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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5791_Библиотеки_им_академика_М_И_Перельмана.pdf
182
9 Breast Pathology in Men
b5
b6
Fig. 9.2 (continued)
b7
1839 Breast Pathology in Men
Fig. 9.2 (continued)
in fi ltration in subareolar region, sometimes
accompanied with colostrum. It spontaneously
passes within several days or weeks and does not
demand any medical in fl uence.
Gynecomastia in puberty is registered in 4–6 %
of adolescents. It is usually bilateral and asymptomatic. In most cases, it spontaneously passes
within several months or years. In some cases, it
can be signi fi cant and last long due to the sensitivity of mammary tissue to estrogen stimulation.
Senile gynecomastia can be met in men older
than 60 years. The abnormality results from fading of testicular function with the change in hormone ratio (relative elevation of estrogen level).
Iatrogenic gynecomastia in adult men is regis-
tered most often. More than 120 drug groups can
induce gynecomastia, such as estrogen, steroids,
glucocorticoids, and gonadotropins. This type of
gynecomastia is reversible and regresses after the
drug cancellation.
Gynecomastia in endocrine and non-endo-
crine diseases can accompany liver or kidney
pathology. It is a consequence of disturbance in
metabolism and excretion of steroid hormones
and prolactin.
Gynecomastia as a paraneoplastic syndrome
can arise in cases of hormone-secreting tumors,
for example, in lung or testicle cancer.
Gynecomastia can be unilateral or bilateral
and symmetric or asymmetric.
Obesity in men leads to breast enlargement
due to adipose tissue hyperplasia ( pseudo-gyne-
comastia ). Only fi brous and adipose tissues can
be detected with US.
184
9 Breast Pathology in Men
True gynecomastia is de fi ned with US by the
presence of subareolar in fi ltration, which can be
of different density and structure (Fig. 9.2b ).
There are several types of gynecomastia, such
as nodular (in the form of roundish intense homogeneous lesion), treelike (in the form of wide
dense fi brous branches), and diffuse glandular
(looks like mastopathy in women).
US examination identi fi es an irregular
hypoechoic area of 5–30 mm in size with indistinct borders that are located in retroareolar
region. Alternatively, breasts in false gynecomastia are represented by homogeneous avascular
adipose component. Another type of gynecomastia is characterized by hyperechoic region with
well-differentiated, against this background,
threadlike hypoechoic ducts that are regularly
distributed and focused to the nipple. The structure of breast tissue in moderate gynecomastia in
retroareolar area often does not exhibit any echographic difference from normal mammary
tissue.
The incidence of fi broadenoma, cyst, abscess,
mastitis, breast tuberculosis, and other diseases is
signi fi cantly lower.
Breast cancer in men accounts for less than
1 % of all breast carcinomas, with the rate of 1
case per 100,000 population. It has a worse prognosis ( fi ve years’ survival rate is 20–30 %), quick
progression, and early metastasis. The average
age of men with breast carcinoma is 55–59 years.
Unilateral localization is characteristic. Eccentric
painless in fi ltration in subareolar area is clinically de fi ned. Thirty percent of cases exhibit skin
thickening, deformation, or ulceration. Ten percent of patients have bloody nipple discharge.
Mammography and US permit differentiation
of gynecomastia from breast carcinoma based on
characteristic location of gynecomastia (retropapillary areas and symmetric character).
Breast carcinoma in men demonstrates the
same US symptoms, as in women. The following
US features are often de fi ned (Figs.
9.3 and 9.4 ):
Solid hypoechoic lesion •
Eccentric location of a tumor •
Indistinct, rough borders with tuberosity of •
margins
Sometimes microcalci fi cations and/or fl uid •
component within the lesion
Expressed desmoplasia of surrounding •
tissues
Abnormal peri- or intranodular blood fl ow •
pattern with CDI, PDI, and 3DPD
Any doubt in benign character of a breast
lesion must result in breast biopsy. Considering
more aggressive development of breast carcinoma in men than in women, regional metastatic
lymphadenopathy is usually observed earlier,
fi rst in axillary areas (Fig. 9.5 ). US features of
metastatic lymph nodes do not differ from those
in women. The volume and expression of changes
depend on the character and stage of breast
cancer.
