Radiography of Gynecomastia and Other Disorders of the Male Breast 1
Diagnostic Radiology
Lee G. Michels, M.D., Richard H. Gold, M.D., and Rolf D. Arndt, M.D. 2 Mammographic features of 22 pathologically proved cases reflecting disorders of the male breast are described. Two patterns of gynecomastia were observed: a dendritic pattern seen in association with breast enlargement for 6 months or more, and a more florid triangular pattern, seen in association with breast enlargement of recent onset. Male breast carcinoma may be distinguished from gynecomastia by its eccentric location, spiculation, and, in some cases, calcification or involvement of the skin and nipple. Benign conditions simulating carcinoma included a case of drug-induced gynecomastia and a case of inflamed inclusion cyst. Breast, abnormalities. Breast, male. Breast neoplasms, diagnosis • Mammography
INDEX TERMS:
Radiology 122: 117 -122, January 1977
•
A LTHOUGH OCCASIONAL reports have stressed the M value of mammography in the detection of carcinoma
mammography. Gynecomastia has been characterized as the male analogue of female mammary dysplasia (13). The enlargement of the breast in gynecomastia is due primarily to the proliferation of stroma in which hypervascularity, fibroblasts, and hyalinization are prominent features and in which true acinar lobules are usually absent. Stromal and ductal proliferation progresses from an early florid stage characterized by intraductal epithelial hyperplasia and a loose, cellular stroma to a late stage characterized by hyalinized stroma (12). The extremes of this spectrum have been termed by Williams (16), Type I, or florid gynecomastia, and Type II, or quiescent, fibrous gynecomastia. The histologic characteristics of each type are related to the duration of the gynecomastia and not to its cause. Bannayan and Hajdu (2) found that patients with gynecomastia of up to 4 months duration manifested the florid type, while those with gynecomastia for a year or more manifested the fibrous type. These authors also noted that pubertal gynecomastia and hormone-induced gynecomastia tended to be bilateral, while idiopathic gynecomastia and gynecomastia induced by nonhormonal drugs were usually unilateral, findings which are in agreement with those of Haagensen (8). Nonhormonal drugs which may induce gynecomastia include digitalis, reserpine, ergotamine, diphenylhydantoin, pheonothiazine, spironolactone, and thiazide diuretics. The resultant gynecomastia is more frequently unilateral than bilateral. Causes of bilateral gynecomastia include exogenous estrogen administration, embryonal cell carcinoma or coriocarcinoma of the tetis, Klinefelter's syndrome, adrenal carcinoma, marijuana use, cirrhosis of the liver, and chronic renal dialysis. Forman (7) described two mammographic patterns of gynecomastia: a dendritic pattern featuring a retro-areolar soft-tissue shadow with prominent extensions radiating into
of the male breast (1, 7, 14), the mammogaphic features of gynecomastia and of benign diseases have been the subject of too few detailed reports (9-11). The purpose of this report is: (a) to describe the mammographic features of gynecomastia, (b) to review its radiological classification, and (c) to highlight the features of some benign and malignant lesions which, because they are found in the male breast, may present a radiological puzzle. MATERIALS AND METHODS
All mammograms of male patients performed in the Mammography Clinic of the UCLA Department of Radiology from 1970 through 1975 were reviewed. Of a total of 34 mammographic examinations, the findings in 22 received pathological correlation. These 22 mammograms form the basis for this report and include 19 cases of gynecomastia, 1 inflammatory process, 1 adenocarcinoma, and 1 case of papillomatosis. DISCUSSION
The normal male breast: Because it consists predominantly of fat and contains few secretory ducts, the normal male breast is homogeneously radiolucent with few if any strands of ductal or interlobular connective tissue and without suspensory ligaments of Cooper (Fig. 1, A). Gynecomastia: Gynecomastia is an abnormal increase in the stromal and ductal components of the male breast. Breast enlargement that results from an increase in fat, such as accompanies obesity, is not true gynecomastia. Gynecomastia and adiposity, although not always distinguishable by palpation (11), are easily differentiated by
1 From the Department of Radiological Sciences (L. G. M., R. H. G.), University of California, School of Medicine, Los Angeles, Calif. Accepted for publication in July 1976. 2 Current address: Radiology Department, St. John's Hospital, Santa Monica, Calif. elk
117
Fig. 1. Normal male breast compared to triangular and intermediate types of gynecomastia. Normal breast. Mediolateral view discloses almost complete absence of both retro-areolar stranding and fibroglandular density. Stromal connective tissue within the mammary fat has a delicate pattern. B. Intermediate type gynecomastia. An 18-year-old with gradual breast enlargement over 3 years. Contralateral breast (Fig. 1, A) was normal. No endocrinologic abnormality. MammographY discloses considerable breast enlargement with a pattern intermediate between dendritic and triangular. Fibrous changes are superimposed upon the early florid, nondendritic pattern usually associated with juvenile gynecomastia. C. Triangular gynecomastia. A 21-year-old man with progressive enlargement of the left breast for 6 months. A homogeneous increase in density extends throughout the breast. Endocrinologic evaluation was negative. Subcutaneous mastectomy revealed gynecomastia featuring legends for D-F are on page' 19 extensive stromal and ductal collagen promeration. A.
