Male breast disease: review of radiologic and clinical findings

Transcription

1 Male breast disease: review of radiologic and clinical findings Poster No.: C-1599 Congress: ECR 2015 Type: Educational Exhibit Authors: P. Rudenko, G. Montoliu, R. M. Viguer Benavent, M. Á. Sánchez Fuster, R. Llorens, M. A. Jarre Mendoza, Y. Ochoa; Valencia/ES Keywords: Cancer, Education, Biopsy, Ultrasound, MR, Mammography, Oncology, Breast DOI: /ecr2015/C-1599 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 38

2 Learning objectives -Review clinical and radiographic features of the most common benign and malignant lesions of the male breast. -Discuss the key radiologic signs of gynecomastia and its differentiation from breast cancer. -Recognize lesions that require biopsy. Page 2 of 38

3 Background Male breast disease includes a wide spectrum of different conditions, most of them benign (gynecomastia or cutaneous lesions), but there is significant overlap in imaging and clinical presentation with malignancies, though radiologist should be familiar with the most common lesions and be able identify the next step in diagnostic workup. Over the last twenty years the percentage of men presenting with breast complaints has increased almost three times from 0,8 to 2,4 % (1). Symptomatic men frequently refer a palpable mass, breast enlargement and tenderness. Gynecomastia is the most common finding in a man with palpable tender subareolar mass. Other benign breast conditions like myofibroblastoma, lipoma, inflammatory and posttraumatic breast lesions are also found with relative frequency in a male population. Male breast cancer accounts for 1% of all breast cancers, being an invasive ductal carcinoma (IDC) not otherwise specified a most common type. Malignancies other than cancer are very uncommon and include metastasis, liposarcoma and lymphoma. Normal anatomy The male breast extends from the second to the sixth rib and normally is composed of skin, subcutaneous fat, few ducts and some stroma elements Fig. 1 on page 6. Approximately half of the male population over 44 years presents palpable breast tissue (2). Page 3 of 38

4 Fig. 1: Normal male breast anatomy. A. Mediolateal oblique (MLO) mammogram shows a normal male breast which consists predominantly of subcutaneous fat. There is no glandular tissue. B. Ultrasound image (US) represents normal male breast anatomy. Pectoralis fascia (PF), pectoralis muscle (PM). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Copper ligaments are absent in male breast. Breast lobular development, which is stimulated by estrogen and progesterone, is extremely rare in men, therefore breast conditions referred to lobular proliferation such as fibroadenoma, phyllodes tumor, lobular carcinoma, carcinosarcoma should not be diagnosed by radiologist in a male breast (3). Imaging Protocols There is no standardized protocol for imaging workup in the male breast. Usually mammography is a first step in imaging a man with a palpable mass. In our institution we routinely perform mediolateral oblique views of both breast, that can be completed with craniocaudal and pectoralis displaced views in those patients who have well-developed pectoral muscle. After mammography we almost always perform ultrasound, to evaluate the mammographic abnormality. Page 4 of 38

5 MRI is generally not indicated in the workup for male breast disease, but can b# used for example in assessment for chest wall invasion in breast cancer. CT is not a method of choice in breast-imaging, but sometimes performed for other condition, it results to be a first imaging modality where a breast abnormality is detected. Page 5 of 38

6 Images for this section: Fig. 1: Normal male breast anatomy. A. Mediolateal oblique (MLO) mammogram shows a normal male breast which consists predominantly of subcutaneous fat. There is no glandular tissue. B. Ultrasound image (US) represents normal male breast anatomy. Pectoralis fascia (PF), pectoralis muscle (PM). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 6 of 38

7 Findings and procedure details Gynecomastia Gynecomastia is the most common disease of a male breast. Clinically it presents with as a soft palpable subareolar mass, which can be tender at the examination. Gynecomastia is caused by benign proliferation of the ductal and stromal tissue in response to hormone (estrogen) stimulation. In males, estrogenic effects are physiologically increased in neonates, adolescents and elderly (4). Some other endocrine disorders, systemic diseases and certain drugs may also cause gynecomastia. See Table 1 below. Table 1. From reference (5). Physiologic causes: Neonatal period Puberty Elderly patients Hormonal: Kleinfelter syndrome Hypogonadism Systemic disoders: Cirrhosis Chronic renal insufficiency and dialysis Hyperthyroidism Neoplasic: Adrenal cortical carcinoma Page 7 of 38

