Imaging of the Male Breast-Beyond the Basics - tnrad.org · Objectives •Review the indications for male breast imaging •Review normal imaging appearance of the male breast •Illustrate

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 …


BI-RADS 3


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



Male presents with left breast mass

BI-RADS 4 – Biopsy was performed.


• 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


Male presents with palpable right breast mass.



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


• 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.



Invasive Mammary Carcinoma



BI-RADS 4 – Biopsy was performed



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


BI-RADS 4 –

9 years later same patient palpates a right axillary lymph node.


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!

[email protected]

Documents

Imaging of the Male Breast-Beyond the Basics - tnrad.org · Objectives •Review the indications for male breast imaging •Review normal imaging appearance of the male breast •Illustrate