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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 11-16

Radio-pathological findings of male breast lesions in the sub-Saharan African population


1 Department of Radiology, College of Health Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
2 Department of Surgery, College of Health Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
3 Department of Pathology, College of Health Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria

Date of Submission09-Nov-2019
Date of Acceptance27-Feb-2020
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Halimat Jumai Akande
Department of Radiology, College of Health Sciences, University of Ilorin Teaching Hospital, Ilorin, Kwara State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_35_19

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  Abstract 


Context: Globally, information about male breast lesions is scarce. Focus is often on clinical presentation with less emphasis on radiological characteristics. Aim: To document and highlight the imaging and pathology findings of male breast diseases in a Sub-Saharan Africa. Materials and Methods: Male patients who had breast ultrasound and/or mammography in a tertiary hospital over a 10year period were reviewed retrospectively. Biodata of the patients, symptoms, and imaging findings with pathology reports were documented and analyzed. Breast ImagingReporting and Data Systems lexicon was used. Results: Fiftyfive male patients were seen and constituted about 1.82% of the total number of breast cases. Their age range was 12–85 years, with a mean of 35.89 ± 18.45 years. Four of these patients had mammograms only, 49 had breast ultrasound scan alone, whereas 2 had a combination of both modalities. The most common clinical indication and radiological findings were breast swelling (60%) and gynecomastia (72.7%), respectively. Gynecomastia was the most common finding pathologically (67.6%), whereas malignancy constituted 14.7%. The lesions were observed more in the right breast (40.7%). Conclusions: Imaging plays a significant role in the evaluation of male breast diseases. Ultrasound has high accuracy in the detection of benign lesions. This study found gynecomastia as the most common benign male breast disease. Breast cancer, although rare cancer among males was observed in a 35yearold young male.

Keywords: Breast diseases, findings, imaging, male


How to cite this article:
Akande HJ, Olafimihan BB, Agodirin OS, Mumini RW, Abdulmajeed AA. Radio-pathological findings of male breast lesions in the sub-Saharan African population. Niger J Basic Clin Sci 2020;17:11-6

How to cite this URL:
Akande HJ, Olafimihan BB, Agodirin OS, Mumini RW, Abdulmajeed AA. Radio-pathological findings of male breast lesions in the sub-Saharan African population. Niger J Basic Clin Sci [serial online] 2020 [cited 2020 Jul 7];17:11-6. Available from: http://www.njbcs.net/text.asp?2020/17/1/11/285469




  Introduction Top


The basic and totipotential mammary glands of males and females are identical at birth and are composed of mammary lobes that drain through lactiferous ducts into the nipple; however, this similarity begins to change at puberty.[1] This is as a result of estrogen and testosterone secretion in girls and boys, respectively.[2] Transient elevation of serum estradiol at the onset of puberty in boys may cause pubertal gynecomastia which usually resolve spontaneously.[3]

Male breast lesions are generally uncommon, and the majority are benign [4],[5] with male breast cancer accounting for 0.7%–1% of breast cancers globally, 2%–9% in some parts of Africa,[6],[7] and 1.9%–6.1% in Nigerian literature.[4],[8],[9] Abnormality of the male breast could therefore be worrisome and warrant consultation, albeit late, because of the psychological feeling of having a so-called “female disease” in this clime. The diagnosis could be challenging to clinicians and radiologists because of the small volume of breast tissues.[10] The Breast Imaging-Reporting and Data System (BI-RADS) lexicon [11] for the management of female breast lesions is well established, but the same is yet to be established for the males using accurate, cost-effective, and noninvasive modalities which may sometimes be unreliable in the imaging of male breast lesions.[10],[12],[13]

The symptoms of the disease of the breast in males include breast swelling, lump, pain, and nipple discharge. Gynecomastia and breast carcinoma are the most common benign and malignant diseases, respectively. Other benign pathologies include epidermal cysts, lipomas, intraductal papillomas, pseudoangiomatous stromal hyperplasia, granular cell tumors, hemangiomas, schwannomas, myofibroblastomas, and fibromatosis.[2],[14] These entities are relatively unfamiliar territory [13] and demand more attention, especially in sub-Saharan Africa, where reports show a higher incidence of male breast cancer.[4],[9] In this study, we document and highlight the imaging and pathology findings of male breast diseases in a Sub-Saharan African to become a sub-saharan African population, thus adding to the database from which an algorithm for male breast disease could be generated to improve decision-making and management.


