Evaluation of the Symptomatic Male Breast

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Date of origin: 2014

American College of Radiology
ACR Appropriateness Criteria®

 

Clinical Condition:         Evaluation of the Symptomatic Male Breast

 

Variant 1:                         Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia.

 

Radiologic Procedure Rating Comments RRL*
Mammography diagnostic 2 ☢ ☢
US breast 2 O
MRI breast without and with IV contrast 1 O
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 2: Male <25 years old with indeterminate palpable breast mass. Initial examination.
Radiologic Procedure Rating Comments RRL*
US breast 8 O
This procedure may be appropriate, but
there was disagreement among panel
Mammography diagnostic 5 members on the appropriateness rating as ☢ ☢
defined by the panel’s median rating.
Mammography may be indicated if US
does not answer the clinical question.
MRI breast without and with IV contrast 1 O
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 3: Male ≥25 years old with indeterminate palpable breast mass. Initial examination.
Radiologic Procedure Rating Comments RRL*
Mammography diagnostic 8 ☢ ☢
This procedure may be appropriate, but
there was disagreement among panel
members on the appropriateness rating as
defined by the panel’s median rating. This
US breast 5 procedure may be indicated as the initial O
imaging examination if the mass is not
suspected to be either gynecomastia or
breast cancer (eg, superficial soft-tissue
mass far from nipple).
MRI breast without and with IV contrast 1 O
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

 

Clinical Condition: Evaluation of the Symptomatic Male Breast
Variant 4: Male ≥25 years old with indeterminate palpable breast mass. Mammography indeterminate
or suspicious.
Radiologic Procedure Rating Comments RRL*
US breast 9 O
MRI breast without and with IV contrast 2 O
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 5:                         Male with physical examination suspicious for breast cancer (suspicious palpable breast mass, axillary adenopathy, nipple discharge, or nipple retraction).

 

Radiologic Procedure Rating Comments RRL*
Mammography diagnostic 9 ☢ ☢
US is complementary to mammography
US breast 8 when clinical suspicion is high and when O
assessing extent of disease.
MRI breast without and with IV contrast 3 O
MRI breast without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

EVALUATION OF THE SYMPTOMATIC MALE BREAST

 

Expert Panel on Breast Imaging: Martha B. Mainiero, MD1; Ana P. Lourenco, MD2; Lora D. Barke, DO3; Amy D. Argus, MD4; Lisa Bailey, MD5; Selin Carkaci, MD6; Carl D’Orsi, MD7; Edward D. Green, MD8; Susan O. Holley, MD9; Peter M. Jokich, MD10; Su-Ju Lee, MD11; Mary C. Mahoney, MD12; Linda Moy, MD13;

 

Priscilla J. Slanetz, MD, MPH14; Sunita Trikha, MD15; Monica M. Yepes, MD16; Mary S. Newell, MD.17

 

Summary of Literature Review

 

Introduction/Background

 

Men with breast symptoms are typically concerned about the cause of their problem and whether or not it is due to breast cancer. The majority of male breast problems are benign, with gynecomastia as the most common cause of a palpable mass, breast enlargement, or pain [1-3]. Gynecomastia occurs physiologically in neonates and adolescents and with aging but can occur at any age as a side effect of many medications and illicit drugs, as a result of hormonal changes, and in the setting of chronic liver disease [4]. Patients presenting with clinical symptoms of gynecomastia are typically younger than men with breast cancer [3]. Breast cancer in males is rare, accounting for <1% of all breast cancers. As gynecomastia is a common physiologic change, gynecomastia and breast cancer may co-exist 50% of the time [5]. However, gynecomastia is not believed to be a risk factor for male breast cancer [6]. Although gynecomastia and breast cancer are the main considerations in most men with a palpable mass, other masses arising from the skin and subcutaneous tissues, such as lipomas, epidermal inclusion cysts, and oil cysts are also commonly encountered. Pseudogynecomastia, due to excess fatty tissue deposition in the breasts, is also common, especially in overweight and obese patients.

