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Original Report |
1
Department of Diagnostic Radiology and Organ Imaging, Chinese University of
Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
2
Division of Diagnostic Imaging, Breast Imaging Section, The University of
Texas M. D. Anderson Cancer Center, Box 57, 1515 Holcombe Blvd., Houston, TX
77030.
3
Department of Anatomical and Cellular Pathology, Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
Received March 24, 2000;
accepted after revision July 7, 2000.
Address correspondence to W. T. Yang.
Abstract
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CONCLUSION. There were five cases of invasive breast carcinoma and three cases of ductal carcinoma in situ of the papillary subtype. All three cases of papillary ductal carcinoma in situ showed cystic features on sonography. Most (4/5) invasive cancers were solid on sonography. The appearance of a complex cystic mass in the male breast on sonography should suggest the possibility of malignancy and therefore warrants biopsy.
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Standard two-view mammography was performed using dedicated film-screen mammographic equipment (Senographe DMR; General Electric Medical Systems, Milwaukee, WI), with additional views as deemed necessary. Mammograms were reviewed for shape, margins, density, size and location of masses, presence and type of calcifications, lymphadenopathy, and skin changes.
Sonography was performed using linear array high-frequency transducers (10.5 MHz) with the Logiq 700 DEU (General Electric Medical Systems) or Elegra Sonoline (Siemens Medical Systems, Erlangen, Germany). For all lesions, color-flow Doppler sonography was performed after gray-scale imaging. Gray-scale parameters noted included the cystic or solid nature of the mass, margin features, posterior acoustic phenomena, and the presence of axillary lymph nodes. Lesions were considered vascular when flow was detected. The distribution of flow was noted. Imaging findings were correlated with the final pathologic diagnoses, which were obtained by core biopsy, excisional biopsy, or mastectomy.
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In all eight patients, masses were identified in the subareolar region, eccentric to the nipple. On sonography, the margins of the lesions were irregular in three patients, indistinct in three, microlobulated in one, and smooth in one patient. Posterior acoustic enhancement was present in three patients, mild shadowing was visible in three, and no posterior acoustic phenomena were visualized in the remaining two patients. Vascularity, as determined by the presence of color flow, was present in five (63%) of the eight lesions studied. The flow was predominantly peripheral and scanty in vessel number (Fig. 2).
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Fine-needle aspiration cytology was performed in all eight patients. Of these, four aspirates (50%) were diagnostic of carcinoma, and in four (50%), the results were inconclusive and reported as cytologic atypia. In two patients with complex partly cystic masses, fine-needle aspiration cytology of the cystic components was inconclusive. Sonographically guided biopsy of the residual solid components of the collapsed cysts was performed with an 18-gauge spring-loaded core needle, which confirmed carcinoma in both these patients (Fig. 3A,3B). All three patients who had ductal carcinoma in situ (DCIS) at final histology had inconclusive diagnoses at fine-needle aspiration cytology. In two patients, abnormal hypoechoic axillary lymph nodes with loss of fatty centers were seen, and sonographically guided fine needle aspiration cytology confirmed metastases to axillary lymph nodes.
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Mammography
There were three lobular, three round, and two irregularly shaped masses.
All masses had partially indistinct margins
(Fig. 4). The masses were
generally high density (n = 6); the two remaining masses were
isodense. The location of the masses was characteristically subareolar
(n = 6); one lesion was situated in the tail of the breast, 4 cm from
the nipple, and one mass was identified in the 12-o'clock position, 3 cm from
the nipple. Skin thickening was shown mammographically in three patients.
Calcifications, which were pleomorphic and casting, were present in one
cancer. No abnormal axillary lymphadenopathy was noted on mammography.
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Surgery
Seven of the patients underwent surgery (modified radical mastectomy in
four, simple mastectomy in two, and wide local excision in one); the remaining
patient is undergoing adjuvant chemotherapy. All patients are alive. The mean
follow-up period was 29 months (range, 6-52 months).
