Evaluation of rare male breast masses using multimodality approach with their histopathological correlation: a case series

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1 Evaluation of rare male breast masses using multimodality approach with their histopathological correlation: a case series Poster No.: C-0662 Congress: ECR 2013 Type: Educational Exhibit Authors: P. S. Wavare, K. Taori, S. S. DHAKATE, J. Rathod, V. N. Bakare ; Nagpur/IN, Nagpur, Ma/IN, NAGPUR, MAHARASHTRA/IN Keywords: Neoplasia, Education, Diagnostic procedure, Decision analysis, MR, Mammography, CT, Breast DOI: /ecr2013/C-0662 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 24

2 Learning objectives To evaluate various benign and malignant male breast masses by using multi-modality approach. To know the mimics of breast masses and their differentiating features. To describe indications, advantages & limitations of different radiological diagnostic modalities in a series of ten male patients with complaints of breast mass. To have histopathological follow up of each patient and retrospectively evaluating each modality used to improve diagnostic skills. Background Gynaecomastia and breast cancer are the two most important and common diseases of the male breast (1). Gynacomastia is the soft, mobile, tender, sub-areolar mass and is most common male breast mass. Breast cancer in men accounts for 0.7% of all breast cancers (2). Most of the other lesions found in the male breast arise from the skin and subcutaneous tissue (fat necrosis, lipoma, epidermal inclusion cysts, leiomyma etc.), lymph nodes, subareolar abscess, hematoma and chronic inflammation (1). Masses involving chest wall (chondrosarcoma of the rib) and pectoral muscles (muscle hemangioma) also present as breast masses and should be considered in the differentials in appropriate clinical settings. Other rare breast masses are cystic lymphangioma, myofibroblastoma, granular cell tumor, fibrocystic changes & varix. Breast masses in female and male differ substantially because, Male breast: o Contains ducts but lack lobules hence lobular malignancies are very rare. o No pregnancy and lactation hence no possibility of lactating adenomas, and rare chance of breast abscess. o Fibroepithelial lesions (Fibroadenoma, phylloides tumor and carcinosarcoma) are extremely rare. We present series of ten rare male breast masses comprising of cystic breast lymphangioma, breast hydatid, breast lymphoma, ductal cancer, chondrosarcoma of rib, pleural mesothelioma and pectoralis major muscle hemangioma. Investigations to evaluate male breast mass are Page 2 of 24

3 Mammography (Allenger's medical systems LTD) machine was used where mass was soft, relatively non tender and large enough to take mammogrammes. Ultrasonography (Aloka and Philips 11 XD) was used to characterise the nature of lesion (solid or cystic), obvious calcifications and vascularity, heterogeneity could be accurately assessed. CT was used in suspected bone lesions, protocols include CT thorax protocol excluding HRCT scan. MRI was used to confirm the nature of lesion, extent of involvement, perfusion pattern. MRI protocols # PROTOCOL:T2W TSE/FSE, T1-weighted FFE, Dynamic contrast enhanced sequences. # SLICE THICKNESS: < 4 mm. # DOSE OF CONTRAST: 0.2 mmol/kg injected as a bolus and often followed by a 10-20ml saline flush # FOR BREAST IMAGING IN THE SAGITTAL PLANE, an image matrix of can be used with zero-filled interpolation to # FIELD OF VIEW :(16-18 cm), and chemical fat suppression. # FOR BILATERAL AXIAL BREAST IMAGING: the field of view is increased to approximately 30 cm, and high-resolution matrices (between 256 and 512) are used to reduce the voxel size. Histopathology follow-up done in each case to confirm the diagnosis. Imaging findings OR Procedure details Cystic lymphangioma Cystic lymphangioma are rare congenital, benign tumors. Eighty percent to 90% of cases appear before the 2 years of age, and 90% occur in the neck or axilla (3-4). Cystic lymphangiomas of the breast are very rare. Cystic lymphangiomas arise either from portions of a lymph sac that are sequestered off or from lymphatic spaces that fail to establish connections with the main lymphatic Page 3 of 24

4 channels (5-6). When involved, the upper outer quadrant of breast, axillary tail of Spence and the subareolar area are the commonly affected sites Lymph vessels of the adult mammary gland originate in the interlobular connective tissue and the walls of the lactiferous ducts. These communicate with the overlying cutaneous lymphatic plexus, especially around the nipple in the subareolar plexus, and then drain to the axilla (7). Breast cystic lymphangiomas show round or lobulated densities on mammography (8). On sonography, a cystic lymphangioma characteristically appears as a multiloculated cystic mass with septa of variable thickness that contain solid components arising from the cyst wall or septa (9). Fine-needle aspiration was also helpful for the presumption of a cystic lymphangioma because the fluid was clear yellow and contained only a few lymphoid cells on cytologic analysis. Surgical excision is the treatment of choice. Injection sclerotherapy, incision and drainage, and irradiation are reportedly ineffective (8). 15Y/M presented with progressively increasing large swelling in antero-lateral aspect of left breast and axilla since birth (fig 1). Fig. 1: large soft tissue swelling in the outer aspect of left breast extending in the lateral chest wall. overlying skin is normal except for pressure desquamation at places and hemorrhagic spot related to previous needle aspiration. Mammography could not be done since it was mildly tender with desquamated skin. On evaluation, radiograph revealed radiodensity with few foci of amorphous calcifications (fig 2). Page 4 of 24

