In a large amount of pain

mycobrondi · April 2019

Guess some back story.

33 year old male, started feeling run down and lethargic last year real bad in the fall, could barely stay awake a whole day would nap a lot. Had all sorts of tests and stuff bloodwork would come back fine, no problems there. Got referred to an internist and started more diagnostics. While this was going on I noticed a lump in my left breast. Not taking any chances about four months ago my left and right axilia, breast and underarm were done. There ended up being two lumps they could not image on the ultrasound but were deemed most likely not a problem.

About a month ago, started getting a on again off again on the opposite side, in the upper chest, underarm and armpit. GP and I said it was most likely an airway thing like pleurisy so we booked an x-ray, I got real busy so had no time to go to it for awhile until about a week ago, x-ray came back clean. Three days ago the pain got real bad, sharp and stabbing. I couldn't handle it so I went to the ER. The ER doctor began to feel my underarm, no problems there but then from my chest to the bottom of my breast along that lymphatic chain, the lymph nodes were swolen. Then he began feeling the breast and it is full of lumps of varying shapes, these were not there four months ago during the ultrasound, they are well defined, one or two is hard the rest are rubbery, some are oblong. None of them are tender and there is nothing behind the nipple. These are all over the place is no organized pattern. He told me he was booking me for a CT scan with contrast immediately and within 24 hours here we are.

I've been trying to find matching symptoms to do a differential diagnosis and rule things out but its quite difficult when it comes to a male breast. The nipple is fine and there is no mass behind it to indicate gynecomastia. Both breasts are somewhat evenly shaped.

If we table everything benign and look at malignancy being a cause which is more likely given the goings on and the particulars about gender and age, breast cancer or lymphoma that has spread to the breast?

Thanks all.

djmammo · April 2019

mycobrondi

Mammography is also the gold standard for lumps in the male breast. The CT scan of your chest will identify any adenopathy in your axillae and mediastinum and will help to r/o lymphoma but is not adequate for evaluating for the lumps in the breast itself.

As a rule of thumb in this context, unilateral enlarged axillary nodes would point to something focal, a list of which would include breast ca, bilateral enlarged axillary nodes would point to something systemic which would include lymphoma. Also most types of lymphoma would show an abnormal CBC with a high white count.

Let us know what the imaging shows.

mycobrondi · April 2019

Ah.. on the bilateral front I did have this pain, only less so on the left side which did resolve hence the ultrasound, once in awhile I do get a sharp pain under there though and those breast lumps are still kicking around.

On the left side of my body there is a posterior cervical lymph node that decided to enlarge back in December, Internist referred me to an ENT for biopsy but ENT recommended an MRI of head and neck. It's still kickin around, They imaged that one with ultrasound as well and it was 11mm on its longest axis with the radiologist remarking that it is of doubtful clinical significance on the report. We just assumed it was idiopathic. What brought all this on in the first place was I woke up with an astounding amount of pain in my upper right abdomen under the rib cage, ER bloodwork showed elevated lipase and amylase so I was admitted until it calmed down, an ultrasound was performed and a liver legion they could not identify was seen, then a triphasic CT was performed to check for hemangioma and the results were inconclusive, they then stuck me in an MRI machine and ruled it a cyst, 3mm but also found a lesion in my gallbladder, during this time I had been losing weight steadily, experiencing extreme fatigue, sweating throughout the night unless I kept the window open a crack in winter and such and itching all over my abdomen which has turned into discolored scaly patches similar to exzcema or some such. Extensive bloodwork revealed just immunoglobulin-M deficiency,

CT with contrast is being done at 1:45, it's outpatient at the hospital so I'm not sure when I'll get the results, May 1st an MRI is being done on my head and neck as well. Here's hoping it's all just unrelated eh, or I'm hoping so. I first started talking to my GP about odd symptoms quite awhile ago, last year really and I can't imagine malignancy would hide so long.

djmammo · April 2019

mycobrondi

The symptoms and blood work do suggest involvement of the hepatobiliary system one way or another but this area would not be affected unless breast cancer were metastatic which seems unlikely without a known primary breast ca. Again mammo is best to evaluate for this.

