Should a male patient with a hypoechoic solid breast mass adjacent to a simple cyst on ultrasound and no clinical gynecomastia undergo a diagnostic mammogram?

Should This Male Patient Undergo Diagnostic Mammogram?

Yes, this male patient with a hypoechoic solid breast mass adjacent to a simple cyst on ultrasound should undergo diagnostic mammogram, regardless of the absence of clinical gynecomastia, because the presence of a solid mass requires complete imaging evaluation to exclude malignancy. 1

Age-Based Imaging Algorithm for Male Breast Masses

The American College of Radiology provides clear age-stratified guidance for male patients with breast masses:

• For men 25 years and older with an indeterminate or suspicious breast mass, mammography or digital breast tomosynthesis (DBT) is the recommended initial imaging study, with sensitivity of 92-100%, specificity of 90-96%, and negative predictive value of 99-100% for distinguishing benign from malignant disease. 1

• For men younger than 25 years, ultrasound is the initial imaging modality of choice; however, if suspicious or indeterminate features are found on ultrasound (such as a solid hypoechoic mass), mammography or DBT should be performed before proceeding to biopsy. 1

Why This Patient Needs Mammography Despite Ultrasound Findings

The presence of a solid hypoechoic mass on ultrasound constitutes a suspicious or indeterminate finding that mandates further imaging evaluation with mammography. 1 Several critical factors support this recommendation:

• Mammography is superior to ultrasound for detecting microcalcifications, which may be the only sign of malignancy in male patients and could be present in areas not visualized on the targeted ultrasound. 1

• Bilateral mammography should be performed routinely in men to assess for symmetry and detect possible contralateral abnormalities that may not have been clinically apparent or evaluated on the initial ultrasound. 1

• Relatively benign imaging findings should be considered more suspicious in male patients due to different breast anatomy compared to females, making comprehensive imaging evaluation essential. 1

Clinical Context: Absence of Gynecomastia Increases Suspicion

The absence of clinical gynecomastia in this patient actually heightens concern for malignancy:

• Gynecomastia typically presents as a soft, rubbery, or firm mobile mass directly under the nipple, and when clinical findings are consistent with gynecomastia or pseudogynecomastia, no imaging is routinely recommended. 2

• However, if the differentiation between benign disease and breast cancer cannot be made clinically, or if presentation is suspicious (such as a solid mass without typical gynecomastia features), imaging is indicated. 2

• Male breast cancer is rare (less than 1% of all breast cancers) but typically presents at median age 63 years, and the presence of a solid mass without gynecomastia warrants exclusion of malignancy. 1

Diagnostic Mammography Technique and Next Steps

Once mammography is ordered, the evaluation should proceed as follows:

• Diagnostic mammography includes additional views beyond screening, such as spot compression or magnification views, to investigate the finding in question and better characterize the solid mass. 3

• Mammography is highly effective at distinguishing gynecomastia from malignancy in men and will help determine the appropriate BI-RADS category for this lesion. 1

• If the mammogram shows BI-RADS category 4-5 (suspicious or highly suggestive of malignancy), core needle biopsy is recommended, preferably with ultrasound guidance for patient comfort, real-time visualization, and sampling accuracy. 3, 2

• If the mammogram shows BI-RADS category 3 (probably benign finding), short-term follow-up with physical examination and imaging (ultrasound and/or diagnostic mammogram) every 6-12 months for 1-2 years is appropriate to assess for stability. 3

Common Pitfalls to Avoid

• Do not assume that benign ultrasound findings alone are sufficient to exclude malignancy in a male patient with a solid breast mass. The negative predictive value of ultrasound alone is not as robust as combined mammography and ultrasound evaluation. 1

• Do not skip mammography based solely on the absence of clinical gynecomastia. Imaging is specifically indicated when clinical differentiation between benign disease and cancer cannot be made. 2

• Avoid unnecessary imaging only in clear cases of clinical gynecomastia, as this can lead to additional unnecessary benign biopsies; however, this patient does not have clinical gynecomastia, making imaging appropriate. 2, 1