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Breast Disease 00 (2014) 1–6 DOI 10.3233/BD-140391 IOS Press
Unusual findings in the male breast patient: A case series Elizabeth K. Arleoa,∗ and Carolyn Eisenb a
New York, NY, USA Cindy Parra-Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
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Keywords: Male breast pathology, gynecomastia, fibromatosis, varices
1. Case 1
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1.1. History
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A 41-year-old male was referred to our Breast Imaging Division for further evaluation of palpable areas of concern in both breasts. He had a personal history of beta thalassemia with secondary iron overload and chronic liver disease from hepatitis C with secondary hypogonadism necessitating hormone therapy for 20 years. His family history was noncontributory. Physical examination revealed bilateral firm, tender, nonmobile masses lateral to the nipples.
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1.2. Imaging findings Real-time ultrasound of both breasts was performed. There were areas of hypoechogenicity in the retroareolar areolar regions on the right (Fig. 1a) and left, corresponding to the sites of palpable concern, compatible with gynecomastia. Additionally, there were bilateral tubular-shaped circumscribed anechoic structures which avidly filled in with color Doppler flow, compat∗ Corresponding
ible with varices (Fig. 1b-e). There was no sonographic evidence of a suspicious cystic or solid lesion in either visualized breast. Of note, due to the markedly tender nature of the bilateral breast findings, bilateral mammography could not be tolerated by the patient as an additional evaluation tool.
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2. Case 2
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2.1. History
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A 51-year-old male was referred to our Breast Imaging Division for further evaluation of a palpable mass in the right breast. He had no significant past medical history and a non-contributory family history. Physical examination of the right breast above the nipple revealed a palpable non-tender mass.
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2.2. Imaging findings
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Ultrasound of the right breast was performed targeted to the 12:00 axis, 5–6 cm from the nipple, the patient’s palpable area of concern, demonstrating a posteriorly-located 2.7 cm oval hypoechoic mass with lobulated margins and no internal color Doppler flow (Fig. 2a, b). Ultrasound-guided core biopsy of the mass was performed (Fig. 2c) with clip placement and
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Abstract. In this case series, we present the history and imaging of several male patients with breast complaints. Given the rise in men presenting with breast cancer, from 1 in 100,000 in the 1970s to 1.5 in 100,000 in 2012 [1,2], these cases presented here together provide the useful reminder that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male (as well as female) patient with a breast complaint.
author: Arleo, Cornell, 425 East 61st Street, 9th Floor, New York, NY 10065, USA. Tel.: +1 212 821 0680; Fax: +1 212 821 0671; E-mail: [email protected].
c 2011/2012 – IOS Press and the authors. All rights reserved 0888-6008/14/$27.50
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E.K. Arleo and C. Eisen / Unusual findings in the male breast patient: A case series
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Fig. 1. 41-year old male with chronic liver disease presents bilateral firm, tender, non-mobile masses lateral to the nipples on both sides. (a) Gray-scale ultrasound image of the right breast palpable area of concern demonstrated benign gynecomastia; a similar appearance was seen at the left breast palpable area of concern (not shown). Additionally (b-e), gray-scale and color Doppler images bilaterally demonstrate marked varices. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391)
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3. Case 3 3.1. History
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post-biopsy mammogram for confirmation (Fig. 2d, e). Pathology yielded fibromatosis, concordant with the imaging findings, which was confirmed at full surgical excision subsequently performed.
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A 69-year-old male was referred to our Breast Imaging Division for further evaluation of bilateral nipple pain for 4 to 5 weeks without nipple discharge. He had a personal history of morbid obesity, diabetes mellitus type II, chronic renal insufficiency, and hypogonadism leading to initiation of a testosterone patch 2 months prior to presentation. Family history was noncontributory. Physical examination revealed tenderness bilaterally to palpation, without masses appreciated.
