Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH
QUICK SEARCH:   [advanced]


     

Published online before print December 21, 2005, 10.1148/radiol.2382041312

(Radiology 2005;238:438.)

A more recent version of this article appeared on December 1, 2005
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow All Versions of this Article:
2382041312v1
238/2/438    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Morakkabati-Spitz, N.
Right arrow Articles by Kuhl, C. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Morakkabati-Spitz, N.
Right arrow Articles by Kuhl, C. K.
© RSNA, 2005

Breast Imaging

Dynamic Contrast-enhanced Breast MR Imaging in Men: Preliminary Results1

Nuschin Morakkabati-Spitz, MD, Hans H. Schild, MD, Claudia C. Leutner, MD, Marcus von Falkenhausen, MD, Götz Lutterbey, MD and Christiane K. Kuhl, MD

1 From the Department of Radiology, University of Bonn, Sigmund-Freud-Str 25, D-53105 Bonn, Germany. Received July 30, 2004; revision requested October 8; revision received June 6, 2005; final version accepted July 8. Address correspondence to N.M. (e-mail: n.morakkabati{at}uni-bonn.de).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Purpose: To prospectively evaluate whether the descriptors of lesion features and the diagnostic criteria that have been established for breast magnetic resonance (MR) imaging in female patients may be used for differential diagnosis with breast MR imaging in male patients as well.

Materials and Methods: The study design was approved by the institutional review board; all patients gave informed consent. The Institutional Review Board and informed consent information applied to the prospective and any retrospective component of the study. Seventeen consecutive male patients (mean age, 53 years ± 14) were referred for imaging of a palpable breast mass. In addition to mammography and high-frequency breast ultrasonography, patients underwent dynamic breast MR imaging in a prone position with a dedicated double-breast surface coil. The standardized protocol consisted of a T2-weighted turbo spin-echo sequence followed by a dynamic series. Findings were recorded by using the terminology and descriptors and by evaluating the diagnostic criteria (related to morphology and enhancement kinetics) that have been developed for breast MR imaging in female patients. Validation was achieved at biopsy (nine patients) or follow-up with clinical examination and conventional imaging (eight patients). Because of the small size of the patient cohort, statistical significance was not tested.

Results: A total of 24 breast abnormalities were diagnosed. Three patients had invasive breast cancer (five tumors), 11 had gynecomastia (six unilateral, five bilateral), two had pseudogynecomastia, and one had a benign solid tumor (angiolipoma). All malignant tumors appeared as irregular masses with heterogeneous internal architecture or rim enhancement and showed rapid initial enhancement (mean value, 137% ± 23) followed by a washout time course (Breast Imaging Reporting and Data System [BI-RADS] category 5). Diffuse and nodular gynecomastia showed slow initial and persistent enhancement with normal-appearing parenchymal architecture (BI-RADS category 2; 15 of 16 breasts in 10 of 11 patients). In one patient with biopsy-proved bilateral gynecomastia, an area with segmental enhancement was classified as suspicious for ductal carcinoma in situ. Pseudogynecomastia did not enhance at all. The angiolipoma showed benign morphologic features and slow initial and persistent enhancement (BI-RADS category 2).

Conclusion: In the small study cohort, the MR imaging features of benign breast diseases and breast cancers in male patients seemed to be comparable to those seen in female patients.

© RSNA, 2005


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Male breast carcinoma is a rare disease, accounting for fewer than 1% of all malignancies in men and for only 1% of all breast cancers (1). Although all subtypes of breast carcinomas seen in women can also be found in men, the most common histologic type is ductal invasive breast cancer. The most common benign breast disease in men is gynecomastia; other rare diseases in the male breast arise from the skin and subcutaneous tissue (eg, fat necrosis, lipoma, or cysts).

The mammographic and ultrasonographic (US) criteria of male breast cancer and of benign breast diseases have been reported to be analogous to those of breast diseases in women (2–13). Although a standardized algorithm for the diagnostic work-up of palpable breast masses in the male breast does not exist, some authors propose to perform x-ray mammography (6–9,11) and, if necessary, high-frequency breast US (6,10,11,14). In indeterminate and suspicious cases, biopsy should be initiated.

Breast magnetic resonance (MR) imaging is increasingly used in female patients for a variety of indications (15–24), but little has been reported about breast MR imaging in male patients (25). Thus, the purpose of our study was to prospectively evaluate whether the descriptors of lesion features and the diagnostic criteria that have been established for breast MR imaging in female patients may be used for differential diagnosis with breast MR imaging in male patients as well. It was not our aim to assess the diagnostic accuracy and clinical usefulness of breast MR imaging in male patients.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
Study Design and Inclusion Criteria
A prospective study was performed in a total of 17 consecutive male patients with palpable breast masses who were referred for imaging at our institution during a study period from 1999 to 2003. The study design was approved by the authors' institutional review board; all patients gave informed consent to be examined after the nature of the procedure had been fully explained to them. The institutional review board and the informed consent information applied to the prospective and any retrospective component of the study.