8 Testicular tumors Hepatocellular carcinoma Pituitary adenoma Drug use: Anabolic steroids Exogenous estrogen Marijuana Thiazide diuretics Cimetidine Tricyclis antidepressants Estrogen therapy Spironolactone Digitalis Omeprazol Idiopathic Gynecomastia by definition is 2 cm or more of subareolar glandular tissue, it can be unilateral, bilateral, symmetric or asymmetric. The hallmark of gynecomastia is it symmetric location under the nipple, usually with ill-defined borders because it lacks capsule and spreads into the surrounding fat tissue (5). Three main mammographic patterns have been described: nodular, dendritic, and diffuse, each of them representing different stages of stromal and ductal proliferation. -Nodular glandular pattern represents an early florid phase, with symptoms duration less than one year (6). At mammography it appears as fan or wedge shaped subareolar density. And on ultrasound we can notice a hypoechoic nodular lesion that can be hypervascular due to proliferation of stroma Fig. 2 on page 24 Page 8 of 38

9 Fig. 2: Nodular pattern of gynecomastia in 60-year-old male who presents tender movile left retroareolar mass. A. Left MLO mammogram shows unilateral round shape subareolar glandular tissue. B. US shows a retroareolar disk shape area with indistinct borders that corrsponds to glandular tissue (yellow arrows). References: Hospital Universitario y Politécnico La Fe - Valencia/ES -Dendritic pattern is seen in the fibrotic or quiescent phase; usually 1 year after the symptoms had started. Both at ultrasound and mammography this pattern classically manifests as "flame shaped" subareolar density with finger-like projections into breast tissue (3) Fig. 3 on page 24. Page 9 of 38

10 Fig. 3: Dendritic pattern of gynecomastia in 58-year-old-male with unilateral, painful, movile mass. A. Retroareolar soft tissue density lesion is seen in a left breast (circle) as an incidental finding on CT image performed for another reason. B. Left MLO mammography shows subareolar density with prominent extensions into the fat. C. US image shows a classic hypoechoic finger-like projections (arrows) spreading into surrounding fat. D. Decrease of retroareolar tissue after Tamoxifen treatment. References: Hospital Universitario y Politécnico La Fe - Valencia/ES -Diffuse pattern is usually seen in a man with very high estrogen levels and combines findings of dentdritic and nodular gynecomastia and resembles female breasts Fig. 4 on page 25. and Fig. 5 on page 26 Page 10 of 38

11 Fig. 4: Bilateral gynecomastia with diffuse pattern in patient with pituitary microadenoma. It looks like female breast, seen even on chest X-ray (blue arrows in A and B). C. Mammogram confirms the presence of bilateral glandular diffuse tissue. D.T1 weighted post contrast MRI image reveals small less enhancing pituatary microadenoma (yellow arrow). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Page 11 of 38

12 Fig. 5: Diffuse pattern in another patient with cirrhosis and treatment with Spironolactone. (A). Bilateral gynecomastia on CT image. (B). MLO mammogram shows bilateral glandular tissue corresponding to diffuse gynecomastia. References: Hospital Universitario y Politécnico La Fe - Valencia/ES The main differential diagnosis for gynecomastia includes breast carcinoma (that will be discussed later) and pseudogynecomastia (4). Pseudogynecomastia consists of excessive fat deposition in breast area, usually in obese patients and doesn't demonstrate palpable glandular tissue Fig. 6 on page 27. Page 12 of 38

