Overuse of Imaging the Male Breast-Findings in 557 Patients

Screening Mammography for Males With Elevated Breast Cancer Risk, Mutation Carriers, and Gynecomastia

INTRODUCTION

The recommendations for annual mammography for male carriers with gynecomastia are controversial. This study investigated the potential link between gynecomastia and breast cancer in male carriers.

PATIENTS AND METHODS

The database of a tertiary medical center was retrospectively searched for all male patients who underwent at least 1 digital mammography study from 2016 to 2023. Known carriers of a pathogenic variant in a high-risk breast-cancer gene were identified. Patients were stratified by carrier status, diagnosis of breast cancer, and diagnosis of gynecomastia. Data on demographics, hormone profile, and pathology results were compared.

RESULTS

The cohort included 446 men of whom 82 were known carriers. Gynecomastia was diagnosed by mammography in 251 patients: 239/364 noncarriers (66%) and 12/82 carriers (15%) (P < .0001). Breast cancer was found in 21/364 noncarriers (6%) and 6/82 carriers (7%) (P < .6), and in 10/251 patients with gynecomastia (4%) and 17/193 (9%) without gynecomastia (P < .05). Among patients without gynecomastia, the number of breast cancer cases was similar in carriers and noncarriers (P = .3). Among patients with gynecomastia, the rate of breast cancer was higher in carriers (P < .08). On logistic regression analysis, the effect of gynecomastia on carriers was significant (P = .02). The odds ratio for a breast cancer diagnosis was 5.8 in the presence of gynecomastia (95% CI, 1.1-31, P < .04) and 0.52 in the absence of gynecomastia (95% CI, 0.2-1.7, P < .3).

CONCLUSION

Gynecomastia may be associated with an increased risk of breast cancer in carriers. Larger studies are needed to determine whether and when to screen male carriers.

Male ductal carcinoma in situ: diagnosis and management of a rare disease in men

Ductal carcinoma in situ is very rare in male patients, accounting for approximately 5%-7% of all male breast cancers. We present a case of a man in his early 70s who presented with bloody nipple discharge and gynaecomastia and was subsequently diagnosed with ductal carcinoma in situ (DCIS). We discuss his management with surgical resection and the consideration of adjuvant treatment. We also review the existing literature on the presentation, diagnosis and management of DCIS in men.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Benign cyst of the male breast. An exceedingly rare entity that may pose a diagnostic dilemma. Management and literature review

Cysts represent the most common cause of a breast mass in women. On the contrary, in men, the presence of a benign apocrine cyst is an exceedingly rare occurrence, with only a few cases reported in the literature. We describe herein a case of benign apocrine breast cyst without concurrent gynecomastia in a 41-year-old male. Diagnostic evaluation and management are discussed, along with a review of the literature. Given the extreme rarity of benign breast cysts in males, a thorough investigation is essential in male patients presenting with cystic breast lesions. Diagnostic breast imaging may be challenging. Surgical resection of the cyst should be considered in the presence of atypical imaging features to exclude underlying malignancy.

Epidemiology of male breast diseases: A 10-year institutional review

OBJECTIVE

To review breast imaging utilization and epidemiology of breast diseases in male patients referred to our breast center.

MATERIAL AND METHODS

A retrospective analysis of all male patients who underwent breast imaging at our institution over a 10 year period (03/14/2008 to 03/13/2018) was performed. Patient history, imaging findings, biopsy reports, surgical interventions and follow-up data were reviewed.

RESULTS

Over the 10 year period, 143 male patients (0.1% of referred breast center patients) underwent breast imaging (versus 139,134 female patients). Mean age was 57.4 years (SD 19.7, median 59, range 21-92 years). The most common indication for referral was a palpable breast mass (98%). The most common diagnosis was gynecomastia (72%). Of the 20 (14%) patients who underwent core biopsy; 1 (0.7%) had breast cancer and the remaining 19 had benign pathologies. Follow-up imaging was recommended for 22 (15.4%) patients, of whom 15 (68%) were lost to follow-up. Two patients under the age of 25 years inadvertently underwent initial mammography instead of ultrasound.

CONCLUSION

The epidemiology of breast diseases in our male patient population mirrors that of the general male population worldwide; with an overwhelming 99.3% cases falling into benign category. Two-thirds of our male patients for whom short interval follow up was recommended were lost to follow-up, signifying the need for a more proactive approach in ensuring their compliance. It is important to increase awareness among referring clinicians and general radiologists regarding male breast imaging recommendations so that the appropriate imaging study is performed.

Differential diagnosis of benign and malignant male breast lesions in mammography

PURPOSE

To investigate the mammographic characteristics in discriminating benign and malignant male breast lesions.

METHODS

Male patients with breast lesions detected by preoperative mammography were enrolled in this study from Jan 2011 to Dec 2018. All lesions were confirmed by biopsy and classified into benign group or malignant group. Imaging features included lesions location, lesion type, lesion density, lesion eccentricity, accompanying signs(calcification, nipple retraction, thickened skin and enlarged lymph nodes) were recorded and analysed by statistical methods. The AUC was calculated to assess their diagnostic performance in distinguishing benign and malignant lesions. This model was further validated by 0.632 bootstrap.

