Imaging Evaluation of Chest Lumps in a 67-Year-Old Man
A 67-year-old man with chest lumps should undergo mammography (or digital breast tomosynthesis) as the initial imaging study, followed by ultrasound if the mammogram is indeterminate or suspicious. 1
Initial Imaging Approach
Mammography should be the first-line imaging modality for men 25 years and older presenting with breast lumps, as it demonstrates high sensitivity (92-100%) and specificity (90-96%) for distinguishing benign from malignant disease in male patients. 1 The American College of Radiology specifically recommends this approach for symptomatic male breast evaluation. 2
- Bilateral mammography should be performed routinely to assess for symmetry and detect possible contralateral abnormalities, with a negative predictive value of 99-100% for malignant disease. 1
- Male patients with nipple discharge have a particularly high incidence (23-57%) of breast cancer, making imaging evaluation critical in this population. 2
Sequential Imaging Strategy
Ultrasound should be added after mammography if the initial mammogram shows indeterminate or suspicious findings. 1 This sequential approach optimizes diagnostic accuracy:
- Ultrasound demonstrates sensitivity of 88.9-100% and specificity of 74-95.3% in male breast evaluation when used as a complementary study. 1
- Ultrasound facilitates characterization of masses and provides real-time guidance for potential biopsy procedures. 2, 1
Clinical Context Considerations
If clinical examination clearly demonstrates gynecomastia, no imaging is routinely recommended, as most men with breast symptoms can be diagnosed based on clinical findings alone. 1 Key distinguishing features include:
- Gynecomastia is bilateral in approximately 50% of patients and often painful, especially when present for less than 6 months. 1
- The median age of presentation for male breast cancer is 63 years, making your 67-year-old patient within the high-risk age range. 1
Biopsy Approach if Needed
Image-guided core needle biopsy is the procedure of choice for suspicious lesions requiring tissue diagnosis, with ultrasound guidance preferred due to patient comfort, real-time visualization, and superior sampling accuracy compared to fine needle aspiration. 1
Common Pitfall to Avoid
Do not start with ultrasound alone in male patients, even though ultrasound is highly sensitive. 2 Mammography remains superior for detecting suspicious microcalcifications and provides better overall characterization in the male breast, where breast tissue density is typically less of a limiting factor than in premenopausal women. 2