DOI: 10.1148/rg.264055116
RadioGraphics 2006;26:993-1006
© RSNA, 2006
Imaging Characteristics of Malignant Lesions of the Male Breast1
Lina Chen, MD2,
Prem K. Chantra, MD2,
Linda H. Larsen, MD,
Premsri Barton, MD,
Montanan Rohitopakarn, MD,
Elise Q. Zhu, MD and
Lawrence W. Bassett, MD
1 From the Department of Radiology, University of California, 200 UCLA Medical Plaza, Room 165-47, Los Angeles, CA 90095-6952 (L.C., P.K.C., L.W.B.); the Department of Radiology, West Los Angeles Veterans Administration Healthcare System, Los Angeles, Calif (P.K.C.); the Department of Radiology, University of Southern California Medical Center, Los Angeles, Calif (L.H.L., E.Q.Z.); and the Department of Radiology, Washington University Medical Center, Seattle, Wash (P.B., M.R.). Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received May 12, 2005; revision requested July 8 and received August 22; accepted August 29. All authors have no financial relationships to disclose.
Address correspondence to L.C. (e-mail: lchen_mail{at}yahoo.com).
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Abstract
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Most men referred for breast imaging have palpable lumps, breast enlargement, or tenderness. Most of the evaluated lesions are benign. Male breast cancer accounts for less than 1% of total male breast lesions. Differentiation between benign and malignant masses is critical because it alleviates patient anxiety and allows unnecessary procedures to be avoided. Clinically suspicious lesions referred for imaging should first be evaluated with mammography. In patients with questionable findings at mammography and for lesions that are difficult to image with mammography, ultrasonography (US) is often useful for further characterization. A discrete mass at mammography or US is suspicious for malignancy. The relationship of the mass to the nipple should be carefully assessed; an eccentric location is highly suspicious for cancer. Secondary signs occur earlier in male patients because of smaller breast size. Such signs include nipple retraction, skin ulceration or thickening, increased breast trabeculation, and axillary adenopathy. US of the axillary region is helpful for staging. At pathologic analysis, cystic lesions commonly demonstrate malignant findings; therefore, all cysts and complex masses should be worked up as potentially malignant lesions. Benign conditions that may mimic male breast cancer include gynecomastia, lipoma, epidermal inclusion cyst, pseudoangiomatous stromal hyperplasia, and intraductal papilloma.
© RSNA, 2006
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LEARNING OBJECTIVES FOR TEST 1
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After reading this article and taking the test, the reader will be able to:- Discuss the risk factors for male breast cancer.
- Describe imaging evaluation of a breast mass in a male patient.
- Identify the mammographic and US features of the common benign and malignant lesions of the male breast.
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Introduction
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The breast tissues of both sexes are identical at birth, remaining quiescent until hormonal influence takes place at puberty (1). Estrogen stimulates breast tissue while androgen antagonizes these effects. During the peripubertal period in boys, there is an increase in estrogen level and a 30-fold increase in testosterone level. There is transient proliferation of the ducts and stroma followed by involution and ultimate atrophy of the ducts. Therefore, the normal male breast is characterized primarily by subcutaneous fat and a remnant of subareolar ductal tissue (Fig 1). Lobular development, which requires both estrogen and progesterone, is usually not observed in men. Cooper ligaments, found in female breasts, are absent in male breasts.
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Figure 1a. Normal male breast. (a) Mediolateral oblique mammogram shows the normal male breast, which consists predominantly of subcutaneous fat. Note the lack of the Cooper ligament. (b) Ultrasonographic (US) image obtained with the expanded field of view panoramic technique shows the anatomy of the normal male breast, which consists of the skin and subcutaneous fat. The pectoralis fascia (PF), pectoralis muscle (PM), ribs, and intercostal muscles (ICM) are also shown.
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Figure 1b. Normal male breast. (a) Mediolateral oblique mammogram shows the normal male breast, which consists predominantly of subcutaneous fat. Note the lack of the Cooper ligament. (b) Ultrasonographic (US) image obtained with the expanded field of view panoramic technique shows the anatomy of the normal male breast, which consists of the skin and subcutaneous fat. The pectoralis fascia (PF), pectoralis muscle (PM), ribs, and intercostal muscles (ICM) are also shown.
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Most men referred for breast imaging have palpable lumps, breast enlargement, or tenderness. Differentiation between benign and malignant masses is critical because it alleviates patient anxiety and allows unnecessary procedures to be avoided. The majority of lesions found in male breasts are benign, with gynecomastia being the most common benign entity. Primary breast malignancy accounts for less than 1% of the total lesions (2). Other conditions can arise from the skin, subcutaneous fat, blood vessels, lymphatics, and nerves. Lobular processes such as lobular carcinoma, fibrocystic change, and adenosis are uncommon in males.
