Pictorial essay: Mammography of the male breast

Mammography is an imaging modality that is widely perceived to be of use only in women for the detection and diagnosis of breast pathologies. Here, we present a pictorial essay on the mammographic spectrum of male breast pathologies


Introduction
Mammography is a sensitive and cost-eff ective imaging modality in women.It is carried out for screening and for diagnostic purposes.3] Patients with complaints of breast enlargement, tenderness or lump are referred for mammography.Gynecomastia is the most common cause of breast enlargement.Patients with breast cancer present with a lump rather than breast enlargement.]

Discussion
The normal male breast consists of subcutaneous fat and remnant subareolar ductal tissue [Figure 1].Lobular development is not seen; hence, lobular processes like lobular carcinoma, adenosis and Þ brocystic changes are not seen in males.Here, we discuss the mammographic features of breast pathologies seen in males.

Gynecomastia
Gynecomastia is the most common cause of male breast enlargement and is usually bilateral.Patients may however present with unilateral breast enlargement or tenderness.Gynecomastia is characterized by hyperplasia of the stromal and ductal elements in the breast.Clinically, the breast is enlarged, soft and tender and a mass may be palpable in the retro-areolar region.[4] Dendritic gynecomastia appears as 'ß ame-shaped' Þ broglandular tissue in the retroareolar area, which radiates from the nipple into the deeper adipose tissue [Figure 2].It is thought to be a result of longstanding gynecomastia.It is histologically characterized by ductal proliferation, with surrounding Þ brotic stroma.In nodular gynecomastia, a nodular, mass-like lesion is seen in the retro-areolar region [Figure 3].In diff use gynecomastia, the mammographic appearance is that of a dense breast.There is enlargement of the breast with diff use density and both dendritic and nodular features may be seen.Absence  of a well-deÞ ned identiÞ able mass and the secondary signs diff erentiate gynecomastia from malignancy.

Pseudogynecomastia
In true gynecomastia there is involvement of the breast tissue.Male breast enlargement, as a result of accumulation of excessive fat tissue with a lack of actual breast tissue, is pseudogynecomastia [Figure 4].This condition is common in older men and overweight young men.

Retro-areolar abscess
On mammography, a retro-areolar abscess appears as a mass   with indistinct margins [Figure 5].There is thickening of the skin.The lesion can be mistaken for carcinoma breast.

Epidermal inclusion cyst
An epidermal inclusion cyst arises from an obstructed hair follicle.On mammogram, there is a well-deÞ ned lesion, which is continuous with the skin [Figure 6].

Tuberculosis
As in women, it is very diffi cult to diff erentiate breast tuberculosis from carcinoma breast, both clinically and radiologically.An ill-deÞ ned mass may be seen on mammography [Figure 7].Diagnosis can only be made on Þ ne needle aspiration biopsy.

Breast cancer
The most common presentation is as a palpable mass.Because there is a paucity of parenchyma as compared with the female breast, the malignancy rapidly progresses to or spiculated [Figures 8, 9].Secondary signs may be seen [Figure 10].
To conclude, the majority of male breast lesions are benign.Diff erentiation between benign and malignant masses is critical.Mammography has been shown to be an accurate method for distinguishing benign gynecomastia from carcinoma breast.Absence of a well-deÞ ned mass and secondary signs favor the diagnosis of gynecomastia, whereas an eccentrically located mass, the presence of secondary features and advanced age of the patient suggest carcinoma breast.

Figure 1 (
Figure 1 (A,B): Normal male breast.Mediolateral oblique (A) and craniocaudal (B) views of both breasts show the normal appearance

Figure 4 :
Figure 4: Pseudogynecomastia.Mediolateral view of the left breast shows only fat.There is absence of retrao-areolar ductal opacities, suggestive of pseudogynecomastia

Figure 6 :
Figure 6: Epidermal inclusion cyst.A well-defi ned space-occupying lesion is seen in this mediolateral view (arrows).This turned out to be an epidermal inclusion cyst on histopathology

Figure 10 (
Figure 10 (A,B): Carcinoma with secondary signs.Mediolateral (A) and craniocaudal (B) views show a mass (black arrows) with involvement of the overlying skin with ulceration (arrowheads) and calcifi cation (white arrows)