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3.2. Imaging findings
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A bilateral digital diagnostic mammogram was performed (Fig. 3a and b), demonstrating heterogeneously dense tissue behind the right nipple, with spot com-
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pression views demonstrating nodular tissue without a discrete mammographically suspicious finding. The left breast demonstrates less dense flame-shaped tissue behind the left nipple, without mammographically discernible suspicious masses. Ultrasound of the bilateral breasts were performed as well, demonstrating anechoic dilated ducts in the right breast, retroareolar region (Fig. 3c); no cystic or solid lesions were seen in the left breast. The impression was of bilateral gynecomastia, right greater than left, with associated right breast duct ectasia. Gynecosmastia was appreciated on subsequent chest x-ray obtained for unrelated purposes as well (Fig. 3d).
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3.3. Discussion
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The purpose of this case series is to present the history and imaging of several male patients with breast complaints. The principal message of these cases is that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male (as well as female) patient with a breast complaint. This is of particular clinical importance given the rise in men presenting with breast issues, from 1 in 100,000 in the 1970s to 1.5 in 100,000 in 2012 [1,2].
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The interpretation of cases 1 and 3 presented above was of gynecomastia, a benign, usually reversible excessive development of the male breast. Histologically, it is defined as the atypical proliferation of ductal and stromal tissue in the male breast and can present with unilateral or bilateral breast symptoms or imaging findings [3]. It typically presents as an asymptomatic subareolar soft mobile mass. Asymptomatic gynecomastia can affect males in all stages of life, with a prevalence of 60–90% in neonates, 50–60% in adolescents, and 70% in males 50–69 years [4]. Neonatal gynecomastia is the result of placental estrogens on neonatal breast tissue, and typically self resolves. Adolescent gynecomastia is due to the excess of estradiol levels relative to testosterone and typically resolves over several months to years. On the other hand, senile gynecomastia is related to the fall of testosterone and its peripheral aromatization to estrogen, resulting in hyperestrenism [5]. Certain conditions that affect the liver and gonads, such as cirrhosis and hypogonadism, are associated with an increase in the endogenous estrogen/androgen ratio, as seen in our patients in cases 1 and 3, respectively [6].
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Fig. 2. 51 year-old male, without significant past medical history, presents with a palpable nontender mass in the right breast. Gray-scale and color Doppler images (a, b) of the right breast palpable area of concern at the 12:00 axis, N5-6, demonstrates a posteriorly-located 2.7 cm oval mass with lobulated margins and no internal color Doppler flow, which underwent ultrasound-guided core biopsy (c) with clip placement as seen on MLO and CC right breast mammographic views (d, e). Pathology yielded fibromatosis (f). (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391)
Gynecomastia can also be drug-induced secondary to anabolic steroids, estrogen treatment for prostate cancer, digitalis, spironolactone, cimetidine, thiazide, reserpine, ergotamine isoniazid, and marijuana [7]. Symptomatic gynecomastia, on the other hand, is a much rarer finding with a considerably lower prevalence [7]. In a study of 214 hospitalized patients that were evaluated for the prevalence of gynecomastia, palpable gynecomastia was detected in 140 patients; none had breast pain or tenderness [8]. Thus, we took note of the bilateral tenderness when evaluating the first and third patients in this series because their tenderness was an unusual presentation for gynecomastia. Symptomatic or asymptomatic, studies report that gynecomastia accounts for 80% of all male breast referrals, while male breast cancer accounts for less than 1% [9,10]. The primary differential consideration with gynecomastia is pseudogynecomastia, which is the result of excessive adipose tissue deposits in the breast, is often the result of obesity and does not involve breast structural changes. In contrast, in gynecomastia, the structure of the male breast changes as ductal struc-