RESULTS

A total of 93 men(median age: 60, range 32-81 years) were enrolled, 43 patients in the benign group and 50 patients in the malignant group. In the univariate logistic analysis, age, lesion location, lesion type, lesion density, lesion eccentricity, calcification, nipple retraction and skin thickening were significantly different (p < 0.05). When the lesion showed a mass in mammography, those with a circumscribed margin were likely malignant (p < 0.05). In the multivariate logistic analysis, non-retro-areola lesions (OR: 6.900, 95 % CI: 1.413∼33.691, p < 0.05), eccentric lesions (OR: 14.566, 95 % CI: 2.800∼75.777, p < 0.05), high-density lesions (OR: 11.052, 95 % CI: 2.235∼54.666, p < 0.05), calcification (OR: 12.715 95 % CI: 1.316∼122.848, p < 0.05) and nipple retraction (OR: 24.681, 95 % CI: 2.853∼213.542 p < 0.05) were associated with breast cancer. Those variables were used to build logistic model and the AUC of the imaging model was 0.904. The imaging model was verified by 0.632 bootstrap resampling, and the AUC after 0.632 bootstrap was 0.892.

CONCLUSION

Mammographic characteristics could contribute to distinguishing malignant and benign male breast lesions, and the imaging model showed excellent diagnostic performance, which may help to guide clinical decision-making.

Quantitative CT Assessment of Gynecomastia in the General Population and in Dialysis, Cirrhotic, and Obese Patients

RATIONALE AND OBJECTIVES

Gynecomastia is the benign enlargement of the male breast because of proliferation of the glandular component. To date, there is no radiological definition of gynecomastia and no quantitative evaluation of breast glandular tissues in the general male population. The aims of this study were to supply radiological-based measurements of breast glandular tissue in the general male population, to quantitatively assess the prevalence of gynecomastia according to age by decades, and to evaluate associations between gynecomastia and obesity, cirrhosis, and dialysis.

MATERIALS AND METHODS

This retrospective study included 506 men who presented to the emergency department following trauma and underwent chest-abdominal computed tomography. Also included were 45 patients undergoing hemodialysis and 50 patients with cirrhosis who underwent chest computed tomography. The incidence and size of gynecomastia for all the study population were calculated.

RESULTS

Breast tissue diameters of 22 mm, 28 mm, and 36 mm corresponded to 90th, 95th, and 97.5th cumulative percentiles of diameters in the general male population. Peaks of gynecomastia were shown in the ninth decade and in boys aged 13-14 years. Breast tissue diameter did not correlate with body mass index (r = -0.031). Patients undergoing hemodialysis and patients with cirrhosis had higher percentages (P < .0001) of breast tissue diameters above 22 mm, 28 mm, and 36 mm.

CONCLUSIONS

Breast tissue diameter is a simple and reliable quantitative tool for the assessment of gynecomastia. This method provides the ability to determine the incidence of gynecomastia by age in the general population. Radiological gynecomastia should be defined as 22 mm, 28 mm, or 36 mm (90th, 95th, and 97.5th percentiles, respectively). Radiological gynecomastia is not associated with obesity, but is associated with cirrhosis and dialysis.

Managing Male Mammary Maladies

This review examines the symptoms, need for referral and management of the benign breast conditions which afflict males, together with the steps that are necessary to exclude or confirm male breast cancer. The most common complaint is gynaecomastia, either true or pseudo, and the majority of these cases need reassurance without over-investigation. Drugs that induce breast enlargement are described in order that, when possible, a medication switch can be made. Men receiving endocrine therapy for prostate cancer may develop painful gynaecomastia and this can be relieved with tamoxifen. All men with breast cancer need mammography as part of their work-up but this should not be used as a screening technique for symptomatic males. Because of lack of lobular development, both cysts and fibroadenomas are very rare in men; but those with nipple discharge need referral and investigation as some will have underlying malignancy.

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.

Value of diagnostic imaging for the symptomatic male breast: Can we avoid unnecessary biopsies?

PURPOSE

To review the use of diagnostic breast imaging and outcomes for symptomatic male patients.

METHODS

We retrospectively evaluated 122 males who underwent diagnostic imaging for breast symptoms at our academic center.

RESULTS

The majority (94%) of cases had negative or benign imaging, with gynecomastia being the most common diagnosis (78%). There were two malignancies, both of which had positive imaging. Fifteen patients underwent percutaneous biopsy, and over half (53%) were palpation-guided biopsies initiated by the referring clinician despite negative imaging. Diagnostic imaging demonstrated 100% sensitivity and 96% specificity for identifying cancer.

CONCLUSIONS

Malignancy is rarely a cause of male breast symptoms. Diagnostic breast imaging is useful to establish benignity and avert unnecessary biopsies.

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.

Incremental Role of Mammography in the Evaluation of Gynecomastia in Men Who Have Undergone Chest CT

OBJECTIVE

The purpose of this study was to determine whether additional breast imaging is clinically valuable in the evaluation of patients with gynecomastia incidentally observed on CT of the chest.

MATERIALS AND METHODS

In a retrospective analysis, 62 men were identified who had a mammographic diagnosis of gynecomastia and had also undergone CT within 8 months (median, 2 months). We compared the imaging findings of both modalities and correlated them with the clinical outcome.

RESULTS

Gynecomastia was statistically significantly larger on mammograms than on CT images; however, there was a high level of concordance in morphologic features and distribution of gynecomastia between mammography and CT. In only one case was gynecomastia evident on mammographic but not CT images, owing to cachexia. Two of the 62 men had ductal carcinoma, which was obscured by gynecomastia. Both of these patients had symptoms suggesting malignancy.

CONCLUSION

The appearance of gynecomastia on CT scans and mammograms was highly correlated. Mammography performed within 8 months of CT is unlikely to reveal cancer unless there is a suspicious clinical finding or a breast mass eccentric to the nipple. Men with clinical symptoms of gynecomastia do not need additional imaging with mammography to confirm the diagnosis if they have undergone recent cross-sectional imaging.