SCIENTIFIC EXHIBIT

Mammographic
Appearances of Male
Breast Disease1
Alan H. Appelbaum, MB, BCh
Gregory F. F. Evans, MB, ChB
Karen R. Levy, MD
Robin H. Amirkhan MD
Terence D. Schumpert, MD

LEARNING
Various male breast diseases have characteristic mammographic appear-
OBJECTIVES ances that can be correlated with their pathologic diagnoses. Male breast
After reading this article cancer is usually subareolar and eccentric to the nipple. Margins of the
and taking the test, the
reader will be able to: lesions are more frequently well defined, and calcifications are rarer and
coarser than those occurring in female breast cancer. Gynecomastia usu-
• Demonstrate familiarity ally appears as a fan-shaped density emanating from the nipple, gradually
with risk factors, histo-
pathologic features, and blending into surrounding fat. It may have prominent extensions into
clinical presentation of surrounding fat and, in some cases, an appearance similar to that of a
male breast cancer and
gynecomastia.
heterogeneously dense female breast. Although there are characteristic
mammographic features that allow breast cancer in men to be recog-
• Recognize the mammo- nized, there is substantial overlap between these features and the mam-
graphic characteristics of
gynecomastia. mographic appearance of benign nodular lesions. The mammographic
• Recognize the mammo- appearance of gynecomastia is not similar to that of male breast cancer,
graphic findings sugges- but in rare cases, it can mask malignancy. Gynecomastia can be mim-
tive of malignancy in the icked by chronic inflammation. All mammographically lucent lesions of
male breast.
the male breast appear to be benign, similar to such lesions in the female
• Identify the mammo- breast.
graphic characteristics of
less common lesions in the
male breast.

Index terms: Breast, diseases, 00.731, 00.744, 05.75 • Breast neoplasms, male, 05.329

RadioGraphics 1999; 19:559–568

1From the Departments of Radiology (A.H.A., G.F.F.E.) and Pathology (R.H.A.), Veterans Affairs Medical Center, 4500 S
Lancaster Ave, Dallas, TX 75216 and the Departments of Radiology (A.H.A., G.F.F.E., K.R.L., T.D.S.) and Pathology
(R.H.A.), University of Texas Southwestern Medical Center, Dallas. Recipient of a Certificate of Merit award for a scien-
tific exhibit at the 1997 RSNA scientific assembly. Received April 30, 1998; revision requested May 27; final revision re-
ceived November 5; accepted November 5. Address reprint requests to A.H.A.
©RSNA, 1999

559
 ■ INTRODUCTION Causes of Gynecomastia
Gynecomastia and breast cancer are the two
most important diseases of the male breast. Physiologic
Most other diseases found in the male breast Senescence
arise from the skin and subcutaneous tissues Puberty
Hormonal
(eg, fat necrosis, lipoma, and epidermal inclu-
Klinefelter syndrome
sion cysts). Some lesions that are common in Hypogonadism
the female breast (eg, fibroadenomas) do not Systemic disease
occur in the male breast (1, pp 342–346). Cirrhosis
Much less is known about mammography in Chronic renal insufficiency
men compared with women. We, therefore, Neoplasm
decided to correlate the mammographic ap- Adrenal carcinoma
pearances and pathologic diagnoses in 97 cases Pituitary adenoma
of histologically proved male breast disease. The Hepatocellular carcinoma
pathologic diagnoses in this series included gy- Drug use
necomastia (n = 65 cases), infiltrating ductal Cimetidine
Marijuana
carcinoma (n = 9), infiltrating ductal carcinoma
Thiazide diuretics
with an in situ component (n = 3), normal (n = Omeprazole
5), lipoma (n = 4), lymph node (n = 3), epider- Tricyclic antidepressants
mal inclusion cyst (n = 2), subareolar abscess Spironolactone
(n = 2), fat necrosis (n = 1), chronic inflamma- Diazepam
tion (n = 1), hematoma (n = 1), and subcutane- Anabolic steroids
ous leiomyoma (n = 1). Sixty-one of the 65 cases Exogenous estrogen
of gynecomastia and 11 of the 12 cases of male Idiopathic
breast cancer were diagnosed as such mammo- Sources.—References 3 and 5.
graphically.
In this article, we describe and illustrate the
mammographic and pathologic appearances of
gynecomastia, male breast cancer, and several cases of male breast cancer have been reported
less common entities as seen in these 97 cases to be associated with gynecomastia, no definite
and as discussed in prior literature. causality has been established (5).

