2. Introduction to male breast tumor..
▶Male breast carcinoma is a
rare disease
▶ < 1% of all malignancies in men
▶ 1% of all breast cancers
3. Introduction to male breast
tumor:
▶ BREAST TUMOR IN MALES…
▶ Testicular tumor such as leydig cell tumors or sertoli
cell tumor such as (peutz Jeghers syndrome) or human
chorionic gonadotropin (Hcg) secreting
choriocarcinoma may result in gynecomastia. Other
tumors such adrenocortical tumors,pituitary gland
tumors (such as, prolactinoma) or broncchogenic
carcinoma, can produce hormones that alter male
female hormone balance and cause gynecomastia.
4. Introduction to male breast tumor:
▶ Clinically suspicious lesions
▶ Imaging evaluation
❑ Mammography
❑ 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. ▶ 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.
Breast Development
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
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/tumor
▶ 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 - to diagnose gynecomastia and breast
carcinoma
▶Diagnostic mammography
▶biopsy
▶ Standard mammographic views -
▶Magnification and spot compression views
▶ suspicious findings on mammography
▶ effective for evaluating male patient as it is for
female
10. Male Breast Tumor
● Male breast tumor - 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 Tumor..
▶ Clinical manifestation (S/S) –
▶ 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
12. Male Breast tumor
■ Histologic subtype :
■ Invasive ductul carcinoma- most common –
85%
■ Male breast contains only ducts
■ Invasive lobular – rare –
■ No lobules formation in male breast
13. Male Breast Tumor :
▶ Treatment
▶ Same as for women
▶Surgery
▶Axillary node dissection
▶Chemotherapy
▶Radiation therapy
18. Defination Of
Gynecomastia
▶ Gynecomastia is enlargement of
the gland tissue of the male breast
. During infancy , puberty
,and in middle aged to older men
gynecomastia can be common
19. 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.
20. 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
22. Gynecomastia
▶ Associated with increased levels of estradiol and decreased
levels
of testosterone
▶ Endocrine and hormonal disorders
▶ Systemic disease
▶ Neoplasm
▶ Drugs :
▶ Spirolactone {aldactone} a diuretics that has anti
androgenic activity
▶ For hypertension {captopril [capoten] ,enalapril
[vasotec]
▶ Anti ulcerative drugs for example : Ranitidine[rantac
or zantac] ,cimetidine [tagamet] and omeprazole
[prilosec]
▶ Cardio problems: digitoxin
▶ Some antibiotics for example : isoniazid,ketoconazole
[nizoral, extina , xolegel , kuric and metronidazole [
flagyl ]
23. TYPES Of Gynecomastia …
▶ mammographic patterns -representing various degrees and
stages of ductal and stromal proliferation
▶ Nodular gynecomastia
▶ Dendritic gynecomastia
▶ Diffuse glandular gynecomastia
24. 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.
26. Nodular Gynecomastia
▶ 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
▶ In cases of equivocal clinical and mammographic
findings
▶ follow-up evaluation
27. Chronic Dendritic Gynecomastia
▶ 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
28. Chronic Dendritic
Gynecomastia
▶ a subareolar hypoechoicstar-shaped,
fingerlike projections or “spider legs”
▶ benignity - directly from the undersurface
of the nipple without causing any overlying
skin thickening or nipple retraction.
29. Chronic Dendritic Gynecomastia
U.S image subareolar hypoechoic nodule with star-shaped
projections into the surrounding echogenic fibrous tissue
30. 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.
31. Diffuse Glandular Gynecomastia
▶Diffuse glandular – 3%
▶ 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.
▶ both nodular and dendritic features are seen surrounded by
diffuse hyperechoic fibrous breast tissue.
33. 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
34. 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
▶ demonstrates one or multiple parallel, homogeneous,
and mildly hyperechoic masses under the skin
▶ capsule is sometimes seen
36. 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
37. 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.
38. 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- non calcified breast mass,
circumscribed or partially circumscribed
solid circumscribed hyper echoic masses
● Recurrence is common after resection
40. Intraductal Papilloma
▶ Intraductal papilloma - benign proliferation of
intraductal mammary epithelium.
▶ Mammography - discrete dense mass against a
background of subareolar changes consistent
with gynecomastia
▶ multiple encentric, subareolar, elongated
and welldefined hypoechoic masses, which
have irregular shapes and are possibly
confined to the lumina of markedly enlarged
central ducts
41. Intraductal papilloma
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
42. DIAGNOSTIC
EVALUATION…
▶ COMPLETE ASSESSMENT OF MALE
PATIENT’S BREAST,
▶ COMPLETE BLOOD COUNT(CBC)
▶ MAMOGRAPHY,
▶ ULTRASOUND,
▶ FNAC
[FINE NEEDLE ASPIRATION
CYTOLOGY],
▶ LIVER FUNCTION TEST AND
▶ HORMONAL ASSESSMENT.
43. Conclusions
● The majority (99%) of male breast lesions are benign
● Mammography- for clinically suspicious lesions
◦ accurate for diagnosing gynecomastia
● useful for further characterization
● The relationship of the mass to the nipple should be carefully
assessed
◦ Encentric location is highly suspicious for cancer
◦the axillary region is helpful for staging In men
- cystic lesions commonly malignant
Cysts and complex masses should be worked up as potentially
malignant lesions
Suspicious lesion - biopsy - guidance is usually preferred
44. RISK FACTORS & COMPLICATIONS..
▶ advanced age
▶ prior irradiction 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
- Klinefelter syndrome.
