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The Male Breast. M.Sklair -Levy, M.D Radiology Department Sheba Medical Center Israel. The Male Breast . Clinical symptoms Unilateral, bilateral breast enlargement Breast pain Breast lump Most of the evaluated lesions are benign Most related to gynecomastia. Introduction .

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The male breast

The Male Breast

M.Sklair-Levy, M.D

Radiology Department

Sheba Medical Center

Israel


The male breast1
The Male Breast

  • Clinical symptoms

    • Unilateral, bilateral breast enlargement

    • Breast pain

    • Breast lump

  • Most of the evaluated lesions are benign

  • Most related to gynecomastia


Introduction
Introduction

  • Male breast carcinoma is a rare disease

    • < 1% of all malignancies in men

    • 1% of all breast cancers


Introduction1
Introduction

  • Clinically suspicious lesions

  • Imaging evaluation

    • Mammography

    • US - In patients with questionable findings at mammography and for lesions that are difficult to image with mammography

  • The relationship of the mass to the nipple should be carefully assessed

    • an eccentric location is highly suspicious for cancer.


Breast Development

  • The breast tissues of both sexes are identical at birth

    • Estrogen stimulates breast tissue

    • Androgen antagonizes these effects

  • At puberty in boys - increase in estrogen,testosterone

    • Transient proliferation of the ducts and stroma

    • Followed by involution and ultimate atrophy of the ducts.


Normal male breast

Characterized:

Subcutaneous fat

Remnant of subareolar ductal tissue

Lobular development - which requires both estrogen and progesterone, is usually not observed in men

Normal Male Breast


Normal male breast us
Normal Male Breast - US

Anatomy of the normal male breast- consists of the skin and subcutaneous fat. The pectoralis fascia (PF), pectoralis muscle (PM), ribs,and intercostal muscles (ICM)


Introduction2
Introduction

  • The two most important disease of the male breast

    • Gynecomastia

    • Breast cancer

  • The majority of lesions in male breasts are benign

  • Other disease arise from the skin&subcutan.

    • Fat necrosis

    • Lipoma

    • Epidermal inclusion cyst


Imaging of the male breast
Imaging of the Male Breast

  • Mammography - diagnose gynecomastia and breast carcinoma

    • Diagnostic mammography

  • Standard mammographic views - CC & MLO

    • Magnification and spot compression views

  • US- suspicious findings on mammography

    • effective for evaluating male patient as it is for female


Male breast cancer
Male Breast Cancer

  • Male breast cancer - uncommon

    • less than 1% of all malignancies in men

    • only 1% of all breast cancers

  • The mean age of diagnosis is 67 years

    • Less than 6% of cases occur in males under the age of 40 years.


Male breast cancer1
Male Breast Cancer

Risk factors

  • advanced age

  • prior irradiation of the chest

  • exogenous estrogen for prostate cancer treatment

  • gender-reassignment procedures

  • liver disease and other diseases associated with hyperestrogenism, androgen deficiency due to testicular dysfunction

  • genetic and chromosomal conditions - BRCA2 , Klinefelter syndrome


Male breast cancer2
Male Breast Cancer

  • Clinical manifestation– hard , fixed , painless mass

    • Bloody nipple discharge common

  • Secondary signs occur earlier in male patients because of smaller breast size.

    • nipple retraction, skin ulceration,thickening,increased breast trabeculation

  • Palpable axillary lymph nodes are present in about 50% of cases


Male breast cancer3
Male Breast Cancer

  • Diagnostic work-up:

    • Bilateral Mammography

    • US

    • Biopsy

  • Staging and treatment are similar to those of female breast cancer


Male breast cancer4
Male Breast Cancer

  • Histologic subtype :

    • Invasive ductul carcinoma- most common – 85%

    • Ductal carcinoma in situ

    • Male breast contains only ducts

    • Invasive lobular – rare –

      • No lobules formation in male breast


Male breast cancer5
Male Breast Cancer

  • Treatment

    • Same as for women

      • Surgery

      • Axillary node dissection

      • Chemotherapy

      • Radiation therapy

  • Prognosis identical


Male breast cancer mammographic appearance
Male Breast Cancer- Mammographic Appearance

  • Location - Subareolar position , eccentric to the nipple

  • Margins– well-defined, ill-defined, spiculated

  • Shape– round, oval, irregular , lobulated

  • Calcification– few , coarser

  • Secondary signs– skin thickening, nipple retraction , axillary lymphadenopathy


Us features male breast cancer
US Features-Male Breast Cancer

  • Male breast cancers have similar US features as in women

    • Masses - nonparallel, discrete, hypoechoic.

