By Douglas M. Duven, M.D., F.A.C.S of the Breast Care Center

Fact: Men can carry and pass on the BRCA gene mutation.
Breast cancer occurs in men & women. Approximately one male is diagnosed for every 100 women. Male breast cancer often presents with a lump or mass. Mammograms are possible for men if indicated. Ultrasound assists in evaluating the male breast tissue. Biopsies are the same as for women – usually an ultrasound guided core biopsy. If a cancer is found, a mastectomy is usually recommended. Male breast cancer is also tested for estrogen and progesterone receptors, Tamoxifen is often prescribed for the ER+/PR + tumors. Men with a lump that is not centrally located (beneath the nipple) should be evaluated for a possible cancer

Fact: Men can carry and pass on the BRCA gene mutation.
The maternal side of the family used to be the focus, now both maternal and paternal sides need to be evaluated for breast, ovarian and pancreatic cancer. Many men develop a breast lump or enlargement that is not cancer.

Gynecomastia is the growth of male breast tissue, commonly located beneath the nipple. Male breast tissue can be affected by hormonal fluctuations and medical conditions. Gynecomastia can be a side effect of many medications, including testosterone supplements. Dietary supplements such as those used by body builders are also a possible source. Some medical conditions such as kidney disease/failure, prostate cancer also raise the incidence of gynecomastia.

Paget’s Disease of the breast is a malignancy, often presenting with a persistent rash, irritation or lesion of the areola or nipple. A punch biopsy of the lesion often is the most frequent biopsy type used to rule out Paget’s Disease. Paget’s can be non-invasive or invasive. Women should be encouraged to report any persistent rash or lesion of their breast to their primary care physician. Frequently, a steroid containing cream is prescribed initially. If there is no improvement using the cream, referral for biopsy is recommended. Paget's is treated with surgery. These tumors are tested for the estrogen and progesterone receptors, with anti-estrogen therapy often recommended. Chemotherapy may be indicated for an invasive Paget's tumor.

Malignant Phyllodes tumors account for less than 1% of breast cancers and typically present as a rapidly enlarging, palpable mass in middle-aged to older women, and may develop over several months. The mammographic appearance is often telling— a very large, relatively circumscribed, round or oval mass. The mass may become extremely large. At close inspection, the margins are often ill defined rather than sharply circumscribed. When detected at a screening examination, the appearance may mimic a fibroadenoma. The ultrasound appearance is similar to that of fibroadenoma, though a phyllodes tumor more frequently contains cystic spaces than does a benign fibroadenoma. On ultrasound, the margins of a phyllodes tumor are typically ill defined. Surgical treatment is similar to other breast cancers, lumpectomy when appropriate or mastectomy.

Inflammatory Breast Cancer is a rare, but aggressive form of breast cancer. Frequently, it presents with redness, swelling, tenderness and a warm sensation of the breast. Often this is initially mistaken for an infectious process. The swelling of the breast tissue and skin is due to the blockage of the lymph channels. The breast skin may have the appearance of orange peel. Often there is no specific mass palpated within the breast. Other symptoms are a rapid increase in breast size, heaviness and marked asymmetry. Ultrasound often shows significant skin edema.  Diagnosis is made by biopsy of the abnormal skin or by core biopsy of a lesion within the breast. Many inflammatory breast cancers are advanced before diagnosed, often with lymph node involvement, sometimes with distant metastasis. Inflammatory breast cancer is most frequently treated with aggressive chemotherapy prior to any definitive surgery. Hormonal therapy is used if the tumor is estrogen/progesterone receptor positive.

Mastitis is an infection of the breast. Frequently, women who are nursing have mastitis, but the condition is not limited to those women. Mastitis can occur at nearly any age. These infections can arise from a breast duct, the nipple can be the entrance site for common skin bacteria, the fluid in the ducts serves as a host for the bacteria. Redness, swelling, fever, and pain are the presenting symptoms. Sometimes, the infection can break through the skin or drain through the nipple. An ultrasound can help to detect an infected pocket of fluid, often this pocket can be drained. The fluid removed may be evaluated by the lab for the type of bacteria and which antibiotics will work best. Oral antibiotics are usually used and often need to be taken for an extended course to fully treat the infection. Surgical removal of the chronically infected area may be required if the mastitis recurs. Women who smoke have a higher incidence of mastitis.

Women and men should report any change(s) of their breast(s) to their physician.


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By Dr. MeMeghna, MD, MS
Diagnostic Radiologist with Milwaukee Radiologist, LTD and currently with Covenant Medical Center

“Detection of breast cancer is difficult by mammogram in dense breasts . . .”

As women are well aware, the purpose of a mammogram is to screen for breast cancer. What many women may not know is that radiologists assess the level of density (proportion of breast and connective tissue compared to fat) in each mammogram to determine sensitivity to detect cancer. Approximately 40 - 50 percent of U.S. women, who have mammograms, have dense breasts. It is important for women and referring physicians to understand that dense tissue is defined by mammography, not by palpation.

Many women mistakenly believe they have ‘dense’ tissue due to the fact they have lumpy breasts when, in fact, they are quite fatty. Breast cancer is typically white on mammogram. Since fatty breasts have a dark background appearance, it is relatively easier to spot the white cancers. However, breasts that have more connective and glandular tissue are denser, and appear whiter on mammograms, which makes detection of small early breast cancers difficult to extremely difficult. Some experts liken it to trying to find a snowball in a snowstorm.