  Materials and Methods Top


We reviewed the clinical, radiological, and pathological records of male patients who had breast ultrasound scan and mammography at the breast imaging suite of our facility between January 2009 and August 2018. The clinical information was retrieved from the medical records, radiology data from the radiology department paper records and digital archives, and pathology data from the pathology department.

Due ethical considerations were adhered to, but consent was not required as the secondary data analysis was performed. However, all information obtained about the patients was kept confidential.

Referrals to the radiology department were from the surgery and outpatient departments, private hospitals, and hospitals in neighboring states. GE Senographe DMR mammography machine (GE Healthcare USA, 2006 model) was used to acquire the mammograms and breast ultrasonography performed with a Sonoscape S30 (Sonoscape Medical Corp., China, 2015 model).

Two standard mammographic views, craniocaudal and mediolateral oblique were obtained, with additional views like the spot compression or magnification done when necessary. The images were reported by the radiologist using the standard BI-RADS lexicon. The sonomammograms were performed using a linear transducer with a frequency of 7.5–10 MHz in longitudinal, transverse, radial, and antiradial planes. These were reported as normal if no lesion was demonstrated or abnormal where lesions were seen and characterized accordingly using the BI-RADS ultrasound lexicon and a final BI-RADS impression allotted. Mammogram reporting and breast ultrasound scans were done by two radiologists each, with more than 10 years' experience in breast imaging. Abdominopelvic and scrotal ultrasound scans were also carried out in some patients with suspected liver and testicular pathologies. Fine-needle aspirations cytology (FNAC) were done by the pathologist under ultrasound guidance, whereas tissue biopsies for histology (incisional or excisional) were taken by the general surgeons and sent to the pathologists for the analysis.

Data were extracted using specially designed pro forma. Demographic results were presented using descriptive statistics, simple tables/charts, and confidence limits. Multivariate analysis was performed by unadjusted logistic regression. The data were analyzed using the Statistical Package for the Social Sciences Chicago, Illinois State (SPSS) software version 20 (IBM Corporation, SPSS Statistics Inc., USA, 2012).


  Results Top


Male breast lesions accounted for 55 out of 2807 (2%) breast lesions seen during the period under review. Their age range was 12–85 years, with a mean of 35.89 ± 18.45 years. Majority of the patients (50.1%) were in the third and fourth decades of life; age in years is as shown in [Figure 1].
Figure 1: Histogram showing age group distribution

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A total of 22 (40%) patients had symptoms on the right breast, 19 (34.5%) were on the left, and 13 (23.6%) were bilateral. The most frequent clinical indication for imaging was breast swelling in 33 (60%), as shown in [Figure 2]. Associated pathologies were seen that comprised 1 (1.8%) Klinefelter syndrome, 4 (7.2%) chronic liver disease cases, a case of prolonged use of medication for peptic ulcer disease, and a patient with prostate cancer on castrate treatment.
Figure 2: Pie chart showing the clinical presentation

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A total of 49 (89%) patients had breast ultrasound scan alone, 4 (7.3%) had mammograms only, and 2 (3.6%) had both ultrasound and mammography.

The diagnoses on ultrasound and mammography are shown in [Table 1]. These were based on the imaging features of the lesions such as the echopattern (anechoic, hypoechoic, hyperechoic, and heterogeneous), shape, margin, and calcifications, which are pointers to likely benignity or malignancy. Gynecomastia was the most common imaging finding; a total of 40 (72.7%) patients had this diagnosis; of which 18 (45%) had associated enlarged axillary lymph nodes.
Table 1: Imaging diagnosis

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Pathological evaluation was available for 34 (61.7%) patients out of the 55 patients [Table 2]. Out of the 34 patient samples subject to histological assessment, 23 (67.7%) were confirmed with gynecomastia, 5 (14.7%) with invasive ductal carcinoma, and other benign entities constituted 6 (17.6%), respectively. These were from 29 of those that had ultrasound scan only, 3 from mammography only, and the two that had both investigations.
Table 2: Pathologic diagnosis

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Correlating ultrasound diagnosis with pathology, 21 records of benign diagnoses were confirmed benign on pathology (100%), but of the 10 suspicious diagnoses, only 4 (40%) were confirmed malignant, and the remaining 6 (60%) were confirmed benign. Of the five patients that had mammogram done, correlation with pathology showed that the three patients with benign mammographic diagnosis were confirmed benign on histology, whereas the two patients with suspicious mammographic findings were confirmed to be malignant (100%).