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Fig. 3. 69-year-old male, with morbid obesity, diabetes mellitus type II, chronic renal insufficiency, and hypogonadism treated with a testosterone patch. CC and MLO views of the bilateral breasts (a) demonstrate bilateral flame-shaped gynecomastia, right greater than left, with diagnostic spot compression views of the right central breast (b) demonstrating nodular tissue. Right breast ultrasound (c) demonstrates prominence of the subareolar ducts, and chest x-ray (d), subsequently obtained for unrelated reasons, demonstrates gynecomastia as well. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391) 129 130 131 132 133 134 135 136 137
tures become enlarged, elongated, branched, with an increase in epithelium [5]. This case series also points to non-gynecomastia pathologies that can affect the male breast, including varices (case 1) and fibromatosis (case 2). Vascular abnormalities of the breast are quite unusual and can be the result of a variety of underlying conditions, ranging from vascular abnormalities to malignant vascular masses [11]. The first patient in this series had chronic
liver disease (secondary to viral hepatitis C). Complications of chronic liver disease include portal hypertension, which can lead to varices, most commonly lower esophageal in location, however signs of chronic liver disease also include gynecomastia, which this patient had, as well as angiomata and caput medusa, which are distended abdominal veins. Thus, we hypothesize that the origin of this male patient’s breast varices stems from his chronic liver disease. However,
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Stang A and Thomssen C. Decline in breast cancer incidence in the United States: what about male breast cancer? Breast Cancer Res Treat 2008; 112: 595-6. [2] Fields EC, DeWitt P, Fisher CM and Rabinovitch R. Management of Male Breast Cancer in the United States: A Surveillance, Epidemiology and End Results Analysis. International Journal of Radiation Oncology Biology Physics 2013; 87: 747-52. [3] Nguyen CE, Kettler MD, Hadro JA. Male Breast Disease: Pictorial Review with Radiologic-Pathologic Correlation. RadioGraphics 2013; 33: 763-79. [4] Georgiadis E, Papandreou L, Evangelopoulou C et al. Incidence of gynaecomastia in 954 young males and its relationship to somatometric parameters. Ann Hum Biol 1994; 6: 579–87. [5] Hunt KK , Newman LA, Copeland EM, Bland KI. Chapter 17. The Breast. In: Brunicardi F AD, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, (ed.) Schwartz’s Principles of Surgery, 9e. New York, NY: McGraw-Hill, 2010. [6] Olsson H, Bladstrom A, Alm P. Male Gynecomastia and Risk for malignant tumors – A Cohort Study. BMC Cancer 2002; 2: 26. [7] Johnson RE, Kermott CA, Murad MH. Gynecomastia- evaluation and current treatment options. Therapeutics and clinical risk management. 2011; 7: 145–8. [8] Niewoehner CB, Nuttall FQ. Gynecomastia in a hospitalized male population. 1984; 77: 633–8. [9] Charlot M, Beatrix O, Réty F. Pathologies of the Male Breast. Diagnostic and Interventional Imaging 2013; 94: 26–37. [10] Al-Allak A, Govindarajulu S, Shere M, Ibrahim N, Sahu AK, Cawthorn SJ. Gynaecomastia: a decade of experience. The surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2011; 9: 255–8. [11] Ozdemir A, Ilgit E, Oznur LK, Ozsunar Y. Breast varices: imaging findings of an unusual presentation of collateral pathways in superior vena cava syndrome. European Journal of Radiology 2000; 36: 104–7. [12] Jesinger RA, Lattin GE, Ballard EA, Glassman LM. Vascular Abnormalities of the Breast: Arterial and Venous Disorders, Vascular Masses, and Mimic Lesions with RadiologicPathologic Correlation. Radiographics 2011; 31: E117–E34. [13] Krishnan PK, Uragoda L, Rao H, Dhar SR. Venous Dilatation Seen on Routine Mammography. Chest Journal 2002; 121: 1361–3. [14] Glazebrook KN, Reynolds CA. Mammary fibromatosis. AJR Am J Roentgenol 2009; 193: 856–60. [15] Lattin GE, Jesinger RA, Glassman LM. Diseases of the Male Breast: Radiologic-Pathologic Correlation. RadioGraphics 2013; 33: 461–89. [16] Matherne TH, Green A Jr, Tucker JA, Dyess DL. Fibromatosis: the breast cancer imitator. South Med J 2004; 97: 1100–3. [17] Schwarz GS, Drotman M, Osborne MP. Fibromatosis of the breast: case report and current concepts in the management of an uncommon lesion. The Breast Journal 2006; 12: 66–71.