 

If the differentiation between benign disease and breast cancer cannot be made on the basis of clinical findings, or if the clinical presentation is suspicious, imaging is indicated [1,2].

 

Overview of Imaging Modalities

 

Mammography

 

Diagnostic mammography is useful in distinguishing benign breast conditions such as gynecomastia from malignancy in symptomatic males [1,2]. A bilateral mammogram is routinely performed in symptomatic males [7], although there is no literature comparing the efficacy of bilateral versus unilateral imaging. A bilateral examination may be useful to assess for symmetry [8] and may detect asymptomatic contralateral gynecomastia or the rare nonpalpable contralateral carcinoma [3].

 

The sensitivity and specificity of mammography for distinguishing malignant from benign breast disease in men is consistently high. Evans et al [5] in a series of 100 patients, reported a sensitivity of 92%, a specificity of 90%, and a negative predictive value (NPV) of 99%. Patterson et al [8], in a series of 166 patients, reported a sensitivity of 100%, a specificity of 90%, and a NPV of 100%. Carrasco et al [3], in a series of 638 patients, reported a sensitivity of 95%, a specificity of 95% and a NPV of 99.7%. Thus, mammography is useful both in identifying breast cancer and for obviating the need for biopsy in patients for whom the benign mammographic appearance confirms the clinical impression. Three patterns of gynecomastia have been described on mammography: nodular (subareolar nodule), dendritic (subareolar flame-shaped tissue), and diffuse glandular (much like a heterogeneously dense female breast) [9]. Breast cancer in men typically presents with an irregular mass but may present as a circumscribed mass or only with calcifications. As men do not have the same background of benign proliferative changes as do women, relatively benign imaging findings such as a circumscribed or cystic mass or punctuate calcifications should be considered suspicious in male patients [3,7,10].

 

Ultrasound

 

Results for breast ultrasound (US) in men are more variable. Carrasco et al [3], in the series of 638 patients, reported a lower sensitivity of US for distinguishing benign from malignant disease (88.9% compared to 95% for mammography) but a similar, high specificity of 95.3%. However, Patterson et al [8], in their series of 166 patients, reported US to have the same sensitivity as mammography (100%) but a lower specificity of 74%. Gynecomastia often appears as a mass on US [11]. Comparison with the contralateral side is often helpful on real-time imaging, as synchronous bilateral breast carcinoma in males is rare. Chen et al [12] evaluated the incremental clinical value of US in 327 symptomatic male patients where mammography was negative or revealed only gynecomastia and found no additional malignancies. However, in that series, US did lead to additional unnecessary benign biopsies. When mammography reveals questionable or suspicious findings, US can assist in clinical management and guide biopsy [3].

 

Magnetic Resonance Imaging

 

Data on the use of magnetic resonance imaging (MRI) in evaluation of male breast disease are limited. One study of 17 male patients investigated whether the descriptors of lesions’ features and diagnostic criteria used in female patients may be used for male patients but did not assess the diagnostic accuracy or clinical usefulness of MRI in male patients [13].

 

Discussion of the Imaging Modalities by Variant

 

The patient’s age and the level of clinical suspicion regarding the patient’s symptoms and physical examination are the main determinants of what, if any, imaging is indicated.

 

Variant 1: Male patient of any age with symptoms of gynecomastia and physical examination consistent with gynecomastia or pseudogynecomastia

Most men with breast symptoms can be diagnosed on the basis of clinical findings without imaging [1,2]. Gynecomastia is bilateral in approximately half of patients. On physical examination, gynecomastia often presents as a soft, rubbery, or firm mobile mass directly under the nipple [3,4]. In addition, gynecomastia is more likely to be painful than cancer [3], especially gynecomastia that has been present for <6 months [3,4].

