Young, Pregnant and Male

Young, Pregnant, and Male: Breast Lesions in Special Populations

The title of this next talk is Young, pregnant, and Male.

To clarify, this is not the patient population we'll be talking about. Whenever I give this talk to the residents and I have that title slide up, one resident will come up to me and say, Karen, is that possible? I kind of just look at them and don't really answer.

What this is, in fact, is a review of the workup and the imaging findings and the management of the commonly encountered breast lesions in young patients, basically children and adolescents, pregnant and lactating patients and male patients. Along the way, we'll show some example images.

Young Patients: Children and Adolescents

We're gonna go ahead and dive into the young patient.

It's important for all of us to realize that the prevalence of breast cancer in this patient population is exceedingly low. The majority of breast masses and breast enlargement is benign and self-limited.

Since breast cancer seems to be relatively ubiquitous in the adult population, the minute their children or adolescent has a breast problem or a focal complaint, anxiety runs high.

We need to recognize as a community that the likelihood of breast cancer, primary breast cancer is exceedingly low.

Ultrasound is almost always the imaging study of choice. The only exception to this may be in a young male, and I'll talk about that when we get to the male portion of the talk, but certainly for young females who come in with a focal complaint or a palpable abnormality, ultrasound is the way to begin that workup.

There is a theoretical risk of injuring a developing breast bud should you decide to do a core biopsy or some sort of biopsy. Keep that in mind.

A conservative approach is what is recommended in the literature. If you do see a finding of some sort, to follow it both clinically and sonographic as opposed to have any sort of intervention.

Developmental Lesions

There are developmental lesions that occur in this patient population in the pre and peri pubertal phases. They can go through premature thelarche, which might raise some concern, asymmetric breast development, accessory supernumerary tissue, and gynecomastia.

In the post pubertal phases, things that might result in a palpable lump or a focal area of concern could be duct ectasia, cystic changes and infection.

To inform you all, the mean age of thelarche in the United States for African American girls is about nine years of age. For Caucasian girls, it's 10.

Premature thelarche is defined as breast development before the age of seven and a half. Premature thelarche is not always associated with precocious puberty. Just because she might have early breast development, it doesn't mean it's going to be a global sign of anything else to come.

An ultrasound could be used to exclude an underlying mass if it's necessary just to reduce some anxiety.

Asymmetric breast development, there could be up to a two year difference in the asymmetry between one breast and the other. Ultrasound could be used in this setting just to exclude the presence of an underlying mass. Eventually, the other breast usually does catch up, but certainly there are times where there remains an asymmetry onto adulthood.

I think we're all familiar with supernumerary breast tissue and gynecomastia. I'll reserve for the male portion of the talk.

Benign Abnormalities: Fibroadenoma

Let's go ahead and talk about some of the more common benign abnormalities that occur in children adolescents. We're gonna start with the fibroadenoma.

Fibroadenoma is the most common breast mass in girls younger than 20. It makes up 91% of all solid breast masses in girls younger than 19.

You can rest assured that if you have a young woman with a palpable lump, more than likely you're dealing with a fibroadenoma.

There is a variant called a juvenile or a cellular fibroadenoma that can sometimes be confused with or suspicious for a phyllodes tumor, and we'll talk about that later.

Fibroadenomas are estrogen sensitive. Puberty is a great time for them to grow when there's a lot of hormonal fluctuation and estrogen is surging. They can vary during the normal menstrual cycle as well.

They're rare before puberty. Ultrasound is the way to begin your evaluation of a suspected fibroadenoma and a palpable lump.

Your differential diagnosis will probably include a tumor. We'll talk about how to sort those two things out from one another.

If a fibroadenoma is found in a young girl, it is not considered a pre malignant condition, and it certainly doesn't mean she's predisposed to develop breast cancer later in life. It's just a fibroadenoma.

There is this potential for injury to the developing breast bud should you decide to biopsy a palpable mass.

Most of the literature surrounding this topic comes from the surgical literature where actual surgical intervention was done, and that theory is sort of extrapolated to core biopsy. There's no real proof that a core biopsy could injure a developing breast bud. It's just something to keep in the back of your mind.

If you have a young girl with a palpable lump and you go to ultrasound, which you will do obviously if she presents to your clinic and it has the typical findings of fibroadenoma, well circumscribed hypoechoic, wider than tall, it is perfectly reasonable to do a follow-up of this. We would follow it for a total of two years.

Surgical excision should definitely be considered for anything that is rapidly growing or has shown interval growth.

If your pathologist puts something on your histo, should you choose to biopsy it, and your pathologist put something on the report that says, hypercellular fibroadenoma or cellular fibroadenoma, that could be their code for telling you that they can't exclude a phyllodes tumor. You can either pick up the phone and call them and ask them to clarify what they mean by that. Or you can send them on for surgical consultation, have the surgeon sort of deal with it, but hypercellularity may imply that you're dealing with a phyllodes tumor as opposed to just a fibroadenoma.

Benign Abnormalities: Pseudoangiomatous Stromal Hyperplasia (PASH)

Next we're gonna talk about something called pseudoangiomatous stromal hyperplasia, otherwise known as PASH.

Most of the room is familiar with this diagnosis. I include this in the talk because it is relatively common in this patient population, and because it has such an ominous sound to it, it sounds like something bad. Pseudoangiomatous stromal hyperplasia, but it is in fact a very benign entity, but it is hormonally stimulated. PASH is not uncommon in this patient population where hormones are fluctuating and bouncing around.