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tients with breast complaints. The principal message of these cases is that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male, as well as female, patient with a breast complaint.
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bilateral breast vein enlargement could also point to occlusion of the superior vena cava, as gradual obstruction of the SVC could result in the development of venous collaterals throughout the breast [11]. Alternatively, unilateral breast vein dilation could be a result of an arterial disorder such as atherosclerosis or breast aneurysm. Vein dilation could also be indicative of a venous abnormality such as axillary or subclavian vein blockage resulting in retrograde flow, congestive heart failure, superficial thrombophlebitis, or more rarely a breast varix [12]. Potential signs of venous obstruction include facial and upper arm swelling and exertional dyspnea [13]. Imaging findings as a result of the aforementioned vascular abnormalities could be mistakenly interpreted as a benign or malignant breast mass and should be excluded [12]. A complication of breast varicies is bleeding or thrombosis [12]. Mammary fibromatosis, or desmoid tumors, are rare and account for 0.2% of all breast tumors [14]. Although the second patient in this case series was a male, they occur more often in women than in men (3:1 ratio) [15]. The reported age of diagnosis ranges from 13 to 83 years old [16]. Mammary fibromatosis is comprised of fibroblasts and myofibroblasts located within the breast parenchyma [15]. It is typically a tumor without metastatic potential, but is locally aggressive and can recur in an estimated 29% of cases [16]; this is why our patient in case 2 had surgical excision of his palpable mass, despite the benign pathological results of the core biopsy. Fibromatosis is most commonly found on the trunk and extremities, and may arise from the muscular aponeuroses at many sites throughout the body [17]. They are variable in size and have been found to range from 1 to 10 cm in diameter, but can grow to be large and to displace surrounding structures [18]. Fibromatosis can often manifest as a painless and firm non-mobile mass that raises concern for carcinoma or can suggest a secondary invasion by a tumor located in the shoulder, pelvic girdle, chest wall, head and neck [19,20]. The etiology of fibromatosis is unknown and most fibromatoses appear sporadically (97%), although several cases have been noted following trauma or breast surgery [19], as well as in association with inherited disorders such as familial adenomatous polyposis (FAP), familial multicentric fibromatosis, or Gardner syndrome [21,22].
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4. Conclusion In conclusion, the purpose of this case series is to present the history and imaging of several male pa-
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[22]
Huang K, Fu H, Shi YQ, Zhou Y, Du CY. Prognostic factors for extra-abdominal and abdominal wall desmoids: A 20-year experience at a single institution. J Surg Oncol 2009; 100: 563–9. Brueckl WM, Ballhausen WG, Förtsch T. Genetic testing for germline mutations of the APC gene in patients with apparently sporadic desmoid tumors but a family history of colorectal carcinoma. Dis Colon Rectum 2005; 48: 1275–81.
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[21]
Rosen PP, Ersenberger D. Mammary Fibromatosis: A benign spindle tumor with significant risk for local recurrence. Cancer 1989; 63: 1362–9. Becker JC, Liegl-Atzwanger B, Ugurel S. Malignant Fibrous, Fibrohistiocytic, and Histiocytic Tumors of the Dermis. In: K W, (ed.). Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York: McGraw-Hill, 2012. Neuman HB, Brogi E, Ebrahim A, Brennan MF, Van Zee KJ. Desmoid Tumors of the breast: a 25 year experience. Ann Surg Oncol 2008; 15: 274–80.