13 Fig. 6: Pseudogynecomastia in obese patient with breast enlargement. A.Bilateral excessive fat deposition in the breast area, some small amount of glandular tissue.b and C.US image of right and left breasts confirms that there is neither mass nor retroareolar glandular tissue. References: Hospital Universitario y Politécnico La Fe - Valencia/ES The treatment of gynecomastia consists in assessment of underlying medical condition. Discontinuation of offending drug or medication typically results in regression of gynecomastia. Antagonist of estrogen receptors (tamoxifen), androgens and aromatase inhibitors may be used. Subcutaneous mastectomy is indicated in cases that are refractory to medical treatment (7). Male breast cancer The overall incidence of male breast cancer is around 1% of all breast cancers and is on the rise. (8). The main risk factors include chronic expose to estrogen, cirrhosis, testicular Page 13 of 38

14 injury, Klinefelter syndrome (50-fold increased risk), BRCA 1 and BRCA 2 mutations, chest wall irradiation (8-11). The entire spectrum of histological variants of breast cancer has been seen in male population. The majority of breast cancers in men are infiltrating ductal carcinomas with incidence ranging from 64-93% (8). Papillary carcinoma is a second in frequency, seen in 3-5 % of male breast cancers and occurring twice as often in men than in women (12). As we have mentioned above the lobular system is not developed in men that is why lobular carcinoma is exceptional and is usually associated with estrogen exposure. Also ductal carcinoma in situ is rare because there is no screening program for men, so usually they present at a later stage with palpable mass found at the examination. Breast cancer manifests clinically as hard, fixed, painless mass. Nipple involvement manifesting as retraction, nipple discharge, ulceration or eczema is seen in 40-50% of patients (8). It has been reported that axillary lymph node involvement is very common and clinically suspicious adenopathy has been seen in approximately half of the patients (13). Mammography is usually a first image modality to be performed, in almost all cases followed by ultrasound (US). Breast cancer typically is positioned subareolar but eccentric to the nipple (in contrast to gynecomastia, which is normally central to the nipple) and occasionally in peripheral location. At mammography most invasive carcinomas appear as high density retroareolar lesions Fig. 7 on page 28 and can present spiculated, lobulated and microlobulated margins Fig. 8 on page 29 (5). Calcifications are rare, but when they occur they are coarser than in women (4). Secondary features such as nipple retraction, skin thickening, and increased trabeculation are worrisome findings (6). Ultrasound features of male breast cancer are similar to those seen in females. Usually it presents with solid, nonparallel, hypoicoic, subareolar mass, with spiculated and microlubulated margins, normally eccentric to the nipple Fig. 7 on page 28 (6). Posterior acoustic features are not helpful for distinguishing benign versus malignant lesions, in a study realized by Chen et al. it was shown that half of the patients does not have any posterior sonographic feature (6). US evaluation of axillary lymph nodes should be routinely performed in patients with suspicious for breast cancer lesions Fig. 7 on page 28. Abnormal enlarged lymph nodes with an absent fatty hilum and asymmetric cortical thicknesses are suspicious for regional metastatic disease. Page 14 of 38

15 Fig. 7: Infiltrating ductal carcinoma not otherwise specified in 59 year-old man. A.Left MLO mammogram shows a dense, spiculated, subareolar mass (thin yellow arrow) with associated skin thickening and nipple retraction (big arrows). Right MLO mammogram shows dendritic gynecomastia. B.US image of enlarged axillary lymph node with an absent fatty hilum, US features indicating tumoral adenopathy. C. Solid, nonparallel, hypoicoic, subareolar mass, with ill-defined borders. References: Hospital Universitario y Politécnico La Fe - Valencia/ES MRI is rarely performed in male breast cancer. It can be used in cases where initial imaging is equivocal, for example in small tumors when there is a difficulty in location of the lesion due to its size and similar texture to surrounding breast tissue in ultrasound exam, or if the lesion is associated with gynecomastia. MRI can also improve evaluation of chest-wall invasion (14). Page 15 of 38