It's typically present in premenopausal women, and it can present very similar to what a fibroadenoma would present as, which is a painless rubbery mobile mass.

You may often see PASH as an incidental finding on your biopsy results of other things, but PASH can also be the sole reason for a focal abnormality on mammography and ultrasound as well.

PASH can sometimes have extremely rapid growth and get to the point where it actually deforms the breast completely. We've seen this at least in our practice several times in young women. In those cases, certainly surgical consultation is warranted. The woman or the girl, the adolescent will push for that because they can tell that something is happening that they don't like.

If the patient is young and the lesion is showing rapid growth, I would definitely recommend on for surgical consultation.

Here's an example. This is a 26-year-old female, so not quite a child or an adolescent, but it illustrates the idea of PASH quite nicely. 26-year-old female who had stopped breastfeeding about eight to nine months earlier. She complained that she felt a painful, palpable lump in her left breast and that it was growing to the point that she felt that it was distorting her left breast.

She came in and she had a focal area, but then again, sort of described a global phenomenon going on in her left breast. We decided to start with a mammogram, which we wouldn't typically do in a 26-year-old, but in this case, we kind of wanted to get a bird's eye view, a whole picture of the breast to see what exactly was going on.

The palpable marker there demonstrates where her focal area of concern was, and we thought there was a pretty nice focal asymmetry that correlated where the palpable marker was. We did a spot compression view, and that's what it looks like.

We went to ultrasound. We did a physical exam, which I would certainly encourage everyone here to do if you have the opportunity to go in and do your own ultrasounds, which we have the luxury of doing all our own ultrasounds. We always will do a physical exam prior to doing an ultrasound. That is such great information. It gives you a lot of pretest probability for what you're about to find or not find. Perhaps when you put your probe down.

In this case, you could definitely feel what she was feeling. It was a discreet area of her breast. When you put the ultrasound probe down, we saw this area, for lack of a better word, that fit with the size and the location and the feel of what she was feeling. It certainly doesn't have your typical appearance of a fibroadenoma and that it's not homogeneously hypoechoic.

It was approaching about four centimeters in size. We couldn't tell her for sure what it was, thought it was benign, but went ahead and did a biopsy of it. We got back pseudoangiomatous stromal hyperplasia because of the size of the lesion and also because of her complaints of it seeming to have rapid growth. We sent her on to meet with a surgeon.

The surgeon's note said that given the fact that this lesion is 4.2 centimeters in size, and there could be sampling error from the lesion and the fact that it's slightly retracting the breast, I recommend we remove the lesion. The woman was more than happy to have that done. On final pathology, it did just come back as more pseudoangiomatous stromal hyperplasia.

That's where we're gonna stop with the benign etiologies in this patient population. We're gonna move on to malignant masses.

Malignant Masses: Phyllodes Tumor

Phyllodes tumor is what we'll start with, also known as cystosarcoma phyllodes. It comprises 1% of lesions in children and adolescents, so pretty rare.

However, it is the most common primary breast malignancy in this patient population, but still its peak prevalence is in the adult population. 5% of phyllodes tumors occur in girls younger than age 20, and they have the potential for invasive growth, recurrence and metastasis.

Phyllodes tumors usually are recommended for surgical excision. It's important to know, though, that there are benign phyllodes, and then there are malignant phyllodes, and most phyllodes actually are indeed benign. We still will recommend excision of them.

They too tend to present as a painless, rapidly growing, movable rubbery mass, similar to what I just told you about PASH. The hallmark of phyllodes tumors is that they're big. They're very big, often greater than six centimeters.

Histologic hallmarks, as I alluded to earlier, is that they have this increased cellular matrix hypercellularity. If you get back on pathology phyllodes, hypercellular fibroadenoma, I would pick up the phone and call the pathologist and have them clarify what they mean by that, because they might just not wanna come down hard that it's a phyllodes tumor.

My understanding of what I've read is that when they're looking through the microscope at these tumors or at the cores that we give them, there is no single histologic feature that allows them to distinguish indolent behavior from metastatic behavior. We can't distinguish those phyllodes tumors either on imaging.

Recurrence rates, however, tend to correspond with tumor biology. Benign and malignant phyllodes tumors can recur, albeit benign phyllodes have a lower recurrence rate than malignant phyllodes.

The sonographic appearance is similar to fibroadenomas in that they tend to be well circumscribed hypoechoic masses. There's a lot of overlap, of course, with the way that a fibroadenoma may look on ultrasound versus a phyllodes tumor.

This is a woman who presented, and this is sort of the classic appearance of what a phyllodes would look like on mammography. It's big and it's dense, and that's exactly what this is, even though the posterior borders are a little bit obscured by this fibroglandular tissue, clearly there's a discreet mass sitting in there. It's right adjacent to the palpable marker.

We went on to ultrasound, and this is what it looked like on ultrasound. It was well circumscribed, it was hypoechoic, and it contained the cystic spaces. The cystic spaces don't mean anything. Fibroadenomas can have cystic spaces in them as well. It just so happened that this phyllodes tumor had some cystic spaces in it.

The phyllodes tumor certainly can be uniformly homogeneous hypoechoic as well. We biopsied it and we got back this cellular fibroadenoma. Luckily, our pathologist went ahead and added their comment. Their comment was that the increased stromal cellularity raised the possibility of a phyllodes and it could not be excluded.

We sent her on to a surgeon who removed it, and in fact, it was a low grade phyllodes tumor at final surgery.