In this article, we present the mammographic and US features of the common benign and malignant lesions of the male breast. Specific topics discussed are imaging of the male breast, male breast cancer, other malignant conditions of the male breast, and benign mimics of male breast cancer. This review is based on the results of 719 mammographic studies and 296 US studies of the male breast performed at the authors’ three institutions (Table).
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Imaging of the Male Breast
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The incidence of breast cancer is too low in male patients to justify screening mammography. Therefore, all imaging of the male breast is diagnostic.
There is a wide variability among individual practices in the availability and utilization of mammography and US for male breast imaging. A standard algorithm for evaluation of the male breast has not been suggested in the literature, to our knowledge.
Mammography has been shown to be an accurate method for distinguishing between benign gynecomastia and breast carcinoma (3). Despite the relatively small size of the male breast, our experiences also suggest that mammography is often technically possible and serves as a useful adjunct to clinical examination. The standard mammographic views, craniocaudal and mediolateral oblique, of each breast are routinely obtained. Magnification and spot compression views may also be used.
When mammography yields suspicious findings not characteristic of gynecomastia, US is just as effective for evaluating the male patient as it is for evaluating female patients (4). The small breast size facilitates penetration with a high-frequency transducer, allowing assessment of deeper regions not accessible on mammograms. Our experiences suggest that performing US in the transverse and oblique sagittal planes can allow better correlation with the mammographic craniocaudal and mediolateral oblique views. Stereotactically guided biopsy is usually not feasible in the male breast because of its small size. Therefore, sonographic guidance is commonly performed (2).
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Male Breast Cancer
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Male breast cancer accounts for 0.7% of total breast cancers (5). Over the past 25 years, the incidence of male breast cancer has risen 26%, from 0.86 to 1.08 per 100,000 population (6). The mean age of diagnosis is 67 years, and less than 6% of cases occur in males under the age of 40 years (7).
Risk factors include advanced age, prior irradiation of the chest, exogenous estrogen for prostate cancer treatment and gender-reassignment procedures, liver disease and other diseases associated with hyperestrogenism, androgen deficiency due to testicular dysfunction, and certain genetic and chromosomal conditions such as BRCA2 mutation and Klinefelter syndrome (8). A family history of breast cancer in a first-degree relative increases the risk two- to fourfold (7). Although a correlation between gynecomastia and breast cancer has been suspected, there has been no reported case of such progression (9), to our knowledge.
The most common presentation in these patients is a palpable mass (10). Skin thickening and nipple retraction may be present. Palpable axillary lymph nodes are present in about 50% of cases (1). Diagnostic work-ups include bilateral mammography and US, and the final diagnosis is made with biopsy. Staging and treatment are similar to those of female breast cancer (7).
Mammographic Features
Approximately 85% of primary male breast cancers are invasive ductal carcinoma of the "not otherwise specified" subtype (1). At mammography, these are typically high-density irregular masses with well-defined contours (Figs 2–7). Margins are usually spiculated, lobulated, or microlobulated. Most are retroareolar since male breast cancers commonly arise from central ducts. They can be distinguished from benign gynecomastia by appearing as a discrete mass, commonly with secondary features (Fig 3a). Eccentric location is not typical for benign gynecomastia and is suspicious for carcinoma (Fig 2a).
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Figure 2a. Invasive ductal carcinoma in a 52-year-old man with a palpable mass. (a) Mediolateral oblique mammogram shows an eccentrically located, irregular, indistinct, dense mass (M) deep in the palpated region with overlying skin thickening (S). The entire lesion could not be imaged with mammography because of its peripheral and deep location. (b) Transverse US image of the palpated region shows the nonparallel, hypoechoic, microlobulated mass with surrounding echogenic breast tissue. The overlying skin thickening is also seen.
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Figure 2b. Invasive ductal carcinoma in a 52-year-old man with a palpable mass. (a) Mediolateral oblique mammogram shows an eccentrically located, irregular, indistinct, dense mass (M) deep in the palpated region with overlying skin thickening (S). The entire lesion could not be imaged with mammography because of its peripheral and deep location. (b) Transverse US image of the palpated region shows the nonparallel, hypoechoic, microlobulated mass with surrounding echogenic breast tissue. The overlying skin thickening is also seen.
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Figure 3a. Invasive ductal carcinoma in a 77-year-old man with a 3-month history of a tender subareolar mass. (a) Coned-down craniocaudal mammogram shows a small, irregular, retroareolar density with nipple retraction and skin thickening. (b) Transverse US image of the nipple region shows the irregular, nonparallel, hypoechoic mass with angular margins and an isoechoic halo (*). The overlying low echogenicity corresponds to the nipple retraction and skin thickening seen on the mammogram.
