A hard mass below the nipple in an older male should raise concern for a serious underlying condition. While gynecomastia is a common benign diagnosis, male breast cancer must be strongly considered—especially when the presentation involves firmness, fixation, or nipple changes.
This guide walks through how to approach this finding including key clinical clues, differentials, diagnostic steps, and test-taking strategy.
An older male, typically over 60 years old, presents with a firm, non-tender mass beneath or near the nipple. Key associated findings may include:
The stem may distract you with patient age, gender, or other benign possibilities—but focus on the red flags.
Male Breast CancerMost commonly invasive ductal carcinoma. Presents as a hard, immobile mass below the nipple. Often diagnosed late due to lack of awareness. Frequently unilateral. May show skin changes, nipple retraction, or discharge.
GynecomastiaCommon in males due to hormonal imbalance, medications, or systemic disease. Tissue is typically soft or rubbery. Symmetrical and often bilateral, though it can be unilateral. Not typically associated with nipple inversion or skin dimpling.
LipomaBenign fatty tumor, soft and mobile, often not fixed to underlying tissue. Rarely causes nipple retraction or skin changes.
Breast Abscess or InfectionUsually seen in younger males or in the setting of trauma or infection. Painful, red, and swollen. Systemic symptoms such as fever may be present.
Metastatic LesionRare but possible. May present as a firm mass in the breast or axilla. History of known malignancy helps differentiate.
Choose breast cancer as the most likely diagnosis when:
Choose gynecomastia when:
If you suspect male breast cancer, the next best step is:
If you suspect gynecomastia, the next best step is:
A hard mass below the nipple in an older male is breast cancer until proven otherwise on the exam. Even though male breast cancer is rare in real life, pattern recognition and high-yield red flag symptoms are important.
Read the question stem carefully, identify whether the tissue is hard or soft, unilateral or bilateral, and whether skin or nipple changes are present. Then pick the most appropriate next step.
If you or someone you know has a firm mass under the nipple—especially with skin changes, asymmetry, or pain—it’s important to get it evaluated right away. At our Newport Beach clinic, Dr. Joseph Cruise specializes in male chest evaluation, including gynecomastia and suspicious breast masses.
Schedule a gynecomastia consultation today for peace of mind and expert guidance.
