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When Should Men Undergo Mammography?

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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As the staff of a state public health hospital, we are responsible for the medical care of most Massachusetts prisoners, most of whom are men. Even when this population is counted with our general patient population, the mix is disproportionately male.

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].

View larger version (25K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Paradigmatic algorithm shows initial mammographic evaluation in men. A man whose physical examination reveals dominant mass, ulceration, or inflammatory changes of the breast should initially undergo aspiration or surgical biopsy. Risk factors are listed in Appendix 1.

References

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1. Jaiyesimi IA, Buzdar AU, Sahin AA, Ross MA. Carcinoma of the male breast. Ann Intern Med 1992;117:771 -777
2. Chantra PK, So GJ, Wollman JS, Bassett LW. Mammography of the male breast. AJR 1995;164:853 -858[Abstract/Free Full Text]
3. Cooper RA, Gunter BA, Ramamurthy L. Mammography in men. Radiology 1994;191:651 -656[Abstract/Free Full Text]
4. Evans GF, Anthony T, Appelbaum AH, et al. The diagnostic accuracy of mammography in the evaluation of male breast disease. Am J Surg 2001;181:96 -100[Medline]
5. Sasco AJ, Lowenfels AB, Pasker-de Jong P. Review article: epidemiology of male breast cancer—a meta-analysis of published case-control studies and discussion of selected aetiological factors. Int J Cancer 1993;53:538 -549[Medline]
6. Joshi A, Kapila K, Verma K. Fine needle aspiration cytology in the management of male breast masses: nineteen years of experience. Acta Cytol 1999;43:334 -338[Medline]
7. Ciatto S, Iossa A, Bonardi R, Pacini P. Male breast carcinoma: review of a multicenter series of 150 cases. Tumori 1990;76:555 -558[Medline]
8. Kanhai RC, Hage JJ, van Diest PJ, Bloemena E, Mulder JW. Short-term and long-term histologic effects of castration and estrogen treatment on breast tissue of 14 male-to-female transsexuals in comparison with two chemically castrated men. Am J Surg Pathol 2000;24:74 -80[Medline]
9. Cocco P, Figgs L, Dosemeci M, Hayes R, Linet MS, Hsing AW. Case-control study of occupational exposures and male breast cancer. Occup Environ Med 1998;55:599 -604[Abstract]

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