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Figure 3b. Invasive ductal carcinoma in a 77-year-old man with a 3-month history of a tender subareolar mass. (a) Coned-down craniocaudal mammogram shows a small, irregular, retroareolar density with nipple retraction and skin thickening. (b) Transverse US image of the nipple region shows the irregular, nonparallel, hypoechoic mass with angular margins and an isoechoic halo (*). The overlying low echogenicity corresponds to the nipple retraction and skin thickening seen on the mammogram.
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Figure 4a. Invasive ductal carcinoma with ipsilateral axillary lymph node metastasis in a 66-year-old man with a 6-month history of a right breast lump. (a) Mediolateral oblique mammogram of the right breast shows a round, microlobulated, high-density mass in the retroareolar region with increased trabeculation of the entire breast. (b) Transverse US image of the right breast shows the round, microlobulated, hypoechoic, complex mass with posterior acoustic enhancement.
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Figure 4b. Invasive ductal carcinoma with ipsilateral axillary lymph node metastasis in a 66-year-old man with a 6-month history of a right breast lump. (a) Mediolateral oblique mammogram of the right breast shows a round, microlobulated, high-density mass in the retroareolar region with increased trabeculation of the entire breast. (b) Transverse US image of the right breast shows the round, microlobulated, hypoechoic, complex mass with posterior acoustic enhancement.
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Figure 5a. Invasive ductal carcinoma with ipsilateral axillary lymph node metastases in a 49-year-old man with a palpable right breast mass. Physical examination demonstrated that the right breast was markedly larger than the left with induration, erythema, and nipple retraction. There were palpable nodes in the right axillary and supra-clavicular regions. (a) Mediolateral oblique mammogram of the right breast shows an irregular, retroareolar, high-density mass with increased trabeculation of the breast. (b) Craniocaudal mammogram of the right breast shows the high-density mass with microcalcification and overlying skin thickening. (c) Transverse US image of the palpated region shows the irregular hypoechoic mass with punctate calcifications and mild posterior acoustic enhancement. (d) US image of the right axilla shows an irregular hypoechoic mass, which represents an abnormal lymph node.
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Figure 5b. Invasive ductal carcinoma with ipsilateral axillary lymph node metastases in a 49-year-old man with a palpable right breast mass. Physical examination demonstrated that the right breast was markedly larger than the left with induration, erythema, and nipple retraction. There were palpable nodes in the right axillary and supra-clavicular regions. (a) Mediolateral oblique mammogram of the right breast shows an irregular, retroareolar, high-density mass with increased trabeculation of the breast. (b) Craniocaudal mammogram of the right breast shows the high-density mass with microcalcification and overlying skin thickening. (c) Transverse US image of the palpated region shows the irregular hypoechoic mass with punctate calcifications and mild posterior acoustic enhancement. (d) US image of the right axilla shows an irregular hypoechoic mass, which represents an abnormal lymph node.
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Figure 5c. Invasive ductal carcinoma with ipsilateral axillary lymph node metastases in a 49-year-old man with a palpable right breast mass. Physical examination demonstrated that the right breast was markedly larger than the left with induration, erythema, and nipple retraction. There were palpable nodes in the right axillary and supra-clavicular regions. (a) Mediolateral oblique mammogram of the right breast shows an irregular, retroareolar, high-density mass with increased trabeculation of the breast. (b) Craniocaudal mammogram of the right breast shows the high-density mass with microcalcification and overlying skin thickening. (c) Transverse US image of the palpated region shows the irregular hypoechoic mass with punctate calcifications and mild posterior acoustic enhancement. (d) US image of the right axilla shows an irregular hypoechoic mass, which represents an abnormal lymph node.
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Figure 5d. Invasive ductal carcinoma with ipsilateral axillary lymph node metastases in a 49-year-old man with a palpable right breast mass. Physical examination demonstrated that the right breast was markedly larger than the left with induration, erythema, and nipple retraction. There were palpable nodes in the right axillary and supra-clavicular regions. (a) Mediolateral oblique mammogram of the right breast shows an irregular, retroareolar, high-density mass with increased trabeculation of the breast. (b) Craniocaudal mammogram of the right breast shows the high-density mass with microcalcification and overlying skin thickening. (c) Transverse US image of the palpated region shows the irregular hypoechoic mass with punctate calcifications and mild posterior acoustic enhancement. (d) US image of the right axilla shows an irregular hypoechoic mass, which represents an abnormal lymph node.