Phyllodes tumors, the treatment is surgical excision. The prognosis is typically favorable because most of them are benign. In fact, both benign and malignant phyllodes tumors can recur and metastasis is rare, but when it happens, it metastasizes through the hematogenous route as opposed to the lymphatic route. How breast cancer typically metastasizes.

Malignant Masses: Primary Breast Cancer

Moving on to primary breast cancer. In this patient population, very rare. Less than 1% of all breast lesions in the child and adolescent group tend to be primary breast cancers, and it's even rarer for boys than girls. Luckily.

However, when this patient population does develop a primary breast cancer, the histologic type tends to be a secretory carcinoma. Secretory carcinomas have a favorable prognosis. They tend to be indolent and slow growing. The five year survival rate is very good.

Always keep in the back of your mind that if you do have the unfortunate experience to diagnose a breast cancer in a child or adolescent, you might wanna think about genetic syndromes. Certainly if you have a child or adolescent present with a focal palpable lump, and you know that there's a BRCA one or BRCA two mutation in that family, that might increase your threshold, or I should say, decrease your threshold for biopsy.

What happens sometimes we see primary breast cancer in this patient population secondary to mantle radiation from Hodgkin's lymphoma. The breasts are in the field of radiation for Hodgkin's lymphoma, and that increases that patient population's risk for developing breast cancer later on.

Malignant Masses: Metastatic Disease

Now we're gonna talk about metastatic disease to the breast. This is the most prevalent type of malignant tumor actually that happens in children and adolescents. Rhabdomyosarcoma, neuroblastoma and leukemias and lymphomas are the most common types that can metastasize to the breast.

Girls unfortunately have a greater likelihood of having a metastasis to the breast than boys. It probably goes without saying any enlarging mass or palpable mass in a patient who has a known malignancy needs to be evaluated, probably with core biopsy, I would say not FNA, and unfortunately, it's typically associated with disease elsewhere and confers a poor prognosis.

That's as far as we're gonna go with our children adolescents and I have two articles, nice review articles here that I refer you to if you wanna delve in deeper to that topic of breast abnormalities in children adolescents.

Pregnant and Lactating Patients

We're gonna move on to pregnant patients, pregnant and lactating patients.

Let's start off with talking about how we as a radiology community approach this patient population. First of all, we know pregnant and lactating women tend to be a younger population. That same population tends to already be dense on mammography, and you throw in the fact that they have this surge in hormones and they become even denser.

This is the same woman, and this is when she's lactating, and this is when she's not lactating. There's definitely a good thought that mammography will have a decreased sensitivity in this patient population.

Usually this patient population is presenting for a diagnostic problem. We're not usually doing screening mammograms in pregnant women or lactating women for that matter. Usually it's a diagnostic problem that you're trying to solve. Typically the diagnostic problem is a palpable lump.

Ultrasound is considered the most appropriate imaging modality to begin with. What we are trying to catch in this patient population is pregnancy associated breast cancer, which almost always presents as a mass. We know that ultrasound is very good at finding masses and differentiating masses from the surrounding normal breast parenchyma.

Ultrasound is a reliable tool to be used in this patient population as a first line imaging modality as opposed to mammography. Certainly if you see an abnormality and you think it's suspicious or you've already biopsied it and it's suspicious, then you should probably move on to bilateral imaging and screen the contralateral breast.

Breast MRI Considerations

How about breast MRI? Of course we need gadolinium to detect breast cancer in breast MRI. Although there are no conclusive teratogenic effects of gadolinium to the fetus, we do know that gadolinium crosses the placenta. It's excreted by the fetal kidneys, and then it just kind of hangs out in the amniotic fluid, and no one's quite sure. We don't really know how long it's gonna stay in that amniotic fluid and the fetus is just gonna sort of bathe in gadolinium and other things for the rest of the gestation.

Breast MRI for the detection of breast cancer is a no-no during pregnancy. If what we're looking for primarily is pregnancy associated breast cancer, then ultrasound should be really good. If you need to do a mammogram also, then between the two of those you'll have most of the information that you'll need.

The ACR is pretty firm about its beliefs in not using MR contrast agents during pregnancy.

How about during lactation? You can do a breast MRI during lactation, albeit probably not gonna be very sensitive. Certainly there's going to be probably increased background parenchymal enhancement due to hormone surges. Your T2 images will probably be almost worthless because it's gonna be bright all over due to the presence of fluid in the milk ducts.

Gadolinium is excreted into the milk duct. If for some reason we do do an MRI in a lactating patient, we counsel her not to breastfeed for 24 hours and to sort of pump and dump so that the fetus is not drinking gadolinium in the milk.

Radiation Exposure

Let's talk a little bit about radiation exposure. The fetus is most susceptible to radiation effects during the first two months of pregnancy. Malformations are believed to occur at exposures greater than 0.05 gray. Keep that number in your head for a moment or two.

The current recommendations, however, are to avoid mammography during the first trimester and probably during throughout their pregnancy. In general, if you can. There's a really heightened sensitivity about radiation within the community.

I think even though we as radiologists might realize that the dose, the amount of radiation associated with a mammogram is exceedingly low, I think most people believe that it's better not to radiate pregnant women than to radiate them unless absolutely necessary for treatment reasons.

Ultrasound again, is the first line tool, and again, you're usually evaluating a palpable lump. Ultrasound should be very good at detecting a mass if one truly exists.