16 The features of male breast cancer are similar to those seen in female: spiculated mass, with washout kinetics enhancement and lymphadenopathy Fig. 8 on page 29. Fig. 8: Another case of invasive ductal carcinoma in 78-year-old patient with palpable mass in a left breast. A.Left MLO mammogram dense mass with partially illdefined lobulated margins (yellow arrowheads) B. US confirms the presence of solid hypoechoic, poorly vascularised mass ( asterisk) C.Post contrast T1 weighted MR image shows a small spiculated mass with rim enhancement (thin arrow). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Gynecomastia versus carcinoma As stated above gynecomastia and breast carcinoma are two most common lesions in male population. Usually they can be differentiated on basis of clinical and radiological examination, but some features can ovelap, both gynecomastia and carcinoma mostly occur in eldery patients, both can be soft, mobile, subareolar and unilateral, that is why biopsy sometimes is needed to differentiate them. Page 16 of 38

17 In the Table 2 clinical and imaging features are presented helpful in differential diagnosis of gynecomastia and breast cancer. Table 2. Differential diagnosis of gynecomastia and breast cancer. From reference (3) Features Gynecomastia Breast carcinoma Age Peripubertal and more than > 60 years 50 years Clinical appearance Soft, tender, mobile mass Soft or hard, usually no tender, mobile or fixed mass. Nipple discharge is sometimes present Relation with nipple Subarealolar central Subareolar eccentric Laterality Uni or bilateral Normally unilateral Mammographic appearance Fan shaped, "flame-like" or Dense mass, sometimes nodular appearance lobulated margin Secondary findings Usually none US appearance Hypoechoic irregular mas Most commonly solid with extensions into hypoechoic, subareolar the surrounding fat. No mass, with spiculated adenopathy. or microlubulated margins. Enlarged axillary lymph nodes. Nipple retraction, skin thickening, calcifications, axillary adenopathy Breast malignancies different to breast cancer Other breast malignancies include lymphoma, liposarcoma and metastaisis from other non breast primary tumors. The metastasis to the breast are very rare, the most common primary malignancies that can present breast metastasis are prostate cancer, non-hodgkin lymphoma, sarcomas, melanoma and lung carcinoima Fig. 9 on page 30, Fig. 10 on page 31. Page 17 of 38

18 Fig. 9: Breast metastasis in 67-year old man with antecedent of liposarcoma, who presents a lump in a left breast. A.Left MLO shows round dense left breast mass (arrows), minimal bilateral gynecomastia is present as well. B. Ultrasound reveals heterogeneous round, well delimitated mass, adjacent to pectoralis muscle(pm). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Page 18 of 38

19 Fig. 10: Same patient as in 9, presents with a lump in a left breast (curved arrows in A, 3D CT reconstruction). Total body CT was performed as a control for metastatic disease. B. Round lesion is seen in a left breast adjacent to the left pectoral muscle (yellow arrowhead) with a loss of fat plane, indicating possible muscle infiltration. C and D. Liver, pelvic, subcutaneous metastasis (thin arrows) and local recurrence of liposarcoma in a right lower extremity (thin arrows). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Myofibroblastoma Myofibroblastoma is a rare, benign stromal tumor (1), being the only breast lesion more common in man than in woman. It usually presents as a firm, painless, mobile mass. Mammographic features usually consist in round, well defined mass that lacks of calcifications Fig. 11 on page 32 (4). At ultrasound it presents like solid, hypoechoic Page 19 of 38

20 mass, that resembles a fibroadenoma in female breast (remember that fibroadenomas do not occur in a male breast!). The treatment usually consists of surgical excision. Fig. 11: Myofibroblastoma in 68 year-old male. A. Right mediolateral oblique (MLO) mammogram shows a round, partially circumscribed, eccentric to the nipple lesion (arrows). B and C. US image presents hypoechoic lobulated lesion, with well defined borders, with some internal flow in Doppler examination (B). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Fat necrosis Fat necrosis may result from accidental trauma, but most cases are seen after surgery or radiation therapy. At mammography it can present as lipid cysts, coarse calcifications, focal asymmetries, microcalcifications, or spiculated masses (15). Page 20 of 38

