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Tomosynthesis in the Male Breast
Male patients are not uncommon in breast imaging centers, where they usually present with clinical symptoms, including breast lumps, pain, or focal swelling. Men are usually distressed by these symptoms and are uncomfortable while in the department. Expediting the imaging process and communicating the results as quickly as possible are desirable.
Tomosynthesis can be very helpful in imaging the male patient because it can help to differentiate glandular tissue from true masses, similar in women’s breasts. By far the most common finding among men presenting for breast imaging is gynecomastia. Breast cancer in men is uncommon, accounting for less than 1% of all breast cancer and less than 1% of all cancer in men. Differentiating gynecomastia from breast cancer is the main objective when imaging male breasts. There are also other specific diagnoses that may occasionally be encountered, such as lipomas, lymph nodes, sebaceous or epidermal inclusion cysts, hematomas, abscesses, fat necrosis, and malignant findings secondary to lymphoma or metastases.
Men do not routinely undergo mammographic screening. However, certain exceptions include those with a personal history of breast cancer (postmastectomy), a history of mantle radiation in childhood or young adulthood, a known genetic mutation (particularly BRCA 1 or 2 carriers), as well as male-to-female transsexuals receiving high-dose estrogen and men with rare syndromes known to increase breast cancer risk (eg, Klinefelter syndrome). For all these individuals the lifetime risk of breast cancer is high enough to justify annual mammography screening ( Fig. 13.1 ). As awareness of individual and familial genetic profiles increases, it is possible that more men may seek breast cancer screening.
Right breast screening.
An 82-year-old man status post–left mastectomy 15 years prior presents for annual screening of the right breast. (A) Two-dimensional mammogram shows mild gynecomastia and a questionable spiculated asymmetry in the subareolar area on the craniocaudal view (arrow) . (B) Tomosynthesis slice images from the lower (B1) and upper (B2) halves of the breast help to establish that the asymmetry represents superimposed tissue.
Imaging the Male Patient
Mammography is the main imaging modality for evaluating male patients. Bilateral mammography in the conventional craniocaudal (CC) and mediolateral oblique (MLO) projections is usually performed. This permits assessment of bilaterality and symmetry of findings, which is often the key to making a diagnosis. In young men under 35 years of age, ultrasound could be considered initially and mammography performed only if the mammographic findings are inconclusive or suspicious.
The normal male mammogram typically demonstrates fatty tissue, a minimal amount of subareolar tissue, intramammary or axillary lymph nodes, and prominent pectoralis muscles. Tomosynthesis would likely not be beneficial if most men presenting for imaging had this normal mammographic appearance because tomosynthesis does not add much benefit to the assessment of fatty tissue over two-dimensional (2D) mammography alone ( Fig. 13.2 ). However, because most men undergoing mammography are symptomatic and often present with gynecomastia, a normal mammographic appearance is not common; thus tomosynthesis often can be helpful.
Most clinically palpable lumps in men occur near the nipple, and compression of this region may be suboptimal, especially if the patient has large pectoralis muscles. As a result, visualization of the subareolar area may be compromised. Clumped subareolar density may make it difficult to clearly differentiate an underlying mass from gynecomastia. Tomosynthesis allows improved assessment of the breast tissue due to the ability to scroll and visualize the tissue in thin slices ( Fig. 13.3 ). If the pectoralis muscles are particularly prominent, additional views of the anterior breast, excluding the pectoralis muscles, can be performed. Gynecomastia has a similar appearance to fibroglandular tissue in a female breast and can be more confidently diagnosed with tomosynthesis. In addition, a focal mass can be more easily identified and better differentiated from adjacent tissue.
When imaging men presenting with palpable lumps eccentric to the nipple, placement of a skin marker overlying the abnormality is very important to permit better assessment of the area of clinical concern. Breast cancer and gynecomastia may coexist, particularly in older men, and identifying a suspicious mass in a background of bilateral gynecomastia can be challenging. In addition, isodense or hypodense masses, such as lipomas, may be difficult to detect. Occasionally, spot compression views with tomosynthesis may be necessary to further evaluate a focal area of concern. Tomosynthesis can also enhance the identification and characterization of a mass in the retroareolar region in men with gynecomastia.
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