In a male patient with a 3‑cm hypoechoic axillary mass suspicious for cancer, should I refer him now to a breast‑surgery specialist (breast surgeon or surgical oncologist) or wait for the diagnostic mammogram and core‑needle biopsy results?

Referral Recommendation for Male Patient with Suspicious Axillary Mass

Refer this patient immediately to a breast surgery specialist (breast surgeon or surgical oncologist) now—do not wait for diagnostic mammogram and core-needle biopsy results. The presence of a 3-cm hypoechoic axillary mass suspicious for cancer warrants urgent specialist evaluation, and the diagnostic workup can proceed in parallel with or be coordinated by the specialist team.

Rationale for Immediate Referral

BI-RADS Category and Tissue Diagnosis Requirements

• A 3-cm hypoechoic axillary mass suspicious for cancer likely represents BI-RADS category 4 or 5 (suspicious or highly suggestive of malignancy), which mandates tissue biopsy. 1
• Core needle biopsy is the preferred diagnostic method and should be performed for any imaging findings consistent with BI-RADS 4 or 5. 1
• In male patients with clinically suspicious axillary lymph nodes, ultrasound-guided fine-needle aspiration or core biopsy should be performed to establish pathologic confirmation of malignancy. 1

Why Specialist Referral Should Not Be Delayed

• Breast surgery specialists and surgical oncologists are essential members of the multidisciplinary team required for optimal breast cancer management, and early involvement improves treatment planning and outcomes. 2
• The specialist can coordinate the diagnostic workup (mammogram, biopsy, additional staging) and ensure appropriate pathologic assessment including hormone receptor status (ER, PR) and HER2 testing, which are critical for treatment decisions. 1
• Male breast cancer patients benefit from evaluation by an experienced team that can perform sentinel lymph node mapping if indicated, assess for additional disease, and develop a comprehensive treatment plan. 1

Male Breast Cancer Considerations

Epidemiology and Presentation

• Male breast cancer is rare (less than 1% of all breast cancers) but typically presents in older men (median age 63-67 years) and is predominantly hormone receptor-positive. 3, 4
• The presentation of an axillary mass in a male patient is particularly concerning and may represent either primary breast cancer with nodal involvement or, less commonly, an occult primary tumor. 1

Diagnostic Workup That Will Be Coordinated

• Bilateral diagnostic mammography should be performed as part of the initial evaluation, as mammography has high sensitivity (92-100%) and specificity (90-96%) for male breast evaluation. 5, 4
• Core needle biopsy under ultrasound guidance is superior to fine-needle aspiration for sensitivity, specificity, and correct histological grading. 5
• Pathologic diagnosis must include assessment of ER, PR, and HER2 status, as male breast cancer is typically hormone receptor-positive and this guides adjuvant therapy decisions. 1, 3

Practical Algorithm for This Case

Immediate Actions (Do Not Wait)

1. Place urgent referral to breast surgery specialist or surgical oncologist today 1
2. Order bilateral diagnostic mammogram if not already done 1
3. Coordinate ultrasound-guided core needle biopsy of the axillary mass 1, 5

What the Specialist Will Manage

• Complete staging evaluation including examination for primary breast lesion 1
• Pathologic confirmation with appropriate immunohistochemistry 1, 3
• Multidisciplinary team discussion involving medical oncology, radiation oncology, and pathology 2
• Surgical planning including sentinel lymph node biopsy or axillary lymph node dissection as appropriate 1

Common Pitfalls to Avoid

• Do not delay referral waiting for "complete workup"—the specialist should coordinate the diagnostic evaluation to ensure appropriate tissue handling and pathologic assessment. 1
• Do not assume this is benign gynecomastia—a 3-cm axillary mass is highly suspicious and requires tissue diagnosis regardless of breast examination findings. 5, 4
• Do not perform fine-needle aspiration alone—core needle biopsy is required for definitive diagnosis and biomarker assessment. 5
• Do not forget that male breast cancer requires the same multidisciplinary approach as female breast cancer, with early specialist involvement improving outcomes. 3, 2

Special Consideration for Male Patients

• All men diagnosed with breast cancer should be offered genetic counseling and germline genetic testing for cancer predisposition genes (BRCA1, BRCA2, CHEK2, PALB2). 3
• Male breast cancer has a higher prevalence of hormone receptor positivity compared to female breast cancer, making endocrine therapy highly effective. 3