Evaluation and Management of Male Breast Mass
For a male with a palpable breast mass, initial evaluation should be based on clinical findings, with gynecomastia being the most common cause, and imaging is only indicated when clinical presentation is suspicious or indeterminate. 1
Initial Clinical Assessment
- Gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple and is often painful, especially when present for less than 6 months 2, 1
- Gynecomastia is bilateral in approximately 50% of patients 2, 1
- Differentiate true gynecomastia (glandular tissue) from pseudogynecomastia (fatty tissue deposition), especially in patients with elevated BMI 2, 1
- Suspicious clinical features warranting further evaluation include: unilateral hard mass, fixed mass, peripheral location (not directly under nipple), nipple discharge, skin changes, or lymphadenopathy 3
Imaging Algorithm Based on Age and Clinical Presentation
When No Imaging Is Needed:
- For men with clinical findings clearly consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended 2, 1
When Imaging Is Indicated (Indeterminate or Suspicious Mass):
For Men Younger Than 25 Years:
- Initial imaging: Ultrasound is recommended as the first imaging study 2, 1
- If ultrasound shows suspicious or indeterminate features, proceed to mammography or digital breast tomosynthesis (DBT) before considering biopsy 2
For Men 25 Years or Older:
- Initial imaging: Mammography or digital breast tomosynthesis (DBT) is recommended 2, 1
- Diagnostic mammography is useful in distinguishing malignancy from benign conditions in symptomatic males 2
- Ultrasound may be used as a complementary imaging modality after mammography 2
Management Options
- Watchful waiting is appropriate for most cases of gynecomastia, as many cases are self-limiting 4
- For persistent or bothersome gynecomastia:
- Address underlying causes if identified (medications, systemic disorders) 5, 6
- Discontinue medications that may cause breast enlargement (e.g., spironolactone) 5
- Consider hormone therapy in appropriate cases: androgens for hypogonadism or antiestrogens for estrogen overproduction 5
- Surgical intervention may be necessary when gynecomastia does not resolve spontaneously or with medical therapy 5, 4
Important Considerations
- Breast cancer in males is rare (accounting for <1% of all breast cancers) but should be ruled out, especially in older men (median age 63 years) 1, 3
- Male breast cancer typically presents as a hard, unilateral mass, often eccentric to the nipple, and may show secondary signs like skin thickening, nipple retraction, and axillary lymphadenopathy 3, 7
- Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 2, 1
Common Pitfalls to Avoid
- Failing to recognize suspicious features that warrant imaging evaluation 3, 7
- Assuming all male breast masses are benign, particularly in men over 40 years of age 3
- Performing unnecessary imaging studies when clinical findings clearly indicate benign gynecomastia 2, 1
- Not considering medication-induced gynecomastia, which may resolve with discontinuation of the offending agent 5, 6