From the Guidelines
For a male patient with a mass in the right breast, the recommended initial imaging is a diagnostic mammogram and ultrasound, as these modalities have high sensitivity and specificity in distinguishing benign from malignant disease 1. The mammogram typically includes standard views (craniocaudal and mediolateral oblique) of both breasts, while the ultrasound provides complementary information about the mass characteristics. Some key points to consider in the evaluation of a male breast mass include:
- Mammography is highly sensitive and specific in distinguishing benign from malignant disease, with sensitivities ranging from 92% to 100%, specificities ranging from 90% to 96%, and negative predictive values (NPV) of 99% to 100% 1.
- Ultrasound can assist in lesion characterization and guide biopsy, but its performance in men may be more variable than mammography 1.
- Male breast cancer typically presents as a firm, painless mass, often subareolar, and tends to be diagnosed at later stages than in women due to lower awareness 1.
- Prompt imaging is crucial as delays in diagnosis can impact prognosis. If these initial studies are concerning, a core needle biopsy guided by ultrasound or stereotactic mammography should be performed to obtain tissue for diagnosis. In cases where mammography and ultrasound are inconclusive or if malignancy is suspected despite negative initial imaging, breast MRI may be considered as a supplementary imaging modality 1. It's essential to note that while breast masses in men are often benign conditions like gynecomastia, approximately 1% of all breast cancers occur in men, so proper evaluation is essential 1.
From the Research
Imaging Modalities for Male Breast Mass
- Mammography and ultrasound are commonly used for imaging the male breast, with mammography as the initial imaging modality of choice and ultrasound when a mass is detected or suspected 2
- The diagnostic performance of Magnetic Resonance Imaging (MRI), ultrasound, and mammography for detection of breast cancer has been compared, with MRI showing the highest sensitivity and ultrasound having the highest specificity in certain cases 3
Evaluation Algorithm
- For men with a palpable breast mass, imaging evaluation is crucial to exclude breast cancer, with mammography and ultrasound being the primary modalities used 2
- The American College of Radiology (ACR) Appropriateness Criteria recommend ultrasound as the initial imaging modality for men under 30 years or for those who are pregnant or lactating, while diagnostic mammography is recommended for men over 40 years 4
Role of Ultrasound
- Ultrasound has been expanding as a supplemental screening tool for breast cancer, especially in dense breasts, and its efficacy, utility, and feasibility as a screening tool are being re-examined 5
- Ultrasound-guided breast biopsy is the standard of care in high-income countries, and training programs are being developed to improve competency in low- and middle-income countries 6