It is always necessary to remember about the
possibility of secondary breast malignancies –
the metastases of cancers of kidney, bladder,
lung, thyroid, or other organs.
Breast US with basic and advanced technolo-
gies in combination with other imaging techniques permits effective primary and differential
diagnosis of breast abnormalities in men and
ef fi cient follow-up.
Fig. 9.3 Breast carcinoma in a
man. ( a ) Breast view. ( b )
Sonograms. Gray scale, CDI,
PDI, panoramic scan, 3DPD,
and US elastography
1859 Breast Pathology in Men
a
b1
b2
186
Fig. 9.3 (continued)
9 Breast Pathology in Men
b3
b4
1879 Breast Pathology in Men
b5
b6
Fig. 9.3 (continued)
188
9 Breast Pathology in Men
b7
Fig. 9.3 (continued)
Fig. 9.4 Cystadenopapilloma
of the breast in a man.
Grayscale US
1899 Breast Pathology in Men
190
9 Breast Pathology in Men
Fig. 9.5 Metastases of breast carcinoma in axillary lymph nodes in a man. Sonograms. Gray scale and US
elastography
Ultrasound Examination of Regional Lymph Nodes
1 0
10.1 Normal and Benign Lymph Nodes
The examination of regional lymph nodes,
especially of axillary area, is an obligatory part of
breast US since the basic lymph out fl ow follows
through the axillary collector. The clinical method
of revealing of abnormal axillary lymph nodes
has low sensitivity (50–88 %) and often fails to
detect deep lymph nodes (Frolov 1996 ; Harchenko
et al. 1996 ; Chissov 2003 ) .
US was considered unable to determine the
structure of normal lymph nodes up to the middle
of the 1990s. US often failed to differentiate normal lymph nodes from the surrounding adipose
tissue, especially lymph nodes smaller than 5 mm
( Tro fi mova 2000a ) . Limited US data was the
consequence of low possibilities of equipment
used at that time. Modern US scanners permit
detection of not only abnormal lymph nodes,
which are smaller than 5 mm in size, but also
metastatic foci of 2–3 mm within their structure.
The objective data on breast lesion determines further patient’s management, including
individual approach to the choice of treatment,
speci fi cation of indications, and adequate volume
of surgery ( Maryasheva 2003 ; Korzhenkova 2004 ;
Kuplevatskaya 2004 ; Allahverdyan and Chekalova
2011 ) . Metastatic lymph nodes (especially, axillary) in several cases can be the fi rst clinical sign
of breast carcinoma. Evaluation of regional metastases of breast carcinoma is complicated with large
number of diseases that demonstrate lymph node
enlargement and dif fi culties in their differential
diagnosis. In patients below 30 years of age,
about 80 % of enlarged lymph nodes are benign.
Meanwhile, in patients older than 50 years, benign
lymph nodes are found only in 40 % of cases.
US of lymph nodes is performed in the standard position of the patient for breast scanning
(Fig. 10.1 ). Axillary lymph nodes are examined
with the patient’s arms under her head.
Axillary, supraclavicular, subclavian, substernal,
and pectoral groups of lymph nodes (Fig. 10.2 )
demand high-frequency US probes of 7.5–15 MHz.
US considers conventional anatomic borders
between the areas to identify the groups of lymph
nodes, such as the supplied below. Lateral edges of
pectoralis minor and latissimus dorsi muscles form
the axillary area; the upper edge of the clavicle and
medial edge of the digastric muscle, supraclavicular
area; projection of subclavian vascular bundle and
the surrounding fat, subclavian area; and intercostal
spaces along the breast bone, parasternal area.
US also detects the subgroups of axillary
lymph nodes located in the following areas:
Medially from pectoralis minor muscle •
Along axillary vessels •
Between pectoralis major and minor muscles •
Axillary lymph nodes can be classi fi ed into
following levels:
Level 1 (inferior axillary) lymph nodes are •
located laterally from the lateral border of
pectoralis minor muscle.
Level 2 (middle axillary) lymph nodes are •
located between medial and lateral edges of
pectoralis minor muscle and interpectoral
(Rotter’s) lymph nodes.
A.N. Sencha et al., Breast Ultrasound,
DOI 10.1007/978-3-642-36502-7_10, © Springer-Verlag Berlin Heidelberg 2013
191