■ GYNECOMASTIA ● Mammographic Appearance with

● Clinical Characteristics
Gynecomastia is common; in one series, 57%
of the male population over 44 years of age
had palpable breast tissue (2). Gynecomastia is
characterized by hyperplasia of ductal and stro-
mal elements of the male breast. It manifests
clinically as a soft, mobile, tender mass in the
retroareolar region (3). Gynecomastia has been
associated with an increased serum level of es-
tradiol and a decreased level of testosterone.
This increased estradiol-to-testosterone ratio
may arise from physiologic changes at puberty
and senescence, but it may also be caused by
endocrine and hormonal disorders, systemic
diseases, neoplasms, and certain drugs (3,4)
(Table).
Although gynecomastia and male breast can-
cer have many similarities and up to 40% of
Pathologic Correlation
Three mammographic patterns of gynecomas-
tia have been described: nodular, dendritic,
and diffuse. Nodular gynecomastia appears as a
fan-shaped density radiating from the nipple; it
may be symmetric or more prominent in the
upper, outer quadrant. The density usually
blends gradually into the surrounding fat, but it
may be more spherical (3,4,9,10) (Fig 1). The
nodular pattern correlates with the pathologic
classification of florid gynecomastia, which is
thought to be the early phase of gynecomastia.
At histologic analysis, florid gynecomastia is
characterized by hyperplasia of the intraductal
epithelium with loose, cellular stroma and sur-
rounding edema (Figs 2, 3).
Dendritic gynecomastia appears as a retro-
areolar soft-tissue density with prominent ex-
tensions that radiate into the deeper adipose
tissue (Fig 4). The dendritic pattern correlates
with the pathologic classification of fibrous gy-
necomastia, which is thought to occur when

560 ■ Scientific Exhibit Volume 19 Number 3

 Figure 3. Florid (nodular) gynecomastia. Photomi-
a. b. crograph (original magnification, ×400; Papanicolaou
stain) of a fine-needle aspirate demonstrates clusters
Figure 1. Nodular gynecomastia. (a) Craniocaudal
of bland, cohesive, ductal epithelial cells.
mammogram shows a subareolar density that appears
wedge shaped. (b) On the mediolateral oblique view,
the density appears more rounded. Note the gradual
tapering of soft tissue into surrounding fat.

Figure 2. Florid (nodular) gynecomastia. Photomi-
crograph (original magnification, ×40; hematoxylin-
eosin stain) of a surgical biopsy specimen shows pro-
liferation of irregularly branching ducts surrounded
by loose, edematous, periductal stroma and residual
adipose tissue.
a. b.
Figure 4. Dendritic gynecomastia. Mediolateral
oblique (a) and craniocaudal (b) mammograms show
stranded densities, which radiate from the nipple
and are more prominent in the upper outer quadrant.

May-June 1999 Appelbaum et al ■ RadioGraphics ■ 561

 Figure 6. Diffuse glandular gynecomastia. Medio-
lateral oblique mammogram of a male breast dem-
Figure 5. Fibrous (dendritic) gynecomastia. Photo- onstrates an appearance that is very similar to that
micrograph (original magnification, ×100; hematoxy- of a heterogeneously dense female breast.
lin-eosin stain) of a surgical biopsy specimen reveals
dense, sparsely cellular, fibrous stroma; no periductal
edema; and minimal surrounding adipose tissue.

gynecomastia has been long-standing (9). The

histologic characteristics of fibrous gynecomas-
tia are ductal proliferation with dense, fibrotic
stroma (9,10) (Fig 5).
Diffuse glandular gynecomastia has a mam-
mographic appearance similar to that of a het-
erogeneously dense female breast (4,10) (Fig 6).
These three mammographic patterns were
adequate to describe all 65 cases of gyneco-
mastia in our series. However, there were two
cases of histologically proved gynecomastia in
which the subareolar density was so small that
classification was difficult (Fig 7). In the 61 cases
of mammographically diagnosed, histologically
proved cases of gynecomastia, 47 (77%) cases
were classified as nodular, 12 (20%) as den-
dritic, and two (3%) as diffuse glandular. In the a. b.
55 cases of mammographically diagnosed, his- Figure 7. Gynecomastia. (a) Craniocaudal mam-
tologically proved gynecomastia in which bilat- mogram shows minimal density radiating from the
eral mammograms were available, 46 (84%) nipple. This finding was histologically proved to
cases were bilaterally asymmetric, one (2%) represent gynecomastia. (b) Magnified view demon-
was bilaterally symmetric, and eight (14%) strates gradual feathering of soft tissue into fat.
were unilateral.

