Transcript Document

The Male Breast
M.Sklair-Levy, M.D
Radiology Department
Sheba Medical Center
Israel
The Male Breast
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Clinical symptoms
Unilateral, bilateral breast enlargement
 Breast pain
 Breast lump
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Most of the evaluated lesions are benign
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Most related to gynecomastia
Introduction
 Male
breast carcinoma is a rare
disease
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< 1% of all malignancies in men
1% of all breast cancers
Introduction
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Clinically suspicious lesions
Imaging evaluation
Mammography
 US - In patients with questionable findings at
mammography and for lesions that are difficult
to image with mammography
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The relationship of the mass to the nipple
should be carefully assessed
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an eccentric location is highly suspicious for
cancer.
Breast Development
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The breast tissues of both sexes are identical
at birth
Estrogen stimulates breast tissue
 Androgen antagonizes these effects
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At puberty in boys - increase in
estrogen,testosterone
Transient proliferation of the ducts and stroma
 Followed by involution and ultimate atrophy of the
ducts.
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Normal Male Breast
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Characterized:
Subcutaneous fat
 Remnant of subareolar
ductal tissue
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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
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The two most important disease of the male
breast
Gynecomastia
 Breast cancer
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The majority of lesions in male breasts are
benign
Other disease arise from the skin&subcutan.
Fat necrosis
 Lipoma
 Epidermal inclusion cyst
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Imaging of the Male Breast
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Mammography - diagnose gynecomastia and
breast carcinoma
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Standard mammographic views - CC & MLO
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Diagnostic mammography
Magnification and spot compression views
US- suspicious findings on mammography
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effective for evaluating male patient as it is for
female
Male Breast Cancer
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Male breast cancer - uncommon
 less than 1% of all malignancies in
men
 only 1% of all breast cancers
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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
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Clinical manifestation – hard , fixed , painless mass
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Bloody nipple discharge common
Secondary signs occur earlier in male patients because
of smaller breast size.
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nipple retraction, skin ulceration,thickening,increased breast
trabeculation
Palpable axillary lymph nodes are present in about
50% of cases
Male Breast Cancer
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Diagnostic work-up:
 Bilateral
Mammography
 US
 Biopsy
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Staging and treatment are similar to those
of female breast cancer
Male Breast Cancer
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Histologic subtype :
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Invasive ductul carcinoma- most common – 85%
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Ductal carcinoma in situ
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Male breast contains only ducts
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Invasive lobular – rare –
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No lobules formation in male breast
Male Breast Cancer
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Treatment
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Same as for women
Surgery
 Axillary node dissection
 Chemotherapy
 Radiation therapy
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Prognosis identical
Male Breast Cancer- Mammographic
Appearance
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Location - Subareolar position , eccentric to the
nipple
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Margins – well-defined, ill-defined, spiculated
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Shape – round, oval, irregular , lobulated
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Calcification – few , coarser
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Secondary signs – skin thickening, nipple
retraction , axillary lymphadenopathy
US Features-Male Breast Cancer
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Male breast cancers have similar US features as
in women
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Masses - nonparallel, discrete, hypoechoic.
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Margins - angulated , microlobulated, or spiculated
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Microcalcification - punctate high echogenicity
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Posterior acoustic features are not helpful for
distinguishing benign versus malignant lesions
no posterior acoustic feature
 posterior enhancement
 posterior acoustic shadowing
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Invasive Duct Carcinoma
Invasive Duct Carcinoma
Invasive Duct Carcinoma
Benign Mimics of Male Breast Cancer
Gynecomastia
Gynecomastia
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Gynecomastia is the most common benign
condition of the male breast
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It is enlargement of the male breast due to
benign ductal and stromal proliferation.
 Causes breast enlargement /subareolar mass
with/without associated breast pain
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It can be unilateral, bilateral symmetric, or
bilateral asymmetric.