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Figure 6a. Bilateral invasive ductal carcinoma with left axillary lymph node metastasis in a patient with a family history of breast cancer who presented with bilateral palpable breast lumps. (a) Craniocaudal mammograms show bilateral lobulated, high-density, retroareolar masses. (b, c) Longitudinal US images of the right (b) and left (c) breasts show the bilateral nonparallel lobulated masses, which are adjacent to but separate from the nipples. The masses are predominantly hypoechoic with mixed internal echogenicity.
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Figure 6b. Bilateral invasive ductal carcinoma with left axillary lymph node metastasis in a patient with a family history of breast cancer who presented with bilateral palpable breast lumps. (a) Craniocaudal mammograms show bilateral lobulated, high-density, retroareolar masses. (b, c) Longitudinal US images of the right (b) and left (c) breasts show the bilateral nonparallel lobulated masses, which are adjacent to but separate from the nipples. The masses are predominantly hypoechoic with mixed internal echogenicity.
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Figure 6c. Bilateral invasive ductal carcinoma with left axillary lymph node metastasis in a patient with a family history of breast cancer who presented with bilateral palpable breast lumps. (a) Craniocaudal mammograms show bilateral lobulated, high-density, retroareolar masses. (b, c) Longitudinal US images of the right (b) and left (c) breasts show the bilateral nonparallel lobulated masses, which are adjacent to but separate from the nipples. The masses are predominantly hypoechoic with mixed internal echogenicity.
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Figure 7a. Bilateral invasive ductal carcinoma with bilateral axillary lymph node metastases in a 48-year-old man with Klinefelter syndrome and a history of bilateral breast lumps for several months. (a) Mediolateral oblique mammograms show bilateral large, retroareolar, spiculated, high-density masses with skin thickening and nipple retraction. (b) Transverse US image of the nipple region of the right breast shows the hypoechoic and irregular retroareolar mass with spiculation and angular margins. There is mild posterior acoustic shadowing. (c) US image of the right axilla shows a hypoechoic lobulated mass, which represents metastatic cancer in a lymph node. Similar US findings were seen on images of the left breast and axilla.
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Figure 7b. Bilateral invasive ductal carcinoma with bilateral axillary lymph node metastases in a 48-year-old man with Klinefelter syndrome and a history of bilateral breast lumps for several months. (a) Mediolateral oblique mammograms show bilateral large, retroareolar, spiculated, high-density masses with skin thickening and nipple retraction. (b) Transverse US image of the nipple region of the right breast shows the hypoechoic and irregular retroareolar mass with spiculation and angular margins. There is mild posterior acoustic shadowing. (c) US image of the right axilla shows a hypoechoic lobulated mass, which represents metastatic cancer in a lymph node. Similar US findings were seen on images of the left breast and axilla.
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Figure 7c. Bilateral invasive ductal carcinoma with bilateral axillary lymph node metastases in a 48-year-old man with Klinefelter syndrome and a history of bilateral breast lumps for several months. (a) Mediolateral oblique mammograms show bilateral large, retroareolar, spiculated, high-density masses with skin thickening and nipple retraction. (b) Transverse US image of the nipple region of the right breast shows the hypoechoic and irregular retroareolar mass with spiculation and angular margins. There is mild posterior acoustic shadowing. (c) US image of the right axilla shows a hypoechoic lobulated mass, which represents metastatic cancer in a lymph node. Similar US findings were seen on images of the left breast and axilla.
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Microcalcification is less commonly seen in males than in females (Fig 5b). It occurs primarily in ductal carcinoma in situ components of tumors, which are not frequently present in male breast cancer (11). Nipple retraction, skin thickening, and increased trabeculation are helpful secondary signs and carry a poor prognosis (Figs 2a, 3a, 4a, 5a, 5b, 7a). They are seen in a larger percentage of men and occur at a smaller lesion size than in women because the male breast is smaller (2).
In our series, two of six patients had bilateral breast cancers, including one patient with Klinefelter syndrome (Fig 7). Klinefelter syndrome is a rare genetic condition (XXY) characterized by reduced or absent sperm production, small testes, and enlarged breasts. These patients have an elevated blood estrogen-to-androgen ratio and therefore a 3% risk and 20-fold increased incidence of breast cancer (12). They are also more likely to have bilateral breast cancer. Other authors have described bilateral breast cancer in 1.4% of male patients (13). Bilateral mammography should always be performed since risk factors predisposing one breast to developing cancer will also affect the other breast.
One of our patients presented with an axillary mass (Fig 8). His mammograms showed only minimal density in the subareolar area. Biopsy of the breast yielded benign tissue. Fine-needle aspiration of the axillary lymph node revealed meta-static adenocarcinoma. Breast cancer manifesting as primary axillary lymph node metastasis is rare, accounting for less than 1% of all male breast cancers (14).