■ MALE BREAST CANCER cases in men. It manifests clinically as a hard,

● Clinical Characteristics
Male breast cancer is substantially less common
than gynecomastia and accounts for 1% (6) of
all cases of breast cancer and 0.17% of all cancer
fixed, painless mass. Bloody nipple discharge is
common (7).
Risk factors for development of male breast
cancer include advanced age, exposure to ion-
izing radiation, occupational exposure to elec-
tromagnetic field radiation, cryptorchidism, tes-

562 ■ Scientific Exhibit Volume 19 Number 3


8. 9. 10.
Figures 8–10. Infiltrating ductal carcinoma.
(8) Craniocaudal mammogram shows a lobulated
mass with a primarily well-defined margin and ec-
centrically located relative to the nipple. (9) Cranio-
caudal mammogram shows a retroareolar mass with
ill-defined margins and nipple retraction. (10) Infil-
trating ductal carcinoma with an in situ component.
Craniocaudal mammogram reveals a lobulated mass
with ill-defined margins and coarse calcifications.
Nipple retraction is also seen.
Figure 11. Infiltrating ductal carcinoma. Photomi-
crograph (original magnification, ×200; hematoxy-
lin-eosin stain) of a surgical biopsy specimen shows
rounded and linear groups of infiltrating malignant
cells with solid and glandular foci.
May-June 1999
Figure 12. Infiltrating ductal carcinoma. Photomi-
crograph (original magnification, ×400; Papanico-
laou stain) of a fine-needle aspirate demonstrates
poorly cohesive groups of large, crowded, pleomor-
phic cells with increased nuclear-to-cytoplasmic ra-
tios, irregular membranes, and macronucleoli.
ticular injury, Klinefelter syndrome, liver dys-
function, family history of breast cancer, and
previous chest trauma (3,4,6,8).
The histologic type of most cases of male
breast cancer is either infiltrating ductal carci-
noma or ductal carcinoma in situ because the
normal male breast contains only ducts, and even
in men with gynecomastia, lobule formation is
rare. However, all other subtypes of carcinoma
seen in women have been found in men (6).
● Mammographic Appearance
Male breast cancer usually occurs in a subare-
olar location or is positioned eccentric to the
nipple; occasionally, it occurs in a peripheral
position. The margins of the lesions may be
well defined, ill defined, or spiculated. The le-
sions may be round, oval, or irregular and are
frequently lobulated. Calcifications are fewer
in number, coarser, and less frequently rod-
shaped than those seen in female breast cancer
(Figs 8–12). Secondary features include skin
thickening, nipple retraction, and axillary
lymphadenopathy (3,4,10,11) (Figs 13, 14).
Appelbaum et al ■ RadioGraphics ■ 563
 a. b.

13. 14.
Figures 13, 14. Infiltrating ductal carcinoma.
(13) Craniocaudal mammogram shows a small lobu-
lated mass with well-defined borders and eccentri-
cally located relative to the nipple. There is obvious
nipple retraction. (14) Mediolateral oblique mam-
mogram reveals a subareolar mass with ill-defined
margins and overlying skin thickening.

In our series, there were 12 cases of male

breast cancer, and calcifications were evident
in three, nipple retraction in seven, and skin
thickening in seven. In 10 cases, the carcinoma
manifested as a nodular lesion, with six lesions
being eccentric, three central, and one distant
relative to the nipple (Fig 15). Six lesions were
well-defined and four ill-defined. Five were
lobulated, one round, and four ovoid. In the re-
maining two cases of primary breast cancer,
one manifested as an ulceration and one was
not visible because it was obscured by con-
comitant gynecomastia (Fig 16).
■ NORMAL MALE MAMMOGRAPHIC
FINDINGS AND LUCENT LESIONS
The normal male mammogram demonstrates
lucent fat with a few strands of ductal or con-
nective tissue extending from the nipple (4,9)
(Fig 17). In four cases in our series, the mam-
c.
Figure 15. Infiltrating ductal carcinoma. (a) Me-
diolateral oblique mammogram shows a mass (arrow),
distant from the nipple and overlying the pectoralis
muscle. A few pleomorphic microcalcifications are
seen adjacent to the mass, which is partially obscured
by gynecomastia. (b) Magnification compression view
better demonstrates the mass and adjacent microcal-
cifications. (c) Photomicrograph (original magnifica-
tion, ×40; hematoxylin-eosin stain) of a resected speci-
men shows linear groups of carcinoma cells with
glandular foci (left) infiltrating an area of fibrous gy-
necomastia (right).
mograms were interpreted as normal, but the
pathologic diagnoses were lipoma, fat necrosis,
adipose tissue, and hematoma.