21 If minimal fibrosis occurs, the mass appears as a radiolucent lesion Fig. 12 on page 33 or as an oil cyst (16). Calcifications are very common, and usually are round, smooth and curvilinear (15). At ultrasound examination fat necrosis have a great variety of appearance, reflecting and amount of fibrosis. Bilgen et al. in a retrospective study of 126 cases of fat necrosis, found a wide distribution of sonographic presentations, being an increased echogenicity of the subcutaneous tissues, with or without small cysts a most common feature (26.9% ), also they found anechoic masses with posterior acoustic enhancement (in 16.6% of cases); anechoic masses with posterior acoustic shadowing (in 15.8% of cases); solid-appearing masses (in 14.2% of cases); cystic masses with internal echoes (in 11.1% of cases); and cystic masses with mural nodules (in 3.9% of cases) (17). Fig. 12: Fat necrosis in 59-year old patient who presented a palpable mass in a right beast. A Right MLO reveals a retroareolar focal partially well-circumscribed radiolucent lesion (white box). B Magnified view shows a thin capsule. C Gray-scale sonogram shows hyperechoic lesion consistent with fat necrosis (yellow arrowheads). References: Hospital Universitario y Politécnico La Fe - Valencia/ES Subareolar abscess Page 21 of 38

22 Subareolar abscess is a localized infection associated with ductal ectasia, chronic inflammation and obstruction (18). Patients usually present with painful subareolar mass, nipple swelling and nipple discharge. At mammography it commonly presents as ill defined mass, with sorounding trabecular thickening (3). At ultrasound image it normally appears as complex, hypoechoic, solid-cystic mass with posterior acoustic enhancement Fig. 13 on page 34. In Doppler examination the vascularity is absent, however some abscess may present some internal flow, making it more suspicious for malignancy and further biopsy is needed to complete the study (3). Fig. 13: Subareolar abscess mimicking malignancy in 53 year-old man with painful left breast mass and skin swelling. A Bilateral gynecomastia is present. Left MLO view demonstrates dense irregular subareolar mass (thin arrow in A). B US image shows heterogeneous mass with irregular margins and posterior acoustic enhancement (arrowheads), findings that are suspicious for malignancy. During biopsy purulent dense material was obtained. Excision demonstrated retroareolar abscess. References: Hospital Universitario y Politécnico La Fe - Valencia/ES Page 22 of 38

23 Page 23 of 38

24 Images for this section: Fig. 2: Nodular pattern of gynecomastia in 60-year-old male who presents tender movile left retroareolar mass. A. Left MLO mammogram shows unilateral round shape subareolar glandular tissue. B. US shows a retroareolar disk shape area with indistinct borders that corrsponds to glandular tissue (yellow arrows). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 24 of 38

25 Fig. 3: Dendritic pattern of gynecomastia in 58-year-old-male with unilateral, painful, movile mass. A. Retroareolar soft tissue density lesion is seen in a left breast (circle) as an incidental finding on CT image performed for another reason. B. Left MLO mammography shows subareolar density with prominent extensions into the fat. C. US image shows a classic hypoechoic finger-like projections (arrows) spreading into surrounding fat. D. Decrease of retroareolar tissue after Tamoxifen treatment. Hospital Universitario y Politécnico La Fe - Valencia/ES Page 25 of 38

26 Fig. 4: Bilateral gynecomastia with diffuse pattern in patient with pituitary microadenoma. It looks like female breast, seen even on chest X-ray (blue arrows in A and B). C. Mammogram confirms the presence of bilateral glandular diffuse tissue. D.T1 weighted post contrast MRI image reveals small less enhancing pituatary microadenoma (yellow arrow). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 26 of 38

27 Fig. 5: Diffuse pattern in another patient with cirrhosis and treatment with Spironolactone. (A). Bilateral gynecomastia on CT image. (B). MLO mammogram shows bilateral glandular tissue corresponding to diffuse gynecomastia. Hospital Universitario y Politécnico La Fe - Valencia/ES Page 27 of 38

28 Fig. 6: Pseudogynecomastia in obese patient with breast enlargement. A.Bilateral excessive fat deposition in the breast area, some small amount of glandular tissue.b and C.US image of right and left breasts confirms that there is neither mass nor retroareolar glandular tissue. Hospital Universitario y Politécnico La Fe - Valencia/ES Page 28 of 38