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Breast Disease 00 (2014) 1–6 DOI 10.3233/BD-140391 IOS Press
Unusual findings in the male breast patient: A case series Elizabeth K. Arleoa,∗ and Carolyn Eisenb a
New York, NY, USA Cindy Parra-Weill Cornell Medical College, 1300 York Avenue, New York, NY, USA
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Keywords: Male breast pathology, gynecomastia, fibromatosis, varices
1. Case 1
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1.1. History
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A 41-year-old male was referred to our Breast Imaging Division for further evaluation of palpable areas of concern in both breasts. He had a personal history of beta thalassemia with secondary iron overload and chronic liver disease from hepatitis C with secondary hypogonadism necessitating hormone therapy for 20 years. His family history was noncontributory. Physical examination revealed bilateral firm, tender, nonmobile masses lateral to the nipples.
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1.2. Imaging findings Real-time ultrasound of both breasts was performed. There were areas of hypoechogenicity in the retroareolar areolar regions on the right (Fig. 1a) and left, corresponding to the sites of palpable concern, compatible with gynecomastia. Additionally, there were bilateral tubular-shaped circumscribed anechoic structures which avidly filled in with color Doppler flow, compat∗ Corresponding
ible with varices (Fig. 1b-e). There was no sonographic evidence of a suspicious cystic or solid lesion in either visualized breast. Of note, due to the markedly tender nature of the bilateral breast findings, bilateral mammography could not be tolerated by the patient as an additional evaluation tool.
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2. Case 2
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2.1. History
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A 51-year-old male was referred to our Breast Imaging Division for further evaluation of a palpable mass in the right breast. He had no significant past medical history and a non-contributory family history. Physical examination of the right breast above the nipple revealed a palpable non-tender mass.
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Ultrasound of the right breast was performed targeted to the 12:00 axis, 5–6 cm from the nipple, the patient’s palpable area of concern, demonstrating a posteriorly-located 2.7 cm oval hypoechoic mass with lobulated margins and no internal color Doppler flow (Fig. 2a, b). Ultrasound-guided core biopsy of the mass was performed (Fig. 2c) with clip placement and
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Abstract. In this case series, we present the history and imaging of several male patients with breast complaints. Given the rise in men presenting with breast cancer, from 1 in 100,000 in the 1970s to 1.5 in 100,000 in 2012 [1,2], these cases presented here together provide the useful reminder that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male (as well as female) patient with a breast complaint.
author: Arleo, Cornell, 425 East 61st Street, 9th Floor, New York, NY 10065, USA. Tel.: +1 212 821 0680; Fax: +1 212 821 0671; E-mail: [email protected].
c 2011/2012 – IOS Press and the authors. All rights reserved 0888-6008/14/$27.50
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Fig. 1. 41-year old male with chronic liver disease presents bilateral firm, tender, non-mobile masses lateral to the nipples on both sides. (a) Gray-scale ultrasound image of the right breast palpable area of concern demonstrated benign gynecomastia; a similar appearance was seen at the left breast palpable area of concern (not shown). Additionally (b-e), gray-scale and color Doppler images bilaterally demonstrate marked varices. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391)
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3. Case 3 3.1. History
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post-biopsy mammogram for confirmation (Fig. 2d, e). Pathology yielded fibromatosis, concordant with the imaging findings, which was confirmed at full surgical excision subsequently performed.
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A 69-year-old male was referred to our Breast Imaging Division for further evaluation of bilateral nipple pain for 4 to 5 weeks without nipple discharge. He had a personal history of morbid obesity, diabetes mellitus type II, chronic renal insufficiency, and hypogonadism leading to initiation of a testosterone patch 2 months prior to presentation. Family history was noncontributory. Physical examination revealed tenderness bilaterally to palpation, without masses appreciated.