564 ■ Scientific Exhibit Volume 19 Number 3


Figure 16. Bilateral infiltrating ductal carcinoma
with an in situ component and gynecomastia. Cranio-
caudal mammograms demonstrate a nodule medial
to the nipple (arrow) and retroareolar gynecomastia
in the right breast as well as gynecomastia in the left
breast. The gynecomastia in the left breast obscured
a 1-cm invasive carcinoma.
Lipomas usually do and fat necrosis can ap-
pear lucent (10,12); thus, the lesions in both of
these cases could have been masked by sur-
rounding lucent fat. A lipoma can also manifest
as a lucent nodule with a thin radiopaque cap-
sule, and fat necrosis can vary from a lucent
nodule to an irregular, spiculated soft-tissue
density mass. Calcifications can occur in fat
necrosis and can be ringlike or angular and
branching (10).
The case diagnosed from the biopsy speci-
men as adipose tissue could have represented
either lipoma, pseudogynecomastia (fat deposi-
tion in the male breast), or normal male breast
tissue. Pseudogynecomastia is difficult to dis-
tinguish from a normal male breast at mam-
mography (4). Diagnosis requires clinical corre-
lation for breast enlargement. Biopsy of a nor-
mal male breast or pseudogynecomastia would
yield adipose tissue. Biopsy of a lipoma may
show a fibrous capsule but frequently yields
only adipose tissue.
May-June 1999
a. b.
Figure 17. Mediolateral oblique (a) and cranio-
caudal (b) mammograms show normal lucent fat
with strands of ductal and connective tissue radiat-
ing from the nipple.
In the case diagnosed as hematoma, review
of the mammograms revealed a small, ill-de-
fined density, which would be consistent with
hemorrhage.
■ OTHER BENIGN BREAST LESIONS
● Epidermal Inclusion Cyst
Epidermal inclusion cysts are usually round,
well-circumscribed, dense masses ranging from
1 to 5 cm in diameter. The cysts are composed
of laminated keratin with a wall of epidermis. If
the cysts rupture, an inflammatory reaction en-
sues (13), and the resulting strandedness and
indistinct margins of the ruptured cysts make it
difficult to distinguish them from malignant le-
sions at mammography.
In our series, there were two cases of epi-
dermal inclusion cysts. One case had the typi-
cal mammographic appearance, and one had
the appearance of inflammation (Figs 18–20).
Appelbaum et al ■ RadioGraphics ■ 565
 Figure 20. Epidermal inclusion cyst. Photomicro-
graph (original magnification, ×100; hematoxylin-
eosin stain) of a resected specimen demonstrates a
subcutaneous or intradermal cyst lined by true squa-
mous epithelium and filled with horny, keratinaceous
18. 19.
material.
Figures 18, 19. Epidermal inclusion cyst.
(18) Craniocaudal mammogram shows a dense, well-
defined nodule distant from the nipple and gyneco-
mastia. (19) Mediolateral oblique mammogram dem-
onstrates two adjacent nodules and scattered calcifi-
cations. Margins of the inferiorly located nodule are
obscured by stranded densities. The superiorly lo-
cated nodule has primarily well-defined borders but
is obscured along the inferior margin. Both nodules
proved to be epidermal inclusion cysts. Obscuration
of borders is presumed to be secondary to inflam-
mation from rupture of the lower cyst.

● Subcutaneous Leiomyoma
Subcutaneous leiomyomas in the male breast
have previously been described as having spicu-
lated margins and being associated with localized
skin thickening and retraction (14). These find-
ings, however, were not seen in the single case
in our series, in which the sole mammographic
finding was an enlarged nipple (Figs 21, 22).

