Applied Radiology

Dr. Esserman is the Director of Breast Imaging and Radiology, Dr. Weisberg and Dr. Odzer are Diagnostic Radiologists and Dr. Gombos is a Resident at Mount Sinai Medical Center, Comprehensive Breast Center, Miami Beach, FL.

Mammography of the male breast can be technically challenging, particularly in young patients with large muscle mass. Compression may be inadequate because the pectoralis muscle is relatively large compared with the breast tissue, and, therefore, the visualization of the breast tissue is unsatisfactory due to the high contrast between the high-density muscle and low-density breast tissue. To alleviate this problem, we applied a modified positioning technique by displacing the pectoralis muscle posteriorly and pulling the breast tissue anteriorly, similar to the technique of Eklund as used for imaging of the augmented breast. ¹

Materials and methods

In addition to the routine views, we performed modified craniocaudal and mediolateral oblique pectoralis displaced views on 10 consecutive male patients referred for mammography. The pectoralis muscle is pushed posteriorly against the chest wall while the subcutaneous breast tissue is gently pulled anteriorly and held in place with the compression device (Figure 1).

Results

The procedure greatly improved the visibility of the breast tissue compared with the standard compression views by showing more details on the images and more breast tissue (Figures 1 and 2) in all cases.

Discussion

Mammography of the male breast is an infrequent examination, accounting for <1% of mammograms. ² Adequate technique for mammographic positioning and visualization is challenging for the mammographers. The standard mediolateral oblique and craniocaudal views are routinely suggested for use. ² The caudocranial (reverse craniocaudal) view can be used as a supplementary projection to maximize the amount of tissue visualized in men who do not have a protuberant abdomen. ³

However, breast tissue in men may be difficult to visualize because of the brightness of the pectoralis muscle. In women, it is of utmost importance to include a wide strip of the pectoralis muscle to maximize the amount of posterior breast tissue on the film. ⁴

Suboptimal imaging of male breast tissue may occur by satisfying this requirement. Supplemental views of the breast without the muscle may be needed to achieve more uniform compression of the breast tissue. The greatest improvement in quality was achieved on the mediolateral oblique view, as this is the view where the greatest amount of muscle is included (Figure 2).

Most of the cases of gynecomastia and other pathologic conditions, such as carcinoma, lipoma, and abscess, occur in the area of the nipple and areola in the male breast. ^2,5,6 The modified pectoralis displaced view can be performed with a small spot compression paddle at the usual area of interest at the subareolar region. Generally, the area is small enough to be included under the spot paddle.

If the pectoralis muscle is properly penetrated, the small male breast tissue may be inadequately compressed and overexposed. Modified pectoralis displaced positioning for men is proposed, similar to the implant displaced views for women with breast augmentation. The breast tissue is pulled over and in front of the pectoralis muscle, which results in improved visualization and compression of the breast tissue. All four images (bilateral, mediolateral, oblique, and craniocaudal views) can be supplemented by pectoralis muscle displaced views or individually as needed on a case-by-case basis. This technique may be applicable to women with small breasts and large pectoralis muscles or women with large muscle mass.

Conclusion

Mammographic examination of male breasts can be difficult, especially since compression may be inadequate. Pectoralis displaced views should be utilized when breast tissue is inadequately visualized on conventional mammography views. This technique is particularly helpful in muscular men.

Acknowledgment

The authors thank Maria De Leon and Mayren Lama-Viamontes for their invaluable assistance in performing the images for this study.