If you do a ultrasound and you see a mass that is suspicious and you go onto biopsy and it's breast cancer, then you might wanna consider doing a mammogram and a bilateral mammogram at that.

If you do a mammogram in a pregnant woman, please use abdominal shielding. Note, and you can counsel her on this, that the dose to the fetus, regardless of the stage of gestation, is negligible and exceedingly low.

Remember, I told you to remember that number 0.05 gray. The standard four view mammogram with abdominal shielding subjects the fetus to 0.004 micro gray of radiation, which really is negligible and isn't going to amount to any sort of malformations or anything untoward.

Copans wrote that this much radiation is over 2 million times less than the absorbed dose the fetus received from natural background radiation over the nine months gestation.

If you do need to do a mammogram in a pregnant woman, you can be very confident in counseling her that it's not going to affect her baby.

Histological Sampling and Biopsy

Now what if you see something and you wanna move on to histological sampling? False positives are at a slightly higher rate in this patient population due to the cellular changes that the breast undergoes from pregnancy and lactation.

It would be nice of you to let your pathologist know that the tissue that you're submitting is from a pregnant or lactating woman, that could help them a little bit.

Certainly if you see anything that is suspicious, please do a core biopsy. It's safe, it's easy, it's cost effective, but there are some risks that you might want to think about and counsel your patient about.

In this patient population, if you move on to core biopsy, they have a slightly increased risk of bleeding because there's some hypervascularity to the breast during pregnancy and lactation. We're just talking probably about a bigger bruise. We're not talking about life-threatening bleeding.

The risk of infection is increased, especially in your lactating patients because milk is a great culture medium for bacterial growth. Counsel them on that and make sure they know how to care for the area after they leave you so that an infection doesn't develop after they leave.

There's the risk of milk fistula in a lactating patient. This is real, and you definitely need to talk to your patients about this. If you are going to do a biopsy in a woman who's lactating and a milk fistula is exactly what it sounds like. Your biopsy needle creates a needle tract through the ducts into the skin.

That poor woman, if she continues to breastfeed and you've created a milk fistula, she's gonna leak milk out of her incision site for the remainder of the time that she breastfeeds.

In order to decrease that from happening, the risk from happening, we ask our lactating patients, first of all, we ask them how long are they gonna continue to breastfeed, and if it's within a reasonable window that they're gonna stop and we can defer the biopsy, then we will until after they're done breastfeeding.

However, if they're gonna continue breastfeeding for the next eight months and we need to biopsy said lesion sooner than that, then we ask the patient to either bring baby or pump with her, ask her to arrive about 30 minutes earlier, and we put her in a nice quiet room and ask her to decompress that breast as much as possible prior to us doing the biopsy.

We use a smaller needle, usually an 18 gauge needle is what we use when we're biopsying something in a lactating woman.

Benign Lesions in Pregnant and Lactating Patients

What are some of the lesions and pathologies that can occur in pregnant and lactating women? There are quite a number. This is a brief list of some of the benign things that can happen to a pregnant lactating breast. This is some of the malignant things.

Obviously we don't have time to cover all these, so I've just selected some of the few and we're gonna hit the high points.

We're gonna start off with gestational and secretory hyperplasia. Another nice review article to refer you to, if you wanna delve into this topic a little deeper since we're sort of just skimming the surface here.

Gestational and secretory hyperplasia are typically manifested as microcalcifications due to secretions. They can have a very strange appearance to them. They can be round and curvilinear and very irregular in appearance, and they can look suspicious in the sense that they're type of morphology that you're not used to seeing.

Here's a nice example. This was a 38-year-old woman who had completed breastfeeding six months prior. She had a ridiculously strong family history, and she had presented for her baseline mammogram, and she had these strange looking calcifications, basically. Some of them were curvilinear, some of them, they were just very chaotic. I hesitate to use the word pleomorphic, but they were, they certainly didn't fit nicely into any BI-RADS descriptor.

They were bilateral and they were diffuse. The distribution suggested to us that they were indeed benign. Given her strong family history and she had a bit of anxiety about it, we decided to biopsy one area to prove essentially that they were indeed benign. They came back as benign breast tissue with focal secretory change and hyperplasia on her mammogram.

A year later when she presented for her screening mammogram, a year later, all of these calcifications were gone.

Galactocele

Now we're gonna move on to galactocele. Galactocele is the most common benign lesion seen in lactating women, and it usually occurs after the cessation of breastfeeding. It's essentially just a cyst that contains milk.

If you have a palpable lump and you do a aspiration of it after you've done an ultrasound of it, you do an aspiration, you get back milky fluid, that's diagnostic of a galactocele.

This is sort of the quintessential look of what you would love to see on a mammogram. If you have a woman who's lactating or recently stopped lactating and she feels a palpable lump, and you have your technologist do a true lateral view, have her stand there for a while, do a true lateral view, you might get lucky enough to see a fat fluid layer.

If you do, you can stop there because this is a benign finding and it fits with the presentation of a galactocele, especially in that patient population. This is the sonographic correlate of that.

Infections: Mastitis and Abscess

Now we're gonna talk about infections. Mastitis commonly occurs during breastfeeding. Milk is a great medium for bacterial growth. Staph and strep are the two most common bugs that cause mastitis. Usually the origin is the infant's nose and throat, and it enters the breast through a cracked nipple or a skin abrasion.

There's this retrograde dissemination throughout the ductal system where all that milk is, and the bacteria just take off, basically. Staph usually manifests as a localized infection, an abscess, whereas strep tends to cause that sort of diffuse mastitis that we see.

