Transcript Document
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
Male breast carcinoma is a rare disease
< 1% of all malignancies in men 1% of all breast cancers
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 - 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)
Introduction
The two most important disease of the male breast Gynecomastia Breast cancer The majority benign of lesions in male breasts are Other disease arise from the skin&subcutan.
Fat necrosis Lipoma Epidermal inclusion cyst
Imaging of the Male Breast
Mammography
breast carcinoma - diagnose gynecomastia and 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 -
uncommon
less than
1%
men of all malignancies in 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 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 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 50% of cases are present in about
Male Breast Cancer
Diagnostic work-up
: Bilateral Mammography US Biopsy Staging and treatment are similar to those of female breast cancer
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 Cancer
Treatment Same as for women Surgery Axillary node dissection Chemotherapy Radiation therapy Prognosis identical
Male Breast Cancer- Mammographic Appearance Location nipple - Subareolar position , eccentric to the 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
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
Invasive Duct Carcinoma
Invasive Duct Carcinoma
Invasive Duct Carcinoma
Benign Mimics of Male Breast Cancer
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.
Gynecomastia
The hallmark of gynecomastia is its central symmetric location under the nipple Reversible in early stages corrected – if the cause is Reversible phase progress to late periductal edema with irreversible stromal fibrosis
Gynecomastia
Associated with increased levels of estradiol decreased levels of testosterone and Physiologic changes at puberty senescence Endocrine and hormonal disorders Systemic disease Neoplasm Drugs
Physiologic Senescence Puberty Hormonal Klinefelter syn Hypogonadism Systemic disease Cirrhosis Chronic renal insufficiency Idiopathic Causes of Gynecomastia Neoplasm Adrenal carcinoma Pituitary adenoma Hepatocellular carcinoma Drug use Cimetidine Marijuana Thiaside diuretics Omeprazole Tricyclic antidepresasants Spironolactone Diazepam Anabolic steroids Exogenouis estrogen
Gynecomastia
3- mammographic patterns degrees and stages of ductal and stromal proliferation -representing various Nodular Dendritic Diffuse glandular
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.
Nodular subareolar density
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 mammographic findings follow-up evaluation and
US - Early Nodular Gynecomastia
subareolar, fanshaped,hypoechoic nodule surrounded by echogenic normal fatty tissue Hypervascular flow within the mass
Chronic Dendritic Dynecomastia Chronic dendritic gynecomastia (quiescent phase) 20% Patients with gynecomastia > 1 year.
Pathology – gynecomastia fibrous g .- long standing 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.
Dendritic subareolar density with posterior linear projections radiating into the surrounding tissue
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- subareolar hypoechoic nodule with star-shaped projections into the surrounding echogenic fibrous tissue
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
–
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 Gynecomastia Enlargement of the breast and diffuse density with both dendritic and nodular features
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 the breasts , without proliferation of glandular tissue. – a fatty proliferation of Difficult to distinguish from normal male breast on mammography Diagnosis requires clinical correlation with breast enlargement
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
Subtle encapsulated fatty mass (arrows) in the palpated region. Parallel, homogeneous, mildly hyperechoic mass with a capsule (arrow) under the skin.
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 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 Cyst well defined, dense, oval mass contiguous to the skin in the palpated region.
Hypoechoic lesion, which is contiguous to the epidermis (arrows) (the “ claw sign ” ) with increased through transmission
Benign Conditions Associated with Gynecomastia Pseudoangiomatous stromal hyperplasia (PASH) glandular hyperplasia - benign stromal tumor formed by myofibroblasts and with Often incidentally seen in gynecomastia Mammography - noncalcified breast mass, circumscribed or partially circumscribed US - solid circumscribed hyperechoic masses Recurrence is common after resection
PASH Dense circumscribed mass Solid hyperechoic mass with posterior acoustic shadowing
Intraductal Papilloma Intraductal papilloma - benign proliferation of intraductal mammary epithelium. Mammography background of subareolar changes consistent with gynecomastia - discrete dense mass against a 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 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
The majority benign ( 99%) of male breast lesions are 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
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