolipolysis applicator was effective in reducing the mean adipose tissue thickness in subjects with male pseudogynecomastia. Lasers Surg. Med. © 2018 Wiley Periodicals, Inc.

The Characteristics and Short-Term Surgical Outcomes of Adolescent Gynecomastia

BACKGROUND

Most adolescent gynecomastia is resolved spontaneously in 3 years. But, persistent gynecomastia could have a negative influence on psychoemotional development on adolescence. The purpose of this study is to report the characteristics of adolescent gynecomastia patients who received the surgeries, and discuss the short-term surgical outcomes.

METHODS

Of the 1454 patients who underwent gynecomastia surgery at Damsoyu hospital from January 2014 to May 2016, 71 were adolescents. Subcutaneous mastectomy with liposuction was performed for adolescent patients who had gynecomastia for more than 3 years and showed psychosocial distress. Demographic and outcome variables were retrospectively analyzed.

RESULTS

The mean age was 17.5 ± 0.77 years old. All gynecomastia cases were bilateral. Simon's grade IIa (35 patients, 49.3%) was the most common, and grade III was not observed. Fifty-one patients (71.8%) were classified as having a glandular-type breast component. Fourteen patients (19.7%) had complications, but only 3 cases (4.2%) required revision. Most of the patients (70 patients, 98.6%) were satisfied with the esthetic results, and the average 5-point Likert score was 4.85 ± 0.40. Recurrence was not observed. As the Simon's grade increased from I to IIA, a higher BMI, larger amounts of breast tissue, and longer operation times were observed.

CONCLUSIONS

Gynecomastia that did not regress spontaneously was mostly the glandular type, so not only liposuction but also surgical removal of glandular tissue is necessary. Surgical treatment, selectively performed in patients who have had gynecomastia for 3 years, and have experienced psychosocial distress, could be an acceptable treatment for adolescent gynecomastia.

LEVEL OF EVIDENCE IV

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Incidental unilateral and bilateral ductal carcinoma in situ encountered in the surgical management of young male gynecomastia

BACKGROUND

The increased risk for malignant tumors associated with male gynecomastia has been well established and many authors have reported cases of concurrent gynecomastia and ductal carcinoma in situ (DCIS) in the same breast. Synchronous bilateral breast cancer in association with gynecomastia is exceptionally rare. We aim to report and evaluate the management outcome of 5 cases of gynecomastia associated with DCIS (1 bilateral and 4 unilateral).

METHODS

A retrospective database analysis of the surgical treatment outcome of 74 male patients who had gynecomastia was done. A bilateral subcutaneous nipple-preserving mastectomy approach was done to all. Histopathology reports were reviewed.

RESULTS

74 patients diagnosed and treated for gynecomastia were included. The incidence rate of gynecomastia in our hospital male patients was 0.17%. The mean age was 22 years, range 17-29 years. Five (6.76%) patients were found in histopathology specimens to have DCIS, 1 patient (23 years old) had bilateral DCIS of low grade, 4 patients had unilateral positive involvement, 3 had right breast DCIS, and 1 had left breast DCIS, and all were of low-grade papillary subtype. The incidence of ductal carcinoma in situ among our series gynecomastia patients was 6.76%.

CONCLUSION

We conclude that gynecomastia is a benign breast disease but recent reports had described malignant variants, mostly DCIS, including 5 young males in our series. Therefore, regardless of the age group, histopathological examination of the resected gynecomastia tissue should be carefully done in all patients. Further evidence-based studies are needed to investigate the optimum management of incidental DCIS in gynecomastia specimens.

CT measurement of breast glandular tissue and its association with testicular cancer

OBJECTIVES

To evaluate the associations between breast glandular tissues diameters as determined by CT and b-hCG levels, histological types, tumour spread and prognosis in patients with testicular germ cell tumour.

METHODS

Ninety-four patients with pre-treatment CT scan and markers (b-hCG, AFP, LDH) were retrospectively collected. A radiologist measured diameters in all CT examinations and correlation between diameters and log (b-hCG) was assessed (Pearson's coefficient). The ability of measured diameters to predict lymphatic and distant haematogenous metastatic spread was evaluated (ROC curves). The associations between measured diameter cut-off values of 20 and 25 mm and International Germ Cell Cancer Collaborative Group (IGCCCG) classification, lymphatic and distant haematogenous metastatic spread and histological subtypes were evaluated (chi squared test).

RESULTS

Breast glandular diameters correlated to log(b-hCG) (r = 0.579) and predicted distant haematogenous metastatic spread (AUC = 0.78). Worse prognosis (intermediate or poor IGCCCG) was shown for 20 mm (27.3 vs. 4.2 %, p = 0.005) and 25 mm (33.3 vs. 6.1 %, p = 0.014). A diameter of 25 mm was associated with non-seminoma (91.7 vs. 48.8 %, p = 0.005).

CONCLUSION

Breast glandular tissue diameters correlated with log(b-hCG) and predicted distant haematogenous metastases. Twenty and 25 mm were associated with worse prognosis and 25 mm was able to distinguish between seminoma and non-seminoma.

KEY POINTS

• CT breast glandular tissue diameter correlates with log(b-HCG) • Gynaecomastia in CT is associated with worse prognosis • Gynaecomastia in CT is associated with non-seminoma histological subtype.

Mammography Findings of Male Breast Diseases

Over the past 2 decades, the percentage of men presenting with breast complaints has increased from 0.8% to 2.4%, and men now account for 1% of all breast cancer cases. The most common male breast mass is gynecomastia, followed by lipoma and epidermal inclusion cysts. Because there is a paucity of parenchyma as compared with the female breast, the malignancy rapidly progresses to the next stage, with the appearance of secondary signs like nipple retraction, fixation to deeper tissues, skin ulceration or adenopathy. Diagnostic evaluation is needed only when the palpable mass is unilateral, hard, fixed, peripheral to the nipple, or associated with nipple discharge, skin changes, or lymphadenopathy. Male breast cancer usually occurs in a subareolar location or is positioned eccentric to the nipple; occasionally, it occurs in a peripheral position. Secondary signs like skin thickening, nipple retraction, and axillary lymphadenopathy may be seen. Microcalcifications can occur. Mammography can accurately distinguish between malignant and benign male breast disease. Radiologists are generally less familiar with breast disease in males compared with females. In this article, we discuss the clinical, and mammographic features of a variety of benign and malignant diseases that can occur in the male breast.

Has color Doppler a role in the evaluation of mammary lesions?

Has color Doppler a role in the evaluation of mammary lesions? A schematic review of color Doppler diagnostic criteria, indicating a benign or malignant lesion, are described.Malignant tumors have a tendency to show increased vascularization, but avascular tumors may be found as well as hypervascular benign tumors.Number of vessels, blood-flow velocity, and intra-tumoral vessel resistance assessed by color Doppler ultrasonography don't permit clear differentiation between malignant and benign tumors, but intra-tumoral blood-flow analysis well correlates with aggressiveness and histological grade of the mass, so a preoperative assessment using Color Doppler may give preliminary prognostic informations useful for therapeutic planning.Color Doppler ultrasound may be valuable also in assessing the efficacy of neoadjuvant chemotherapy and in particular of antiangiogenesis treatments.Color Doppler ultrasound has many other useful applications in the evaluation of diseases of the female and male breast, that are reviewed in the paper.Color Doppler however is not conceived as a stand-alone examination, but associated with B-mode ultrasound that is quite effective as a diagnostic tool, often not requiring Doppler informations.