The organisms can be cultured from the milk, which I thought was interesting. Usually treated quite easily with antibiotics.

If mastitis is the differential diagnosis or what the clinician is worried about and there's no focal area of concern, imaging isn't really gonna help too much. If there is a focal area of concern, a focal area of erythema, or certainly a palpable lump, then we can do ultrasound to see if there's an underlying abscess.

If there is an underlying abscess, we can aspirate that and send that fluid off for gram stain culture and sensitivity and aspirating, it sometimes brings the patient a little bit of relief too, because these can be very tense basically, and just sort of relieving some of that tension sometimes brings a little bit of relief to the patient.

Abscesses though sometimes do not resolve just with antibiotics and actually need surgical excision and drainage. We can do ultrasound guided aspiration to at least get them on the right track with the right antibiotic therapy.

Sometimes the stuff is pretty thick, so you might need to use a pretty large gauge needle in order to drain it. Please use lidocaine or anesthesia while you're doing these. The patient's usually already in pain as it is, and I know there's some schools of thought that two sticks is worse than one.

I have had some patients say to me, you know what? Don't gimme any lidocaine, just get in and get out and be done with it and fine. If that's what the patient wants, I'm happy to oblige. For the most part, in my experience at least, I see most women like lidocaine.

The lidocaine can hang around for a little bit, and I've read in the literature too, that you can even irrigate that cavity with some lidocaine after you've aspirated it, and the lidocaine will kind of hang around and give her some relief after you're done with the procedure as well.

If she does have mastitis or abscess, she might be concerned that she can no longer breastfeed. That's not the case. The infant is where she got the infection from. It's not gonna hurt the infant to continue to breastfeed.

In fact, what she wants to do is continually decompress that breast and get rid of that milk as much as possible. If she doesn't feel comfortable breastfeeding, then she should certainly pump and keep that breast decompressed and rid it of all the bacteria ridden milk, essentially.

Lactating Adenoma

Let's talk a little bit about benign tumors that can occur in pregnant and lactating women. There is something called a lactating adenoma. It occurs in response to the physiologic changes to pregnancy and lactation, and they usually regress actually spontaneously after the woman goes back to sort of a baseline state.

A lactating adenoma will look for all the world just like a fibroadenoma. It's hard to distinguish them, but sometimes they can have sort of radiolucent, hyperechoic areas because there's fat within them.

This was a 26-year-old female who was 31 weeks pregnant, and she had been feeling this mass that she said was getting larger, and we biopsied it and it was a lactating adenoma.

Fibroadenoma

Now we're gonna talk about fibroadenomas. Fibroadenomas are actually the most common tumor found in pregnancy and lactation. The school of thought is that they were probably there all along, just that the hormonal fluctuations with pregnancy and lactation induced growth, and now they become clinically apparent essentially, because fibroadenomas are hormone sensitive tumors.

Fibroadenomas look the same in pregnant lactating women as they do in non-pregnant lactating women. They tend to have benign features to them.

Palpable fibroadenomas or palpable masses in a pregnant woman should be histologically sampled. That's what it says in much of the literature that I've reviewed and after sort of reviewing the literature about pregnancy associated breast cancer, I have a low threshold for biopsying newly palpable masses in pregnant women, and we'll get there later in this talk.

However, if the mass is incidentally found, you're doing the ultrasound for other reasons, she can't feel it and it fits all the criteria for a fibroadenoma, in those cases, those can be followed closely with ultrasound.

That does it for the benign things we're gonna talk about. We're gonna move on to malignant tumors, and we're really just gonna focus on pregnancy associated breast carcinoma for the purposes of this talk.

Malignant Tumors: Pregnancy-Associated Breast Cancer

Pregnancy associated breast cancer is defined as cancer that occurs during pregnancy or within one year of delivery. It comprises 3% of all breast malignancies, which quite frankly, I thought was rather high. I would not have thought that 3% of breast cancers occur in pregnant women. 3% isn't a big number, but again, more than I had expected.

The prevalence of pregnancy associated breast cancer is expected to increase as women defer childbearing to later ages in life.

The problem with pregnancy associated breast cancer, they tend to be large and more advanced at the time of diagnosis, they're typically associated with a poor outcome. They are high grade tumors. Lymph node involvement is usually there in greater than 50% of the cases at the time of diagnosis, and they're typically the HER2 positive type of breast cancers, which is an aggressive form of breast cancer that tends to recur.

All of these sort of poor prognostic features of pregnancy associated breast cancer are partially due to the fact that it's an aggressive type of breast cancer that these women form. Also partially because we tend to delay the diagnosis of these tumors in these women because it's a pregnant woman with a palpable lump, you can imagine that she has physiologic changes going on and it's easy to discount that as a benign finding and not do anything about it and let it go.

By the time it finally does become clinically suspicious enough to act on, it's out of the gate and it's metastasized. This is one of those diagnoses that you just don't wanna miss. We never wanna miss breast cancer, but certainly in a young pregnant woman it would be a tragedy.

They typically present with a palpable mass. Ultrasound should definitely do the job. In terms of finding it on papers, they say that ultrasound is 100% sensitive for detecting pregnancy associated breast cancer.

Any discreet palpable breast mass in a pregnant woman should probably, in my eyes, be biopsied.

Here's an example of a 34-year-old woman who came in. She was 10 months postpartum and she was complaining of focal pain. She also had a family history of breast cancer, so we did bilateral mammographic imaging on her. It was the first time we had met her.

