4

5. Vizcaı́no I, Gadea L, Andreo L, et al.Short-term follow-up results in 795nonpalpable probably benign lesionsdetected at screening mammography.Radiology. 2001;219:475-483.

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6. Helvie MA, Pennes DR, Rebner M,Adler DD. Mammographic follow-upof low-suspicion lesions: compliancerate and diagnostic yield. Radiology.1991;178:155-158.

Imaging Characteristics of MaleBreast Disease

Adibelli ZH, Oztekin O, Gunhan-Bilgen I,et al (Izmir Bozyaka Training and ResHosp, Turkey; Ege Univ, Izmir, Turkey)

Breast J 16:510-518, 2010

The purpose of the study was todescribe the imaging findings of malebreast disease. One hundred andsixty-four male patients, who under-went mammography and ultrasonog-raphy (US) between January 1999 andDecember 2008, were retrospectivelyevaluated. Seventy-five patients (46%)underwent biopsy, and 89 patients(54%) were diagnosed radiologically.The radiologic and pathologic diag-noses in 164 cases of this series were13 cancers (8%), including one ipsilat-eral and one contralateral breastcancers, 147 cases of gynecomastia(90%), one fibroadenoma (0.6%), twocases of fibrocystic disease of thebreast (1.2%), and one epidermoidinclusion cyst (0.6%). Three mammo-graphic patterns were adequate todescribe all 147 cases of gynecomastiain our series: 53 patients (36%) hadnodular gynecomastia, 46 patients(31%) had dendritic gynecomastia,and 48 patients (33%) had diffusegynecomastia. Gynecomastia was uni-lateral in 65% of cases (n¼ 95), andbilateral in 35% of cases (n¼ 52). Onphysical examination, two of themalignant lesions had no clinic featuresof malignancy (15%). On mammog-raphy, 11 of 13 malignant masseswere demonstrated (85%). A mass

with microcalcifications was seen onmammograms in one case (9%). Thecontours of the masses were irreg-ular in nine cases (82%), well-circumscribed in two cases (18%).The location of the masses was retroar-eolar in seven cases (64%) and eccen-tric to the nipple in four cases (36%).The size of the masses varied between0.5 cm and 5 cm (mean 2.4 cm).Nipple retraction was evident in fivecases (45%), and skin thickening infour cases (36%). All of the malignantmasses were demonstrated on ultra-sound; however, one of them wasseen retrospectively after mammog-raphy. All of the masses were hypo-echoic and solid, the contours werewell-defined and smooth in two masses(15%), and irregular in 11 masses(85%), and five masses (39%) hadposterior prominent shadowing. Axil-lary lymphadenopathia was detectedin two cases (15%). One patient hada previous contralateral breast cancer,and one had an ipsilateral. Onmammography, breast cancer charac-teristically exhibits an irregular subar-eolar mass, nipple retraction, and skinulceration or thickening, but some-times breast cancer has a well-circumscribed contour and punctuatedmicrocalcifications. Ultrasonographyis essential and useful for further char-acterization and helpful for demon-strating lymphadenopathies of theaxillary region.

Breast imaging has a limited rolein evaluating symptomatic men. Menare usually referred for breast imaging

ly

because physicians do not feel compe-tent to deal with male breast diseaseand consider the breast imager to bemore expert.

The most frequent clinical issue isthe differentiation of gynecomastiafrom cancer. Although imaging mayassist in the diagnosis, it is usuallyreadily made on the basis of thesymptoms. Gynecomastia is classicallysoft, tender, not associated with anychanges in the nipple, and frequentlybilateral. Cancers are hard, non-tender, and often associated withchanges in nipple contour or nippledischarge. These clinical symptoms arethe basis of the imaging diagnosis.

The presence of gynecomastiadoes not exclude the presence ofa carcinoma, as Adibelli and col-leagues point out. The coexistenceof the two is probably related toincreased levels of circulating estro-genic compounds being the etiologicfactor for both conditions. Therefore,in the presence of an imaging patternof gynecomastia, but with clinicalsymptoms suggesting cancer, biopsy isappropriate.

It is important also to alwaysremember that a malignant breastmass in men may represent metastaticdisease. The pattern of primary andmetastatic tumors in men can beidentical. Because of the rarity ofprimary breast cancer in men, oneshould be certain that a malignantmass is not metastatic.