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A bilateral digital diagnostic mammogram was performed (Fig. 3a and b), demonstrating heterogeneously dense tissue behind the right nipple, with spot com-
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pression views demonstrating nodular tissue without a discrete mammographically suspicious finding. The left breast demonstrates less dense flame-shaped tissue behind the left nipple, without mammographically discernible suspicious masses. Ultrasound of the bilateral breasts were performed as well, demonstrating anechoic dilated ducts in the right breast, retroareolar region (Fig. 3c); no cystic or solid lesions were seen in the left breast. The impression was of bilateral gynecomastia, right greater than left, with associated right breast duct ectasia. Gynecosmastia was appreciated on subsequent chest x-ray obtained for unrelated purposes as well (Fig. 3d).
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The purpose of this case series is to present the history and imaging of several male patients with breast complaints. The principal message of these cases is that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male (as well as female) patient with a breast complaint. This is of particular clinical importance given the rise in men presenting with breast issues, from 1 in 100,000 in the 1970s to 1.5 in 100,000 in 2012 [1,2].
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The interpretation of cases 1 and 3 presented above was of gynecomastia, a benign, usually reversible excessive development of the male breast. Histologically, it is defined as the atypical proliferation of ductal and stromal tissue in the male breast and can present with unilateral or bilateral breast symptoms or imaging findings [3]. It typically presents as an asymptomatic subareolar soft mobile mass. Asymptomatic gynecomastia can affect males in all stages of life, with a prevalence of 60–90% in neonates, 50–60% in adolescents, and 70% in males 50–69 years [4]. Neonatal gynecomastia is the result of placental estrogens on neonatal breast tissue, and typically self resolves. Adolescent gynecomastia is due to the excess of estradiol levels relative to testosterone and typically resolves over several months to years. On the other hand, senile gynecomastia is related to the fall of testosterone and its peripheral aromatization to estrogen, resulting in hyperestrenism [5]. Certain conditions that affect the liver and gonads, such as cirrhosis and hypogonadism, are associated with an increase in the endogenous estrogen/androgen ratio, as seen in our patients in cases 1 and 3, respectively [6].
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Fig. 2. 51 year-old male, without significant past medical history, presents with a palpable nontender mass in the right breast. Gray-scale and color Doppler images (a, b) of the right breast palpable area of concern at the 12:00 axis, N5-6, demonstrates a posteriorly-located 2.7 cm oval mass with lobulated margins and no internal color Doppler flow, which underwent ultrasound-guided core biopsy (c) with clip placement as seen on MLO and CC right breast mammographic views (d, e). Pathology yielded fibromatosis (f). (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391)
Gynecomastia can also be drug-induced secondary to anabolic steroids, estrogen treatment for prostate cancer, digitalis, spironolactone, cimetidine, thiazide, reserpine, ergotamine isoniazid, and marijuana [7]. Symptomatic gynecomastia, on the other hand, is a much rarer finding with a considerably lower prevalence [7]. In a study of 214 hospitalized patients that were evaluated for the prevalence of gynecomastia, palpable gynecomastia was detected in 140 patients; none had breast pain or tenderness [8]. Thus, we took note of the bilateral tenderness when evaluating the first and third patients in this series because their tenderness was an unusual presentation for gynecomastia. Symptomatic or asymptomatic, studies report that gynecomastia accounts for 80% of all male breast referrals, while male breast cancer accounts for less than 1% [9,10]. The primary differential consideration with gynecomastia is pseudogynecomastia, which is the result of excessive adipose tissue deposits in the breast, is often the result of obesity and does not involve breast structural changes. In contrast, in gynecomastia, the structure of the male breast changes as ductal struc-