5 Fig. 2: Well defined, rounded radiodensity along left lateral wall with few faint foci of amorphous calcification. Heterogenous multiloculated cysti lesion with echogenic solid component and areas of soft tissue vascularity. Ultrasound revealed multiple compressible cystic spaces (fig 2). CT scan revealed heterogeneous multicystic lesion with enhancing walls and soft tissue component within (fig 3). Fig. 3: Heterogenous multicystic lesion with enhancing walls with soft tissue component Fluid aspiration and FNAC revealed the clear yellow fluid containing only a few lymphoid cells. Final diagnosis was cystic lymphangioma. Breast lymphoma Primary breast lymphoma is a rare condition. Primary malignant lymphoma account for about 0.12% to 0.53% (10, 11) of all breast malignancies, most of which are in females. Hence it is extremely rare in males. Mucosa associated lymphoid tissue (MALT) is present in gastrointestinal tract and bronchus, Primary breast lymphoma is a disease included in spectrum of MALT associated lesions with sex hormone dependency (12). Page 5 of 24

6 48Y/M presented with unilateral palpable mass in left breast. Ultrasound revealed well defined, lobulated, homogeneously hypoechoic mass lesion with mild vascularity (fig 4). Fig. 4: well defined lobulated reltively homogeneous, hypoechoic mass with mild vascularity. On MRI study, T1-weighted MR image shows a well-defined isointense, lobulated lesion and maintained fat planes with the underlying pectoralis muscle. T2-weighted MR image shows a mildly hyperintense lesion compared to muscle (fig 5). Fig. 5: TIW isointense and T2W hyperintense lobulated lesion. maintained fat planes with underlying pectoralis muscle. Dynamic MR imaging reveals type II perfusion curve (fig 6). Page 6 of 24

7 Fig. 6: Dynamic MR imaging showing a type II perfusion curve. Immunohistochemistry study showed the diffuse positivity of round cells for CD 20. Final diagnsosis of primary breast lymphoma was given. Pectoralis major muscle hemangioma. 45Y/M presented with the c/o swelling and pain in left breast. Mammography revealed well defined radio-opacity involving supero-lateral and inferolateral quadrant of left breast with lobulated margins not separately visualized from underlying muscles (fig 7). Page 7 of 24

8 Fig. 7: well defined radio opacity involving superolateral and inferolateral quadrant of left breast with lobulated margins. MRI revealed heterogenous lobulated lesion involving pectoralis major muscle which appear hyperintense on Fat suppressed T2W sequence (fig 8). Page 8 of 24

9 Fig. 8: hyperintense lesion in fat supressed T2 sequence. Post-operative follow-up confirmed diagnoses of pectoralis major muscle hemangioma (fig 9). Fig. 9: post operative specimen of muscle hemangioma. Ductal malignancy of breast: Page 9 of 24

10 Ductal carcinoma is a commonest malignancy of the breast in male however it is still rare and comprises of 0.17% of all cancers in men (1). Risk factors for breast cancer in men include testicular abnormalities such as undescended testes, congenital inguinal hernia, orchiectomy, and orchitis (15). Condition which increase the estrogen levels like advanced age, klinefelter's syndrome and abnormal liver function (2, 16). Higher incidence in people from China and Africa is due to hyperestrogenism secondary to parasitic liver disease. Gynacomastia is not a risk factor for breast cancer (15) Usually these cancers present as a unilateral painless subareolar mass. This subareolar location is just like in gynecomastia, but usually it is eccentric to the nipple. Unlike gynecomastia, malignancy presents with bloody nipple discharge. DCIS is rare possibly because there is no screening program for men, so they will present when there is a palpable mass. Various malignant masses in breast are Infiltrating duct carcinoma types include % invasive ductal - 2.6% papillary, - 1.8% colloid % lobular Liposarcoma Lymphoblastic lymphoma metastasis 58Y/M presented with c/o pain and breast mass since 2yr. ultrasound revealed irregular, hypoechoic mass lesion with vascularity within. Since mass was very small and tender mammography was avoided (fig 10). Page 10 of 24

