Diagnostic Imaging for Males with Suspicious Breast Lumps

Age-Based Imaging Algorithm

The American College of Radiology recommends ultrasound as the initial imaging modality for men under 25 years due to the low incidence of breast cancer in this age group 1, 2
For men under 25 years, if suspicious or indeterminate features are found on ultrasound, mammography or digital breast tomosynthesis (DBT) should be performed before proceeding to biopsy 1, 2
The American College of Radiology recommends mammography or DBT as the initial imaging study for men 25 years and older 3, 4, 5
Mammography demonstrates high sensitivity (92-100%), specificity (90-96%), and negative predictive values (99-100%) in distinguishing benign from malignant disease in men 25 years and older 3, 4
Bilateral mammography is routinely performed to assess for symmetry and detect possible contralateral abnormalities in men 25 years and older 4

Mammography is superior for detecting microcalcifications, which may be the only sign of malignancy in men 3, 4
Mammography is highly effective at distinguishing gynecomastia from malignancy in men 1
Ultrasound performance in men may be more variable than mammography, with sensitivity ranging from 88.9-100% and specificity of 74-95.3% depending on the study 4, 5
Ultrasound is particularly useful for characterizing masses and guiding biopsies when needed in men 3

Male breast cancer is rare (less than 1% of all breast cancers) but typically presents at a later age (median 63 years) than in women, according to the American College of Radiology 5
Relatively benign imaging findings should be considered suspicious in male patients due to different breast anatomy, as recommended by the American College of Radiology 3

Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies, as noted by the American College of Radiology 1
Failing to proceed to mammography when ultrasound findings are indeterminate in younger men can lead to delayed diagnosis, according to the American College of Radiology 1, 2

The National Comprehensive Cancer Network (NCCN) recommends that diagnostic mammography for a male patient with a solid breast mass should include additional specialized views—such as spot‑compression or magnification—to better characterize the lesion and guide appropriate BI‑RADS categorisation. 6

According to NCCN guidelines, if diagnostic mammography assigns a BI‑RADS category 4 or 5 (suspicious or highly suggestive of malignancy) for a male breast lesion, a core‑needle biopsy—preferably performed under ultrasound guidance for real‑time visualization and patient comfort—is indicated. 7
NCCN guidance also states that when diagnostic mammography yields a BI‑RADS category 3 (probably benign) for a male breast lesion, short‑term follow‑up with clinical examination and repeat imaging (ultrasound and/or diagnostic mammography) every 6–12 months for 1–2 years is appropriate to confirm stability. 7