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Figure 8a. Metastatic adenocarcinoma in an axillary lymph node with occult primary breast cancer in a 77-year-old man with a left axillary mass. Fine-needle aspiration of the axillary lymph node demonstrated an adenocarcinoma with mucin. Surgical biopsy of the breast tissue demonstrated no histopathologic abnormality. (a) Coned-down mediolateral oblique mammogram shows minimal glandular density in the subareolar area. (b) Transverse US image of the nipple region shows nipple shadowing. (c) US image of the left axilla shows a lobulated hypoechoic mass, which represents an enlarged lymph node.
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Figure 8b. Metastatic adenocarcinoma in an axillary lymph node with occult primary breast cancer in a 77-year-old man with a left axillary mass. Fine-needle aspiration of the axillary lymph node demonstrated an adenocarcinoma with mucin. Surgical biopsy of the breast tissue demonstrated no histopathologic abnormality. (a) Coned-down mediolateral oblique mammogram shows minimal glandular density in the subareolar area. (b) Transverse US image of the nipple region shows nipple shadowing. (c) US image of the left axilla shows a lobulated hypoechoic mass, which represents an enlarged lymph node.
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Figure 8c. Metastatic adenocarcinoma in an axillary lymph node with occult primary breast cancer in a 77-year-old man with a left axillary mass. Fine-needle aspiration of the axillary lymph node demonstrated an adenocarcinoma with mucin. Surgical biopsy of the breast tissue demonstrated no histopathologic abnormality. (a) Coned-down mediolateral oblique mammogram shows minimal glandular density in the subareolar area. (b) Transverse US image of the nipple region shows nipple shadowing. (c) US image of the left axilla shows a lobulated hypoechoic mass, which represents an enlarged lymph node.
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US Features
Male breast cancers have similar US features as in women. All of our invasive ductal carcinoma cases were nonparallel, discrete, hypoechoic masses. The margins are angulated (Fig 3b), microlobulated (Fig 2b), or spiculated (Fig 7b). Microcalcification can be seen as punctate high echogenicity at US (Fig 5c). Posterior acoustic features are not helpful for distinguishing benign versus malignant lesions, since four of our breast cancer cases had no posterior acoustic feature, two had posterior enhancement, and two had posterior acoustic shadowing.
In our experience, sonography is helpful in assessing the relationship of the mass to the nipple. A retroareolar mass at mammography may be seen clearly eccentric to the nipple at US (Fig 6). Skin thickening and nipple retraction can also be easily appreciated at US (Figs 2b, 3b). US is also useful for lesions located deep in the breast, which may be difficult to see at mammography (Fig 2).
When evaluating a suspicious breast lesion, US of the axillary region should be routinely performed (Figs 5d, 7c, 8c). Enlarged axillary lymph nodes occur in 50% of male patients with breast cancer.
One of our cancer patients presented with a complex mass with both solid and cystic components at US (Fig 4b). Other investigators have also reported male breast malignancy presenting as complex masses, with the majority of histopathologic outcomes being papillary ductal carcinoma in situ. Therefore, a circumscribed mass at mammography with cystic components at sonography in a male patient must be considered suspicious for malignancy (15).
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Other Malignant Conditions of the Male Breast
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Lymphoma
The majority of unilateral axillary lymphadenopathy is due to benign conditions such as reactive hyperplasia, infection, or granulomatous disease. The most common causes of malignant lymph nodes include lymphoma and metastatic disease from breast cancer, lung cancer, melanoma, and squamous cell cancer (16). Forty-four percent of cases of breast lymphoma are primary, although 22% are manifestations of disseminated disease and 29% represent recurrence of preexisting lymphoma (17).
Mammograms of our patient with Hodgkin lymphoma showed no breast mass but multiple enlarged dense left axillary lymph nodes (Fig 9a, 9b). A patient with mantle cell lymphoma had mammograms showing multiple circumscribed oval and lobular subcutaneous lymph nodes (Fig 10a). Mantle cell lymphoma is a form of B-cell lymphoma that usually manifests as disseminated disease (16). The sonographic features of malignant lymph nodes include an irregularly thickened cortex and distorted or absent fatty hila (Figs 5d, 7c, 8c, 9c, 10b).
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Figure 9a. Hodgkin lymphoma in a 58-year-old man with a new lump in the left axilla and hardening of the left breast associated with intermittent pain. (a, b) Bilateral mediolateral oblique mammograms (a) and coned-down views of the axilla (b) show no suspicious breast mass. However, there are multiple enlarged dense lymph nodes in the left axilla (b). (c) US image of the left axilla shows one of the large hypoechoic masses with loss of normal architecture.