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Fig. 3. 69-year-old male, with morbid obesity, diabetes mellitus type II, chronic renal insufficiency, and hypogonadism treated with a testosterone patch. CC and MLO views of the bilateral breasts (a) demonstrate bilateral flame-shaped gynecomastia, right greater than left, with diagnostic spot compression views of the right central breast (b) demonstrating nodular tissue. Right breast ultrasound (c) demonstrates prominence of the subareolar ducts, and chest x-ray (d), subsequently obtained for unrelated reasons, demonstrates gynecomastia as well. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140391) 129 130 131 132 133 134 135 136 137
tures become enlarged, elongated, branched, with an increase in epithelium [5]. This case series also points to non-gynecomastia pathologies that can affect the male breast, including varices (case 1) and fibromatosis (case 2). Vascular abnormalities of the breast are quite unusual and can be the result of a variety of underlying conditions, ranging from vascular abnormalities to malignant vascular masses [11]. The first patient in this series had chronic
liver disease (secondary to viral hepatitis C). Complications of chronic liver disease include portal hypertension, which can lead to varices, most commonly lower esophageal in location, however signs of chronic liver disease also include gynecomastia, which this patient had, as well as angiomata and caput medusa, which are distended abdominal veins. Thus, we hypothesize that the origin of this male patient’s breast varices stems from his chronic liver disease. However,
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Stang A and Thomssen C. Decline in breast cancer incidence in the United States: what about male breast cancer? Breast Cancer Res Treat 2008; 112: 595-6. [2] Fields EC, DeWitt P, Fisher CM and Rabinovitch R. Management of Male Breast Cancer in the United States: A Surveillance, Epidemiology and End Results Analysis. International Journal of Radiation Oncology Biology Physics 2013; 87: 747-52. [3] Nguyen CE, Kettler MD, Hadro JA. Male Breast Disease: Pictorial Review with Radiologic-Pathologic Correlation. RadioGraphics 2013; 33: 763-79. [4] Georgiadis E, Papandreou L, Evangelopoulou C et al. Incidence of gynaecomastia in 954 young males and its relationship to somatometric parameters. Ann Hum Biol 1994; 6: 579–87. [5] Hunt KK , Newman LA, Copeland EM, Bland KI. Chapter 17. The Breast. In: Brunicardi F AD, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE, (ed.) Schwartz’s Principles of Surgery, 9e. New York, NY: McGraw-Hill, 2010. [6] Olsson H, Bladstrom A, Alm P. Male Gynecomastia and Risk for malignant tumors – A Cohort Study. BMC Cancer 2002; 2: 26. [7] Johnson RE, Kermott CA, Murad MH. Gynecomastia- evaluation and current treatment options. Therapeutics and clinical risk management. 2011; 7: 145–8. [8] Niewoehner CB, Nuttall FQ. Gynecomastia in a hospitalized male population. 1984; 77: 633–8. [9] Charlot M, Beatrix O, Réty F. Pathologies of the Male Breast. Diagnostic and Interventional Imaging 2013; 94: 26–37. [10] Al-Allak A, Govindarajulu S, Shere M, Ibrahim N, Sahu AK, Cawthorn SJ. Gynaecomastia: a decade of experience. The surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2011; 9: 255–8. [11] Ozdemir A, Ilgit E, Oznur LK, Ozsunar Y. Breast varices: imaging findings of an unusual presentation of collateral pathways in superior vena cava syndrome. European Journal of Radiology 2000; 36: 104–7. [12] Jesinger RA, Lattin GE, Ballard EA, Glassman LM. Vascular Abnormalities of the Breast: Arterial and Venous Disorders, Vascular Masses, and Mimic Lesions with RadiologicPathologic Correlation. Radiographics 2011; 31: E117–E34. [13] Krishnan PK, Uragoda L, Rao H, Dhar SR. Venous Dilatation Seen on Routine Mammography. Chest Journal 2002; 121: 1361–3. [14] Glazebrook KN, Reynolds CA. Mammary fibromatosis. AJR Am J Roentgenol 2009; 193: 856–60. [15] Lattin GE, Jesinger RA, Glassman LM. Diseases of the Male Breast: Radiologic-Pathologic Correlation. RadioGraphics 2013; 33: 461–89. [16] Matherne TH, Green A Jr, Tucker JA, Dyess DL. Fibromatosis: the breast cancer imitator. South Med J 2004; 97: 1100–3. [17] Schwarz GS, Drotman M, Osborne MP. Fibromatosis of the breast: case report and current concepts in the management of an uncommon lesion. The Breast Journal 2006; 12: 66–71.