Patients and Data Validation
The mean age of the 17 study participants was 53 years (range, 19–71 years; standard deviation, 14). Diagnoses were validated with histologic verification in nine of 17 patients for whom, on the basis of clinical examination and conventional imaging findings, malignancy could not be excluded or if the patient wished breast surgery for cosmetic reasons. Seven of 17 patients with unsuspicious conventional imaging findings underwent clinical examination and high-frequency breast US follow-up studies for at least 24 months after breast MR imaging. In one patient who received the diagnosis of gynecomastia on the basis of clinical assessment, mammography, and breast US, the follow-up was less than 24 months (ie, 18 months).

Because of our limited experience with breast MR imaging in men, the need for breast biopsy was not based on breast MR images but exclusively on clinical grounds, conventional imaging findings, and patient's demand.

Conventional Imaging
As part of their regular clinical work-up, all patients underwent two-view (mediolateral oblique and craniocaudal) mammography (Senograph; Siemens Medical Systems, Erlangen, Germany) of the clinically suspicious breast, followed by high-frequency breast US (HDI 5000; Philips Medical Systems, Best, the Netherlands) with 7.5–13-MHz probes performed by a physician.

Breast MR Imaging
Breast MR imaging was performed with a 1.5-T system (ACS II and ACS-NT; Philips Medical Systems). Male patients were positioned prone in a standard bilateral breast coil. The breast MR protocol consisted of a T2-weighted turbo spin-echo sequence (repetition time msec/echo time msec, 3800/120; flip angle, 90°; field of view, 280–320 mm; 31 sections with 3-mm section thickness, without gap; number of signals acquired, two; 512 x 512 matrix), followed by a dynamic series (two-dimensional gradient-echo technique) of five dynamic image stacks (260/4.6; flip angle, 90°; 400 x 512 matrix; 31 sections with 3-mm section thickness; temporal resolution of 115 seconds per acquisition; field of view, 280–320 mm) or seven dynamic image stacks (260/4.6; flip angle, 90°; full 256 x 256 matrix; 31 sections with 3-mm section thickness, without gap; temporal resolution of 60 seconds per acquisition; field of view, 280–320 mm). The first series was obtained just before power injection of 0.1 mmol per kilogram of body weight gadopentetate dimeglumine (Magnevist; Schering, Berlin, Germany) and a 20-mL flush of saline solution (3 mL/sec).

Postprocessing of MR Imaging Data
Image subtraction was performed to suppress the signal from fat. Enhancement rates were quantified with region-of-interest–based analysis (26). Relative enhancement rates (percentage of signal intensity increase) were calculated according to the formula (SIc – SI)/SI x 100, where SI and SIc are the signal intensities before and the first after, respectively, contrast enhancement. By plotting the signal intensity over time, signal intensity–time curves were generated for each enhancing lesion. A qualitative assessment of signal intensity–time courses was performed as described previously (26).

Data Analysis
Findings of MR examinations were prospectively interpreted in consensus by two radiologists (N.M. and C.K.K., with 6 and 14 years, respectively, of experience in breast MR imaging). The radiologists were informed about clinical history and mammographic and US findings. The readers were asked to identify focal or diffuse enhancement to describe their breast MR imaging appearance by using the terminology and descriptors suggested in the Academic College of Radiology Breast Imaging Reporting and Data System (BI-RADS) MR imaging lexicon and to classify them by using the BI-RADS categories (27). One of the authors participated in the development of the BI-RADS lexicon. Therefore, a draft version was available to the authors since the very beginning of this study and was used to describe and categorize the breast MR diagnoses. The data acquisition, the reading of the MR images, and the assessment of the MR imaging findings have been performed prospectively by using the draft version of MR imaging lexicon.

Analysis of lesion morphology was initially performed analogous to the BI-RADS lexicon (27) in that enhancement was being assessed as being a mass or non-masslike enhancement. Non-masslike enhancement was initially further subdivided into linear, segmental, focal, or diffuse. For masses, the shape, margins, and internal mass enhancement were assessed. Dynamic enhancement characteristics were assessed by considering the initial enhancement phase and the delayed enhancement pattern.