Are you jaundiced? They mention the pancreas on the CT? Alcohol?

mycobrondi · April 2019

Nothing abnormal in the pancreas on CT or MRI, they just tell me that the chronic elevating of lipase and amylase is being caused by that. Nope, no jaundice. Haven't touched a drop of alcohol for about four years now. I can imagine given my gender and age that even the thought of primary breast cancer or even other malignancies would be secondary but I've got to assume if it was truly metastatic breast cancer or other malignancy that has now entered the breast it would be announcing it's presence in a far more significant way. My GP figured the pancreas could have some kind of dysfunction with the sphincter of Oddi but when we start addressing one thing something else pops up and seems more urgent, The head MRI coming up is to look for adenomas I think and demylenation. Was also tested for Addisons because my cortisol was in the double digits on two blood tests in a row but then fine on the next one weeks later.

I guess it's just a game of wait and see, I live in a small Canadian city where our top specialist is our doctor of internal medicine so limited resources. I was supposed to be referred to an endocrinologist hence the referral by my general surgeon who did not want to remove my gallbladder at my GPs request (because of the lesion) but the internist decided he was going to try and take over diagnostics, made a fuss about how much had been done so far, then proceeded to do months of the same himself and finally relented that he couldn't figure out what was going on, booked the MRI and referred me to an endrocrinologist which has a one year waiting time.

It's been a road, haha.

djmammo · April 2019

mycobrondi

If this goes on too long without an answer start looking at large university tertiary care hospital centers. They are full of very smart people who love a good mystery. Good luck.

DATNY · April 2019

Have you ever got tested for good ol' Lyme disease?

mycobrondi · April 2019

I don't believe I've been tested for Lyme disease ever no.

Funny you should mention that djmammo, I'm flying to Thunder Bay Ontario to hook up with the Thunder Bay Regional Health Sciences Center, I was told the same thing about them, love a good mystery.

I've got a copy of my CT on cd, the images I mean since the radiologist won't be able to look at anything until later this evening I figure I might as well see what I look like on the inside before they tell me they can't figure out what the lumps are haha, thanks all.

mycobrondi · April 2019

@djmammo, I got the DICOM file for my chest CT, should a lay person even bother looking at this?

mycobrondi · April 2019

R

Well, I don't believe it to be breast cancer anymore at the very least, sorry to bother you nice folks. Not sure what's going on there but uh, that shouldn't be like that I figure.

djmammo · April 2019

mycobrondi

I am a big fan of showing patients their imaging and CT is probably the best for teaching anatomy. It would be best to go over it with someone who knows how to read them, but comparing with images in an anatomy atlas is also useful. The problem comes when trying to decide if something you see is "normal" or not and whether you are the type to become anxious over your 'self diagnosis'.

That caveat being stated, here is a site with normal CT anatomy of the abdomen in three planes. If your disc of images doesn't come with a DICOM viewer you may have to download one.

mycobrondi · April 2019

Hello again djmammo, the hospital gave me a CD with my dicom, dicomdir, the radiologists report and such. Nothing was really noted about the soft tissue outside of the chest as they seemed to be more interested in the interior of things, so I guess I have no answer on the lumps. I'm using Radiant and I've gone through each view quite a number of times. For the life of me everything appears to be normal where those lumps are, maybe a little bit of this and that there which could just be some dense tissue so.. still no answers there.

The radiologist did note some other things though which I guess kind of suck. Prominence of the thymus measuring 7 x 4 x 3cm with an average post contrast density of 15hu, no mass effect noted but I will note that my sternum is on quite a bit of an angle, oh well.

There's plenty of dark blobs in the breasts so I guess one could assume that's just denser fatty tissue, necrotic fat, or some such? Not sure, but at the very least I suppose I can rest easy since they never once mentioned anything outside the chest in the report at all, good or bad.

But they did note diffuse bilateral tree-in-bud appearance that was not appreciated on my last CT but there's no lymphadenopathy associated with it being infective or inflammatory, as well as subpleural ground loss (I assume they meant ground glass, this was dictated) opacification seen in the lateral aspect of the right lower lobe measuring 13 mm. The radiologist has recommended reassessment using HRCT now.

So I guess I'm at square one all things considered, the thymus thing will probably get investigated I imagine but I figure if there was breast cancer or lymphoma in the breast this would have shown it.

You have an absolutely fascinating job, incredible to see these things the way you guys get to. I'm morbidly fascinated by looking through these scans and knowing "Hey, thats me, inside!"

