Contributed by: Steven J. Rockoff, MD and Diana L. Lam, MD - June 1, 2020
A 61-year-old man presents to his doctor because he is concerned about a palpable finding in his right breast. His doctor agrees that he is able to appreciate the area of concern on physical exam. The most appropriate test to order is:
A. CT of the chest B. Diagnostic ultrasound C. Diagnostic mammogram D. Diagnostic MRI E. CA-125 blood test
C. Diagnostic mammogram
Explanation: According to the American College of Radiology Appropriateness Criteria, for a male who is 25 years or older, the most appropriate imaging exam to perform first with a clinically indeterminate palpable breast mass is a diagnostic mammogram.
The diagnostic mammogram is performed. A BB skin marker is placed over the area of palpable concern in the right breast. What is your assessment and recommendation?
A. BI-RADS 0 (Incomplete); Recommend diagnostic ultrasound B. BI-RADS 1 (Negative); Recommend one year follow-up C. BI-RADS 2 (Benign); No follow-up needed D. BI-RADS 3 (Probably Benign); Recommend six month follow-up E. BI-RADS 4 (Suspicious); Recommend biopsy
C. BI-RADS 2 (Benign); No follow-up needed
Explanation: This patient has gynecomastia, which is the most common etiology of a tender and palpable breast mass in males. The mammographic appearance of gynecomastia can vary based on the time course, but the classic appearance is increased tissue density in the subareolar region, often with a “flame shape”. Gynecomastia is a benign process of epithelial hyperplasia, and when identified on mammography, does not warrant further work-up. Gynecomastia is not significantly associated with an elevated risk of male breast cancer. In older males, mammography is the first line modality in the setting of a male breast complaint, in part because gynecomastia usually has a suspicious sonographic appearance, and the diagnosis can often be made with mammography alone.
Any suggestion of a mass on mammography, however, should prompt further evaluation with ultrasound and possible ultrasound-guided biopsy.
This patient actually has mild gynecomastia on the left side as well. Bilateral (and asymmetric) gynecomastia is not uncommon.