Using unadjusted logistic regression, the probability of a lesion being malignant when ultrasonography revealed an irregular shape was 80%. Logistic regression did not show a significant association between other ultrasound features (echopattern, calcification, shape, and margin) and the probability of malignancy [Table 3] and [Table 4].
Table 3: Imaging features with malignancy outcome

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Table 4: Cross-tabulation of age groups with pathology

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  Discussion Top


Imaging of the male breast is not routinely done due to the rarity of male breast cancer which is low compared to female breast cancer. In addition, breast cancer in males is also less common than gynecomastia and other benign pathologies.[8],[9],[15],[16] Nonetheless, male breast diseases are worrisome. Male breast cancer constitutes about 1% of all breast cancers.[14],[17] In this study, benign lesions were seen in about 85% of the patients. Gynecomastia still remains the most common benign male breast lesion as documented in several studies.[14],[18],[19] Other benign lesions were documented such as chronic suppurative mastitis, atypical ductal hyperplasia (ADH), intraductal papilloma, sebaceous cyst, and fibroadenoma. Although there are few studies that documented laterality of male breast lesions, our study found a preponderance of unilateral affectation on the right side. This is unlike the study by Mustapha et al. which recorded preponderance of bilateral involvement with the left breast dominating in their study.[20] However, in terms of pathologically confirmed cancer cases, cancer was more common in the left breast than the right which is similar to some previous studies locally.[8],[21]

Ultrasonography being a readily available and safe-imaging modality was used more in this study. This is bearing in mind the adolescent age group and the need to use a relatively safe imaging modality on them. The most common sonographic findings were focal, oval, and circumscribed hypoechoic lesions. Most of these were diagnosed and confirmed to be gynecomastia, documented by several studies as the most common benign male breast lesion.[14],[18],[19] Gynecomastia, whose the incidence has been reported to be higher in blacks compared to the Caucasians, is a reversible cause of enlargement of the male breast which in its early stage is characterized by the benign proliferation of intraductal epithelium, periductal inflammation, and surrounding edema that typically presents as a painful breast swelling [Figure 3], [Figure 4], [Figure 5], [Figure 6].[9],[22],[23] Most of the sonographic findings in this study conformed to the early-stage gynecomastia. The late stage is characterized by dilated ducts surrounding stromal fibrosis which sonographically often show as irregular, ill-defined hypoechoic lesion which could mimic malignancy, and may explain the high rate of false-positive ultrasound findings recorded in this study. However, the irregular shape had a high prediction for malignancy as documented in previous studies.[2],[24],[25] Enlarged axillary nodes were found in about 45% of patients with the ultrasound diagnosis of gynecomastia. Physiologically, gynecomastia is seen in neonates, adolescents, and the elderly. Most confirmed gynecomastia cases were in their second and third decades which fit in the adolescent type. The incidence decreased thereafter, although the elderly type was also seen, but no neonatal case was reported in this study.
Figure 3: Gynecomastia (diffuse). Craniocaudal view of both breasts showing extensive retroareolar density on the right

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Figure 4: Gynecomastia (nodular). Mediolateral oblique mammogram of both breasts showing fan-shaped retroareolar opacity with right axillary lymph node

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Figure 5: Gynecomastia. Transverse sonogram of both breasts showing bilateral gynaecomastia, more on the left

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Figure 6: Gynecomastia. Photomicrograph of a core biopsy specimen showing increased dense collagenous connective tissue and marked micropapillary epithelial hyperplasia of the lining ducts. The lining epithelial cells are columnar to cuboidal with multilayered epithelium in areas and small papillary tuft. There is surrounding periductal hyalinization and fibrosis