● Subareolar Abscess
Subareolar abscess is a chronic lesion associated
with duct ectasia, which tends to recur unless
treated by excision of both the abscess and duct
(15). We have seen no prior descriptions of the
mammographic appearance of this lesion in male
patients.
Two cases of subareolar abscess were seen
in our series. In one, the abscess appeared as a
nodule with indistinct borders and punctate
calcifications (Fig 23). In the second case, no
Figure 21. Subcutaneous leiomyoma. Craniocaudal
mammogram shows an enlarged nipple, which proved
to be a subcutaneous leiomyoma. Gynecomastia is
evident.
discrete mass was seen, and only stranded den-
sities radiating from the nipple were noted. This
case was originally mistaken for gynecomastia,
but a review of the images revealed skin thick-
ening, a finding suggestive of the correct diag-
nosis (Fig 24).

566 ■ Scientific Exhibit Volume 19 Number 3


Figure 22. Subcutaneous leiomyoma. Photomicro-
graph (original magnification, ×50; hematoxylin-eosin
stain) of a resected specimen reveals a poorly de-
marcated mass composed of interlacing bundles of
bland, benign smooth muscle fibers with varying
amounts of intermingled collagen bundles.
23. 24.
Figures 23, 24. Subareolar abscess. (23) Magni-
fied craniocaudal view reveals a nodule with indis-
tinct borders and punctate calcifications, located
posterior to the nipple. (24) Mediolateral oblique
mammogram shows stranded inflammatory changes
that mimic gynecomastia. No mass is identifiable,
but skin thickening is seen.
May-June 1999
Figure 25. Intramammary lymph node. Me-
diolateral oblique mammogram shows a nodule
with a lucent center and well-defined borders.
● Lymph Nodes
A well-defined nodule in the upper outer quad-
rant of the breast with a lucent center or hilar
notch is considered pathognomonic of an intra-
mammary lymph node (1, p 105).
In our series, there were three cases of intra-
mammary lymph nodes, which manifested as
well-defined breast nodules. One contained a
lucent center and had a well-defined margin
and was interpreted as a benign lymph node
(Fig 25). The other two did not demonstrate a
lucent center or a hilar notch and were consid-
ered potentially malignant.
■ CONCLUSIONS
Breast cancer in men has mammographic fea-
tures that allow it to be recognized, but there is
a significant overlap in the mammographic ap-
pearances of benign nodular breast lesions and
breast cancer. Both malignant and benign lesions
may show either circumscribed or poorly de-
fined margins. Coarse calcifications are seen in
both benign and malignant masses. A location
distant from the nipple may be the most useful
finding to suggest a benign lesion, but it is not
definitive. In our series, nipple retraction was
seen only in malignant lesions, but it was not
present in five of the 12 cases of male breast can-
cer. At our institution, tissue diagnosis of nodu-
lar lesions is pursued unless malignancy can be
definitively excluded on the basis of mammo-
graphic or clinical findings.
Appelbaum et al ■ RadioGraphics ■ 567
 The mammographic appearances of gyneco-
mastia and breast cancer do not overlap. How-
ever, gynecomastia can be mimicked by chronic
inflammatory conditions (Fig 26). In our series,
malignancy was masked in only one of 61 cases
of mammographically diagnosed, histologically
proved cases of gynecomastia. In this case, a
mass coexistent with gynecomastia was sus-
pected clinically. We recommend that biopsy
should not be performed routinely when gyneco-
mastia is seen but only if a coexistent lesion is
suspected clinically or mammographically.
All mammographically “invisible” lesions of
the male breast in our series were benign, and
similar lesions in the female breast have been
described as lucent lesions. Lucent lesions of
the female breast are invariably benign (1, p
68). We have no reason to believe that this is
different in men.
Figure 26. Chronic inflammation. Mediolat-
Acknowledgments: We gratefully acknowledge eral oblique mammogram demonstrates stranded
the assistance of Nancy S. Gray for photography, Su- densities radiating from the nipple that mimic
san A. Boshart, RT(R) (M), for locating cases, and gynecomastia. These findings actually repre-
Dorothy P. Smith, BA, for composition of the scien- sented chronic inflammation and fibrosis from
tific exhibit associated with this article. a wound that would not heal.

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568 ■ Scientific Exhibit Volume 19 Number 3