    • Margins - angulated , microlobulated, or spiculated

    • Microcalcification - punctate high echogenicity

    • Posterior acoustic features are not helpful for distinguishing benign versus malignant lesions

      • no posterior acoustic feature

      • posterior enhancement

      • posterior acoustic shadowing






Gynecomastia
Gynecomastia

  • Gynecomastia is the most common benign condition of the male breast

  • It is enlargement of the male breast due to benign ductal and stromal proliferation.

    • Causes breast enlargement /subareolar mass with/without associated breast pain

  • It can be unilateral, bilateral symmetric, or bilateral asymmetric.


Gynecomastia1
Gynecomastia

  • The hallmark of gynecomastia is its central symmetric location under the nipple

  • Reversible in early stages– if the cause is corrected

    • Reversible phase progress to late periductal edema with irreversible stromal fibrosis


Gynecomastia2
Gynecomastia

  • Associated with increased levels of estradiol and decreased levels of testosterone

    • Physiologic changes at puberty senescence

    • Endocrine and hormonal disorders

    • Systemic disease

    • Neoplasm

    • Drugs


Causes of gynecomastia

Physiologic

Senescence

Puberty

Hormonal

Klinefelter syn

Hypogonadism

Systemic disease

Cirrhosis

Chronic renal insufficiency

Idiopathic

Neoplasm

Adrenal carcinoma

Pituitary adenoma

Hepatocellular carcinoma

Drug use

Cimetidine

Marijuana

Thiaside diuretics

Omeprazole

Tricyclic antidepresasants

Spironolactone

Diazepam

Anabolic steroids

Exogenouis estrogen

Causes of Gynecomastia


Gynecomastia3
Gynecomastia

  • 3- mammographic patterns -representing various degrees and stages of ductal and stromal proliferation

    • Nodular

    • Dendritic

    • Diffuse glandular


Gynecomastia4
Gynecomastia

  • Nodular G.- most common–77%

  • Pathology– florid g. –early phase

    • patients with gynecomastia < 1year

  • The majority of patients will present with

    • nipple tenderness , palpable lump

  • Mammography-nodular subareolar density

    • The typical mammographic confirms the diagnosis and requires no further imaging work-up.


Mammography nodular g
Mammography - Nodular G.

Nodular subareolar density


Nodular g
Nodular G

  • US- a subareolar fan- or disk-shaped hypoechoic nodule surrounded by normal fatty tissue

    • The zone of transition may be poorly defined, with lobular margin

    • Hypervascularity can be seen secondary to stromal proliferation

  • US - In cases of equivocal clinical and mammographic findings

    • follow-up evaluation


Us early nodular gynecomastia
US - Early Nodular Gynecomastia

Hypervascular flow within the mass

subareolar, fanshaped,hypoechoic nodule surrounded by echogenic normal fatty tissue


Chronic dendritic dynecomastia
Chronic Dendritic Dynecomastia

  • Chronic dendritic gynecomastia (quiescent phase) -20%

    • Patients with gynecomastia > 1 year.

    • Pathology–fibrous g.- long standing gynecomastia

    • Fibrosis becomes the dominant process and is irreversible.

  • Mammography - dendritic subareolar density with posterior linear projections radiating into the surrounding tissue toward the uoq


Mammography chronic dendritic g
Mammography - Chronic Dendritic G.

Dendritic subareolar density with posterior linear projections radiating into the surrounding tissue


Chronic dendritic gynecomastia
Chronic Dendritic Gynecomastia

  • US- a subareolar hypoechoic star-shaped, fingerlike projections or “spider legs”

    • benignity - directly from the undersurface of the nipple without causing any overlying skin thickening or nipple retraction.


Us chronic dendritic gynecomastia
US- Chronic Dendritic Gynecomastia

US- subareolar hypoechoic nodule with star-shaped projections into the surrounding echogenic fibrous tissue


Chronic dendritic gynecomastia1
Chronic Dendritic Gynecomastia

  • The clinical history, particularly the duration of symptoms, can also be helpful in making this diagnosis.

    • patients may have an acute episode of gynecomastia in addition to chronic dendritic gynecomastia.

      • both phases can be seen at imaging simultaneously.