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Figure 9b. Hodgkin lymphoma in a 58-year-old man with a new lump in the left axilla and hardening of the left breast associated with intermittent pain. (a, b) Bilateral mediolateral oblique mammograms (a) and coned-down views of the axilla (b) show no suspicious breast mass. However, there are multiple enlarged dense lymph nodes in the left axilla (b). (c) US image of the left axilla shows one of the large hypoechoic masses with loss of normal architecture.
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Figure 9c. Hodgkin lymphoma in a 58-year-old man with a new lump in the left axilla and hardening of the left breast associated with intermittent pain. (a, b) Bilateral mediolateral oblique mammograms (a) and coned-down views of the axilla (b) show no suspicious breast mass. However, there are multiple enlarged dense lymph nodes in the left axilla (b). (c) US image of the left axilla shows one of the large hypoechoic masses with loss of normal architecture.
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Figure 10a. Mantle cell lymphoma in a 51-year-old man with dyspnea due to pleural effusion. Bilateral breast masses were found at admission; CT showed mediastinal, retroperitoneal, and pelvic masses. (a) Mammograms show bilateral circumscribed, oval or lobular, high-density masses. (b) Longitudinal US image shows one of the hypoechoic, circumscribed, microlobulated masses.
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Figure 10b. Mantle cell lymphoma in a 51-year-old man with dyspnea due to pleural effusion. Bilateral breast masses were found at admission; CT showed mediastinal, retroperitoneal, and pelvic masses. (a) Mammograms show bilateral circumscribed, oval or lobular, high-density masses. (b) Longitudinal US image shows one of the hypoechoic, circumscribed, microlobulated masses.
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Dermatofibrosarcoma
Dermatofibrosarcoma is an uncommon, slow-growing, but locally aggressive fibrous tumor also called spindle cell tumor. It is more common in males than females, usually occurring between the ages of 20 and 50 years. There is a high rate of local recurrence after surgical excision, and complete resection is recommended (18). Our patient with this diagnosis initially presented with a palpable small right breast mass. Mammograms showed a high-density mass with ill-defined margins, and US revealed a lobulated hyperechoic mass (Fig 11a, 11b). He underwent right breast lumpectomy but presented 3 years later with a new lump at the surgical site. Mammograms obtained during the second presentation again showed a high-density irregular mass, with US demonstrating a mass with mixed echogenicity (Fig 11c, 11d). Fine-needle aspiration again revealed spindle cell tumor, identical to the initial surgical specimen.
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Figure 11a. Dermatofibro-sarcoma in a 49-year-old man who initially presented with a palpable small right breast mass and underwent right breast lumpectomy. He presented 3 years later with a new lump at the surgical site. (a) Mammogram (magnification view) from the initial presentation shows a small spiculated mass. (b) Transverse US image of the palpated region shows the hyperechoic mass with lobulated margins extending to the dermis. (c) Craniocaudal mammogram from the second presentation shows a spiculated mass in the same region. (d) Transverse US image of the palpated region shows the superficial lobulated mass with mixed internal echogenicity.
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Figure 11b. Dermatofibro-sarcoma in a 49-year-old man who initially presented with a palpable small right breast mass and underwent right breast lumpectomy. He presented 3 years later with a new lump at the surgical site. (a) Mammogram (magnification view) from the initial presentation shows a small spiculated mass. (b) Transverse US image of the palpated region shows the hyperechoic mass with lobulated margins extending to the dermis. (c) Craniocaudal mammogram from the second presentation shows a spiculated mass in the same region. (d) Transverse US image of the palpated region shows the superficial lobulated mass with mixed internal echogenicity.
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Figure 11c. Dermatofibro-sarcoma in a 49-year-old man who initially presented with a palpable small right breast mass and underwent right breast lumpectomy. He presented 3 years later with a new lump at the surgical site. (a) Mammogram (magnification view) from the initial presentation shows a small spiculated mass. (b) Transverse US image of the palpated region shows the hyperechoic mass with lobulated margins extending to the dermis. (c) Craniocaudal mammogram from the second presentation shows a spiculated mass in the same region. (d) Transverse US image of the palpated region shows the superficial lobulated mass with mixed internal echogenicity.
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Figure 11d. Dermatofibro-sarcoma in a 49-year-old man who initially presented with a palpable small right breast mass and underwent right breast lumpectomy. He presented 3 years later with a new lump at the surgical site. (a) Mammogram (magnification view) from the initial presentation shows a small spiculated mass. (b) Transverse US image of the palpated region shows the hyperechoic mass with lobulated margins extending to the dermis. (c) Craniocaudal mammogram from the second presentation shows a spiculated mass in the same region. (d) Transverse US image of the palpated region shows the superficial lobulated mass with mixed internal echogenicity.
