What is the approach to a male patient presenting with right breast pain and no signs of infection?

Approach to Male Patient with Right Breast Pain and No Signs of Infection

For a male patient presenting with right breast pain and no signs of infection, diagnostic imaging with mammography and ultrasound is recommended as the initial approach, followed by appropriate tissue sampling if suspicious findings are identified.

Initial Evaluation

Clinical Assessment

• Determine characteristics of the pain:
  • Duration, location, intensity
  • Relationship to physical activity or pressure
  • Presence of any palpable mass, nipple discharge, skin changes
  • Unilateral (concerning) vs. bilateral (more likely benign)

Risk Assessment

• Age: Breast cancer risk increases with age, with median age of 63 years for male breast cancer 1
• Family history of breast cancer
• Previous chest radiation
• Known genetic predisposition (BRCA mutations)
• Medications that may cause gynecomastia (hormonal therapies, some cardiovascular agents)

Diagnostic Imaging Algorithm

For males ≥25 years:

1. Diagnostic mammography as initial imaging modality 2

   • High sensitivity (92-100%) and specificity (90-96%) for male breast evaluation 2
   • Can differentiate between gynecomastia and malignancy
   • Patterns of gynecomastia on mammography: nodular, dendritic, or diffuse glandular 1

2. Breast ultrasound as complementary imaging

   • Particularly useful for focal pain or palpable abnormalities
   • Can distinguish solid from cystic lesions
   • Sensitivity of 88.9-100% and specificity of 74-95% 2

For males <25 years:

1. Ultrasound as initial imaging modality 2
   • No radiation exposure
   • Better visualization in dense breast tissue

Management Based on Imaging Findings

If imaging is normal (BI-RADS 1):

• Provide reassurance and symptomatic management:
  • Over-the-counter pain medications
  • Ice packs or heating pads
  • Support garments if helpful 1

If simple cyst is found (BI-RADS 2):

• Drainage may be considered for symptom relief if the cyst correlates with the area of pain 1
• No further workup needed 2

If complicated cyst is found (BI-RADS 3):

• Follow-up imaging every 6 months for 1-2 years 1
• Symptomatic management of pain

If suspicious findings (BI-RADS 4-5):

• Tissue sampling is required 1, 2
  • Core needle biopsy is preferred over fine-needle aspiration 2
  • Complete imaging workup before biopsy to avoid changes that may confuse interpretation 2

Important Considerations

When to Biopsy Regardless of Imaging

• Any highly suspicious breast mass detected by palpation requires biopsy regardless of imaging findings 2
• Clinical suspicion of malignancy should prompt biopsy even with negative imaging 2

Pitfalls to Avoid

1. Do not dismiss breast pain in males

   • Although rare, male breast cancer has a strong association with symptoms including pain 1
   • 57% of males presenting with nipple discharge were found to have underlying malignancy in one study 1

2. Do not rely solely on clinical examination

   • Clinical breast examination alone has limited sensitivity 2
   • Negative imaging does not completely rule out cancer if clinical suspicion is high 2

3. Do not miss coexisting conditions

   • Approximately 50% of men with breast cancer may have coexisting gynecomastia 1
   • Gynecomastia is not a risk factor for male breast cancer but may mask underlying malignancy 1

Follow-up

• For patients with normal imaging or benign findings:
  • Reassess if symptoms persist or worsen
  • Consider referral to breast specialist if pain is severe or persistent despite conservative measures
• For patients with suspicious findings:
  • Prompt referral to breast surgeon following biopsy
  • Multidisciplinary approach for confirmed malignancy

By following this structured approach, clinicians can effectively evaluate and manage male patients presenting with breast pain while ensuring that potentially serious conditions are not missed.