The initial descriptors (28,29) that were used before the current BI-RADS lexicon was published differed slightly. However, the concept and the meaning were identical. To adhere to the current BI-RADS terminology, we performed a retrospective one-to-one translation of the initial wording to the descriptors used in the current version of the BI-RADS lexicon (Table 1). A BI-RADS assessment category was assigned to each patient in accordance with the current BI-RADS lexicon.


View this table:
[in this window]
[in a new window]
  		Table 1. One-to-One Translation of Initial Wording to Current Descriptors

 
Statistical Analysis
For statistical analysis, a software package (Excel 2000; Microsoft, Redmond, Wash) was used. The mean values, ranges, and standard deviations of the enhancement rates of benign and malignant breast disease were calculated. Because of the small size of our patient cohort, we did not test for statistical significance. The data have to be considered preliminary until they are validated in a much larger group of patients.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Table 2 shows the breast MR imaging diagnoses for the 17 male patients with 24 breast abnormalities. Three patients had ductal invasive breast cancer with five different cancer lesions. Eleven patients had gynecomastia (six unilateral, five bilateral), two patients had pseudogynecomastia, and one patient had angiolipoma. The sizes of the enhancing breast cancer were 7, 10, 11, 25, and 66 mm (mean, 24 mm; standard deviation, 25 mm). The angiolipoma measured 6 mm.


View this table:
[in this window]
[in a new window]
  		Table 2. Patients' Final Diagnoses

 
Image Analysis
A mass was identified in four of 17 patients (all breast cancers and one benign mass). Non-masslike enhancement was identified in 11 of 17 patients (all cases of gynecomastia), with diffuse enhancement in 10 of 11 patients and segmental enhancement in one of the 11 patients. All breast cancers (n = 5) appeared as masses with irregular shape and margins. Three of the five tumors showed rim enhancement (Fig 1 ), and two of the five tumors had heterogeneous enhancement. None of the breast cancers revealed homogeneous enhancement or internal septations. All breast cancers revealed rapid initial enhancement, with mean enhancement rates (Fig 2) of 137% (range, 106%–159%; standard deviation, 23). All five breast cancers revealed a washout time curve.



View larger version (50K):
[in this window]
[in a new window]
  		Figure 1a: Palpable mass in left breast of 58-year-old man. Mammography and high-frequency US (not shown) showed multifocal breast cancer (BI-RADS category 5); breast MR yielded the same diagnosis. Histologic examination revealed ductal invasive breast cancer. (a) Oblique mammogram shows three lesions (arrows) suspicious for multifocal breast cancer. Transverse (b) pre- and (c) postcontrast T1-weighted gradient-echo dynamic MR images (260/4.6, 90° flip angle) show a mass (arrow in b) and an irregular mass (arrow in c) with rim enhancement. (d) Transverse dynamic subtracted MR image shows irregular mass (arrow) with rim enhancement. (e) Signal intensity–time curve demonstrates washout.

 


View larger version (69K):
[in this window]
[in a new window]
  		Figure 1b: Palpable mass in left breast of 58-year-old man. Mammography and high-frequency US (not shown) showed multifocal breast cancer (BI-RADS category 5); breast MR yielded the same diagnosis. Histologic examination revealed ductal invasive breast cancer. (a) Oblique mammogram shows three lesions (arrows) suspicious for multifocal breast cancer. Transverse (b) pre- and (c) postcontrast T1-weighted gradient-echo dynamic MR images (260/4.6, 90° flip angle) show a mass (arrow in b) and an irregular mass (arrow in c) with rim enhancement. (d) Transverse dynamic subtracted MR image shows irregular mass (arrow) with rim enhancement. (e) Signal intensity–time curve demonstrates washout.

 


View larger version (71K):
[in this window]
[in a new window]
  		Figure 1c: Palpable mass in left breast of 58-year-old man. Mammography and high-frequency US (not shown) showed multifocal breast cancer (BI-RADS category 5); breast MR yielded the same diagnosis. Histologic examination revealed ductal invasive breast cancer. (a) Oblique mammogram shows three lesions (arrows) suspicious for multifocal breast cancer. Transverse (b) pre- and (c) postcontrast T1-weighted gradient-echo dynamic MR images (260/4.6, 90° flip angle) show a mass (arrow in b) and an irregular mass (arrow in c) with rim enhancement. (d) Transverse dynamic subtracted MR image shows irregular mass (arrow) with rim enhancement. (e) Signal intensity–time curve demonstrates washout.