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tients with breast complaints. The principal message of these cases is that a comprehensive clinical history and focal physical examination is critical when assessing the symptomatic male, as well as female, patient with a breast complaint.
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bilateral breast vein enlargement could also point to occlusion of the superior vena cava, as gradual obstruction of the SVC could result in the development of venous collaterals throughout the breast [11]. Alternatively, unilateral breast vein dilation could be a result of an arterial disorder such as atherosclerosis or breast aneurysm. Vein dilation could also be indicative of a venous abnormality such as axillary or subclavian vein blockage resulting in retrograde flow, congestive heart failure, superficial thrombophlebitis, or more rarely a breast varix [12]. Potential signs of venous obstruction include facial and upper arm swelling and exertional dyspnea [13]. Imaging findings as a result of the aforementioned vascular abnormalities could be mistakenly interpreted as a benign or malignant breast mass and should be excluded [12]. A complication of breast varicies is bleeding or thrombosis [12]. Mammary fibromatosis, or desmoid tumors, are rare and account for 0.2% of all breast tumors [14]. Although the second patient in this case series was a male, they occur more often in women than in men (3:1 ratio) [15]. The reported age of diagnosis ranges from 13 to 83 years old [16]. Mammary fibromatosis is comprised of fibroblasts and myofibroblasts located within the breast parenchyma [15]. It is typically a tumor without metastatic potential, but is locally aggressive and can recur in an estimated 29% of cases [16]; this is why our patient in case 2 had surgical excision of his palpable mass, despite the benign pathological results of the core biopsy. Fibromatosis is most commonly found on the trunk and extremities, and may arise from the muscular aponeuroses at many sites throughout the body [17]. They are variable in size and have been found to range from 1 to 10 cm in diameter, but can grow to be large and to displace surrounding structures [18]. Fibromatosis can often manifest as a painless and firm non-mobile mass that raises concern for carcinoma or can suggest a secondary invasion by a tumor located in the shoulder, pelvic girdle, chest wall, head and neck [19,20]. The etiology of fibromatosis is unknown and most fibromatoses appear sporadically (97%), although several cases have been noted following trauma or breast surgery [19], as well as in association with inherited disorders such as familial adenomatous polyposis (FAP), familial multicentric fibromatosis, or Gardner syndrome [21,22].
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4. Conclusion In conclusion, the purpose of this case series is to present the history and imaging of several male pa-
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Galley Proof
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Huang K, Fu H, Shi YQ, Zhou Y, Du CY. Prognostic factors for extra-abdominal and abdominal wall desmoids: A 20-year experience at a single institution. J Surg Oncol 2009; 100: 563–9. Brueckl WM, Ballhausen WG, Förtsch T. Genetic testing for germline mutations of the APC gene in patients with apparently sporadic desmoid tumors but a family history of colorectal carcinoma. Dis Colon Rectum 2005; 48: 1275–81.
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[21]
Rosen PP, Ersenberger D. Mammary Fibromatosis: A benign spindle tumor with significant risk for local recurrence. Cancer 1989; 63: 1362–9. Becker JC, Liegl-Atzwanger B, Ugurel S. Malignant Fibrous, Fibrohistiocytic, and Histiocytic Tumors of the Dermis. In: K W, (ed.). Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York: McGraw-Hill, 2012. Neuman HB, Brogi E, Ebrahim A, Brennan MF, Van Zee KJ. Desmoid Tumors of the breast: a 25 year experience. Ann Surg Oncol 2008; 15: 274–80.
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File: bd391.tex; BOKCTP/ljl p. 6
E.K. Arleo and C. Eisen / Unusual findings in the male breast patient: A case series
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