A 24-year-old man presented with a 5-year history of a palpable left breast mass which was now painful and increasing in size. Physical exam revealed a firm, round mass 2cm from the nipple. Mammogram shows a corresponding circumscribed, oval, high density mass, which is heterogeneously hypoechoic, antiparallel, and in contact with the overlying dermis. There was a small amount of internal vascularity on color Doppler (not shown). No skin tract was identified.
Men present with various breast masses, most commonly gynecomastia — a benign condition characterized by tender subareolar tissue which is fan or flame-shaped on mammogram and directly behind the nipple. While this patient does have a mild degree of gynecomastia, the abnormality in question (denoted by palpable marker) does not fit those characteristics. Another consideration for this mass which abuts the skin is an epidermal inclusion cyst (EIC). EICs may show vascularity on Doppler if inflamed, though absence of a clear sinus tract to the skin surface makes this diagnosis unlikely. Since there are clinical and imaging features concerning for malignancy (firm, remote from areola, increasing size, antiparallel), this lesion was classified as a BI-RADS 4 — suspicious abnormality, and biopsy was recommended.
The result from ultrasound-guided core tissue sampling was a schwannoma. This benign peripheral nerve sheath tumor typically occurs in the head and neck, spine, and extremities. It is rare to encounter a schwannoma in the breast, particularly in a man. Given that the mass was symptomatic/painful, the patient was referred for surgical excision.
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Tharin B, Book S. At the Viewbox: Unusual Breast Mass—Schwanomma. J Am Osteopath Coll Radiol. 2014;3(1):28.