 


View larger version (61K):
[in this window]
[in a new window]
  		Figure 1d: Palpable mass in left breast of 58-year-old man. Mammography and high-frequency US (not shown) showed multifocal breast cancer (BI-RADS category 5); breast MR yielded the same diagnosis. Histologic examination revealed ductal invasive breast cancer. (a) Oblique mammogram shows three lesions (arrows) suspicious for multifocal breast cancer. Transverse (b) pre- and (c) postcontrast T1-weighted gradient-echo dynamic MR images (260/4.6, 90° flip angle) show a mass (arrow in b) and an irregular mass (arrow in c) with rim enhancement. (d) Transverse dynamic subtracted MR image shows irregular mass (arrow) with rim enhancement. (e) Signal intensity–time curve demonstrates washout.

 


View larger version (16K):
[in this window]
[in a new window]
  		Figure 1e: Palpable mass in left breast of 58-year-old man. Mammography and high-frequency US (not shown) showed multifocal breast cancer (BI-RADS category 5); breast MR yielded the same diagnosis. Histologic examination revealed ductal invasive breast cancer. (a) Oblique mammogram shows three lesions (arrows) suspicious for multifocal breast cancer. Transverse (b) pre- and (c) postcontrast T1-weighted gradient-echo dynamic MR images (260/4.6, 90° flip angle) show a mass (arrow in b) and an irregular mass (arrow in c) with rim enhancement. (d) Transverse dynamic subtracted MR image shows irregular mass (arrow) with rim enhancement. (e) Signal intensity–time curve demonstrates washout.

 


View larger version (27K):
[in this window]
[in a new window]
  		Figure 2: Bar graph shows mean enhancement rates of benign (n = 19) and malignant (n = 5) breast disease in 17 patients.

 
The mean enhancement of all benign breast conditions was 21% (range, 8%–85%; standard deviation, 20). In gynecomastia, there was low-signal-intensity fibroglandular tissue with an internal architecture similar to what we would call "normal fibroglandular tissue" on MR images of the female breast. There was a homogeneous, non-masslike, slow, and persistent enhancement of the fibroglandular tissue in 15 of 16 breasts of the 10 of 11 patients.

In one patient with biopsy-proved bilateral gynecomastia, there was a non-masslike segmental enhancement of the lateral part of the fibroglandular tissue of the right breast. Enhancement in this area was somewhat more rapid than that of the remaining normal-appearing fibroglandular tissue (enhancement of this area was 49%, compared with 10% in the remaining fibroglandular tissue). In this patient, findings of mammography were correctly assessed as negative, and biopsy was initiated on the basis of suspicious clinical findings (palpable lump in the lateral part of the breast).

In another patient, unilateral nodular gynecomastia (Fig 3) appeared as retroareolar fibroglandular breast tissue with very slow enhancement (enhancement rate, 27%). In this patient, clinical and breast US findings were suspicious. Therefore, the patient underwent breast surgery, which revealed gynecomastia.



View larger version (37K):
[in this window]
[in a new window]
  		Figure 3a: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (137K):
[in this window]
[in a new window]
  		Figure 3b: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (97K):
[in this window]
[in a new window]
  		Figure 3c: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (100K):
[in this window]
[in a new window]
  		Figure 3d: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (81K):
[in this window]
[in a new window]
  		Figure 3e: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (10K):
[in this window]
[in a new window]
  		Figure 3f: A palpable mass in right breast in a 45-year-old man. The patient underwent surgery, and histologic examination revealed gynecomastia. (a) Oblique mammogram shows a mass (arrow) behind the nipple classified as focal nodular gynecomastia (BI-RADS category 2). (b) Vertical (top) and transverse (bottom) high-frequency breast US scans show an irregular hypoechoic breast lesion (arrow) rated as BI-RADS category 4. (c) Transverse precontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) of the dynamic series shows a mass (arrow) behind the nipple. (d) Transverse postcontrast T1-weighted gradient-echo MR image (260/4.6, 90° flip angle) from dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (e) Transverse subtracted image of the dynamic series shows persistent enhancement of the retroareolar breast parenchyma (arrow) rated as BI-RADS category 2. (f) Signal intensity–time curve demonstrates persistent enhancement.

 
Two patients had pseudogynecomastia. We found fatty tissue without fibroglandular structures, and no contrast enhancement. The angiolipoma (Fig 4) appeared as a mass with oval shape, smooth margins, and homogeneous contrast enhancement. The enhancement was slow and persistent (17%).