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Benign Mimics of Male Breast Cancer
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Gynecomastia
Gynecomastia is the most common benign condition of the male breast (19). It is enlargement of the male breast due to benign ductal and stromal proliferation. It can be unilateral, bilateral symmetric, or bilateral asymmetric. The hallmark of gynecomastia is its central symmetric location under the nipple. Three mammographic patterns of gynecomastia have been described representing various degrees and stages of ductal and stromal proliferation (20). They are the nodular, dendritic, and diffuse glandular patterns.
Early nodular gynecomastia (florid phase) is seen in patients with gynecomastia for less than 1 year. The majority of patients who seek medical attention will present with nipple tenderness or a palpable lump, which has persisted for months. At mammography, there is nodular subareolar density (Fig 12a). At US, there is a subareolar fan- or disk-shaped hypoechoic nodule surrounded by normal fatty tissue (Fig 12b). The zone of transition may be poorly defined, but the lobular margin can usually be appreciated. Hypervascularity can be seen secondary to stromal proliferation (Fig 12c). The typical mammographic appearance of gynecomastia usually confirms the diagnosis and requires no further imaging work-up. In cases of equivocal clinical and mammographic findings, US or follow-up evaluation should be considered.
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Figure 12a. Early nodular gynecomastia. (a) Craniocaudal mammogram shows a nodular subareolar density. (b) Transverse US image shows the subareolar, fan-shaped, hypoechoic nodule surrounded by echogenic normal fatty tissue. (c) Color Doppler image shows hyper-vascular flow within the mass.
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Figure 12b. Early nodular gynecomastia. (a) Craniocaudal mammogram shows a nodular subareolar density. (b) Transverse US image shows the subareolar, fan-shaped, hypoechoic nodule surrounded by echogenic normal fatty tissue. (c) Color Doppler image shows hyper-vascular flow within the mass.
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Figure 12c. Early nodular gynecomastia. (a) Craniocaudal mammogram shows a nodular subareolar density. (b) Transverse US image shows the subareolar, fan-shaped, hypoechoic nodule surrounded by echogenic normal fatty tissue. (c) Color Doppler image shows hyper-vascular flow within the mass.
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Chronic dendritic gynecomastia (quiescent phase) is seen in patients with gynecomastia for longer than 1 year. Fibrosis becomes the dominant process and is irreversible. Mammograms typically show dendritic subareolar density with posterior linear projections radiating into the surrounding tissue toward the upper-outer quadrant (Fig 13a). At sonography, there is a subareolar hypoechoic lesion with an anechoic star-shaped posterior border, which can be described as fingerlike projections or "spider legs" insinuating into the surrounding echogenic fibrous breast tissue (Fig 13b). For the unfamiliar interpreter, the appearance may look suspicious for malignancy. However, a useful feature that suggests its benignity is that this star-shaped mass arises directly from the undersurface of the nipple without causing any overlying skin thickening or nipple retraction. The clinical history, particularly the duration of symptoms, can also be helpful in making this diagnosis. A number of patients may have an acute episode of gynecomastia in addition to chronic dendritic gynecomastia. Therefore, both phases can be seen at imaging simultaneously.
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Figure 13a. Chronic dendritic gynecomastia. (a) Craniocaudal mammogram shows a dendritic subareolar density with posterior linear projections radiating into the surrounding tissue. (b) Transverse US image shows the subareolar hypoechoic nodule with star-shaped projections into the surrounding echogenic fibrous tissue.
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Figure 13b. Chronic dendritic gynecomastia. (a) Craniocaudal mammogram shows a dendritic subareolar density with posterior linear projections radiating into the surrounding tissue. (b) Transverse US image shows the subareolar hypoechoic nodule with star-shaped projections into the surrounding echogenic fibrous tissue.
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Diffuse glandular gynecomastia is commonly seen in patients receiving exogenous estrogen. At mammography, there is enlargement of the breast and diffuse density with both dendritic and nodular features (Fig 14a). At sonography, both nodular and dendritic features are seen surrounded by diffuse hyperechoic fibrous breast tissue (Fig 14b). The distinguishing feature from malignancy is the extensive disease without a discrete mass and absence of secondary signs.
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Figure 14a. Diffuse gynecomastia. (a) Craniocaudal mammogram shows enlargement of the breast and diffuse density with both dendritic and nodular features. (b) Transverse US image shows the diffusely heterogeneous breast with both nodular and dendritic projections surrounded by diffuse hyperechoic fibrous tissue.
