What is the appropriate workup and management for an adult male presenting with breast pain?

Workup for Breast Pain in Adult Males

For adult males presenting with breast pain, the workup should be guided by clinical examination findings: most men with typical gynecomastia do not require imaging, but those with suspicious features (unilateral, hard, fixed, or eccentric masses) should undergo diagnostic mammography if age ≥25 years or ultrasound if younger than 25 years. 1, 2

Initial Clinical Assessment

Key History and Physical Examination Elements

• Differentiate true gynecomastia from pseudogynecomastia: True gynecomastia presents as soft, rubbery, or firm mobile tissue directly under the nipple, often painful especially when present <6 months, while pseudogynecomastia is fatty tissue deposition particularly in elevated BMI patients 2

• Assess pain characteristics: Determine if pain is focal/persistent versus diffuse/noncyclical, as focal persistent pain may warrant further investigation despite low malignancy risk (0-3% in isolated breast pain) 1

• Evaluate for suspicious features requiring imaging: Unilateral presentation, hard or fixed mass, eccentric location, nipple retraction, bloody nipple discharge, skin retraction, or axillary adenopathy 1, 2

• Medication and hormonal assessment: Review medications that can cause gynecomastia (spironolactone, antiandrogens, ketoconazole, GnRH agonists, 5-alpha reductase inhibitors, estrogens, anabolic steroids) 3

• Physical examination components: Assess body habitus/BMI, virilization status through body hair patterns, complete testicular examination for size/consistency/masses/varicocele, prostate assessment, and visual fields for pituitary disorders 2

Imaging Algorithm Based on Clinical Findings

When Imaging is NOT Routinely Recommended

No imaging is needed for men with clear clinical findings of benign gynecomastia or pseudogynecomastia, as unnecessary imaging leads to additional benign biopsies without improving outcomes 2, 1

When Imaging IS Indicated

Proceed with imaging when differentiation between benign disease and breast cancer cannot be made clinically or when presentation is suspicious 1, 2

Age-Based Imaging Protocol:

For men younger than 25 years:

• Initial study: Ultrasound (breast cancer extremely unlikely in this age group) 1, 2
• If ultrasound shows suspicious or indeterminate features, proceed to mammography or digital breast tomosynthesis (DBT) before biopsy recommendation 2

For men 25 years and older:

• Initial study: Diagnostic mammography or DBT (both are equivalent alternatives with sensitivity 92-100%, specificity 90-96%, NPV 99-100%) 1, 2
• Follow with ultrasound if mammography is indeterminate or suspicious 1

For any age with highly suspicious examination findings (suspicious palpable mass, axillary adenopathy, nipple discharge, nipple retraction):

• Both mammography/DBT AND ultrasound are appropriate, with mammography/DBT as initial modality and ultrasound as complementary 1

Laboratory Evaluation

Measure serum estradiol in all men presenting with gynecomastia or breast symptoms, particularly before starting testosterone therapy in testosterone-deficient patients 2, 4

Refer to endocrinologist if elevated baseline estradiol for assessment of hormonal imbalances including testosterone deficiency, elevated estradiol, abnormal LH levels, and hyperprolactinemia 2

Management Based on Findings

For Benign Gynecomastia Without Imaging Abnormalities:

• Observation is appropriate: Noncyclical breast pain has spontaneous resolution in up to 50% of patients 2

• Conservative measures for persistent pain: Acetaminophen, NSAIDs, physical activity 1

• Consider selective estrogen receptor modulators in testosterone-deficient patients with low or low-normal LH levels, particularly those interested in preserving fertility 2

• Monitor testosterone-treated patients: Symptoms sometimes abate with continued observation 2

For Suspicious Imaging Findings:

Image-guided core needle biopsy is the procedure of choice (superior to fine-needle aspiration for sensitivity, specificity, and histological grading) 2

Biopsy guidance selection:

• Ultrasound-guided for lesions visible on ultrasound (preferred for patient comfort, real-time visualization, no radiation) 2
• Stereotactic-guided for lesions only visible on mammography 2
• DBT-guided for lesions only visible on DBT 2

Post-biopsy marker clip placement to confirm tissue sampling and aid correlation 2

Common Pitfalls to Avoid

• Avoid unnecessary imaging in clear cases of gynecomastia, which increases benign biopsies without benefit 2

• Do not dismiss focal, persistent pain: While malignancy risk is low, cancer can occasionally present with well-localized persistent pain 1

• Recognize that relatively benign imaging findings (circumscribed masses, round calcifications) should be considered suspicious in males due to lack of typical benign proliferative changes seen in women 1

• Remember male breast cancer is rare but occurs (median age 63 years, <1% of all breast cancers), requiring appropriate vigilance in older men 1, 2

• Perform imaging before biopsy as post-biopsy changes may confuse image interpretation 2