View larger version (70K):
[in this window]
[in a new window]
  		Figure 4a: Palpable mass in right breast in a 42-year-old man. Mammography (not shown) revealed gynecomastia. High-frequency breast US (not shown) revealed a breast lesion with oval shape and smooth borders. On the basis of conventional imaging, the lesion was rated as BI-RADS category 2. Histologic examination revealed angiolipoma. Transverse (a) precontrast and (b) postcontrast T1-weighted gradient-echo MR images (260/4.6, 90° flip angle) of the dynamic series show a mass (arrow in a) and a mass with contrast enhancement (arrow in b). (c) Transverse subtracted image from dynamic series shows a mass with contrast enhancement (arrow). (d) Transverse postcontrast T1-weighted MR image with frequency-selective fat suppression method (600/4.6, 90° flip angle) shows a contrast-enhancing mass (arrow) with smooth margins rated as BI-RADS category 2. (e) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (73K):
[in this window]
[in a new window]
  		Figure 4b: Palpable mass in right breast in a 42-year-old man. Mammography (not shown) revealed gynecomastia. High-frequency breast US (not shown) revealed a breast lesion with oval shape and smooth borders. On the basis of conventional imaging, the lesion was rated as BI-RADS category 2. Histologic examination revealed angiolipoma. Transverse (a) precontrast and (b) postcontrast T1-weighted gradient-echo MR images (260/4.6, 90° flip angle) of the dynamic series show a mass (arrow in a) and a mass with contrast enhancement (arrow in b). (c) Transverse subtracted image from dynamic series shows a mass with contrast enhancement (arrow). (d) Transverse postcontrast T1-weighted MR image with frequency-selective fat suppression method (600/4.6, 90° flip angle) shows a contrast-enhancing mass (arrow) with smooth margins rated as BI-RADS category 2. (e) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (69K):
[in this window]
[in a new window]
  		Figure 4c: Palpable mass in right breast in a 42-year-old man. Mammography (not shown) revealed gynecomastia. High-frequency breast US (not shown) revealed a breast lesion with oval shape and smooth borders. On the basis of conventional imaging, the lesion was rated as BI-RADS category 2. Histologic examination revealed angiolipoma. Transverse (a) precontrast and (b) postcontrast T1-weighted gradient-echo MR images (260/4.6, 90° flip angle) of the dynamic series show a mass (arrow in a) and a mass with contrast enhancement (arrow in b). (c) Transverse subtracted image from dynamic series shows a mass with contrast enhancement (arrow). (d) Transverse postcontrast T1-weighted MR image with frequency-selective fat suppression method (600/4.6, 90° flip angle) shows a contrast-enhancing mass (arrow) with smooth margins rated as BI-RADS category 2. (e) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (44K):
[in this window]
[in a new window]
  		Figure 4d: Palpable mass in right breast in a 42-year-old man. Mammography (not shown) revealed gynecomastia. High-frequency breast US (not shown) revealed a breast lesion with oval shape and smooth borders. On the basis of conventional imaging, the lesion was rated as BI-RADS category 2. Histologic examination revealed angiolipoma. Transverse (a) precontrast and (b) postcontrast T1-weighted gradient-echo MR images (260/4.6, 90° flip angle) of the dynamic series show a mass (arrow in a) and a mass with contrast enhancement (arrow in b). (c) Transverse subtracted image from dynamic series shows a mass with contrast enhancement (arrow). (d) Transverse postcontrast T1-weighted MR image with frequency-selective fat suppression method (600/4.6, 90° flip angle) shows a contrast-enhancing mass (arrow) with smooth margins rated as BI-RADS category 2. (e) Signal intensity–time curve demonstrates persistent enhancement.

 


View larger version (10K):
[in this window]
[in a new window]
  		Figure 4e: Palpable mass in right breast in a 42-year-old man. Mammography (not shown) revealed gynecomastia. High-frequency breast US (not shown) revealed a breast lesion with oval shape and smooth borders. On the basis of conventional imaging, the lesion was rated as BI-RADS category 2. Histologic examination revealed angiolipoma. Transverse (a) precontrast and (b) postcontrast T1-weighted gradient-echo MR images (260/4.6, 90° flip angle) of the dynamic series show a mass (arrow in a) and a mass with contrast enhancement (arrow in b). (c) Transverse subtracted image from dynamic series shows a mass with contrast enhancement (arrow). (d) Transverse postcontrast T1-weighted MR image with frequency-selective fat suppression method (600/4.6, 90° flip angle) shows a contrast-enhancing mass (arrow) with smooth margins rated as BI-RADS category 2. (e) Signal intensity–time curve demonstrates persistent enhancement.

 
BI-RADS Classification of Diagnoses
BI-RADS category 5 was assigned to all invasive breast cancers (n = 5) because they exhibited features that are typical for breast cancer in female patients and appeared as masses with suspicious morphology and suspicious enhancement kinetics. BI-RADS category 2 was assigned to the angiolipoma because it had benign morphologic and kinetic features. BI-RADS category 2 was assigned to gynecomastia in 15 of 16 breasts (10 of 11 patients) because it showed normal-enhancing breast parenchyma.