This is where the palpable lump is not too much going on on the mammogram. You might argue that there's a little bit of a convex asymmetry there. The spot compression magnification view, not very remarkable. If anybody wants to say that there might be something there, I'd give it to you, but certainly not glaring.

We went to ultrasound and unfortunately I have the answer down here as to what this is, but this, I did this ultrasound, I worked up this woman, and I can tell you that when I felt it, and when I did the ultrasound, I was trying very hard to make this a fibroadenoma, right? She's young, she just had a baby. I want it to be benign.

It's oval ish, it's parallel ish, right? But those borders just aren't as sharp as you want them to be for a fibroadenoma. I'm talking during, I'm thinking in my mind this could just be one of those weird looking fibroadenomas and everything's gonna be fine.

I think more for my benefit, I decided to cruise up to our axilla and say, see, even your lymph nodes look fine. Obviously that's not what happened. Her lymph nodes looked remarkably abnormal. My stomach sank, my heart sank the whole thing.

Unfortunately we biopsied this and it all came back invasive ductal carcinoma. The lymph nodes of course, were metastatic as well. I'm happy to say she's doing fine. Actually, that was probably about four years ago, and I've kept up with her, and she seems to be doing okay.

That does it for the young and pregnant portion of this talk, and we're gonna move on to the male portion of the talk.

Male Patients

A little bit about the anatomy of the male breast. It's not very complex. Basically you just need to know that at birth, males and female breasts are essentially the same, and that tissue remains quiescent until puberty, at which time the relative imbalance of androgens and estrogens will cause some transient proliferation in ducts of a young man.

Ultimately, though, that ductal tissue will atrophy and involute and he'll basically just be left with subcutaneous fat and remnants of ductal tissue in the subareolar location.

It's important for us as radiologists to realize that lobular development in a male breast is exceedingly rare, which means lobular derived lesions are exceedingly rare in men. Fibroadenomas cysts are both lobular derived lesions that are very common in the female population, but they're very rare in the male population.

If you find a mass in a man and you feel the urge to just lump it as a fibroadenoma or a cyst, maybe you should just think about that a little bit harder, because again, it happens, but it's exceedingly rare.

Mammographically, this is essentially what a normal male breast will look like. Just subcutaneous fat, no real fibroglandular tissue. Maybe a wisp, who knows if that's fibroglandular tissue or not, but essentially just very radiolucent.

Common Lesions: Gynecomastia

What are the most common lesions that affect the male breast gynecomastia? It is by far and away the most common reason why men present to us for evaluation of a palpable lump.

It is defined as the benign enlargement of fibroglandular elements. There's also an entity called pseudogynecomastia, which is just essentially increased subareolar fat.

Breast cancer can occur in the male breast, although it is rare, and essentially any lesion that occurs in a female breast can occur in a male breast, although at a significantly lower incidence. Lobular derived lesions are rarer still.

Let's talk about gynecomastia again. It is defined as the benign enlargement of fibroglandular elements, and it happens physiologically and normally in three age groups in men and the neonatal male, the pubertal male, and in the elderly male.

This is all just due to a relative imbalance of estrogens and androgens. To some degree, gynecomastia is a normal process of aging in men. It's due to the relative imbalance and decrease in androgens due relative to estrogens.

It's also important for us to know that there are no reported cases of gynecomastia progressing to breast cancer. This is one of those times in the world of imaging that if you can diagnose gynecomastia on imaging alone, you can reassure that patient that he doesn't have cancer and it won't turn into cancer. We don't get that luxury very often. I take advantage of it whenever I can.

Physiologic gynecomastia also happens in an adolescent boy, usually between the ages of 10 to 14, anywhere from four to 65% of male boys will get it. It usually appears about six months after other secondary sex characteristics arrive, and it typically regresses within six months to a year. It can be asymmetric.

There are some pathologic causes of course, of pubertal gynecomastia, which I'm sure you would know about prior to the development of gynecomastia. Testicular tumors and hyperthyroidism might be something that clinicians wanna keep in their back of their mind if that gynecomastia doesn't regress spontaneously.

Certainly there are exogenous causes of gynecomastia in this age population, anabolic steroids, and perhaps marijuana might be the two most common offenders. There are a few anti-epileptic drugs as well that can induce gynecomastia.

How about in the older man? As free testosterone levels decline with age, gynecomastia is physiologic to some degree. You throw on top of that a whole host of medications that can exacerbate gynecomastia, and you've got a pretty robust portion of the population that has gynecomastia.

Pathologic diseases. Anything essentially that affects the liver, kidneys, or lung can also cause gynecomastia. Gynecomastia is not rare in the older male.

How is gynecomastia treated? If we catch it early enough, or if the clinician catches it early enough and can find the offending drug or the offending agent that's causing it or exacerbating it, and they take it away, it can regress.

Testosterone treatment has been used before and tamoxifen has also been written up to work with this, although it's not FDA approved for the treatment of gynecomastia.

If gynecomastia has been present for greater than a year, then it's unlikely to regress. Really the only options that a man would have at that point are surgical. In my experience, most men don't care about surgery. They don't need to have it removed. They just wanna be reassured that it's not breast cancer.

The only exception of this rule is perhaps if you're dealing with a younger man who wants to have it treated permanently.

Imaging Approach for Male Breast

How do we image a male breast? How do we approach men when they come to us with an area of concern? There is no such thing as screening a male breast, even though we know that there are some men out there with a higher risk of developing breast cancer than the typical male. All imaging in men is considered diagnostic.

