From the Guidelines
The workup for a male breast lump should begin with a thorough clinical history and physical examination, followed by diagnostic mammography or digital breast tomosynthesis (DBT) in men 25 years of age or older, and ultrasound in men younger than 25 years of age, as recommended by the American College of Radiology 1. The initial evaluation of a male breast lump is crucial in determining the underlying cause, which can range from benign conditions such as gynecomastia to malignant conditions like breast cancer.
- Key factors to consider in the clinical history include:
- Family history of breast cancer
- BRCA mutations
- Klinefelter syndrome
- Liver disease
- Previous chest radiation
- Physical examination should focus on:
- Palpable breast mass
- Axillary adenopathy
- Nipple discharge
- Nipple retraction If the clinical presentation is suspicious for breast cancer, diagnostic mammography or DBT is recommended, irrespective of patient age, as it is equivalent to ultrasound in terms of diagnostic accuracy 1. In cases where the initial imaging is suspicious or inconclusive, tissue sampling should be performed, with core needle biopsy preferred over fine needle aspiration for tissue diagnosis. Additional laboratory tests, such as liver function tests, complete blood count, and hormone levels (estradiol, testosterone, luteinizing hormone, and follicle-stimulating hormone), may be necessary to evaluate for hormonal imbalances that may contribute to gynecomastia. It is essential to note that while most male breast lumps are benign, male breast cancer accounts for approximately 1% of all breast cancers and should not be overlooked, as it often presents at more advanced stages due to delayed diagnosis, contributing to poorer outcomes compared to female breast cancer 1.
From the Research
Male Breast Lump Workup
- The male breast is susceptible to various benign and malignant processes, with gynecomastia being the most common abnormality 2.
- Imaging of the symptomatic male breast begins with a diagnostic mammogram in patients ≥25 years and targeted ultrasound in patients <25 years 2.
- If the breast finding is incompletely imaged or occult at mammography, targeted ultrasound must be performed, and if the breast finding is suspicious at targeted ultrasound in a younger patient, mammography must be performed 2.
- The American College of Radiology (ACR) Appropriateness Criteria recommend that men with an indeterminate palpable mass start with ultrasound if the patient is <25 years of age, and mammography if the patient is ≥25 years of age or has a highly concerning physical examination 3.
Diagnostic Evaluation
- A complete diagnostic evaluation is necessary to distinguish between benign and malignant pathologies, as there is overlap in clinical and imaging features 2.
- Suspicious findings require biopsy, and mammography is useful in identifying cancer and obviating the need for biopsy in patients with a benign mammographic impression 3.
- Physical examination has been documented to be as effective as mammography in distinguishing benign from malignant lesions, and both have been reported as highly accurate for the identification of malignancy 4.
Risk of Breast Cancer
- Breast cancer is an uncommon cause of breast enlargement in adult males, accounting for <1% of all male cancers 5.
- Men with unilateral breast masses have a low incidence of breast cancer, and a male patient with a palpable unilateral breast mass consistent with gynecomastia does not require surgical biopsy unless other clinical indications prevail 5.
- A practical approach to guide clinicians in the evaluation of male patients with breast masses is proposed, considering the patient's history, physical examination, and mammography results 4.