In the one patient with segmental enhancement in the right breast, the finding was rated as suspicious because segmental enhancement at MR imaging in the female breast can be indicative of ductal carcinoma in situ. Accordingly, BI-RADS category 4 was assigned. Biopsy, which had been indicated on clinical grounds (suspicious palpable lump), revealed gynecomastia.

In one patient, a palpable lump had newly developed in the right breast. Mammography revealed a mass classified as focal nodular gynecomastia (BI-RADS category 2); breast US (13-MHz probe) revealed a hypoechoic mass with irregular borders. The finding was read as equivocal, and biopsy was recommended (BI-RADS category 4). Retroareolar fibroglandular breast tissue was seen on MR images. After contrast material administration, there was slow initial and persistent enhancement. BI-RADS category 2 was assigned. Biopsy was performed and revealed gynecomastia. In the two patients with pseudogynecomastia, the breast was entirely fatty and did not enhance at all, resulting in BI-RADS category 1.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
Breast cancer in men is such a rare disease that the development of diagnostic and therapeutic guidelines is difficult. In the past, surgical intervention in men with a palpable breast mass was performed without breast imaging (8); this recommendation acknowledged that the diagnostic accuracy of mammography in the evaluation of male breast masses was undefined. Often surgery is also performed for cosmetic reasons on a patient's demand.

Meanwhile, a considerable amount of data has been published about mammography in male breast disease, which suggests that mammography can accurately help distinguish between malignant and benign male breast diseases (1–6,9–13), such that the routine use of mammography could substantially reduce the need for biopsy (7–11). A high positive predictive value, sensitivity, and specificity have been reported for x-ray mammography and breast US in the diagnosis of breast cancer in male patients (10). Currently, the general recommendation for the work-up of palpable masses in male patients is to perform x-ray mammography (to distinguish gynecomastia and pseudogynecomastia and to identify suspicious lesions), followed by high-frequency breast US in patients with focal breast lumps (30). In cases of inconclusive and suspicious findings, breast biopsy should be initiated. Inconclusive findings can occur particularly in patients with unilateral gynecomastia and particularly in gynecomastia of the nodular type.

Up to now, to our knowledge there have been no reports about the appearance of male breast disease at contrast-enhanced MR imaging. There is one report on MR imaging of gynecomastia in patients with human immunodeficiency virus infection (25); the study did not, however, use contrast enhancement because a diagnosis or differential diagnosis of breast disease was not the objective.

Our preliminary results in this small series of male patients indicate that the breast MR imaging appearance of benign and malignant breast disease in male patients is comparable to the findings in female breast MR imaging. Of 17 patients, two had pseudogynecomastia, which is as easily diagnosed with breast MR imaging as it is with mammography. We found fatty tissue without fibroglandular structures and no contrast enhancement. Accordingly, BI-RADS category 1 was assigned. Of course, these patients are least likely to ever benefit from breast MR imaging.

As expected, true gynecomastia was the most frequent condition in our group; it was present in 11 of 17 patients. At dynamic breast MR imaging, the fibroglandular tissue appeared similar to that of normal female breast parenchyma: We found a normal-appearing internal architecture of the fibroglandular tissue, which showed slow and persistent enhancement. Consequently, BI-RADS category 2 was correctly assigned in 15 of 16 breasts.

Our data show that, as in female patients, breast MR imaging may result in false-positive diagnosis in male patients as well. In one patient with bilateral gynecomastia, segmental enhancement was present in the lateral part of the breast, a finding that in women would be considered suspicious for ductal carcinoma in situ and would lead to biopsy. This patient eventually underwent excisional biopsy of the lateral part of the breast because of a clinically suspicious palpable lump. Biopsy revealed gynecomastia without atypias. In another patient with nodular gynecomastia, clinical and breast US findings were suspicious for invasive cancer. At mammography, the lesion was correctly classified as benign (BI-RADS category 2). In breast MR imaging, there was only normal fibroglandular breast tissue with slow and persistent enhancement after contrast agent administration, resulting in BI-RADS category 2. This patient underwent biopsy on the basis of clinical and US findings, which confirmed mammographic and breast MR imaging diagnoses.