11 Fig. 10: small subareolar right breast mass. ultrshowing irregular mass with vascularity within.mri revealed pectoral muscle invasion. MRI showed the invasion of pectoral muscles by the mass. Histopathology final diagnosis was invasive ductal carcinoma (fig 10). Chondrosarcoma of the rib 23 Yr old male came with complaints of hard swelling in the right breast since 4 months. Radiograph chest PA reveals (fig 11) well defined homogenous radio-opacity in right mid zone with broad base towards mediastinum & silhoutting right heart border. Page 11 of 24

12 Fig. 11: radiograph chest PA and latral view of patient with right breast mass shows mass silhouting the right heart border. Radiograph chest & lateral reveals well defined homogenous radio-opacity in anterior mediastinum with soft tissue radio-opacity seen anterior to sternum. CT scan revealed well defined, lobulated, hypodense lesions at the costochondral junctions of right 2nd & 3rd ribs with extrapleural intrathoracic space extension posteriorly, indenting on the right atrium without any contrast enhancement (fig 12). Fig. 12: well defined, lobulated, hypodense, non enhancing lesion at costochondral junction of right 2nd and 3rd rib with intrathoracic extension. Page 12 of 24

13 There is mild gynecomastia noted with the lesion. Biopsy from the lesion revealed well differentiated chondrosarcoma. Breast Hydatid Hydatid disease is caused by a larva of Echinococcus granulosus and rarely Echinococcus multilocularis. It can involve any site of the body and can vary in its presentation. Painless swelling is the most common presenting complaint in case of hydatid disease of breast. Man is usually an accidental host, primary hosts being Dogs, Sheep, etc. Hydatid disease can be found in any age group and any body sites. Common sites involved according to incidence are: Liver - 75%, Lungs-15%, Muscles - 04%, Kidneys - 02%, Spleen-02%, Bone-01%, Others 01% (e.g. Brain, Breast, Heart orbit, etc.) (13). The breast is a rare primary site accounting for only 0.27% of all cases (14). Although rare; hydatid disease should always be borne in mind in patients with palpable breast lumps, particularly in endemic regions. Histologically hydatids consists of three layers Endocyst (Parasite component of capsule) (13). Ectocyst (Cyst membrane) - it is substance secreted by parasite (14). Pericyst is organized host granulation tissue. 60 Y/M presented with the c/o firm, tense & lobulated swelling in left breast, with lump in right hypochondrium. Clinically overlying skin was normal with nipple displaced anteromedially (fig 13). Page 13 of 24

14 Fig. 13: firm tense, lobulated, swelling in the left breast. Ultrasound revealed large cystic lesion with well-defined wall having racemose interior, and CT scan revealed multiple hydatids involving lung, liver and left breast with daughter cysts within (fig 14). Fig. 14: well defined cyst with racemose interior on USG and multiloculated cyst involving breast, lung and liver. Page 14 of 24

15 Hydatid cyst was confirmed on post-operative follow-up. Pleural mesothelioma 60/M came with complaints of breathlessness, swelling and pain in left breast since 1 year. Radiograph (fig 15) revealed extensive nodular pleural thickening and collapse consolidation involving left lung. Fig. 15: hard swelling adjacent to the left nipple with radiograph showing extensive pleural thickening and collapse consolidation involving left lung. On CT scan there was left anterior rib destruction, circumferential and nodular left sided enhancing pleural thickening with contracted left hemithorax giving 'rind like appearance' (fig 16). Page 15 of 24

16 Fig. 16: anterior rib destruction with extensive pleural thickening. USG guided biopsy was done and final diagnosis of pleural mesothelioma was given. Patient was given one session of chemotherapy and expired on follow up. Observations: We studied different relatively uncommon male breast masses as follows. Lesion Number Breast ductal malignancy 3 Pectoralis major muscle hemangioma 1 Breast hydatid 1 Breast lymphoma 1 Cystic lymphangioma 1 Lipoma 1 Chondrosarcoma of the rib 1 Pleural mesothelioma 1 Careful evaluation of male breast masses is necessary for accurate diagnosis. On male mammography alone malignant masses can appear perfectly benign and vice versa. Patients with tender masses and smaller masses hesitate to give consent for mammography. Ultrasound is very helpful in superficial structures like breast. It can accurately differentiate solid and cystic lesions without radiation, can predict the vascularity and malignant nature of the lesion. MRI is important in relatively difficult cases to differentiate between malignant and benign lesions, degree of invasion in to the surrounding soft tissue and perfusion pattern and hence is more reliable. CT scan is important in bony lesions like chondrosarcoma of rib, to determine bony destruction and intra-thoracic extension and in patients who cannot afford costly investigations like MRI. Page 16 of 24

