Nipple discharge in male patients: Imaging findings.
Poster No.:
C-0082
Congress:
ECR 2012
Type:
Scientific Exhibit
Authors:
R. Muñoz Carrasco, M. Alvarez Benito; CORDOBA/ES
Keywords:
Ultrasound, Mammography, Breast, Comparative studies,
Neoplasia
DOI:
10.1594/ecr2012/C-0082
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Purpose
Breast carcinoma in men is an uncommon disease. Male breast carcinoma represents
less than 1% of all reported breast cancers and less than 1% of all cancers in men.
The vast majority of male breast cancers are invasive ductal carcinoma (82%). Ductal
carcinoma in situ represents 4.8% of all male breast cancers.
Nipple discharge in male patients is rare. Nevertheless, male patients with nipple
discharge have a higher incidence of carcinoma than female patients.
Although most male breast carcinomas are clinically apparent and typically presents as
a palpable mass, the first and unique clinical sign in a patient with ductal carcinoma in
situ may be bloody nipple discharge.
Nipple discharge in men can be related to benign breast conditions such as
gynaecomastia, duct ectasia and papilloma.
Physical breast examination is very sensitive for the detection of male breast cancer but
lacks specificity. A hard painless mass in the subareolar region, eccentric to the nipple
or a mass fixed to the skin, nipple or chest is a very sensitive indicator for male breast
carcinoma. Accompanying signs include nipple discharge and axillary lymphadenopathy.
Nipple discharge cytology is very specific for detection of malignant breast lesions but
its sensitivity is low.
Both mammography and breast ultrasound have showed a high diagnostic performance
in male patients with breast symptoms.
Due to its strong association with underlying malignancy, an increased awareness of the
significance of nipple discharge in men may allow for earlier detection of breast carcinoma
improving the prognosis. In the same way, unnecessary procedures must be avoided in
benignant diseases.
To our knowledge, there has been very little published experience with mammography
and/or breast ultrasound of male patients with nipple discharge. The purpose of our study
is to analyse the contribution of mammography and breast ultrasound in the evaluation
of male patients with nipple discharge.
Methods and Materials
A retrospective study was undertaken in which male patients at our hospital with
nipple discharge were examined with mammography and/or breast ultrasound between
Page 2 of 14
September 1993 and December 2010. The hospital's breast mammography and breast
ultrasound database was searched for male patients with a clinical history of nipple
discharge. We included in this study the patients with an adequate clinical-radiological
follow-up (minimum of 1 year) or with histopathological results.
A standard database for further analysis was designed and included the following patient
data: physical examination findings, mammographic and/or ultrasonography findings,
cytohistological results, data from the clinical-radiological follow-up, stage and treatment
in cases of carcinoma, and final diagnosis.
On physical examination two categories were determined: positive or suspected
malignancy (hard and eccentric to nipple mass or mass fixed to skin, nipple or chest wall)
and negative or no suspected malignancy (soft, retroareolar and centred with respect to
the nipple mass, diffuse breast enlargement without palpable mass and normal breast
examination).
Mammograms were performed on three units specialised in mammography: Mammo
Diagnost UC (Philips Medical System, Best, The Netherlands), Senographe DMR
(General Electric Medical System,Milwaukee,Wisconsin,USA) and Lorad Selenia
(Hologic,Danbury,USA). Standard examinations were both mediolateral-oblique and
craniocaudal views of each breast. All mammograms were read by two radiologists
and discordant interpretations were solved with discussion. The mammographic findings
were placed in one of the predetermined categories according to theAmericanCollegeof
Radiology BI-RADS lexicon. Gynaecomastia and pseudogynaecomastia were placed
in BI-RADS category 2. The mammographic criteria used to diagnose gynaecomastia,
pseudogynaecomastia and normal male breast were those described by So et al.
and Appelbaum et al. Gynaecomastia was diagnosed when mammography showed
a subareolar density concentrically distributed around the nipple with three possible
patterns (nodular, dendritic and diffuse). Pseudogynaecomastia appears as an enlarged
breast with preponderance of radiolucent fat and the absence of dense retroareolar
tissue. Normal male breast appears in mammography as radiolucent fat with a few
strands like subareolar densities extending from the nipple. Intramammary lymph nodes
can be found in normal male breast.
