A 63-year-old man comes to the office for evaluation of a left breast mass. The patient noticed a small lump in the left breast a few months ago after he was struck in the chest. He expected the lump to disappear, but it has since enlarged and becomes irritated by the heavy protective vest he wears while working as a corrections officer. Medical history is significant for obesity, hypertension, and obstructive sleep apnea. Physical examination shows an obese habitus with increased fatty breast tissue bilaterally. There is a 2-cm firm, fixed, nontender subareolar mass in the left breast with nipple inversion. The right breast has no discrete masses. There is no axillary or supraclavicular lymphadenopathy. The rest of the physical examination is unremarkable. Which of the following is the best next step in management of this patient?
This older man has an enlarging left breast mass that is firm, fixed, and causing nipple inversion (ie, infiltration into the lactiferous ducts behind the nipple). This presentation is suspicious for breast cancer and should prompt imaging (eg, mammography) followed by tissue sampling (eg, core biopsy), a workup that directly mirrors that of a palpable breast mass in a woman.
Breast cancer is less common in men than in women but shares many of the same risk factors, including increasing age and excessive estrogen stimulation (eg, increased adipose tissue aromatization of androgens to estrogens in obesity). As in this patient, most affected men have a unilateral, firm, nontender subareolar mass, often with nipple involvement. The mass may initially go undetected or it may be noted incidentally after unrelated trauma, as likely happened in this patient who noticed the lump after being struck in the chest. Although fat necrosis (which can develop after trauma) can occasionally have a similar clinical presentation, malignancy must always be ruled out first (eg, imaging, biopsy).
Mammography is first line for imaging, with adaptations (eg, smaller tissue compression paddles) as necessary. Breast ultrasound may also be helpful to further characterize mammographic abnormalities and aid biopsy. If suspicious features (eg, microcalcifications, spiculated margins) are seen on imaging, a core biopsy is performed.
(Choices A and E) Gynecomastia, the benign proliferation of male breast glandular tissue, is caused by an increased ratio of estrogen to androgen activity, as may occur in hypogonadism (assessed via early-morning testosterone level) and some testicular germ cell tumors (assessed via testicular ultrasound). Gynecomastia can present as a firm, subareolar mass; however, it is more typically bilateral (vs unilateral), mobile (vs fixed), and tender (vs nontender) during its growth phase.
(Choice B) Direct excision, without preceding imaging or biopsy, may be considered for a mass that is clearly benign on physical examination (eg, a well-circumscribed, nonfixed, soft lipoma). In contrast, this patient's mass has concerning features (eg, firm, fixed, nipple changes) that warrant diagnosis before excision; if breast cancer is present, a more extensive surgery (eg, mastectomy) will be necessary to reduce the risk of recurrence.
(Choice D) Hyperprolactinemia (assessed via serum prolactin level) in men can rarely cause gynecomastia and galactorrhea, but a unilateral, firm, fixed breast mass is more consistent with cancer.
Educational objective:
The workup of a suspicious breast mass (eg, unilateral, firm, fixed, causing nipple retraction) is the same in men as in women: imaging (eg, mammography, ultrasound) is performed first, followed by tissue sampling (eg, core biopsy).