That being said, we do screening mammograms on some men who are BRCA two or have a personal history of breast cancer, but they're all coded as diagnostic.

If a man comes in with an area of concern or palpable lump, there's no standard algorithm written up as to how to approach them. I'll tell you what we do. We always, and this is across the age groups. We've unfortunately done this to 14-year-old boys, and we do this to 72-year-old men. When they come in with a palpable lump. We always do bilateral imaging, CC and MLO views, and we do a spot compression view over the area of concern.

We reserve ultrasound only for lesions that look suspicious to facilitate ultrasound guided biopsy. Gynecomastia has a pretty typical appearance on mammography. We feel comfortable diagnosing it from mammograms alone.

We do not do ultrasounds in all men that come in with a palpable lump. We stop at the mammogram if we feel it's gynecomastia. Stereotactic biopsy usually isn't feasible in men just because they don't have enough tissue to drop down into the stereotactic unit.

There are three forms of gynecomastia, nodular dendritic in diffuse distinguishing which type you're looking at. Mammographically is pretty clinically insignificant. We certainly don't take the time to say in our report which type we're looking at. It's either gynecomastia or it's not essentially.

For the purposes of this talk, we'll go through this quickly.

Types of Gynecomastia

Nodular gynecomastia tends to be the type of gynecomastia that's been present for less than one year, and it looks like a nodular subareolar density.

Gynecomastia is often a bilateral process, and that is why we do bilateral imaging because the findings in the contralateral breast help us to make a diagnosis or guide us on a diagnosis when we're dealing with the side of concern. It's often bilateral, but often asymmetric.

Here's a case of a man complaining of a palpable lump in the right. Clearly he has bilateral subareolar densities. I showed you the case earlier of a normal male breast that was completely fat. This man has something, it's bilateral, it's a little bit asymmetric, but both sides are concentric to the nipple.

Gynecomastia is always concentric to the nipple, and that's because that's where those ductal remnants live. If they're going to be proliferated or stimulated, that's where the gynecomastia is gonna be formed right behind the nipple.

We always do our spot mag view, and we would feel very comfortable calling this gynecomastia and stopping. It is a density that emanates backwards from the nipple. It was bilateral, albeit asymmetric, and it has sort of pockets of lucency within it.

We would stop here and call it gynecomastia if you felt the need to do an ultrasound or if you're in your practice, you do an ultrasound for all palpable lumps, then be prepared for what gynecomastia can look like on ultrasound. It can look very suspicious, basically. If you don't know what gynecomastia looks like, you might start doing unnecessary biopsies.

Gynecomastia will be hypoechoic and can have very irregular margins to it. If you think about the way that gynecomastia looks on mammography, this is just that island of fibroglandular tissue and it's the sonographic correlate to what you're seeing on mammography.

Dendritic gynecomastia is a more chronic form of gynecomastia. It's usually been present for more than a year, and it's typically irreversible because by this time a certain amount of fibrosis sets in. Unfortunately the man might be stuck with it.

Here is an example of what dendritic gynecomastia can look like. We did bilateral imaging. He has nothing on the right, but it doesn't matter because this spot compression magnification view is classic for gynecomastia. It's a focal area of density right behind the nipple, emanating back that sort of flame shape morphology that we learn about with nice concave scalloped margins to it, it looks like a pocket of tissue. It does not look like a discreet mass.

We would stop here and reassure him that he's fine. If you did ultrasound, this is what you would find though. Nothing wrong with doing an ultrasound if that's how you practice, but be prepared for what gynecomastia looks like and be able to diagnose it and feel comfortable with this look on ultrasound.

Then finally, there's diffuse gynecomastia. Diffuse gynecomastia is often seen with exogenous estrogen treatment, which men will get sometimes for the treatment of prostate cancer. Typically it affects both breasts. The entire breast is enlarged because they have this influx of estrogen.

This is what it looks like on mammography. If I didn't tell you this was a man, you might think that this was a woman. That's perfectly reasonable because all this is is breast tissue, the proliferation of fibroglandular tissue, and on that spot compression magnification view, there's no discreet mass here, it's just tissue emanating back from the nipple. Bilateral gynecomastia done.

Pseudogynecomastia

Let's move on to pseudogynecomastia. This is the picture I showed you earlier. Every once in a while you'll have a man present saying that they feel a lump and they almost grab their entire breast. You do imaging and there's nothing there except subglandular fat.

Obviously you can reassure this man that he doesn't have breast cancer, doesn't have anything worrisome, and essentially what he's feeling is just unfortunately subareolar fat.

Breast Cancer in Men

Let's talk about breast cancer. In men, it's very rare. It comprises less than 1% of all breast cancers. The mean age at diagnosis is 67, and it's uncommon in men less than 40.

Stage for stage. It has a similar prognosis as female breast cancer, but male breast cancer is typically caught at a later stage. This is for a variety of reasons. It's partly due to the fact that we don't screen men. Because the incidence of breast cancer is so rare, and also because men are more likely to, they don't do breast exams routinely. They're not counseled to do breast exams like women are.

They don't, and if they do a breast exam and they find something, they're more likely to ignore it. There's been a handful of times, unfortunately, that I've talked to men with breast cancer and they say, you know, they felt it. They went on the internet and they found that gynecomastia is the most common reason. They just let it go. Finally at some point decided that it probably was something that needed to be checked out.