Ultrasound was performed by using a 7.5 mHz transducer (Sonolayer SSA-250ª,
Toshiba) and 7.5-10 mHz transducer (MyLab70, Esaote Biomedica). The ultrasound
findings were classified into categories according to theAmericanCollegeof Radiology
BI-RADS lexicon. Gynaecomastia and pseudogynaecomastia were placed in BIRADS category 2. The ultrasound criteria used to diagnose gynaecomastia,
pseudogynaecomastia and normal male breast were those described by Stewart et al.
and Sarteschi et al. There are two characteristic ultrasound patterns of gynaecomastia:
discrete subareolar, triangular or nodular, hypoechoic area, centric to the nipple and
overall increase in the volume and echogenicity of the breast parenchymal tissue.
In pseudogynaecomastia, ultrasound shows hypoechoic adipose tissue accumulation
Page 3 of 14
separated by echogenic septa. The normal mammary disk appears as a triangular,
hypoechoic area which is centred with respect to the nipple and measures less than 8mm.
Discharge was classified as bloody based on color only.
We reviewed cytological findings from the smears from the nipple discharge. Findings
were classified as positive, negative, inconclusive and inadequate.
Histological confirmation was made by core needle biopsy or surgical biopsy. The clinical
follow-up of the patients consisted of a chart review, telephone interview, or both.
Radiological follow-up was performed with mammography and/or ultrasound.
The final diagnosis was made based on histopathological results or, if no diagnostic tissue
was obtained, a clinical follow-up was required for at least 1 year to confirm the benign
radiological diagnosis.
Using standard formulae, the sensitivity, specificity, positive predictive value and negative
predictive value of physical breast examination, mammography and ultrasound for
the detection of malignant disease were calculated. We considered as positive the
mammograms or ultrasounds classified as BI-RADS categories 3, 4 and 5, and as
negative those classified as BI-RADS categories 1 and 2.
Results
Between September 1993 and December 2010, a total of 1143 male patients underwent
mammography and/or breast ultrasound in our Department of Radiology. Twenty four
(2.1%) among these patients presented with a complaint of nipple discharge and they are
the basis of this study. Twenty mammograms and 17 breast ultrasounds were performed
in these patients.
Male patients aged between 13 and 83 years (mean age: 49 years; SD:±22.03).
The final diagnoses were: 4 (16.7%) infiltrating carcinomas, 1 (4.2%) ductal carcinoma
in situ, 10 (41.7%) gynaecomastias, 2 (8.3%) pseudogynaecomastias and 7 (29.2%)
normal. Nipple discharge in men was associated to carcinoma in 20.8%.
All 20 mammograms and 17 ultrasound examinations were reviewed. Mammograms and
ultrasound examinations performed on all the patients with infiltrating carcinoma showed
a mass classified as BI-RADS categories 4 and 5 (Fig.1). All these patients also noted
a breast mass. In all these patients the physical breast examination was positive or
suspected malignancy. Ultrasound was more sensitive than mammography for identifying
axillary lymphadenopathy in these patients (0/4 vs 1/4).
Page 4 of 14
Mammography showed calcifications (classified as BI-RADS category 4) in the patient
with carcinoma in situ. These calcifications were not visible on ultrasound and the only
conspicuous clinical sign in this patient was bloody nipple discharge. In this patient the
physical breast examination did not suspect malignancy.
Radiological findings of all the patients without malignancy were classified as BI-RADS
categories 1 and 2 (Figs 2 and 3). In three of these patients the physical breast
examination was suspected malignancy.
The diagnostic performance of physical breast examination, mammography and
ultrasound for detection of malignant breast lesions is show in Table 1.
Cytologic evaluation of the nipple discharge was performed in five patients: two
cases were considered inadequate, one case inconclusive and two cases negative
for malignancy (true negative results). The nipple discharge cytology of one of our
patients with a bloody discharge without a breast mass with suspected malignancy was
inconclusive. A ductal carcinoma in situ was histopathologically diagnosed.
One core-needle biopsy guided by ultrasound was performed. The result of the coreneedle biopsy was positive for malignancy (true positive result).
The results of the different diagnostic methods of the male patients included in our study
are show in Table 2.
