Type:
Educational Exhibit
Keywords:
Education and training, Diagnostic procedure, Ultrasound, Mammography, Management, Breast
Authors:
D. Suleimenova, M. Eghtedari, H. Ojeda-Fournier; La Jolla, CA/US
DOI:
10.26044/ecr2019/C-0084
Findings and procedure details
Introduction of ACR Appropriateness Criteria®
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Background: in the 1990’s there was a lack of evidence-based decision making tools to assist medical practitioners with their choice of imaging technique
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What is this: A practical guideline to help clinicians and radiologists choose appropriate imaging modality or technique for evaluation of specific disease or condition
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Who: Created by a panel of experts in subspecialty fields and revised periodically
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What the experts do: Monitor,
collect,
critically appraise and analyze data on specific clinical topic or disease
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Where to find: Free access for clinical use,
research,
scientific and/or informational purposes,
available at https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria/About-the-ACR-AC
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Currently contains 179 diagnostic and interventional radiology topics which cover more than 1560 clinical scenarios
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There are 9 topics in Breast Imaging: Screening,
imaging of pregnant and lactating women,
implant evaluation,
breast pain,
evaluation of nipple discharge,
monitoring response to neoadjuvant systemic therapy for breast cancer,
Stage I breast cancer (initial workup and surveillance for local recurrence and distant metastases in asymptomatic women),
palpable breast masses,
and evaluation of symptomatic male breast
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New topics added every two years
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Goals: ensures the most effective and safe use of radiology
Imaging modalities used to evaluate the male breast
Evaluation of symptomatic male breast: Benign
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The most common complaints in men are pain,
swelling,
mass,
and nipple discharge [4]
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The most common imaging finding is gynecomastia- an abnormal increase in stromal and ductal components of male breast
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Causes of gynecomastia:
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Physiologic: Common in newborns,
adolescents and men over 60 years old [5]
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Disbalance of reproductive hormones (estrogens and testosterone): Exogenous estrogen administration,
Klinefelter's syndrome,
hypogonadism.
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Neoplasms: Embryonal cell carcinoma,
choriocarcinoma of the testis (rare),
adrenal carcinoma,
hepatocellular carcinoma.
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Use of certain medications and drugs: Thiazide diuretics,
anti-androgens,
anabolic steroids,
marijuana,
etc.
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Systemic disease: Chronic disease of liver such as cirrhosis (Figure 5),
chronic renal dialysis [6]
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Clinical symptoms of gynecomastia: Swelling and tenderness of the breast; subareolar lump; may be soft,
rubbery or firm on palpation,
but generally is not as hard as a cancer; mobile; unilateral in 50% of cases [7]
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Imaging appearance of gynecomastia:
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Other benign entities:
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Pseudogynecomastia (Figure 9): Excessive development of fatty tissue in male breasts
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Fat necrosis
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Lipomas (Figure 10)(Figure 11)(Figure 12)
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Sebaceous cysts (Figure 13)
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Epidermal inclusion cysts
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Abscesses (Figure 14)
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Hamartoma
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Fibroadenoma (Figure 15)
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Radial scar or complex sclerosing lesion (Figure 16)
Evaluation of symptomatic male breast: Malignant
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Male breast cancer is rare and accounts for 0.3% of all male cancer and represents 1% of breast cancer cases
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Clinical presentation: Hard,
painless,
eccentric,
subareolar mass
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May be fixed to the skin or chest wall and usually unilateral (Figure 17)
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Clinical secondary signs of malignancy include: nipple or skin retraction,
nipple discharge,
axillary lymphadenopathy (Figure 18) [9]
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Male breast cancer risk factors: age (usually occurs in men over 60 years old with a median age of 67 years old),
family history of breast cancer,
BRCA1/2 mutations,
exogenous estrogen or progesterone use,
obesity,
and chest wall irradiation [10]
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Imaging findings suspicious for malignancy: Subareolar mass,
usually eccentric to the nipple with any margin
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Associated imaging features: skin or nipple retraction,
microcalcifications of ANY shape and distribution (Figure 19),
axillary lymphadenopathy [11]
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See Figures 20-24 for examples of male breast cancer
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Other malignancies can present in the male breast including metastatic disease,
lymphoma (Figure 25),
schwannoma,
melanoma,
etc.
ACR Appropriateness Criteria® use for evaluation of male breast
Variants determine what,
if any,
imaging is indicated and are based on age and level of clinical suspicion,
five variants are defined:
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Variant 1: Symptomatic male of any age,
when his clinical examination is consistent with benign gynecomastia or pseudogynecomastia
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Variant 2: Male patient younger than 25 years old with indeterminate breast lump
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Probability of breast cancer is extremely low.
Only 1% of breast cancer occur in men younger than 30 years old
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Initial appropriate imaging modality: Ultrasound
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Comparison with contralateral breast is useful,
because bilateral cancers are rare [12]
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Doppler flow has no additional value
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Mammography or tomosythnesis could be performed prior to biopsy in order to exclude benign entities such as fat necrosis and gynecomastia
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Variant 3: Male patient older than 25 years old with indeterminate breast lump
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Initial appropriate imaging modality: Mammography
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Bilateral- to assess symmetry
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Muscle displaced view can be performed in case of extremely developed pectoralis muscles obscuring breast tissue
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Sensitivity from 92% to 100%,
specificity from 90 to 96% as reported in studies [13] [14]
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If mammography demonstrate gynecomastia no additional imaging or biopsy is needed
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Ultrasound can serve as a supplemental imaging tool or to guide a biopsy
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Variant 4: Male patient older than 25 years old with indeterminate palpable breast mass and indeterminate or suspicious mammography or digital breast tomosynthesis results
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Variant 5: Male of any age with suspicious clinical examination findings (firm fixed painless breast mass,
nipple discharge of ANY color,
skin or nipple retraction,
axillary adenopathy)
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Full imaging evaluation (mammography or DBT +ultrasound)
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Breast cancer in men typically presents with an irregular mass but may present as a focal asymmetry,
asymmetry,
or microcalcifications (Figure 26)
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On ultrasound male breast cancers typically manifest as hypoechoic solid masses with irregular borders; however,
cystic or circumscribed masses in men should also be viewed with suspicion
MRI
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There is a lack of evidence on the use of breast MRI in symptomatic men
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MRI is inappropriate for initial imaging of male breast,
there are few studies reporting the use of breast MRI in males [16]
Chest CT
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Incidental findings of male breast lesions are reported frequently
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Inappropriate to characterize breast lesions
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Gynecomastia can be seen as a small high density area in the subareolar region (Figure 27)
Transgender issues
Pictorial algorithm for evaluation of symptomatic male patients
Figure 30 shows the suggested algorithm for evaluation of male breast