Invasive breast cancer was identified in three of 17 patients, with multifocal cancer in one patient (three individual lesions). All five breast tumors had an irregular shape and irregular margins and showed rapid contrast enhancement and washout. All cancers showed rim enhancement or at least a heterogeneous internal architecture. Accordingly, both in terms of lesion morphology and contrast-enhancement kinetics, the breast carcinomas in our male patients did not differ from the appearance of typical breast cancer in female patients. Consequently BI-RADS category 5 was assigned to all breast cancers.

Our only benign breast mass was an angiolipoma. It had imaging features that corresponded exactly to those of typical benign breast tumors in female breast MR imaging: It showed only slow and persistent enhancement, an oval shape, and smooth margins. Accordingly, BI-RADS category 2 was assigned.

In summary, by using the breast MR imaging criteria established in female patients in this subset of male patients, the MR assessment categories would be rated as true-positive in five of five breast conditions (three patients) and true-negative in 18 of 19 breast conditions (14 patients). It is important to note that the routine work-up of palpable lumps in men should consist of mammography, US in case of questions about mammographic findings, and biopsy if any suspicion persists. We are aware that breast MR imaging may have no effect on the clinical management of most male breast diseases—and we are far from advocating routine use of breast MR imaging in male patients.

Our study had the following limitations. First, in one patient who received the diagnosis of gynecomastia on the basis of the clinical picture and mammographic, US, and breast MR imaging findings, validation is limited in that we have uneventful follow-up for only 18 months. Although there was no suspicion of breast cancer on the basis of either of the diagnostic tests performed, we cannot definitively rule out a false-negative diagnosis. A more important limitation was the small size of our patient cohort. It is impossible to draw general conclusions from our data, and the findings have to be considered preliminary until they are validated in a much larger group of patients. Furthermore, we have to indicate that the frequency of cancer versus gynecomastia observed in this study was caused by substantial selection bias, because referring physicians had selected those male patients for breast imaging whose breast lumps were most likely to be malignant. However, since it was not our purpose to compare diagnostic accuracies, selection bias should not impair the validity of our conclusions.

We have to indicate retrospective bias in that we had to translate our BI-RADS MR imaging terminology into definite BI-RADS MR imaging terminology, while data acquisition, reading of MR images, and assessment of MR imaging findings have been performed prospectively with the draft version of the current BI-RADS MR imaging lexicon. However, this was a mere exchange of wording; the concept and meaning were identical.

In conclusion, our preliminary results suggest that the diagnostic criteria (regarding enhancement kinetics and morphology) that have been established for breast MR imaging in female patients may be transferable to breast MR imaging of male patients.


   FOOTNOTES
 

Abbreviations: BI-RADS = Breast Imaging Reporting and Data System

Authors stated no financial relationship to disclose.

Author contributions: Guarantors of integrity of entire study, N.M., C.K.K.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, N.M.; clinical studies, N.M., C.C.L., M.v.F., G.L., C.K.K.; statistical analysis, N.M., M.v.F., G.L.; and manuscript editing, N.M.