Risk factors for male breast cancer include advanced age prior irradiation to the chest wall, exogenous estrogen treatment, anything that causes hypoandrogenism basically. Then of course, there are some chromosomal abnormalities that we know about as well that might increase the man's risk of developing breast cancer.

Infiltrating ductal is the most common type. DCIS and Paget's have both been reported. Infiltrating lobular is rare because lobular derived lesions are rare in the male breast.

This is a 67-year-old man presented with a palpable lump. Here's his mammogram. Always start off with bilateral imaging. Very clearly this is not gynecomastia, right? It's in the right location, it's concentric to the nipple, but this is a mass, this is a dense, discreet mass on spot compression magnification views.

It has microlobulated borders to it. It does not have this nice convex scalloped margins. It doesn't just fan out and fade away into the surrounding breast tissue. If you did a physical exam, you would feel that it's hard as a rock.

This is what it looks like on ultrasound. It looks similar to female breast cancer. It's a mass with microlobulated margins. It needs a biopsy. That was invasive ductal carcinoma.

This poor man had had just a ton of things that he's dealt with over the years. He was 71, he had had breast cancer 10 years ago and was considered cured. He had a history of melanoma as well. He had an uncle with breast cancer, and he was now noticing left nipple inversion.

I still to this day have no idea how this happened, but somehow his clinician bypassed mammo and ultrasound workup and he ended up on our MRI list. He got an MRI. We don't do breast MRIs in men, but this was his breast cancer. It's a highly enhancing mass emanating back from the nipple, very irregular margins.

Unfortunately, just like I stated earlier, he had involved lymph nodes as well, and this is what his mass looked like on ultrasound. This was one of those ugly lymph nodes up in the axilla.

This is a 73-year-old man who was status post left mastectomy for a personal history of breast cancer, and he was now complaining of pain in the right breast. His clinician sent him to us for a diagnostic workup.

We started with a mammogram, and this might be hard to see from the back of the room, but every so often he had these little clusters of calcifications, some of which were starting to take on a linear distribution. Given his history, we decided to biopsy these, we were able to get him into the stereotactic table and get a sample.

These came back as atypical ductal hyperplasia. He went on for mastectomy. From my conversations with the surgeons, there's really no role for lumpectomy in the male breast. If they have an abnormality such as ADH and certainly malignancy, they go straight to mastectomy.

Other Lesions in Male Breast

What about other things that occur in the male breast? Gynecomastia tops the list for both benign and malignant. It's the most common lesion that we see in the male breast, but following gynecomastia, lipomas are the second most common masses, followed by epidermal inclusion cyst or sebaceous cyst, and then a whole host of other things on the malignant side.

Metastasis can sometimes occur to the male breast with prostate lymphoma, melanoma and lung being some of the types of cancers that will metastasize to the breast.

Here's an example of a man came in with a palpable lump. On the right breast, there's the palpable marker. We did our bilateral imaging. You don't see obvious signs of gynecomastia on the spot compression magnification view right underneath that palpable marker, you can almost hallucinate a very lucent but circumscribed mass.

We took him to ultrasound and this is what we saw. We saw a very well circumscribed, superficial, uniformly hyperechoic mass. We felt very comfortable calling this lipoma, given the findings on mammogram and ultrasound and told him he was fine and let him go.

Here's another man that presented with two palpable lumps in the right breast. There's one up here and one down here. This isn't gynecomastia. This is a discrete mass, two discrete masses.

In these cases, we always take the man to ultrasound, and this is beautiful. You saw some examples of these earlier. This is a well circumscribed mass that demonstrates a tract extending to the skin surface that was the bigger mass. The smaller mass was completely contained within the skin and also demonstrated a pore to the skin surface.

He has two sebaceous cysts in that breast, both of which are considered benign, and again, reassured him that he was fine and let him go.

That is it for the young pregnant male talk.

Summary

In summary, with regard to the pediatric and adolescent population, the majority of boys will experience some sort of gynecomastia during puberty. The most common mass in girls younger than 20 is a fibroadenoma.

Remember that if you get back a cellular fibroadenoma or a hypercellular fibroadenoma, you might need to call your pathologist to have them explain that to you. Primary breast cancer in this patient population is exceedingly rare. Conservative follow-up with clinical follow-up and ultrasound is what's recommended.

Pregnant and lactating patients. The most appropriate imaging tool to begin with is always ultrasound because you're trying to exclude pregnancy associated breast cancer, which typically presents as a palpable mass. The most common benign breast lesion during lactation is a galactocele. The most common tumor in pregnancy and lactation is a fibroadenoma.

Remember that pregnancy associated breast cancer tends to have a very poor prognosis. There is literature out there that supports doing a biopsy in any newly palpable mass in a pregnant woman.

Male patients, gynecomastia is always concentric to the nipple. The minute you have a lump or a mass in a male breast that's eccentric to the nipple doesn't mean it's breast cancer, but you can't account that as gynecomastia.

There is a trimodal physiologic phase for gynecomastia in men neonates, pubertal, and in the aging population. Gynecomastia can be diagnosed with mammograms alone.

I don't know how many people do ultrasounds for palpable lumps in men routinely. We used to, we don't anymore though, because we just got to the point where we thought, you know, we felt confident diagnosing it off of mammography. Cysts are rare. Fibroadenomas are rare. Just keep that in the back of your mind.

Male breast cancer appears similar to female breast cancer. It's usually an easy diagnosis, unfortunately, because it usually looks like a dense round mass right behind the nipple.

Thank you.