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Opinion |
1 Department of Radiology, Lemuel Shattuck Hospital, 170 Morton St., Boston, MA 02130-3735.
Received November 19, 2001;
accepted after revision December 10, 2001.
Address correspondence to S. Munn.
Introduction
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It is not at all rare for these men to report a breast abnormality to a prison clinician. The practitioners routinely request mammograms, because certain mammographic appearances are suggestive or predictive of benign or malignant entities [1,2,3,4]. However, to enable our department to evaluate these requests properly, I have searched the literature, unfortunately in vain, for guidance on whether and when mammography would be appropriate as the first examination after abnormalities are found on palpation of the adult male breast.
Breast cancer occurs rarely in men [1, 5]. The incidence is approximately one case per million men in their early 30s but about 65 times higher for men at least 85 years old [1]. The median age of male patients at diagnosis is approximately 68 years [5]. Gynecomastia is far more common than the unilateral, painless, indurated, and firm (even hard) lump typical of breast cancer. In contrast, it is often bilateral, usually freely mobile, and moderately tender [1].
Men whose physical examinations reveal a dominant mass, ulceration, or inflammatory changes in the breast should undergo aspiration or surgical biopsy [1]. Fine-needle aspiration is an appropriate initial step to obtain a pathologic diagnosis [1, 6]. If the needle procedure is inconclusive, surgical biopsy is likely indicated [1].
Usually, men are referred for mammography because of other findings, such as a lump, breast enlargement, or tenderness [2, 3], and that has been our experience as well. The primary role of mammography has been to determine that mammographically apparent gynecomastia corresponds (in size and location) to a palpable abnormality, saving some patients unnecessary biopsy [3, 4]. A secondary goal is to exclude malignancy co-existing with gynecomastia [4], although carcinoma can also be obscured on mammography by gynecomastia [1].
Mammography is not a substitute for palpation [4], and not all men with abnormal findings on palpation need mammography [3]. One article [3] defined a subgroup whom the authors think do not need mammography—on the basis, in part, of the absence of anyone younger than 50 years among the four patients with primary breast cancer in 263 men studied. However, a multicenter report of 150 male breast cancers included 12 cases in men younger than 40 years [7]. Unfortunately, I have been unable to find comprehensive, authoritative advice regarding circumstances that should (rather than do) [2, 3] lead to mammography in men.
The goal should be to image those who most likely would benefit from imaging while avoiding examinations (and attendant cost and irradiation) of those who most likely would not. Figure 1 indicates the paradigmatic algorithm we currently use regarding initial mammographic evaluation in men. Transgender patients [8] and others [1, 5, 9] (Appendix 1) were borne in mind in the creation of this algorithm. It is offered in hope that it (or a variation) will be tested and improved in a multicenter trial: garnering sufficient patients for meaningful statistics from one center is difficult with this rare disease [7].
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