Six of the 24 patients underwent excisional biopsy after mammography or breast
ultrasound. The histopathological results were: 1 gynaecomastia (16.7%) and 5
carcinomas (83.3%).
Eighteen of the 24 patients were followed up clinically. At the time this article was written,
the patients had been followed up for 14-193 months after mammography and/or breast
ultrasound (mean, 55.3 months). Two patients underwent radiological follow-up (with
mammography in one patient and with ultrasound in the other one). In all the patients the
clinical and/or radiological follow-up did not demonstrate changes.
The stage at presentation in cases of carcinoma was as follows: stage 0: 1 patient; stage
IA: 1 patient; stage IIB: 1 patient; stage IIIA: 1 patient. One patient was not staged at the
moment of the presentation.
In all patients with carcinoma surgery was performed (modified radical mastectomy in
three, simple mastectomy in one and local excision in the other one).
Table 1. Diagnostic accuracy of physical breast examination, mammography and
ultrasound for detection of malignant breast lesions in male patients with nipple
discharge.
Page 5 of 14
Sensitivity
Specificity
PPV
NPV
Physical breast 80%
examination
62.5%
57.1%
83.3%
Mammography
100%
100%
100%
100%
Ultrasound
80%
100%
100%
92.3%
Table 2. Results of the different diagnostic methods in male patients with nipple discharge
Patient
Age
Physical Mammography
UltrasoundCytology Corebreast
of nipple needle
examination
discharge biopsy
Diagnosis
1
67
Negative Category Category Inconclusive
4
2
Ductal
carcinoma
in situ
2
80
Positive
Category Category 4
4
-
Infiltrating
carcinoma
3
78
Positive
Category Category 4
4
-
Infiltrating
carcinoma
4
59
Positive
Category Category 4
4
-
Infiltrating
carcinoma
5
44
Positive
Category 2
-
-
Gynaecomastia
6
13
Negative Category Category 2
2
-
Gynaecomastia
7
15
Negative -
-
Gynaecomastia
8
46
-
9
54
Category Category 2
2
Pseudogynaecomastia
10
69
Category Category 2
2
Pseudogynaecomastia
11
62
Category Category 2
2
Gynaecomastia
12
83
Category Category Negative
1
1
Normal
Positive
Category
1
Category 2
-
Normal
Page 6 of 14
13
47
14
41
Positive
15
28
Negative .
Category 2
Gynaecomastia
16
38
Negative Category Category 2
2
Gynaecomastia
17
47
Category Category
1
1
Normal
18
25
.
Category
1
Normal
19
19
.
Category
1
Normal
20
38
Category .
1
21
78
22
16
23
69
Negative Category .
2
24
61
Category .
2
Positive
Category .
1
Inadecuate
Normal
Category .
2
Inadecuate
Gynaecomastia
Normal
Category Category
5
5
Positive
Category Category
2
2
Infiltrating
carcinoma
Gynaecomastia
Gynaecomastia
Negative
Gynaecomastia
Images for this section:
Page 7 of 14
Fig. 1: Mediolateral oblique (A) and craniocaudal (B) mammograms of the right breast
show a irregular mass, eccentrically located relative to the nipple. The nipple is retracted
and the overlying skin is thickened. The lesion was classified as BI-RADS category 5. An
infiltrating ductal carcinoma was probed.
Page 8 of 14
Fig. 2: Nodular gynaecomastia. Mediolateral oblique (A) and craniocaudal (B)
mammograms of the right breast show a subareolar density concentrically distributed
around the nipple (nodular pattern). Transverse ultrasound images (C) show a discrete
subareolar, nodular hypoechoic area, centric to the nipple.
Page 9 of 14
Page 10 of 14
Fig. 3: Bilateral gynaecomastia (dendritic pattern). Mammograms of a male breast show
a glandular opacity radiating from behind the nipple into the fatty tissue.
Page 11 of 14
Conclusion
Breast carcinoma must always be excluded in male patient with nipple discharge. An
increased awareness of this clinical sign may allow for earlier detection of breast cancer.
Mammography and breast ultrasound are useful in the evaluation of male patients
with nipple discharge diagnosing carcinoma in initial stages and avoiding unnecessary
biopsies given its high negative predictive values.
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