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Figure 14b. Diffuse gynecomastia. (a) Craniocaudal mammogram shows enlargement of the breast and diffuse density with both dendritic and nodular features. (b) Transverse US image shows the diffusely heterogeneous breast with both nodular and dendritic projections surrounded by diffuse hyperechoic fibrous tissue.
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Less Common Benign Conditions
Lipoma is the second most common benign lesion in the male breast (2). Mammography typically shows a subtle encapsulated fatty mass in the palpated area (Fig 15a). US usually demonstrates one or multiple parallel, homogeneous, and mildly hyperechoic masses under the skin (Fig 15b). A capsule is sometimes seen.
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Figure 15a. Lipoma. (a) Craniocaudal mammogram shows a subtle encapsulated fatty mass (arrows) in the palpated region. (b) Transverse US image shows the parallel, homogeneous, mildly hyperechoic mass with a capsule (arrow) under the skin.
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Figure 15b. Lipoma. (a) Craniocaudal mammogram shows a subtle encapsulated fatty mass (arrows) in the palpated region. (b) Transverse US image shows the parallel, homogeneous, mildly hyperechoic mass with a capsule (arrow) under the skin.
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Epidermal inclusion cyst is the third most common benign lesion in the male breast. Most often, these cysts arise from obstructed or occluded hair follicles, at the sites of previous skin trauma such as a surgical wound or insect bites (21). The "cyst" may be a misnomer because they are composed of laminated keratin surrounded by stratified squamous epithelium. Mammograms reveal a well-defined dense oval mass contiguous with the skin in the palpable area (Fig 16a). An important sonographic feature is a hypoechoic lesion that is contiguous with the epidermis, the claw sign (Fig 16b), with increased through transmission. This feature is the key to distinguishing this benign condition from cystic malignancies of the male breast.
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Figure 16a. Epidermal inclusion cyst. (a) Mammogram (spot magnification view) shows a well-defined, dense, oval mass contiguous to the skin in the palpated region. (b) Transverse US image shows the hypoechoic lesion, which is contiguous to the epidermis (arrows) (the "claw sign") with increased through transmission.
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Figure 16b. Epidermal inclusion cyst. (a) Mammogram (spot magnification view) shows a well-defined, dense, oval mass contiguous to the skin in the palpated region. (b) Transverse US image shows the hypoechoic lesion, which is contiguous to the epidermis (arrows) (the "claw sign") with increased through transmission.
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Benign Conditions Associated with Gynecomastia
Pseudoangiomatous stromal hyperplasia is a benign stromal tumor formed by myofibroblasts and with glandular hyperplasia in some cases (22). Pseudoangiomatous stromal hyperplasia is often incidentally seen in gynecomastia. The usual presentation is a noncalcified breast mass, circumscribed or partially circumscribed at mammography (Fig 17a). US findings are solid circumscribed hyperechoic masses (Fig 17b). Recurrence is common after resection.
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Figure 17a. Pseudoangiomatous stromal hyperplasia. (a) Coned-down mammogram shows a dense circumscribed mass. (b) Transverse US image shows the solid hyperechoic mass with posterior acoustic shadowing.
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Figure 17b. Pseudoangiomatous stromal hyperplasia. (a) Coned-down mammogram shows a dense circumscribed mass. (b) Transverse US image shows the solid hyperechoic mass with posterior acoustic shadowing.
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Intraductal papilloma is a benign proliferation of intraductal mammary epithelium. Mammography usually shows a discrete dense mass against a background of subareolar changes consistent with gynecomastia (Fig 18a). US features include multiple eccentric, subareolar, elongated and well-defined hypoechoic masses, which have irregular shapes and are possibly confined to the lumina of markedly enlarged central ducts (Fig 18b). There are cystic areas, which may represent associated ductal ectasia (Fig 18c).
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Figure 18a. Intraductal papilloma. (a) Craniocaudal mammogram shows a discrete dense mass against a background of subareolar density, which is consistent with gynecomastia. (b) Transverse US image shows multiple eccentric, subareolar, elongated, well-defined, hypoechoic masses, which have irregular shapes and are possibly confined to the lumina of markedly enlarged central ducts. (c) Longitudinal US image shows cystic areas, which may represent associated ductal ectasia.
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Figure 18b. Intraductal papilloma. (a) Craniocaudal mammogram shows a discrete dense mass against a background of subareolar density, which is consistent with gynecomastia. (b) Transverse US image shows multiple eccentric, subareolar, elongated, well-defined, hypoechoic masses, which have irregular shapes and are possibly confined to the lumina of markedly enlarged central ducts. (c) Longitudinal US image shows cystic areas, which may represent associated ductal ectasia.
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Abstract
LEARNING OBJECTIVES FOR TEST...