Pathology
Infiltrating ductal cancer was documented in five patients (63%). The
remaining three patients (38%) had DCIS, including one with a microinvasive
component. All three cases of DCIS were classified as papillary subtype. The
mean primary tumor size was 1.5 cm (range, 1.1-1.9 cm), with node-positive
metastatic disease in three (60%) of five patients who underwent axillary
dissection. One patient who is undergoing chemotherapy had sonographically
guided confirmation of an axillary nodal metastasis, and two patients with
histologically proven DCIS did not have pathologic evaluation of axillary
lymph nodes. Most tumors were well differentiated (grade 1 or 2) (7/8 [88%]),
estrogen receptor-positive (7/8 [88%]), and progesterone receptor-positive
(7/8 [88%]). Lymphovascular invasion was seen in one (20%) of five invasive
cancers.
Sonography showed cystic masses (size range, 2.2-2.4 cm) in all three patients with DCIS, which corresponded to the histopathologic findings (Figs. 3A and 3B). Solid lesions were seen in four patients with infiltrating ductal cancer; and in the remaining patient with invasive carcinoma, a complex cystic mass was seen on sonography.
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Approximately 85% of breast cancers in men are infiltrating ductal cancers [12, 13]. Most invasive tumors are moderately or poorly differentiated, but low-grade and tubular carcinomas have been described [12]. DCIS is found in 35-50% of male breast cancers [13]. Pure DCIS without an associated infiltrating ductal cancer is less common, representing approximately 5% (range, 2.3-17%) of all breast cancers in men [14]. The predominant histopathologic appearance in most cases of DCIS in men is that of the papillary subtype (75%), and the typical presenting feature in these men is a nodular, partially cystic mass frequently associated with nipple discharge [14].
The mammographic findings in male breast cancer in this series are consistent with previous reports of malignant masses in men [1, 2]. These masses typically occur in the subareolar region with margins that may be well-defined, ill-defined, or spiculated. All masses in this series had partially indistinct margins. Breast cancers in men may be round, oval, irregular, or lobulated. Calcifications are infrequent, and calcifications were present in only one patient (13%) in this series. Other investigators have noted calcifications occurring in 13-30% of breast cancers in men [2]. Calcifications in male breast cancer are coarser and less frequently linear compared with calcifications seen in breast cancer in women. Secondary features that may be seen on mammography in men with breast cancer include skin thickening, nipple retraction, and axillary lymphadenopathy.
To the best of our knowledge, the systematic description of high-frequency gray-scale and color Doppler sonography features of male breast cancers has not been previously reported in the literature. Since the early sonographic description of male breast cancer in the 1980s [3], there have been anecdotal case reports including sonography of male breast cancers [4,5,6]. This report details the gray scale and color-flow imaging features in men with breast cancer.
A complex cystic mass was seen in four (50%) of eight men with breast cancer in this series, and this finding on sonography should suggest the possibility of malignancy. In our experience with more than 30 benign breast masses in men, including gynecomastia and breast abscess (five of which were pathologically proven and 25 diagnosed by imaging and follow-up for more than 1 year), no cystic lesions have been encountered. Similarly, we have not identified simple benign breast cysts in men. Three of the four complex cystic lesions in this series were proven to represent papillary DCIS at histopathology. These findings are consistent with data from a recent large retrospective clinicopathologic study of 114 male patients with DCIS (84 with pure DCIS and 30 with DCIS associated with invasive cancer) [14]. Seventy-five percent of the tumors in the study were of the papillary subtype, and the typical presentation for papillary DCIS was a partially cystic palpable mass [14]. The sonographic findings of male breast cancers described in this report would appear to correlate with these histopathologic features. Papillary DCIS has been described as having a prominent cystic component, constituting 3-5% of male breast cancers and 1-2% of female breast cancers [12, 13]. Mammographic and sonographic features of papillary lesions have been described in the female breast [15], but, to our knowledge, no case series on the sonographic features of papillary DCIS in the male breast has been reported.
There are practical and diagnostic implications regarding complex cystic masses seen in men on sonography. Aspiration of the cyst fluid alone was unable to provide a definitive diagnosis of malignancy in two (67%) of the three cases of DCIS in this series. These results concur with a review that reported the difficulty in confirming malignant cells by aspiration cytology of cyst fluid [6]. Sonographically guided core biopsy of the remnant solid component after aspiration of fluid may be necessary to establish a diagnosis. Our results suggest that fine-needle aspiration cytology may be unsuccessful in male patients with DCIS, particularly in lesions that are cystic. Complex cystic breast masses in men are suggestive of malignancy, and papillary DCIS should be considered in the differential diagnosis. Additional studies are needed to delineate the frequency of complex cystic masses in men with breast cancer.
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