1. M.Sklair-Levy, M.D Radiology Department Sheba Medical Center Israel
The Male Breast
M.Sklair-Levy, M.D
Radiology Department
Sheba Medical Center
Israel

2. The Male Breast Clinical symptoms
Unilateral, bilateral breast enlargement
Breast pain
Breast lump
Most of the evaluated lesions are benign
Most related to gynecomastia

3. Introduction Male breast carcinoma is a rare disease
< 1% of all malignancies in men
1% of all breast cancers

4. 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.

5. 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.

6. 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

7. 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)

8. 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

9. 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

10. 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.

11. 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

12. 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

13. Male Breast Cancer Diagnostic work-up:
Bilateral Mammography US
Biopsy
Staging and treatment are similar to those of female breast cancer

14. 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

15. Male Breast Cancer Treatment Prognosis identical Same as for women
Surgery
Axillary node dissection
Chemotherapy
Radiation therapy
Prognosis identical

16. 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

17. 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

18. Invasive Duct Carcinoma

19. Invasive Duct Carcinoma

20. Invasive Duct Carcinoma

21. Benign Mimics of Male Breast Cancer
Gynecomastia

22. 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.

23. 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

24. 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

25. 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

26. Gynecomastia
3- mammographic patterns -representing various degrees and stages of ductal and stromal proliferation
Nodular
Dendritic
Diffuse glandular

27. 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.

28. Mammography - Nodular G.
Nodular subareolar density

29. 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

30. US - Early Nodular Gynecomastia
Hypervascular flow within the mass
subareolar, fanshaped,hypoechoic nodule surrounded by echogenic normal fatty tissue

31. 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

32. Mammography - Chronic Dendritic G.
Dendritic subareolar density with posterior linear projections radiating into the surrounding tissue

33. 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.

34. US- Chronic Dendritic Gynecomastia
US- subareolar hypoechoic nodule with star-shaped projections into the surrounding echogenic fibrous tissue

35. 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.

36. Diffuse Glandular Gynecomastia
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.

37. Diffuse Glandular Gynecomastia
Enlargement of the breast and diffuse density with both dendritic and nodular features

38. Diffuse Glandular Gynecomastia
US - both nodular and dendritic features are seen surrounded by diffuse hyperechoic fibrous breast tissue

39. Diffuse Glandular Gynecomastia
Heterogeneous breast with both nodular and dendritic projections surrounded by diffuse hyperechoic fibrous tissue.

40. 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

41. 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

42. Lipoma
Parallel, homogeneous, mildly hyperechoic mass with a capsule (arrow) under the skin.
Subtle encapsulated fatty mass (arrows) in the palpated region.

43. 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

44. 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.

45. 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.

46. Benign Conditions Associated 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

47. PASH Solid hyperechoic mass with posterior acoustic shadowing
Dense circumscribed mass

48. 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

49. 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

50. 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

51. 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

52. THANK YOU