Mammographic features of Gynaecomastia :
Mammography is recommended for the evaluation of the male breast if the differential diagnosis between gynecomastia and lipomastia (fatty enlargement) is not clinically evident, and in all cases of unilateral breast symptoms.
Lipomastia or pseudo-gynecomastia is diagnosed when there is prominent adipose tissue without retroareolar densities on mammography (Figure 3) .
Gynecomastia usually appears as a fan shaped density emenating from the nipple gradually blending into the surrounding fat ( Figure 1) .
Gynecomastia is classified on mammography into two main pattern :
- The focal pattern (nodular & dendritic) .
- The diffuse pattern.
The focal pattern wheras the abnormality is restricted to the subareolar region, it is either nodular (figure 2 & 4) or dendritic (figure 1) with fibrous strands extending to the deeper fatty tissues.
The diffuse pattern is characterized by the presence of more pronounced proliferation, nodular confluent parenchymal densities which appear like a female mammary gland with fibrocystic disease (figure 5 & 6 ).
Calcification is not a feature of Gynecomastia (5) and was not encountered in any of our cases.
In our study , 60 cases of Gynaecomastia were mammographically classified as dendritic (70%), Nodular (20%) and diffuse (10%) and these results were conforming with previously published (2, 14 & 18).
Bilateral gynaecomastia was diagnosed in 65% of cases while unilateral gynaecomastia where encountered in only 35% of cases . In a published series, bilateral gynaecomastia was encountered in 52% of cases and unilateral presentation was found in 48% of cases (11).
Histopathological classification of Gynaecomastia and correlation to mammographic patterns :
Gynaecomastia has been classified pathologically into two pattern :
- The florid pattern.
- The fibrous pattern.
The florid pattern which is thought to be the early phase, characterized by hyperplasia of the intraductal epithelium, loose cellular stroma and surrounding odema.
The fibrous gynecomastia is thought to occur when gynaecomastia is long standing. At histopathology, fibrous gynecomastia is characterized by ductal proliferation with dense fibrotic stroma.
Histopathological diagnosis was obtained in 24 out of 60 cases in our study and accordingly our patients were classified into Florid (25%) and fibrous types (75%). In our study, it was found that the dendriitic gynecomastia correlated well with the fibrous gynecomastia and the nodular gynecomastia correlated with the florid type and this is seen related to the duration of the condition (table 3), It was found that gynaecomastia less than 4 months duration , were mostly nodular type and corresponding to florid gynaecomastia , however gynaecomastia of more than 4 months duration were the dendritic and diffuse types and were corresponding mostly to the fibrous type on histopathology. Our results were similar to previously published by Applebaum and colleagues in 1999 (1). Also our results were matching with the previously stated by Buchberger and colleagues , Gynecomastia of long duration representing the fibrous type shows mammograhyically a denderitic or diffuse pattern (2) .
Ultrasonographic features of Gynaecomastia :
- Concerning the sonographic appearance , gynecomastia has been described as a welldefined retroareolar flame shaped hypoechoic lesion (figure 1 & 2) , hyperechoic pattern (figure 4), focal hyperechoic and diffuse echogenic parenchyma with prominent ducts indicating total development of the lactiferous duct unit (5 & 6).
- In most of cases there is increased thickness of the mammary stroma measured from the nipple to the pectoral muscle , more than 1 cm (figure 4).
In our study , it was found that the retroareolar hypoechoic lesion is the most frequently encountered form, it was found in 58.33% of our cases, next to it was the focal hyperechoic that was found in 25% of cases , then the diffuse hyperechoic appearance , it was observed in 10% of cases and the finally came the diffuse proliferation of the glandular stroma with development of the lactiferous ducts , a pattern similar to fibroadenosis of a female breast & was noted in 6.66% of our cases (table 2).
Correlation between the histopathological patterns and ultrasound features :
There was a strong correlation between the sonographic appearance and the histopathologic forms in relation to the duration (table 4). In 24/60 histopathologically proven cases , it was noted that the hypoechoic pattern correlated well with the florid gynaecomastia , All florid gynaecomastias appeared on US as a hypoechoic lesion , however the echogenic pattern either focal or diffuse with or without development of the lactiferous ducts were seen in gynecomastia of longer duration and all were proved to be fibrous type by histopathology representing 73% of cases presented after more than 4 months duration (table 4). These results were similar to previously published (2).
Gynaecomastia and cancer breast !
Male breast cancer usually presents as a breast lump. Less commonly men may present with nipple discharge, skin ulceration, fixation of the breast to the chest wall (17). Cancer is more likely if the lump is eccentric and discrete as opposed to a central subareolar lesion in gynaecomastia (figure 8). Ultrasound breast scan is the imaging of choice followed by sampling using fine needle cytology or a core biopsy (16 & 11).
Cancer of the male breast is a rare disease accounting for less than 1% of cancers in men as well as less than 1% of all breast cancers.Male breast cancer is similar to female one , but characterized characterized by a high hormone receptors positivity. Gynaecomastia is found in association with male breast cancer but there is no convincing evidence associating gynaecomastia with the development of breast cancer (10&13).
In our series, two cases of breast cancer were encountered (2/75) with a relative frequency of incidence about 2.6 %. Patients presented with hard lumps, one case was associated with gynacomastia and the other one was not. The differentiation between breast cancer and unilateral gynaecomastia was a diagnostic problem. However, by mammography cancer is usually eccentric and discrete and the speculated margins are not surrounded by radiolucent halo as opposed to dendritic gynecomastia whereas the dendritic extensions to the deeper fatty tissue are usually surrounded by radiolucent halos. Gynacomastia usually presents with a central subareolar mass, however cancer breast is more likely to be eccentric and discrete (Figure 8). Microcalcification which is a sign of breast cancer is not reported in gynaecomastia. Ultrasonography is the imaging method of choice, diagnostic criteria for female counterpart can be safely applied to male cancer breast (solid , hypoechic , irregular outline , taller than wide, microcalcification, non-homogenous back-shadowing ..etc) (figure 8) . Thus additional sonography of the breast should be performed to increase the diagnostic confidence (14) . When breast cancer presents with a non-calcified central subareolar mass with a questinable radiologic appearance , the integration of biopsy and cytology is therefore be a must (10 & 7).
Gynaecomastia and fibroadenoma !
Although there are characteristic mamographic features that allow breast cancer in men to be recognized, there is substantial overlap between features and mammographic appearances of benign conditions and hence breast ultrasound plays a major role .
The finding of fibroadenoma implies the development of the terminal ductal lobular unit (TDLU) which is abnormal in male , suggesting that the breast has come under oestrogen or oestrogen -like influence. Fibroadenoma appears on mammography as a welldefined dense mass and by ultrasound it is seen as a solid hypoechoic lesion (figure 7) .It is very important in male breast to differentiate fibroadenoma and other benign lumps from the nodular pattern of gynaecomastia and ultrasound plays an important role in this issue and also provide guidance to FNB (12).