Professional Documents
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Leonard M. Glassman
This review is based on a presentation given by Leonard Glassman and adapted for the
Radiology Assistant by Robin Smithuis.
We will discuss:
Normal male
mammogram
Classic
features of
gynecomastia
Lesions that
require a
biopsy
by Leonard M. Glassman
Normal Male
Mammogram
When you do breast imaging in a male, always stick to the following rule:
'If it is not normal, gynecomastia or classically benign,
it needs a biopsy'.
So, first we're going to give you a couple of examples of the normal male breast, just to get
used to what normal looks like.
Then we will discuss gynecomastia and finally discuss some specific tumors.
Obviously, the lesions in this last category will need a biopsy, unless you are sure that it is
classically benign, like for instance a lymph node or lipoma.
Gynecomastia
Gynecomastia
Gynecomastia: nodular glandular pattern.Notice how it blends into the surrounding fat.
Imaging pattern
There are three imaging patterns:
Nodular
glandular
(acute florid
phase)
Dendritic
(chronic
fibrotic phase)
Diffuse
glandular
If you think about the mammogram on the left as the breast of a woman instead of a man,
than you might say that there is an ill-defined mass and you might conclude that this is a
malignancy .
However, in a man this indistinct border is a sign of a gynecomastia.
On the far left a mammogram of a male with gynecomastia and next to it a mammogram of
an eight year old girl with juvenile hypertrophy.
Notice that they look very much the same.
Nodular pattern
On the left a mammogram and an ultrasound image of a patient with a nodular glandular
pattern of gynecomastia.
Notice that it is situated underneath the nipple.
The ultrasound image shows the typical appearance of gynecomastia: a hypoechoic mass with
lobulation or even spiculation.
If this was seen in a woman, you would say that this is a mass with microlobulation and
spiculation, i.e. Birads IV or V.
In a man this is typical for gynecomastia.
On the left the same ultrasound image, but now in the normal position.
Notice how 'malignant' it looks.
On the left a T2W-image with fatsat and a T1W-image after Gadolinium with fatsat.
A radiologist who was not used to looking at 'male' mammograms ordered the MR for
problem solving.
Obviously this MR was performed for the wrong reason.
MR should not be used to solve a problem that can be solved with mammography.
Anyhow the MR shows gynecomastia of the nodular pattern.
Dendritic Pattern
On the mammogram on the left we can imagine, that there is fibrosis with extension into the
fat.
This is different from the glandular edema-like appearance in the acute phase of
gynecomastia.
The ultrasound shows a spiculated appearance.
These cases clearly demonstrate that gynecomastia can have an appearance which we would
call malignant in a woman.
Unfortunately some of the malignant lesions in a man can look benign and we will show
some examples in the next chapter.
The images on the left simply look like small female breasts.
This was a patient who was on estrogen therapy for prostate carcinoma.
Pseudogynecomastia
Pseudogynecomastia
Benign Lesions
Let's first start with a list of lesions that should not be diagnosed in male patients, because
they simply do not get these lesions.
A man does not get a lactating adenoma, because it is only seen in pregnancy.
Because there are very few lobules in a man, lobular tumors are extremely rare.
There are only a few invasive lobular carcinomas reported in men.
Fibroepithelial lesions are also extremely rare because they too start in the lobules.
So do not diagnose a fibroadenoma in a man, even if it looks like a fibroadenoma.
When you get a biopsy result that says fibroadenoma, get another pathologist.
Myofibroblastoma
Myofibroblastoma
Myofibroblastoma is an interesting lesion because it is the only one lesion that is more
common in men than in women.
It presents as a freely moveable, solitary, palpable, firm mass.
There are no calcifications.
The mean age is in the late 50's.
Myofibroblastoma eccentric to the nipple in a patient with a little bit of gynecomastia bilaterally
Notice that the lesion on the left has a indistinct border as is usually seen in gynecomastia,
but on the mammogram it is not located directly under the skin.
So this is not gynecomastia and a biopsy is necessary.
Epidermal inclusion cyst is a skin lesion. It presents as a round well circumscribed dense
mass.
On the left a small epidermal inclusion cyst. Notice how it raises the skin.
On the left a T2W image demonstrating the cystic nature and the pathology specimen.
Granulomatous Mastitis
Granulomatous Mastitis
Varix
Varix
On the left a lesion that looks like a cyst, but remember that cysts originate in the lobules and
men do not have lobules, unless they take estrogen.
This is a varix and if you puncture it, you get a big red surprise.
Leiomyoma
Leiomyoma
On the left a lesion, that looks like a fibroadenoma, but men do not get fibroadenomas.
It is a solid encapsulated mass and at biopsy it happened to be a leiomyoma.
If there are more than 2 mitoses per high power field the pathologist calls it a
leiomyosarcoma.
Male Breast
Cancer
Invasive ductal carcinoma
Paget's disease of the nipple and skin ulceration are more common than in women.
There is a long list of carcinoma risk factors and they are the same as in women:
Advanced age
Family
history
Jewish
heritage
Chest wall
irradiation
Hyperestroge
nism
Hyperthyroidi
sm
Exposure to
hepatotoxins
Occupational
exposure to
high heat
(steel
industry)
BRCA 2 is
seen in 4 -
16% of male
breast cancer
patients (40%
in Iceland)
Undescended
testes
Orchiectomy
and orchitis
Klinefelter's
syndrome (47,
XXY - 6% of
all male breast
cancer is in
Klinefelter -
3% lifetime
risk)
On the left a huge invasive ductal carcinoma with some coarse benign looking calcifications.
Other
malignancies of
the male breast
Metastases
Metastases from prostate cancer are the most common metastases in males.
It results from hematogenous spread and is usually seen in patients with widespread disease.
It presents as round or lobulated non-calcified masses.
On the left a patient with two metastases of a small cell lung carcinoma.
Liposarcoma
Liposarcoma
On the CT on the left you can see the density of the lesion that proved to be a liposarcoma.
Conclusion
In conclusion we can say, that male breast disease either presents as mass, pain or nipple
discharge.
Gynecomastia and invasive ductal cancer are the most common lesions in the male breast, but
there are other rarer benign and malignant lesions.
Gynecomastia and carcinoma can usually be differentiated, but biopsy is sometimes
necessary to separate them.
All lesions eccentric to the nipple need biopsy unless they are characteristically benign,
i.e.contain fat or typical lymph node.
On the left a list of characteristics of gynecomastia versus carcinoma.
Notice that there are many similarities.
Both gynecomastia and carcinoma occur mostly at the age of 60 and can be soft, mobile,
subareolar and unilateral.
So that does not help.
Carcinoma is usually eccentric, while gynecomastia is never eccentric.
Gynecomastia has to have extensions into the surroundig fat.
Carcinoma sometimes may have spiculations, that can look the same.
Actually we call it extension into the fat, if we think it is gynecomastia and spiculation, if we
think it is a carcinoma.
On the left two cases, that demonstrate, that it can be difficult to differentiate gynecomastia
from carcinoma on a mammogram.
The carcinoma on the right is a little bit more encapsulated than the gynecomastia on the
right.
In less than 10% of the cases a biopsy can be needed to make the differentiation.
The last cases on the left look very similar to each other.
Based on the mammogram these two can not be differentiated.
In those rare instances a biopsy is needed.