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Pathophysiologically, different mechanisms have been postulated which ultimately lead to hormonal imbalance of estrogen and testosterone on the breast tissue.[3],[26],[27] Some of the causes of this hormonal imbalance include ingestion of medications such as antiandrogens, protease inhibitors, drugs for peptic ulcer disease, antipsychotics, and spironolactone among others. Other causes include diseases such as chronic liver disease, endocrine disease, neoplasm, and primary hypogonadism/failure as seen in Klinefelter syndrome, castration.[26],[27],[28] Elicited causes included four cases of chronic liver disease, a case of prolonged ingestion of drugs for peptic ulcer, treatment for prostate cancer and Klinefelter syndrome in a 20 year old. As reported in many studies, pubertal gynecomastia is quite common, and most times, reassurance is all that is needed in the management of these young patients as it usually resolves over time. For the pathological cases, withdrawal of the causative medication or treatment of the primary cause may reverse the condition. Otherwise, medical or surgical options may have to be explored like the use of radioactive iodine or reduction mammoplasty.[29],[30]

Carcinoma of the male breast constituted about 14.7% of the pathologically proven breast diseases in this study, with a mean age of 59.6 years. The incidence of male breast cancer has been increasing worldwide, with a reported increase from 0.85 to 1.3 per 100,000 men in the United States in 2000 to about 2%–9% in some African countries.[6],[7],[15] In Africa, the high incidence of cirrhosis of the liver and hepatocellular carcinoma has been postulated for the higher incidence of gynecomastia and male breast cancer. However, reverse is the case of female breast cancer in blacks as it is lower compared to Caucasians; however, a previous study done on females in the same setting showed a high incidence of female breast cancer.[21],[31] Four out of the five cases of male breast cancer were seen in the sixth and seventh decades which are the typical age as reported by previous studies [Figure 7] and [Figure 8].[8],[9],[20] However, a case was seen in a young male in his fourth decade, which is an unusual age of presentation. Among the known risk factors for breast cancer such as advancing age, genetic (BRCA1/BRCA2) mutation, family history, and additionally in males, gonadal dysfunction; advanced age was the only risk factor we could link to breast cancer in this study. We were unable to carry out genetic analysis and the two patients that had a positive family history had benign entities on histology. Invasive ductal carcinoma was the histologic subtype of all the breast cancers recorded in this study which is the most common [Figure 9]. No case of lobular carcinoma was seen attesting to its rarity as documented previously.[4],[8] Fibroadenoma of the male breast is very rare; however, some few cases have been reported in the literatures.[32],[33] A case of fibroadenoma was recorded in this series. ADH is also a rare condition, but sometimes an incidental finding in males with gynecomastia. Histology revealed two cases of this rare disease in this study. Unlike in the females where ADH has been established to increase the risk of breast cancer by 4–5 folds, there is a lack of consensus on its determination as a risk factor to developing male breast cancer.[34],[35]
Figure 7: Invasive ductal carcinoma. Transverse sonogram of the right breast showing a fairly discernible oval, heterogeneous lesion with indistinct margin confirmed as invasive ductal carcinoma

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Figure 8: Right breast cancer. Mediolateral oblique mammogram of both breasts showing the generalized increased density of the right breast with skin thickening and irregularity confirmed as invasive ductal carcinoma

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Figure 9: Invasive ductal carcinoma: Photomicrograph of a core biopsy specimen showing malignant epithelial cells disposed in the solid sheets, and the cells are medium-to-large with marked increased in nuclear-to-cytoplasmic ratio, dispersed chromatin, vesicular nuclei, prominent nucleoli, and scanty cytoplasm. The histology features are consistent with invasive carcinoma of no special type

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  Conclusion Top


Imaging plays a significant role in the evaluation of male breast diseases. Ultrasound has high accuracy in the detection of benign lesions. This study found that gynecomastia is the most common benign male breast disease. Breast cancer, although rare cancer in males was seen in a 35-year-old young male.

Acknowledgment

The authors would like to thank Mrs. Rashidat Adewale: Imaging Scientist, Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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