As Adibelli and colleagues report,the discovery of clinically inapparentbreast cancer among their cases raises

the question of whether screeningmammography is appropriate in menwith a history of breast cancer. Thereis no consensus on this issue. Althoughbilateral breast cancer was present in2 men in this series, literature reviews

indicate that bilaterality in men isrelatively rare. If screening mammog-raphy is used routinely for men witha prior history of breast cancer, itsyield will be much lower than that inthe same population of women. There-

Breast

fore, few—if any—experts recommendits routine use in this setting.

D. D. Dershaw, MD

Incidental Breast LesionsIdentified by 18F-Fluorodeoxyglucose-PositronEmission Tomography

Chung A, Schoder H, Sampson M, et al(Memorial Sloan-Kettering Cancer Ctr,NY)

Ann Surg Oncol 17:2119-2125, 2010

Background.—Positron emissiontomography (PET) scanning is nowpart of the standard evaluation forpatients with a variety of differentmalignancies. We describe our experi-ence with breast incidentalomas ina large series of PET scans performedfor patients without a known historyof breast cancer.

Materials and Methods.—FromMarch 2000 through June 2007,approximately 45,000 PET scans wereperformed; 163 had breast findingsunrelated to the primary malignancy.In 103 of 163 (63%), findings includedphysiologic variation, lactation, im-plants, or benign calcifications. Chartreview was conducted in the remaining60 of 163 patients (37%).

Results.—In 20 of 60 patients(33%), no additional evaluation wasperformed due to advanced stage ofthe primary malignancy; 40 of 60(67%) underwent additional imagingand evaluation. In 16 of 40 patients(40%), the lesion resolved on repeatPET; the lesion persisted in 10 of 40(25%). Additional breast imaging wasperformed in 14 of 40 (35%). In total,

12 of 40 (30%) underwent biopsy; 7 of40 (18%) were positive for malignancy.

Conclusions.—In our experience,29% of breast incidentalomas (7 of 24)with persistent imaging findings weremalignant. Further evaluation of theselesions should be based on overall clin-ical status. In patients where resultswould not change overall management,biopsy may not be warranted.

In this article, Chung and col-leagues report a retrospective studythat addresses the significance ofincidental abnormalities in the breast,axilla, or chest wall (‘‘incidentalomas’’)in patients undergoing PET evaluationfor reasons other than breast malig-nancy. Of a total of 45 000 18F-fluorodeoxyglucose (FDG)-PET scans,60 revealed incidental focal breast,chest wall, or axillary FDG uptake.Twelve of these patients underwentbreast biopsy in order to obtain a tissuediagnosis, and in 7 patients the biopsywas positive for malignancy.

While the findings reported byChung and colleagues are of interest,similar findings have been reportedpreviously in a study by Ishimori andcolleagues published in 2005.1 Thisearlier study included 1912 patientswho underwent 18F-FDG-PET studiesfor various reasons. The investigatorsfound that 1.2% of these patients had18F-FDG-avid unsuspected tumors.Two of these patients had incidentalunsuspected malignant breastcarcinomas proven by needle biopsy.

I agree with Chung and colleaguesregarding the problems with their studydesign, such as lack of control for age,breast density, and menstrual cycle. Inaddition, there is lack of uniformity inthe approach and evaluation of thePET findings as well as a lack of tissuediagnosis in the majority of the patientsin the study. These problems, as theauthors suggest, primarily arose fromthe retrospective nature of the dataincluded. While prior studies havefound that standardized uptake value(SUV) is helpful in determining themalignant potential of a lesion, thisstudy found that SUV measurementswere not helpful. Chung and col-leagues recommend a follow-up PETscan, as many of these incidentalfindings resolve either because of theirbenign nature or secondary to chemo-therapy that the patients receive forother reasons. This approach is alsomore practical because the advancedstage of some of the primary malig-nancies makes the diagnosis of breastcancer less urgent.

As a busy practicing clinician, Iagree that the evaluation of‘‘incidentalomas’’ should be made onan individual basis, based on thepatient’s overall condition and lifeexpectancy. That is, while the exactnature of these newly discoveredlesions is of academic interest, anaggressive approach is not appropriatefor patients with advanced disease andwill merely decrease their quality of lifeand increase their health care costs.

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