74 patients are considered,
of which 58 cases (78%) present benign pathology with a mean age of 43.6 years.
Fig. 3
Within this group the majority of lesions is related to gynecomastia (48 cases,
83%),
of which 26 cases (54%) are gynecomastia bilateral and 22 cases (46%) unilateral.
Within bilateral gynecomastia,
the subdivision is made between asymmetric bilateral gynecomastia (16 cases,
61%) and symmetric bilateral (10 cases,
39%).
Between the asymmetric bilateral gynecomastia there is a majority of cases of the left breast (9 cases,
56%),
as well as the unilateral gynecomastia (14 cases,
63%).
Left asymmetrical bilateral gynecomastia is indeed reported in literature as more frequent,
being the cause of this unknown (4) (5).
There are three patterns that can be seen with mammography,
namely nodular,
dendritic,
and diffuse gynecomastia with two characteristic US patterns,
namely focal and hypoechoic,
and diffuse and hyperechoic.
These patterns are related with the gynecomastia development which ranges from the glandular hyperplasia to a more diffuse fibrosis (3).
Fig. 4 Fig. 5 Fig. 6 Fig. 7
The treatment of gynecomastia normally involves the evaluation of physiological causes such as the hormonal unbalance during puberty,
with spontaneous regression as a result in most cases.
Also,
its regression can be achieved with the interruption of the offending drug / medication or the treatment of the hormonal unbalance,
provided the fibrosis is not already irreversible.
If the gynecomastia is refractory to hormonal or medic manipulations,
a possible treatment could be selective modulators of the receptor of oestrogens or aromatase inhibitors.
As a last resort,
surgical therapy could be considered for patients with unacceptable symptoms (2).
The resting cases of benign pathology are 4 lipomas (7%),
2 pseudogynecomastia (3.4%),
1 inflammation (1.7%),
1 hematoma/fat necrosis (1.7%),
1 hamartoma or fibroadenolipoma (1.7%) and 1 epidermal inclusion cyst (1.7%).
Lipoma was diagnosed in 4 patients with a frequency of 50% in each breast.
Clinically it manifests as a soft and non-painful mass.
At US an oval slightly hyperechoic and relatively avascular mass is discovered.
Occasionally,
it can be hypoechoic or isoechoic Fig. 8 No mammography was carried out.
However,
in medical literature this is associated with a lesion of fat density,
radiotransparent and circumscribed (6).
Lipomas are benign mesenchymal tumours that are composed of mature adipose tissue.
Surgical scission will be performed only for aesthetical reasons (3).
Two patients presented pseudogynecomastia,
bilateral in both cases.
In the physical exploration of these patients an enlargement of the male breast was found,
reason for which they consulted the medical practitioner.
The mammographic or US findings have shown fat content with absence of glandular tissue.
Fig. 9
One patient presented inflammation of the right breast.
Symptoms are typical of acute infection with pain,
erythema,
heat,
skin thickening,
and edema (6).
In medical literature,
acute mastitis presents in the mammography,
as a unilateral breast enlargement with skin thickening,
and retroareolar density increase (7).
In this work,
at US hypoechoic bands are found,
in relation with the breast edema.
Fig. 10 Follow-up is carried out until the breast went back to its normal dimensions.
Acute mastitis is a limited infectious process caused by bacteria such as staphylococci or less commonly streptococci,
but it can complicate with abscess formation (6).
Another patient presented a lesion compatible with fat necrosis or hematoma in the right breast.
It is a benign lesion,
correspondent to a sequel of the breast fat that is generally referred to a breast trauma or surgery.
In our work,
at US an oval nodule presented,
circumscribed,
hyperechoic with an anechoic area within,
parallel to the cutaneous plane and with good sonic transmission.
At US Doppler is avascular.
Fig. 11 In case flow is present,
an underlying neoplasm should be suspected (3).
Follow-up was carried out,
observing its reduction until disappearance both by image and clinically with absence of pain.
It is known in literature that these lesions present a variable aspect in mammography,
which ranges from masses,
up to distortions and dystrophic calcifications.
In doubtful cases,
biopsy is indicated (3).
One patient presented hamartoma,
also known as fibroadenolipoma,
in the left breast.
Mammogram shows well-circumscribed,
oval mass surrounded by a thin pseudocapsule and containing both fat and soft-tissue densities (both radiolucent and radiodense components).
Sometimes this is described as a”breast within a breast” or a "slice of sausage" appearance.
At US,
internal echotexture mixed with both hyperechoic and hypoechoic components (8).
As well as women if these findings are confirmed,
it is not necessary to carry out a biopsy and it is classified category BIRADS 2.
(9) Fig. 12
Another patient presented an epidermal inclusion cyst in the right breast.
It is a lesion of cutaneous or subcutaneous localisation and it represents the third cause of benign lesion in the male breast.
At clinical examination,
it presents as a rounded nodule,
soft,
adhered to the skin but with some mobility.
At US the epidermal inclusion cyst presents as a well-defined and hypoechoic mass,
with posterior enhancement (7) Fig. 13 .
However,
this could also be of heteroechoic mass and be similar to a complex or solid lesion.
An important finding,
is that part of the lesion can localise between the two echogenic lines represented by the shallow and deep layers,
thereby suggesting its cutaneous origin (7).
At mammogram they present as high-density masses,
rounded and circumscribed,
with diameters ranging between 1 and 5 cm.
(7) They are peripherally localised,
in relation with the skin.
If the cyst breaks,
the lost of the well-circumscribed margins can take place,
thereby making it difficult the differential diagnosis with a malign lesion at mammogram (10).
We find malign pathology in 4 cases (5.4%),
being all of them unilateral. Mean age is 66 years.
The histological results are 3 non-specific infiltrating ductal carcinomas and 1 papillary encapsulated carcinoma with focuses of non-specific infiltrating ductal carcinomas.
Patients consulted for palpation of a retroareolar mass and/or with retraction of the nipple.
At mammogram,
one of non-specific infiltrating ductal carcinoma in the left breast presented as an irregular mass,
spiculated retroareolar eccentric to the nipple with retraction of the latter and adjacent to the areolar-nipple complex.
At US it presents as a spiculated hypoechoic mass,
eccentic to the nipple.
Fig. 14
The other two non-specific infiltrating ductal carcinomas (both in the right breast) present themselves respectively as a lobuled mass and as a partially indistinct margins mass with microcalcifications.
The latter present at US a hypoechoic irregularly - shape solid mass with non-circumscribed margins,
internal vascularisation and eccentric to the nipple.
Fig. 15
The papillary encapsulated carcinoma with focuses of non-specific infiltrating ductal carcinoma presented as a retroareolar nodule in the left breast,
lobulated,
well circumscribed,
and dense at mammogram.
It presented amorphous and pleomorphic microcalcifications.
At US a hypoechoic heterogeneous solid nodule presented,
irregular margins with echogenic focus within (microcalcifications).
Biopsy was carried out in all cases.
Fig. 16 The presence of microcalcifications is less common appearing coarser and less linear than in female breast cancers (2).
Treatment of male breast cancer depends on the stage of disease at the time of diagnosis and the hormone receptor status of the tumour.
The resting 12 cases (16.2%) are normal,
with 44 years mean age.
Mammography of normal male breast is composed of skin and fat elements.
At US the skin presents as hyperechoic,
hypoechoic fatty lobules and the pectoral muscle.
Fig. 2