The sensitivity for detection of breast cancer varies between 30% for extremely dense breasts to 80% for fatty breasts. Not only is detection of breast cancer difficult by mammogram in dense breasts, but having dense breasts is considered one of several other risk factors for breast cancer. Some authors have suggested 4 to 6 times increased risk of developing breast cancer in women with dense breasts compared to women with fatty breasts.

Hence, given the relatively diminished performance of mammography in women with dense breasts and the increased risk for breast cancer, there has been a recent wave to evaluate supplemental screening by other modalities for women with dense breasts. FDA mandates that dense breast tissue notification be included in the formal mammography report sent to referring physicians, which has practiced throughout the nation for more than a decade.

Recently, in seven states—Connecticut, New York, Texas, Virginia, Maryland, Hawaii and California —the plain-language report that women receive following their regular screening mammograms must now include information regarding whether they have dense breast tissue. With mammography density notification legislation pending in at least 18 more US states, including Iowa, and a bill introduced in the US House of Representatives, a large number of women in due time, across the country may be learning more about their mammographic breast density in their plain-language letters. This information is provided to raise awareness and to encourage women to start discussions with their doctors to determine whether additional screening options may be right for her.

Most breast imagers believe that every woman has a right to know her mammographic breast density, but what is unclear is what the patient could do with that information. There are still many unanswered questions about the biology of breast cancers and breast density. Assessing breast density on a mammogram is sometimes subjective and can vary between radiologists. Many women, when told they have dense breast tissue, may feel that they absolutely must have additional testing. Others may be anxious or confused and drop out of screening altogether. However, it is important to have as much information as possible and realistically discuss risk/benefits.

​Screening Modalities - In the realm of screening mammography, it is clear that digital mammography has improved performance than film screen mammography in dense breast women and that Tomosynthesis (3D mammography) has superior performance than 2D digital mammography in all types of breast composition. The additional screening modalities that are available to patients are whole breast ultrasound and breast MRI. While there is improved sensitivity when screening ultrasound or MRI or both are included along with mammography, it is also known that ultrasound and MRI tend to find more false-positives, thereby increasing unnecessary biopsies and creating additional healthcare costs. Since mammography is the only modality where mortality benefit has been documented, ultrasound or MRI screening are only to be considered as supplemental to mammography and not as a substitute to mammography.

High Risk Women - American Cancer Society, American College of Radiology and National Comprehensive Cancer Network categorize women as high risk if they have any of the following risk factors.

• BRCA mutation
• First-degree relative of BRCA carrier, but untested
• Lifetime risk 20–25% or greater, as defined by risk assessment models that are largely dependent on family history like Tyrer-Cuzick, BRCAPRO, BOADICEA
• Radiation to chest between age 10 and 30 years
• Li-Fraumeni syndrome, Cowden and Bannayan-Riley-Ruvalcaba syndromes and their first-degree relatives

Since the combined sensitivity of mammography and sonography is only 52%, compared to 92.7% for combined mammography and MRI, in high risk women, breast MRI is recommended over sonography as supplemental screening modality in this population. Since 2007, insurance companies have been covering annual screening breast MRI in the above mentioned high risk women. Most of these women are typically younger and tend to have dense breasts on mammogram.

Currently, there is insufficient evidence to recommend for or against MRI screening in women with intermediate lifetime risk, which includes women with 15–20% lifetime risk, those with only heterogeneously or extremely dense breast on mammography or only with a personal history of breast cancer. In these patients, American Cancer Society recommends that insurance payment should not be a barrier and that screening decisions should be made on a case-by-case basis, as there may be particular factors to support MRI. In several US states, screening ultrasound is being utilized as an adjunct to mammography to screen women with dense breasts who may not qualify for breast MRI.

​Advantages to the incorporation of sonography into a breast cancer screening program include the fact that breast ultrasound is well tolerated, noninvasive, and relatively inexpensive. Also, it is easy to biopsy lesions seen only by sonography. However, limitations are also evident. The examination is operator dependent, and the skills of individual technologists and radiologists are variable. While cancers detected with screening sonography have generally been stage I invasive breast cancers, there is no data to assess the ability of sonographic screening to decrease breast cancer mortality. Another issue is reimbursement of screening breast ultrasound by insurance is questionable and many patients may have to pay out of pocket for this test, possibly a few hundred dollars. Currently only, Connecticut and Illinois mandate insurance company coverage. There is insufficient evidence to support the use of other imaging modalities such as thermography, breast specific gamma imaging (BSGI), positron emission mammography (PEM), or optical imaging for breast cancer screening. Radiation dose from BSGI and PEM are 15-30 times higher than the dose of a digital mammogram, and they are not indicated for screening in their present form.

Conclusion
For all women, irrespective of whether they have dense breasts or not, annual screening mammogram is recommended starting at age 40. If a woman has dense breasts on mammogram, she is encouraged to talk to her doctor to know whether she is a high risk patient for breast cancer. If she is a high risk patient, then she will qualify for annual screening breast MRI in addition to the annual mammogram.

If she is not a high risk patient, then the debate is still out whether supplemental screening options (ultrasound or MRI) might be beneficial. Further studies, some underway, are needed to better define the appropriate target population and to see its effects on patient outcomes. Until more absolute recommendations become available for women with dense breasts who have intermediate to low risk for breast cancer, these supplemental screening modalities will have to be addressed on a case by case basis, understanding that sometimes there may or may not be insurance coverage and that the patient might have to bear the cost.

If a woman does not have dense breasts on mammogram, then there may be other factors that may still place her at increased risk for breast cancer and hence she is encouraged to talk to her doctor. 


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