   References
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Hill A, Yagmur Y, Tran KN, Bolton JS, Robson M, Borgen PI. Localized male breast carcinoma and family history: an analysis of 142 patients. Cancer 1999;86:821–825.[CrossRef][Medline]
  2. Tukel S, Ozcan H. Mammography in men with breast cancer: review of the mammographic findings in five cases. Australas Radiol 1996;40:387–390.[Medline]
  3. Dershaw DD. Male mammography. AJR Am J Roentgenol 1986;146:127–131.[Abstract/Free Full Text]
  4. Cappabianca S, Grassi R, D'Alessandro P, Del Vecchio A, Maioli A, Donofrio V. Metastases to the male breast from carcinoma of the urinary bladder. Br J Radiol 2000;73:1326–1328.[Abstract]
  5. Yang WT, Whitman GJ, Yuen EH, Tse GMK, Stelling CB. Sonographic features of primary breast cancer in men. AJR Am J Roentgenol 2001;176:413–416.[Abstract/Free Full Text]
  6. Gunhan-Bilgen I, Bozkaya H, Ustun EE, Memis A. Male breast disease: clinical, mammographic and ultrasonographic features. Eur J Radiol 2002;43:246–255.[CrossRef][Medline]
  7. Munn S. When should men undergo mammography? AJR Am J Roentgenol 2002;178:1419–1420.[Free Full Text]
  8. Volpe CM, Raffetto JD, Collure DW, Hoover EL, Doerr RJ. Unilateral male breast masses: cancer risk and their evaluation and management. Am Surg 1999;65:250–253.[Medline]
  9. Evans GF, Anthony T, Turnage RH, et al. The diagnostic accuracy of mammography in the evaluation of male breast diseases. Am J Surg 2001;181:96–100.[CrossRef][Medline]
  10. Partik B, Mallek R, Rudas M, Pokieser P, Wunderbaldinger P, Helbich TH. Malignant and benign diseases of the breast in 41 male patients: mammography, sonography and pathohistologic correlations [in German]. Rofo 2001;173:1012–1018.[Medline]
  11. Merkle E, Muller M, Vogel J, et al. Clinical relevance of mammography in men [in German]. Rofo 1996;164:7–12.[Medline]
  12. Bock K, Iwinska-Zelder J, Duda VF, et al. Validity of the breast imaging reporting and data system BI-RADS(TM) for clinical mammography in men [in German]. Rofo 2001;173:1019–1024.[Medline]
  13. Appelbaum AH, Evans GF, Levy KR, Amirkhan RH, Schumpert TD. Mammographic appearance of male breast disease. RadioGraphics 1999;19:559–568.[Abstract/Free Full Text]
  14. Ciatto S, Iossa A, Bonardi R, Pacini P. Male breast carcinoma: review of a multicenter series of 150 cases. Coordinating Center and Writing Committee of FONCAM, Italy. Tumori 1990;76:555–558.
  15. Bedrosian I, Mick R, Orel SG, et al. Changes in the surgical management of patients with breast carcinoma based on preoperative magnetic resonance imaging. Cancer 2003;98:468–473.[CrossRef][Medline]
  16. Harms SE. Breast Cancer Staging Working Group report. J Magn Reson Imaging 1999;10:991–994.[CrossRef][Medline]
  17. Munot K, Dall B, Achuthan R, Parkin G, Lane S, Horgan K. Role of magnetic resonance imaging in the diagnosis and single-stage surgical resection of invasive lobular carcinoma of the breast Br J Surg 2002;89:1296–1301.[CrossRef][Medline]
  18. Liberman L, Morris EA, Kim CM, et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR Am J Roentgenol 2003;180:333–341.[Abstract/Free Full Text]
  19. Liberman L, Morris EA, Dershaw DD, Abramson AF, Tan LK. MR imaging of the ipsilateral breast in women with percutaneously proven breast cancer. AJR Am J Roentgenol 2003;180:901–910.[Abstract/Free Full Text]
  20. Lee SG, Orel SG, Woo IJ, et al. MR imaging screening of the contralateral breast in patients with newly diagnosed breast cancer: preliminary results. Radiology 2003;226:773–778.[Abstract/Free Full Text]
  21. Morakkabati N, Leutner CC, Schmiedel A, Schild HH, Kuhl CK. Breast MR imaging during or soon after radiation therapy. Radiology 2003;229:893–901.[Abstract/Free Full Text]
  22. Morris EA, Liberman L, Ballon DJ, et al. MRI of occult breast carcinoma in a high-risk population. AJR Am J Roentgenol 2003;181:619–626.[Abstract/Free Full Text]
  23. Munot K, Dall B, Achuthan R, Parkin G, Lane S, Horgan K. Role of magnetic resonance imaging in the diagnosis and single-stage surgical resection of invasive lobular carcinoma of the breast. Br J Surg 2002;89:1296–1301.[CrossRef][Medline]
  24. Kuhl CK, Schmutzler RK, Leutner CC, et al. Breast MR imaging screening in 192 women proved or suspected to be carriers of a breast cancer susceptibility gene: preliminary results. Radiology 2000;215:267–279.[Abstract/Free Full Text]
  25. Schinina V, Busi Rizzi E, Zaccarelli M, Carvelli C, Bibbolino C. Gynecomastia in male HIV patients: MR and US findings. Clin Imaging 2002;26:309–313.[CrossRef][Medline]
  26. Kuhl CK, Mielcarek P, Klaschik S, et al. Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions? Radiology 1999;211:101–110.
  27. Ikeda DM, Hylton NM, Kinkel K, et al. Development, standardization, and testing of a lexicon for reporting contrast-enhanced breast magnetic resonance imaging studies. J Magn Reson Imaging 2001;13:889–895.[CrossRef][Medline]
  28. Kuhl CK, Schild HH. Dynamic interpretation of MRI of the breast. J Magn Reson Imaging 2000;12:965–974.[CrossRef][Medline]
  29. Kuhl CK. MRI of breast tumors. Eur Radiol 2000;10:46–58.[CrossRef][Medline]
  30. Cardenosa G. Breast imaging companion. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2001; 401–412.




This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow All Versions of this Article:
2382041312v1
238/2/438    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Morakkabati-Spitz, N.
Right arrow Articles by Kuhl, C. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Morakkabati-Spitz, N.
Right arrow Articles by Kuhl, C. K.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE