127

Male

D. David

Dershaw1

Mammography

Over a 7-year

period,
94 mammograms
were performed
for male breast disease.
breast enlargement,
tenderness,
mass, and previous mastectomy.
Fatty enlargement
was easily diagnosed.
Gynecomastia
was unilateral in 28 of 40 cases
and easily differentiated
from malignancy
in all but one patient in whom nipple retraction
was present. In cases of bilateral gynecomastia,
eight showed asymmetric
involvement.
Three carcinomas
were studied, two of which were clinically obvious. One asymptomatic
cancer was detected
on routine follow-up in a man with previous mastectomy.
Indications

included

Mammography
of the male breast is an unusual examination,
constituting
well
under 1% of all mammograms
performed
at this institution
in the past 7 years. The
diagnoses
were limited to fatty enlargement
of the breasts, which is not a pathologic
phenomenon,
gynecomastia,
and carcinoma.
Less than 1% of all breast cancers
occur in men and this constitutes
0.2% of malignancies
in men. Gynecomastia,
however,
is a common
entity, especially
in adolescent
boys and in men over 50. In
adolescents
some series cite its frequency
at 50% [1 ]. Experience
with mammography in men over a 7-year period is reviewed
here.

Materials

and

Methods

Between

1978 and January 1 985, 15,967 mammograms

were performed at this hospital.
94 (0.56%) were performed on 89 men. Follow-up data were available on 49 of
these patients and are the basis for this report.
Examinations were performed on dedicated mammography equipment, a CGA Senograph
with a nominal 0.6-mm focal spot, molybdenum target, beryllium window, and a 0.03-mm
molybdenum filter. Both mediolateral and craniocaudal views of each breast were routinely
done. In two patients, a previous mastectomy
had been performed
and unilateral mammography was performed on three occasions in each of these patients.
One
patient with
Of these,

gynecomastia

had

two

studies.

pathologic data were obtained by review of patient charts. Patients were

excluded from this series when charts were not available, surgery was performed outside
this institution, or there was inadequate clinical follow-up to confirm a diagnosis. Fifteen
patients had biopsies.
Clinical

and

Results
Received June 21 , 1985; accepted after revision
September

1 1 , 1985.

Department
of Diagnostic Radiology, Memorial
Sloan-Kettering
Cancer
Center,
1 275 York Ave.,
NewYork, NY 10021.
I

AJR 146:127-131, January 1986

0361-803X/86/1461-0127
C American
Roentgen Ray Society

Of the 49 patients studied,

40 had gynecomastia,
five had fatty breasts without
true gynecomastia,
three had infiltrating
ductal carcinoma,
and one patient was
status post mastectomy
and was being followed with mammography
of the clinically
normal opposite
breast. Patients with gynecomastia
were aged 21 -81 years (mean,
56). Men with cancer
were aged 62, 74, and 82 (mean, 73).
Fatty breasts (fig. 1), which were often associated
with clinical obesity,
had an
absence of retroareolar
density, and except for increased
volume their pattern was
that of a normal male breast. The breasts were radiolucent
without
any mass or

128

DERSHAW

AJR:146,

January

1986

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Fig. 1 -Bilateral
density is present.

mediolateral mammograms. Fatty breasts. No retroareolar

Fatty density of breasts is interrupted only by supporting
stroma and vasculature.

Fig. 2.-Bilateral
mediolateral
mammograms. Bilateral gynecomastia,
left
greater than right, in 51 -year-old man. Cause is indeterminate. Flame-shaped,
glandular proliferation is symmetrically
positioned
behind nipple.

calcifications.
Three of these five patients
underwent
biopsy
for palpable
masses.
Histology
of the specimens
revealed
fatty or fibrofatty
tissue.
In patients with gynecomastia,
28 had unilateral and 1 2 had
bilateral disease.
In those affected
unilaterally,
the left breast
was involved in 1 5 patients
and the right in 1 3. Of those 12
men with bilateral disease, eight had one breast more severely
involved than the other. The left breast was more prominently
involved in five and the right in three.
All men with gynecomastia
showed
a pattern of glandular
proliferation
extending
from the nipple into the fatty tissue of
the breast. This glandular
density
was triangular
or flameshaped. In 27 men, this density was symmetrically
positioned
behind the nipple (fig. 2). Some asymmetry
in the pattern was
seen in 1 3 patients.
In no patients with gynecomastia
was a
coexistent
malignancy
found nor did one develop
in these
men during the period they were clinically observed.
One patient
with gynecomastia
had two mammograms
done 1 year apart (fig. 3). These showed
progressive
development of a ductal and glandular
pattern.
In patients
with unilateral
gynecomastia
of determinable
causes, all were drug-induced.
These included digitalis preparations in five patients and thiazides
in four. In addition, there
were single instances
due to spironolactone,
diazepam,
cyclophosphamide,
heroin-methadone
abuse,
and marijuanaLSD
abuse. Two patients had bilateral disease secondary
to

exogenous
estrogen
given as part of therapy
for prostate
carcinoma.
Vincristineand prednisone-induced
bilateral disease was seen in another
patient.
Three other men had
systemic
diseases
resulting
in bilateral gynecomastia.
These
included
cirrhosis,
chronic renal failure on dialysis,
and unspecified chronic liver disease with methadone
abuse.
Two men with prostate
carcinoma
who were receiving
exogenous
estrogen
had a mammographic
pattern that differed from that in all other patients.
They showed
a more
diffuse proliferation
of ductal and glandular elements
and their
mammograms
resembled
those of female breasts (fig. 4). In
one of these patients,
multiple nodules mimicked
a fibrocystic
pattern
(fig. 5). No further
evaluation
of this patient
was
performed.
Nine patients with mammographic
findings of gynecomastia
had biopsies at this center. In five the specimen
was read as
gynecomastia.
In the other four patients,
histologies
were
interpreted
as focal mastitis,
papillomatosis,
fibrosis and duct
hyperplasia,
and duct stasis
with penductal
mastitis
and
chronic inflammation.
One patient with gynecomastia
had nipple retraction
associated with a triangular
pattern
of retroareolar
density.
No
calcifications
were present.
The pattern was difficult clinically
and mammographically
to differentiate
from breast cancer,
and biopsy
was required
to exclude
this diagnosis.
Only
fibrofatty
tissue was found at biopsy.

AJR:146,

January

1986

MALE

MAMMOGRAPHY

Fig. 3.-Left
medaterel
mammograms, 1 year apart in 70-year-old man
followed for pronounced, right gynecomastia. Minimal, left subareolar density
on original study (A) was increased 1 year later (B).

Infiltrating
ductal carcinoma
was found in three men. In two
the lesion was clinically
apparent
(fig. 6). Routine,
follow-up
mammography
revealed a nonpalpable
nodule in one patient,
who had had a mastectomy
7 years earlier (fig. 7). Biopsy of
the mass identified
a new carcinoma,
and a modified
radical
mastectomy
was performed.
In this patient and in one of the
other two men, the axillary nodes were free of disease.
The
third patient had positive nodes at level 1.
The two cancers
that were clinically
evident were central
retroareolarlesions.
Nipple deformity
and skin thickening
were
present in both men. Scattered,
fine calcifications
were present in one breast, but were not associated
with the tumor
mass. They did not have the pattern of malignant
microcalcifications.
Their significance
was undetermined.
No increase
in vascularity
was associated
with either lesion.
The nonpalpable
malignancy
was eccentric
in the lower,
inner quadrant.
This 1 -cm nodule had incomplete
marginal
definition
and was new since the mammogram
performed
3
years earlier. No microcalcifications
or secondary
signs of
tumor were present.

Discussion
The normal male breast is composed
predominantly
of fat
with few secretory
elements.
Radiographically
it appears
lucent with a few strands coursing
through its volume.

129

Fig. 4.-Bilateral
mediolateral
mammograms.
Diffuse, markedly
increased,
glandular density bilaterally in man with carcinoma of prostate treated with
estrogen. Bilateral, prominent, draining veins are present.

The most common

indication
for mammography
in men is
gynecomastia.
The condition
has two peak periods:
one in
adolescence,
where it is reported
in greater
than 50% of
normal
boys aged 1 2-i 5, and again with advancing
age,
largely in men over 65 [1]. The earlier condition
is believed to
be due to elevated
serum estradiol.
The latter condition
may
reflect testicularfailure
with diminishing
levels of total and free
serum testosterone,
increasing
serum luteinizing
hormone,
and unchanged
serum estradiol
[1 ]. In addition,
a large numher of drugs and disease
states can induce gynecomastia.
Drug-induced
gynecomastia
was seen in many patients in the
present series. Digitalis preparations
and thiazides were most
often responsible,
but spironolactone,
diazepam,
exogenous
estrogen,
cyclophosphamide,
heroin-methadone
combination, and marijuana-LSD
combination
were also causative
agents.
Gynecomastia
also has been associated
with the
administration
of androgens,
human chorionic
gonadotropin,
methyl-dopa,
cimetidine,
isoniazid,
amphetamines,
reserpine,
and tricyclic antidepressants
[1]. A long list of disease states
may also produce gynecomastia.
Along with the chronic renal
and hepatic diseases seen in this series, these include resolving malnutrition,
disordered
thyroid function,
adrenal insufficiency and tumors,
Klinefelter
syndrome,
testicular
tumors,
and several other tumors and disease states [2]. Of all these
causes, only Klinefelter
syndrome
seems to have an increased
incidence
of breast cancer associated
with gynecomastia
[3].
On physical
examination
in gynecomastia,
a subareolar,