 

Variant 2: Male <25 years old with indeterminate palpable breast mass; initial examination

 

Breast cancer is a disease of older men and typically presents at a later age than in women, at a median age of 63 years [14]. Only 6% of male breast cancers occur under the age of 40 and 1% under the age of 30 [15]. Because of the relationship of breast cancer to increasing age, age-based protocols that do not include mammography in younger men have been developed [3,16]. Some authors suggest using US is useful as the initial imaging modality in the young male who is unlikely to have breast cancer and who presents with an indeterminate physical symptom [3]. However, gynecomastia and oil cysts can have a suspicious appearance on US but can typically be diagnosed as benign on mammography. Therefore, if there are suspicious features on US, mammography should be performed before a biopsy recommendation is made.

 

Variants 3 and 4: Male ≥25 years old with indeterminate palpable breast mass; initial examination and next examination if mammography is indeterminate or suspicious

 

For men with an equivocal physical examination and of an age at which breast cancer is more likely, mammography is recommended as the initial imaging modality. Mammography is highly sensitive and specific in distinguishing benign from malignant disease and is likely more sensitive than US at detecting breast cancer due to the ability to visualize microcalcifications [3]. When mammography is diagnostic of gynecomastia, US is not typically necessary. US can be used as an adjunct to mammography if the mammogram is indeterminate or suspicious or if mammography does not reveal a cause for the palpable finding.

 

Variant 5: Male with physical examination suspicious for breast cancer (suspicious palpable breast mass, nipple discharge, or nipple retraction)

Male breast cancer usually presents quite differently than gynecomastia. Male breast cancer is rarely bilateral and typically presents with a painless, hard, subareolar mass, often eccentric to the nipple. With breast cancer, there may be secondary signs of malignancy such as nipple or skin retraction, nipple discharge, or axillary lymphadenopathy [10].

 

Breast cancers in men often present at a more advanced stage than breast cancers in women, with up to 47% of men having axillary nodal involvement at the time of diagnosis [10]. In addition, nipple discharge is suspicious for breast cancer in men, with 2 studies showing carcinoma in 23%–57% of men presenting with this symptom [17,18].

 

For men with a highly suspicious physical finding, mammography is recommended as the initial imaging study with US useful in assisting with clinical management decisions and in guidance for biopsy [3].

 

Summary of Recommendations

 

Men with typical symptoms of gynecomastia or pseudogynecomastia do not usually need imaging.

 

For men with an indeterminate palpable mass, begin with US if the patient is <25 years of age, as breast cancer is highly unlikely. Mammography should be performed if US is suspicious.

 

For men ≥25 years of age, or men with a highly concerning physical examination, begin with mammography. US is useful if mammography is inconclusive or suspicious.

 

Summary of Evidence

 

Of the 18 references cited in the ACR Appropriateness Criteria® Evaluation of the Symptomatic Male Breast document, 1 is categorized as a good quality therapeutic study. Additionally, 16 references are categorized as diagnostic references including 1 good quality study and 7 quality studies that may have design limitations. There are 9 references that may not be useful as primary evidence.

 

The 18 references cited in the ACR Appropriateness Criteria® Evaluation of the Symptomatic Male Breast document were published between 1977–2014.

 

While there are references that report on studies with design limitations, two good quality studies provide good evidence.

 

Relative Radiation Level Information

 

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

 

Relative Radiation Level Designations

 

Relative Radiation Level* Adult Effective Dose Estimate Pediatric Effective Dose Estimate
Range Range
O 0 mSv 0 mSv
<0.1 mSv <0.03 mSv
☢ ☢ 0.1-1 mSv 0.03-0.3 mSv
☢ ☢ ☢ 1-10 mSv 0.3-3 mSv
☢ ☢ ☢ ☢ 10-30 mSv 3-10 mSv
☢ ☢ ☢ ☢ ☢ 30-100 mSv 10-30 mSv

 

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”.

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

References

  1. Hanavadi S, Monypenny IJ, Mansel RE. Is mammography overused in male patients? 2006;15(1):123-126.
  2. Hines SL, Tan WW, Yasrebi M, DePeri ER, Perez EA. The role of mammography in male patients with breast symptoms. Mayo Clin Proc. 2007;82(3):297-300.
  3. Munoz Carrasco R, Alvarez Benito M, Munoz Gomariz E, Raya Povedano JL, Martinez Paredes M. Mammography and ultrasound in the evaluation of male breast disease. Eur Radiol. 2010;20(12):2797-2805.
  4. Braunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007;357(12):1229-1237.
  5. Evans GF, Anthony T, Turnage RH, et al. The diagnostic accuracy of mammography in the evaluation of male breast disease. Am J Surg. 2001;181(2):96-100.
  6. Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. 2006;367(9510):595-604.
  7. Chen L, Chantra PK, Larsen LH, et al. Imaging characteristics of malignant lesions of the male breast. 2006;26(4):993-1006.
  8. Patterson SK, Helvie MA, Aziz K, Nees AV. Outcome of men presenting with clinical breast problems: the role of mammography and ultrasound. Breast J. 2006;12(5):418-423.
  9. Michels LG, Gold RH, Arndt RD. Radiography of gynecomastia and other disorders of the male breast. 1977;122(1):117-122.
  10. Mathew J, Perkins GH, Stephens T, Middleton LP, Yang WT. Primary breast cancer in men: clinical, imaging, and pathologic findings in 57 patients. AJR Am J Roentgenol. 2008;191(6):1631-1639.
  11. Dialani V, Baum J, Mehta TS. Sonographic features of gynecomastia. J Ultrasound Med. 2010;29(4):539-547.
  12. Chen PH, Slanetz PJ. Incremental clinical value of ultrasound in men with mammographically confirmed gynecomastia. Eur J Radiol. 2014;83(1):123-129.
  13. Morakkabati-Spitz N, Schild HH, Leutner CC, von Falkenhausen M, Lutterbey G, Kuhl CK. Dynamic contrast-enhanced breast MR imaging in men: preliminary results. 2006;238(2):438-445.
  14. Greif JM, Pezzi CM, Klimberg VS, Bailey L, Zuraek M. Gender differences in breast cancer: analysis of 13,000 breast cancers in men from the National Cancer Data Base. Ann Surg Oncol. 2012;19(10):3199-3204.
  15. Crichlow RW, Galt SW. Male breast cancer. Surg Clin North Am. 1990;70(5):1165-1177.
  16. Taylor K, Ames V, Wallis M. The diagnostic value of clinical examination and imaging used as part of an age-related protocol when diagnosing male breast disease: an audit of 1141 cases from a single centre. 2013;22(3):268-272.
  17. Morrogh M, King TA. The significance of nipple discharge of the male breast. Breast J. 2009;15(6):632-638.
  18. Munoz Carrasco R, Alvarez Benito M, Rivin del Campo E. Value of mammography and breast ultrasound in male patients with nipple discharge. Eur J Radiol. 2013;82(3):478-484.

 

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

1Principal Author, Rhode Island Hospital, Providence, Rhode Island. 2Co-author, Rhode Island Hospital, Providence, Rhode Island. 3Panel Vice-chair, RIA/Invision Sally Jobe Breast Centers, Greenwood Village, Colorado. 4University of Cincinnati, Cincinnati, Ohio. 5Bay Area Breast Surgeons, Oakland, California, American College of Surgeons. 6Ohio State University, Columbus, Ohio. 7Emory University Hospital, Atlanta, Georgia. 8The University of Mississippi Medical Center, Jackson, Mississippi. 9Mallinckrodt Institute of Radiology, Saint Louis, Missouri. 10Rush University Medical Center, Chicago, Illinois. 11University of Cincinnati, Cincinnati, Ohio. 12University of Cincinnati, Cincinnati, Ohio. 13NYU Clinical Cancer Center, New York, New York. 14Beth Israel Deaconess Medical Center, Boston, Massachusetts. 15North Shore University Hospital, Manhasset, New York. 16University of Miami, Miami, Florida. 17Panel Chair, Emory University Hospital, Atlanta, Georgia.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

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