Diffuse glandular gynecomastia
Diffuse Glandular Gynecomastia

  • Diffuse glandular–3%

    • Patients receiving exogenous estrogen

  • Mammography- enlargement of the breast , similar to heterogeneously dense female breast

  • Irreversible stromal fibrosis and ductal epithelial atrophy develop, the breast enlargement may decrease but not completely resolve.


Diffuse glandular gynecomastia1
Diffuse Glandular Gynecomastia

Enlargement of the breast and diffuse density with both dendritic and nodular features


Diffuse glandular gynecomastia2
Diffuse Glandular Gynecomastia

  • US - both nodular and dendritic features are seen surrounded by diffuse hyperechoic fibrous breast tissue


Diffuse Glandular Gynecomastia

Heterogeneous breast with both nodular and dendritic projections surrounded by diffuse hyperechoic fibrous tissue.


Pseudogynecomastia
Pseudogynecomastia

  • Pseudogynecomastia – a fatty proliferation of the breasts , without proliferation of glandular tissue.

  • Difficult to distinguish from normal male breast on mammography

  • Diagnosis requires clinical correlation with breast enlargement


Less common benign conditions
Less Common Benign Conditions

  • Lipoma - second most common benign lesion in the male breast

  • Mammography typically shows a subtle encapsulated fatty mass in the palpated area

  • US - demonstrates one or multiple parallel, homogeneous, and mildly hyperechoic masses under the skin

    • capsule is sometimes seen


Lipoma
Lipoma

Parallel, homogeneous, mildly hyperechoic mass with a capsule (arrow) under the skin.

Subtle encapsulated fatty mass (arrows) in the palpated region.


Epidermal inclusion cyst
Epidermal Inclusion Cyst

  • Epidermal inclusion cyst is the third most common benign lesion in the male breast

  • Arise from obstructed or occluded hair follicles, at the sites of previous skin trauma such as a surgical wound or insect bites

  • Composed of laminated keratin surrounded by stratified squamous epithelium


Epidermal inclusion cyst1
Epidermal Inclusion Cyst

  • Mammography- well-defined dense oval mass contiguous with the skin in the palpable area

  • US- hypoechoic lesion that is contiguous with the epidermis, the claw sign , with increased through transmission.

    • This feature is the key to distinguishing this benign condition from cystic malignancies of the male breast.


Epidermal inclusion cyst2
Epidermal Inclusion Cyst

Hypoechoic lesion, which is contiguous to the epidermis (arrows) (the “claw sign”) with increased through transmission

well defined, dense, oval mass contiguous to the skin in the palpated region.


Benign conditions associated with gynecomastia
Benign ConditionsAssociated with Gynecomastia

  • Pseudoangiomatous stromal hyperplasia (PASH)- benign stromal tumor formed by myofibroblasts and with glandular hyperplasia

    • Often incidentally seen in gynecomastia

  • Mammography- noncalcified breast mass, circumscribed or partially circumscribed

  • US - solid circumscribed hyperechoic masses

  • Recurrence is common after resection


PASH

Solid hyperechoic mass with posterior acoustic shadowing

Dense circumscribed mass


Intraductal papilloma
Intraductal Papilloma

  • Intraductal papilloma - benign proliferation of intraductal mammary epithelium.

  • Mammography - discrete dense mass against a background of subareolar changes consistent with gynecomastia

  • US– multiple eccentric, subareolar, elongated and welldefined hypoechoic masses, which have irregular shapes and are possibly confined to the lumina of markedly enlarged central ducts

    • cystic areas - represent associated ductal ectasia


Intraductal papilloma1
Intraductal papilloma

US-multiple eccentric, subareolar, elongated,well-defined, hypoechoic masses ;US image shows cystic areas, which may

represent associated ductal ectasia.

discrete dense mass against a background of subareolar density, which consistent with gynecomastia


Conclusions
Conclusions

  • The majority (99%) of male breast lesions are benign

  • Mammography- for clinically suspicious lesions

    • accurate for diagnosing gynecomastia

  • US useful for further characterization

  • The relationship of the mass to the nipple should be carefully assessed

    • Eccentric location is highly suspicious for cancer

    • US of the axillary region is helpful for staging


Conclusions1
Conclusions

  • In men - cystic lesions commonly malignant

    • Cysts and complex masses should be worked up as potentially malignant lesions

  • Suspicious lesion - biopsy - US guidance is usually preferred



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