Male Breast Cancer Imaging

Breast cancer in men is a rare entity with less than one percent of all breast cancers occurring in men (1). However, when considering the absolute number of men affected by breast cancer every year, male breast cancer should not be ignored. Nearly 2,000 men will be diagnosed with breast cancer in the United States every year and on average, will present with a more advanced disease state compared to women (2). Invasive ductal carcinoma is the most common breast cancer in men, as it is in women. The median age of diagnosis is 67 years in males versus 61 years in females (2). Clinically, invasive ductal carcinoma in men typically occurs as an eccentric peri-areolar mass (3). Bloody nipple discharge is also a suspicious symptom (4). When dealing with male breast pathology and imaging work-up, it is important to have a firm understanding of the benign findings. Almost all breast pathology in women can also be found in men (3). Gynecomastia is the most common anomaly of the male breast and is commonly seen in adolescent and elderly males due to physiologic hormonal changes. It has distinct imaging features that set it aside from malignancy (1). The radiological work-up of male breast cancer should begin only when thorough clinical exam has been performed. For the most part, the clinical exam is sufficient to delineate benign and malignant lesions. Imaging is not warranted unless the clinical presentation is ominous or uncertain (5). Also, clinicians should be aware of risk factors for male breast cancer, such as a family history of breast cancer, BRCA gene mutation, history of chest radiation, or history of hormonal diseases. Nguyen advocated mammography as the first imaging tool to evaluate a mass that is clinically suspicious (1). Taylor suggested an age-related approach, similar to the initial use of ultrasound in symptomatic women under 40, rather than the initial use of mammograms (4). Ultrasound did not generally add to the clinical work-up in men diagnosed with gynecomastia by mammogram, and no malignancies were detected with negative or benign mammographic findings (6). Ultrasound led to unnecessary biopsies and patient anxiety in this sub-group. In this issue of The Journal, Lapid et al. presented a study on the usefulness of imaging in the work-up of male breast cancer (7). This was a retrospective study over 10 years and included 557 male patients with imaging of the breast. The most common indications for imaging were enlargement of the breast (74%), pain (24%), and “lumps” (10%). Mammography was performed in 65% of patients, ultrasound in 51% of patients, and both were utilized in 26% of patients. The vast majority of examinations, 519, were given a BI-RADS 1 or 2. Twenty-nine patients were given a BI-RADS 3, seven patients were given a BIRADS 4, and two patients were given a BI-RADS 5. One of the most prominent aspects of the study was the use of fine-needle aspiration (FNA) in the first half of the study for the work-up of gynecomastia. Ultimately, 134 FNAs, core biopsies, and/or surgical excisions were performed in BI-RADS 1 or 2 patients. Malignancy was ruled out in 122 of these patients, while the rest of this sub-group did not have a final pathologic diagnosis within the given time frame of the study. This subgroup demonstrated that it is unnecessary to biopsy clinically and radiographically benign conditions. It would be helpful if the authors provided final histologic data in this subgroup so that the negative predictive value of a benign BI-RADS assessment could have been improved. Twenty men with BI-RADS 3 underwent tissue diagnosis and all twenty had a benign diagnosis. Five malignancies were diagnosed in the BI-RADS 4 and 5 groups. Interestingly, one of the patients diagnosed with malignancy was originally diagnosed in the BIRADS 3 group with benign histopathology and was subsequently assigned a BI-RADS 4 for development of suspicious calcifications on short-term follow-up Address correspondence and reprint requests to: Iraj Khalkhali, MD, LA BioMed, 1124 W, Carson Street, Torrance, CA 90501, USA, or e-mail: irajkhalkhali@gmail.com