An example of the "debris" I see in my breast. On the left there.

mycobrondi · April 2019

Oh and incidentally, something that was learned within the past 24 hours, the pain is excruciating but laying on the floor with a pillow folded underneath my chest and laying on my stomach on it instantly makes the pain go away.

Like, immediately.

DATNY · April 2019

You should definitively find a doc to at least carry a standard Lyme test. Being young, from a small town, with lots of unexplained symptoms -I see this often enough where I live.

mycobrondi · April 2019

Alright I'll mention the lyme disease to my internist or GP, not sure when I would have been bitten by a tick but hey, they're testing everything else so why not.

djmammo · April 2019

mycobrondi

CT does not have the resolution necessary to evaluate breast masses in males or females, only mammography will show that kind of detail.

Odd about lying on the pillow. Perhaps that position puts pressure on or conversely relieves pressure on something related to the pain? I will leave that to the clinical diagnosticians.

mycobrondi · April 2019

Yeah that's what I was thinking, in the DICOM there it looks like the radiologist made sure to select that image of what I believe is to be the thymus, in the second image I posted. It was standing alone by itself in the DICOM, I'm not exactly hip but after comparing it to other CT scans it's pretty damn big which I guess explains the measurements seen on the report, I noticed that my sternum is off on an angle there and I can't help but wonder if the thymus is pushing it out, causing pain in the ribcage cartilage and that laying on my sternum pushed everything back to flush?

Ah well, I guess I'll see if they're willing to do a male mammography on me, really would be good to know because being able to feel these lumps and not being able to see them is quite maddening, I can only assume how people must feel when they're only given an ultrasound and then told "Well, there's a lump but we can't see it"

Stuff like this makes me want to take the medical radiation technology program in my hometown but eh, average of 200 applicants a year with a class size of 17.

Fascinating stuff though, will be looking forward to the mammogram and figuring out what the HRCT shows in the lungs and finding out why my thymus is so danged big but low HU.

mycobrondi · April 2019

Hey djmammo, if your'e around, I have a question for you is all. My lumps got handwaved as "possibly lipoma" so that sucks but after playing with my DICOM, learning and going through every image in the sequences going all over with the window settings.. There's uh, well I'm not sure, and funny enough, these two things are both on the same side that filled with lumps, still can't get that mammogram from my internist or GP, sadly but hey, maybe there's something to what I got going on.. and what I got going on I'm really hoping isn't metastatic from or to the breast.

On my report the radiologist noted a 13mm pure-ground glass opacity with no parenchymal nodules spotted. I wanted to get a better look at it so I used the Phillips dicom software the hospital put on the CD with my dicom, I assume that's what they use, I didn't like the program so I got RadiANT and started playing around with window settings, going through the images in each sequence, enjoying it all and then, I found something weird and I can't explain it. I guess what worries me is this seems to be going through the interostal muscle, then.. into and through the pleural space.. and it lines up on cc, tv and ap axis with my unknown pure-GGO. so.. something got into the chest wall and on the other side has decided to grow? This was post-contrast.

And then there's this one, also has me stumped. Again same thing, couldn't see it on Phillips but after playing in Radiant I saw it in the post-contrast as well.

So I keep looking through reports and studies and pictorials of lesions and masses and human anatomy, trying to find something similar in other CT's with lesions but usually those scans are done and put online because the patient had a huge lesion so I really have nothing to compare it to but the sudden blinding amount of pain I'm experiencing, combined with palpable lumps in my left axilia, trunk and especially my right breast and no answers.. well, you can see where I'm at now. Concerned that there is spread to or from my breast and that either of these could be that.

If you need any information I can supply it size, hounsfield units, all that jazz., if you need the DICOM itself, I can do that to. If you need clinical findings prior, I've memorized them all, bloodwork and such. If ya have any idea what these could be I'd be very much obliged because unless I can make a case there ain't gonna be a mammogram and any suggestions to investigate these are gonna be dismissed without investigation cause, well.. doctor doesn't like it when I try to figure things out haha.

djmammo · April 2019

mycobrondi

I am prohibited from evaluating imaging on line, it is a forum policy and a legal concern as well. Even if it were feasilble, I haven't read a CT since 2003, just breast imaging.

Let us know when you can post the mammogram report.

In a large amount of pain

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