Gynecomastia
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The hallmark of gynecomastia is its central
symmetric location under the nipple
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Reversible in early stages – if the cause is
corrected
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Reversible phase progress to late periductal edema
with irreversible stromal fibrosis
Gynecomastia
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Associated with increased levels of estradiol and
decreased levels of testosterone
Physiologic changes at puberty senescence
 Endocrine and hormonal disorders
 Systemic disease
 Neoplasm
 Drugs
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Causes of Gynecomastia
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Physiologic
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Klinefelter syn
Hypogonadism
Systemic disease
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Senescence
Puberty
Hormonal
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Cirrhosis
Chronic renal
insufficiency
Idiopathic
Neoplasm
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Adrenal carcinoma
Pituitary adenoma
Hepatocellular carcinoma
Drug use
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Cimetidine
Marijuana
Thiaside diuretics
Omeprazole
Tricyclic antidepresasants
Spironolactone
Diazepam
Anabolic steroids
Exogenouis estrogen
Gynecomastia
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3- mammographic patterns -representing various
degrees and stages of ductal and stromal
proliferation
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Nodular
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Dendritic
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Diffuse glandular
Gynecomastia
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Nodular G.- most common – 77%
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Pathology – florid g. – early phase
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The majority of patients will present with
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patients with gynecomastia < 1year
nipple tenderness , palpable lump
Mammography-nodular subareolar density
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The typical mammographic confirms the diagnosis and requires
no further imaging work-up.
Mammography - Nodular G.
Nodular subareolar density
Nodular G
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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
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US - In cases of equivocal clinical and
mammographic findings
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follow-up evaluation
US - Early Nodular Gynecomastia
Hypervascular flow within the mass
subareolar, fanshaped,hypoechoic nodule
surrounded by echogenic normal fatty
tissue
Chronic Dendritic Dynecomastia
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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.
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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
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US- a subareolar hypoechoic star-shaped,
fingerlike projections or “spider legs”
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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
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The clinical history, particularly the duration of
symptoms, can also be helpful in making this
diagnosis.
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patients may have an acute episode of gynecomastia
in addition to chronic dendritic gynecomastia.
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both phases can be seen at imaging simultaneously.
Diffuse Glandular Gynecomastia
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Diffuse glandular – 3%
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Patients receiving exogenous estrogen
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Mammography- enlargement of the breast ,
similar to heterogeneously dense female breast
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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
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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
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Pseudogynecomastia – a fatty proliferation of
the breasts , without proliferation of glandular
tissue.
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Difficult to distinguish from normal male breast
on mammography
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Diagnosis requires clinical correlation with
breast enlargement
Less Common Benign Conditions
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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
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capsule is sometimes seen
Lipoma
Parallel, homogeneous, mildly hyperechoic
mass with a capsule (arrow) under the skin.
Subtle encapsulated fatty mass
(arrows) in the palpated region.
Epidermal Inclusion Cyst
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Epidermal inclusion cyst is the third most
common benign lesion in the male breast
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Arise from obstructed or occluded hair
follicles, at the sites of previous skin trauma
such as a surgical wound or insect bites
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Composed of laminated keratin surrounded
by stratified squamous epithelium
Epidermal Inclusion Cyst
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Mammography- well-defined dense oval mass
contiguous with the skin in the palpable area
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US- hypoechoic lesion that is contiguous with
the epidermis, the claw sign , with increased
through transmission.
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This feature is the key to distinguishing this benign
condition from cystic malignancies of the male
breast.
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.
Benign Conditions
Associated with Gynecomastia
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Pseudoangiomatous stromal hyperplasia (PASH)- benign
stromal tumor formed by myofibroblasts and with
glandular hyperplasia
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Often incidentally seen in gynecomastia
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Mammography- noncalcified breast mass, circumscribed
or partially circumscribed
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US - solid circumscribed hyperechoic masses
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Recurrence is common after resection
PASH
Dense circumscribed mass
Solid hyperechoic mass with
posterior acoustic shadowing
Intraductal Papilloma
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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
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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
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The majority (99%) of male breast lesions are
benign
Mammography- for clinically suspicious lesions
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accurate for diagnosing gynecomastia
US useful for further characterization
The relationship of the mass to the nipple should be
carefully assessed
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Eccentric location is highly suspicious for cancer
US of the axillary region is helpful for staging
Conclusions
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In men - cystic lesions commonly malignant
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Cysts and complex masses should be worked up as
potentially malignant lesions
Suspicious lesion - biopsy - US guidance is
usually preferred
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