29 Fig. 7: Infiltrating ductal carcinoma not otherwise specified in 59 year-old man. A.Left MLO mammogram shows a dense, spiculated, subareolar mass (thin yellow arrow) with associated skin thickening and nipple retraction (big arrows). Right MLO mammogram shows dendritic gynecomastia. B.US image of enlarged axillary lymph node with an absent fatty hilum, US features indicating tumoral adenopathy. C. Solid, nonparallel, hypoicoic, subareolar mass, with ill-defined borders. Hospital Universitario y Politécnico La Fe - Valencia/ES Page 29 of 38

30 Fig. 8: Another case of invasive ductal carcinoma in 78-year-old patient with palpable mass in a left breast. A.Left MLO mammogram dense mass with partially ill-defined lobulated margins (yellow arrowheads) B. US confirms the presence of solid hypoechoic, poorly vascularised mass ( asterisk) C.Post contrast T1 weighted MR image shows a small spiculated mass with rim enhancement (thin arrow). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 30 of 38

31 Fig. 9: Breast metastasis in 67-year old man with antecedent of liposarcoma, who presents a lump in a left breast. A.Left MLO shows round dense left breast mass (arrows), minimal bilateral gynecomastia is present as well. B. Ultrasound reveals heterogeneous round, well delimitated mass, adjacent to pectoralis muscle(pm). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 31 of 38

32 Fig. 10: Same patient as in 9, presents with a lump in a left breast (curved arrows in A, 3D CT reconstruction). Total body CT was performed as a control for metastatic disease. B. Round lesion is seen in a left breast adjacent to the left pectoral muscle (yellow arrowhead) with a loss of fat plane, indicating possible muscle infiltration. C and D. Liver, pelvic, subcutaneous metastasis (thin arrows) and local recurrence of liposarcoma in a right lower extremity (thin arrows). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 32 of 38

33 Fig. 11: Myofibroblastoma in 68 year-old male. A. Right mediolateral oblique (MLO) mammogram shows a round, partially circumscribed, eccentric to the nipple lesion (arrows). B and C. US image presents hypoechoic lobulated lesion, with well defined borders, with some internal flow in Doppler examination (B). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 33 of 38

34 Fig. 12: Fat necrosis in 59-year old patient who presented a palpable mass in a right beast. A Right MLO reveals a retroareolar focal partially well-circumscribed radiolucent lesion (white box). B Magnified view shows a thin capsule. C Gray-scale sonogram shows hyperechoic lesion consistent with fat necrosis (yellow arrowheads). Hospital Universitario y Politécnico La Fe - Valencia/ES Page 34 of 38

35 Fig. 13: Subareolar abscess mimicking malignancy in 53 year-old man with painful left breast mass and skin swelling. A Bilateral gynecomastia is present. Left MLO view demonstrates dense irregular subareolar mass (thin arrow in A). B US image shows heterogeneous mass with irregular margins and posterior acoustic enhancement (arrowheads), findings that are suspicious for malignancy. During biopsy purulent dense material was obtained. Excision demonstrated retroareolar abscess. Hospital Universitario y Politécnico La Fe - Valencia/ES Page 35 of 38

36 Conclusion In the setting of a palpable mass in a male patient, mammography is a first image modality to apply, usually completed with ultrasound. Gynecomastia and breast cancer are the most common lesions, normally they can be differentiated on the basis of clinical and radiographic features. Gynecomastia consists in retroaleolar tissue that is concentric to the nipple-areola complex and bilateral in half of the cases, while breast carcinoma is typically located eccentric to the nipple and usually is unilateral. We have always keep in mind that some malignant lesions in men can have a benign appearance, so a biopsy should be performed always when radiologist is not completely sure that the lesion is benign. Gynecomstia and pseudogynecomastia can be diagnosed on the basis of image and clinical work-up and normally do not require biopsy, as well as characteristically benign lesions containing fat (lipomas) or typical lymph nodes. Lesions eccentric to the nipple require biopsy (excluding normal lymph nodes and fat containing lesions). Familiarity with radiologic and clinical features of most common male breast conditions will allow accurate interpretation of findings and reduce unnecessary diagnostic and treatment procedures. Page 36 of 38

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