Is a breast MRI appropriate for a male breast mass?

Breast MRI is Not Appropriate for Initial Evaluation of Male Breast Mass

Breast MRI is generally not indicated for the evaluation of a male breast mass. 1 Mammography or digital breast tomosynthesis (DBT) should be used as the initial imaging modality, followed by ultrasound if needed.

Recommended Imaging Algorithm for Male Breast Mass

Initial Imaging Based on Age:

• For males ≥25 years old:

  • Diagnostic mammography or DBT is the recommended first-line imaging study 1
  • These modalities have high sensitivity (92-100%), specificity (90-96%), and negative predictive values (99-100%) for male breast evaluation 1

• For males <25 years old:

  • Ultrasound is recommended as the initial imaging modality 1, 2
  • If suspicious features are found on ultrasound, mammography or DBT should follow before biopsy recommendation 1

Secondary Imaging:

• Ultrasound should be performed if mammogram/DBT is indeterminate or suspicious 1
  • Helps with lesion characterization and biopsy guidance
  • Performance may be more variable than mammography (sensitivity 88.9-100%, specificity 74-95%) 1

Why MRI is Not Appropriate

1. Lack of evidence: There is no relevant literature supporting the use of MRI as an initial imaging study for male breast masses 1

2. No clear indications: Currently, there are no clear guidelines for performing breast MRI in male patients, even those diagnosed with breast cancer 3

3. Established alternatives: Mammography and ultrasound provide excellent diagnostic accuracy for male breast evaluation:

   • Mammography demonstrates high sensitivity (92-100%) and specificity (90-96%) 1
   • Combined mammography and ultrasound have a negative predictive value of 99.8% 1

4. Limited utility: Male breast cancers typically present as irregular masses or with calcifications that are well-visualized on mammography 1, 4

Clinical Considerations

• Male breast cancer typically presents at a median age of 63 years 1
• Most male breast problems are benign, with gynecomastia being the most common cause of palpable masses 1, 4
• Male breast cancer often presents with associated symptoms (palpable lump, skin/nipple retraction, nipple discharge) 1
• Bilateral mammography is routinely performed to assess for symmetry and detect asymptomatic contralateral abnormalities 1

Potential Pitfalls

• Relying solely on ultrasound without mammography when findings are suspicious may lead to missed diagnoses, as mammography is more sensitive for microcalcifications 1, 2
• Ordering unnecessary MRIs increases healthcare costs and may delay appropriate management 5
• Even in women with palpable masses and negative mammogram/ultrasound, breast MRI has low yield for cancer diagnosis (low specificity of 70%) 5

By following the evidence-based imaging algorithm of mammography/DBT followed by ultrasound as needed, clinicians can effectively evaluate male breast masses while avoiding unnecessary advanced imaging studies.