17 Chondrosarcoma of the rib, pleural mesothelioma and pectoralis major muscle hemangioma are not the true breast masses however they mimic the breast lesion. It is important that any patient presenting with breast swelling can have wide range of differential and should be evaluated with multimodality approach to diagnose underlying disease. Images for this section: Fig. 1: large soft tissue swelling in the outer aspect of left breast extending in the lateral chest wall. overlying skin is normal except for pressure desquamation at places and hemorrhagic spot related to previous needle aspiration. Fig. 2: Well defined, rounded radiodensity along left lateral wall with few faint foci of amorphous calcification. Heterogenous multiloculated cysti lesion with echogenic solid component and areas of soft tissue vascularity. Page 17 of 24

18 Fig. 3: Heterogenous multicystic lesion with enhancing walls with soft tissue component Page 18 of 24

19 Fig. 7: well defined radio opacity involving superolateral and inferolateral quadrant of left breast with lobulated margins. Page 19 of 24

20 Fig. 10: small subareolar right breast mass. ultrshowing irregular mass with vascularity within.mri revealed pectoral muscle invasion. Page 20 of 24

21 Fig. 15: hard swelling adjacent to the left nipple with radiograph showing extensive pleural thickening and collapse consolidation involving left lung. Page 21 of 24

22 Conclusion Male breast masses are rare; various non breast lesions (like chondrosarcoma of the rib, pectoralis major muscle hemangioma and pleural mesothelioma) can also mimic breast mass and hence should be carefully evaluated with multimodality approach for accurate diagnosis. Mammography is cheap, safe, easily available modality. However it could not be used in tender masses, small lesions, hard flat lesion and gives less information about the mass are its disadvantages other than radiation exposure. Ultrasound accurately distinguishes solid lesions from cystic, better information about characteristics, nature and vascularity of the lesion. It is radiation less, and relatively cheap. It is not very useful for complete extent of the lesion and intrathoracic extension. MRI is important in relatively difficult cases to differentiate between malignant and benign lesions, degree of invasion in to the surrounding soft tissue and perfusion pattern and hence is more reliable. It is costly and unaffordable in many patients. CT scan is important in bony lesions, to determine bony destruction and intra-thoracic extension and in patients who cannot afford costly investigations like MRI. Histopathology follow up and retrospectively studying the images in all modalities used help to improve the diagnostic skills. References (1) Applebaum AH, Evans GF, Levy KR, Amirkhan RH, Schumpert TD. Mammographic appearances of male breast disease. RadioGraphics 1999; 19: (2)Giordano SH. A review of the diagnosis and management of male breast cancer. Oncologist 2005; 10: (3)Emery PJ, Bailey CM, Evans JNG. Cystic hygroma of the head and neck. J Laryngol Otol 1984; 98: (4)Singh S, Baboo ML, Pathak LC. Cystic lymphangioma in children: report of 32 cases including lesions at rare sites. Surgery 1971; 69: (5)Menville JG, Bloodgood JC. Subcutaneous angiomas of breast. Ann Surg 1933; 97: Page 22 of 24

23 (6) Kangesu T. Cystic hygroma of the breast in childhood. Br J Clin Pract 1990; 44: (7) Harris JR, Lippman ME, Morrow M, Hellamn S. Diseases of the Breast. 1st ed. Philadelphia, PA: Lippincott-Raven; (8) Hessler C. Cystic lymphangioma of the breast: first roentgen description. Radiology 1967; 88: (9) Sheth S, Nussbaum AR, Hutchins GM, Sanders RC. Cystic hygromas in children: sonographic-pathologic correlation. Radiology 1987; 162: (10) Mambo NC, Burke JS, Butler JJ: Primary malignant lymphoma of the breast. Cancer 39: , 1977 (11) Wiseman C, Liao KT: Primary lymphoma of the breast. Cancer 29: , 1972 (12) Hugh JC, Jackson FI, Hanson J, Poppema S: Primary breast lymphoma: an immunohistologic study of 20 new cases. Cancer 66: , 1990 (13) M. Beckett Howorth, Echinococcosis of bone, the journal of bone and joint surgery vol-xxvii, No, 3, July-1945; (14) Vege A ortega E, Cavada A. Garijo F: Hydatid cyst of the breast: Mammographic findings, AJR 1994; 162: (15) Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. Lancet 2006; 367: (16) Yang WT, Whitman GJ, Yuen EH, Tse GMK, Stelling CB. Sonographic features of primary breast cancer in men. AJR 2001; 176: Personal Information Dr Prasad Wavare, (INDIA) wavareprasad@rocketmail.com Dr. Kishor Taori (HOD) Dr. Dhakate (GUIDE) Page 23 of 24

24 Dr. Jawahar Rathod (Senior Assit Prof) Dr. Vishal Bakare Dr. Rakhi P. Puria Page 24 of 24