130

DERSHAW

Fig. 5.-Bilateral
prostatic

fibrocystic

carcinoma.

disease.

mediolateral
mammograms.
Man treated with estrogen
for
Dense, nodular pattern in both breasts resembles
female

AJR:146,

Fig. 6.-Right
ductal carcinoma.

retraction.

meduolateral mammograms
A, 74-year-old

man:

eccentric,

in two pabents with infiltrating

subareolar
mass and nipple

Left breast was normal. B, 82-year-old

and skin retraction.

mass with nipple

January 1986

man: stellate,

subareolar

AJR:i46,

January 1986

MALE

MAMMOGRAPHY

palpable mass, which may be well defined or more diffuse, is

present. A localized nodule may be palpable; tenderness
may
be present.
This condition
is usually reported
as predominantly unilateral.
However,
at least one recent series reports
a predominance
of bilateral
gynecomastia
[4]. In our 40
patients, 28 had unilateral disease, and eight of the 1 2 bilateral
disease cases had asymmetry
of involvement.
Histologically,
a pattern of dense, fibrous connective
tissue
is present.
Marked proliferation
of ducts and stroma is seen.
Formation
of acini and lobules has never been identified
[2,
5]. Some inflammatory
reaction may be present.
The prognosis
in this condition
depends,
as would
be
expected,
on the cause.
In adolescent
gynecomastia,
one
series demonstrated
resolution
in all but 8% of 52 boys at
the end of 3 years [6]. A series of 1 1 5 adult patients
with
adequate
follow-up
showed
44% with spontaneous
regression of their gynecomastia
[2]. In only five patients
in the
current series was a clinical description
of resolution
or diminution of symptomatology
found.
Carcinoma
of the male breast is an unusual lesion with a
frequency
equaling
only about 0.9% of the occurrence
of
female breast cancer [7] and 0.2% of all malignancies
in men
[1]. Peak age of the disease
is 60 with the peak incidence
in
the fifth and sixth decades
[4, 7]. A case of a 6-year-old
boy
with breast cancer has been reported;
thymic irradiation
had
been given at birth to this child [8]. The lesion may be central
or peripheral.
The central
position
is frequent,
and nipple
involvement
and ulceration
of the overlying
skin are common
[9]. When correlated
with lesions of similar stage in women,
the overall prognosis
is the same [10].
Radiographically,
microcalcifications
are an unusual finding.
Although
one report
claims
they are never present
[1 1],
another
series of 20 male breast cancers
had a 30% frequency of microcalcifications
within the tumor mass [1 2]. One
of our patients
had small calcifications
within fatty tissue
adjacent
to the tumor
mass, but these did not have an
appearance
of malignant
microcalcifications
and the significance of their association
was undetermined.
I have been
unable to find a report of a male breast cancer presenting
radiographically
as microcalcifications
without
an associated
mass.
The malignant
mass may be relatively
well delineated
or
may have a stellate appearance
like that of scirrhous
cardnoma in the female. As well defined breast nodules
in men
are likely to represent
cancer,
biopsy
of these lesions
is
indicated
[1 2]. The presence
of axillary
adenopathy
is an
important
prognostic
sign in men as well as in women.
No
adenopathy
was seen in our three patients.
On axillary dissection, axillary nodal metastases
were found in one of these
patients,
and this was limited to level 1 nodes.
No reports of mammography
in postmastectomy
men are
available.
The single case in this series of diagnosis
of a
nonpalpable
carcinoma
in a postmastectomy
man suggests

131

that mammography
may be indicated
on an annual basis in
these patients as it is in the postmastectomy
woman.
These
patients remain at risk for disease in the contralateral
breast.
Gynecomastia
may not always be readily differentiated
from
carcinoma.
Some degree of eccentricity
may be present
in
gynecomastia,
although
this is more pronounced
in carcinoma. Nipple retraction
may be associated
with gynecomastia
[1 3] as it was in one case in this series, and in this situation
biopsy may be needed
to exclude
the diagnosis
of malignancy.
Sonography
has been used to evaluate
gynecomastia.
Patterns
of retroareolar
hypoedhogenidty
or a more diffuse
pattern of increased
echoes is described
as characteristic
of
this condition
[1 4, 1 5]. A reported
case of sonography
of
male breast cancer indicated only subtle sonographic
findings,
although
obvious
malignant
mammographic
changes
were
present [16].

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