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Fig. 2. Dendritic gynecomastia. A. Dendritic gynecomastia of unknown origin. A 67-year-old man noted progressive chronic enlargement of both breasts with recent onset of tenderness on the right. Mammograms reveal a generalized increase in the retro-areolar fibrous component of both breasts. Although a biopsy was not performed, follow-up revealed no clinical change for 3 years. B. Bilateral dendritic gynecomastia of unknown origin. A 51-year-Old man with a 5-year history of bilateral breast enlargement. Endocrinologic studies were negative except for slightly increased urinary estrogen level. Mammogram reveals extensive dendritic gynecomastia. Similar changes were present in the other breast. C and D. Spironolactone-induced dendritic gynecomastia. A 65-year-old man receiving spironolactone for hypertension, noted unilateral breast enlargement 2 weeks before mammography. Radiographs reveal a retro-areolar mass with distinct margins which on palpation was freely movable.
...- Figure 1, A-F is on page 118. D. Intermediate type of gynecomastia. A 29-year-old man with gradual enlargement of the left breast for 4 years. Cephalocaudal view reveals increased density throughout most of the breast. The posterior margin of the density is ill defined. Pathology: Ductal hypertrophy, stromal fibrosis, with a single intraductal papilloma not detectable in the mammogram. E. Triangular, drug-induced gynecomastia. A 53-year-old man with diphenylhydantoin-induced progressive breast enlargement for 5 months. Cephalocaudal view discloses trlanqular gynecomastia with benign-appearing calcification (arrow). F. Bilateral triangular gynecomastia associated with cirrhosis. Chronic alcoholic, age 67, with tenderness and enlargement of the left breast over a span of 3 months. Nodularity was palpable beneath both areolae and was more prominent on the left. Mammogram reveals subareolar masses of indistinct outline and venous prominence. Similar changes were present contralaterally.
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Fig. 3. A 64-year-old man with bloody discharge from the right nipple for 15 months. Physical examination revealed mild bilateral gynecomastia. Mammography reveals a slight increase in density (arrows) deep to the prominent nipple, compatible with mild gynecomastia. Fig. 4. Benign lesions masquerading as carcinomas. A. Drug-induced gynecomastia resembling carcinoma. A 54-year-old man under treatment for hypertension with spironolactone for 5 months, with a 3-week history of a nontender mass. Mammogram reveals a poorly marginated, slightly spiculated mass (arrows) beneath the areola and apparent skin thickening. B. Inflammatory lesion masquerading as carcinoma. A 52-year-old man with a 1-month history of a progressively enlarging, nontender subareolar mass. Mammogram discloses a homogeneous subareolar density. the margin of which is, in part, poorly delineated. Pathology revealed a ruptured epidermal inclusion cyst associated with fibrosis, chronic inflammation, and a foreign-body reaction.
the deeper adipose tissue, and a triangular, nondendritic pattern featuring a retro-areolar soft-tissue density with few, if any, radiating extensions. The dendritic pattern, present in four of our patients, could be correlated with the typical pathological features of the Type II or fibrous pattern and with gradual breast enlargement over a long duration (Fig. 2). The triangular pattern was present in 15 of our patients, usually those whose breast enlargement was of recent onset and featured Type I or florid pathological changes (Fig. 1, C, E, and F). Of these 15, 12 manifested breast enlargement for 6 months or less. Two patients with
breast enlargement of many years' duration featured combined pathological and mammographic features of both types (Fig. 1, B, and D). Other benign conditions: Inflammatory disease of the breast may present a difficult differential diagnostic problem both clinically and mammographically. Spiculation of the periphery of a lesion, nipple retraction, and thickening of skin may result either from the desmoplastic response incited by an underlying carcinoma, or from the scarring associated with an inflammatory process. Papillomas may result in a bloody discharge from the nipple and
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Fig. 5. Carcinoma. A. Scirrhous carcinoma and co-existent gynecomastia in a 58-year-old man. Mammography reveals a 3-cm by 4-cm central mass with iII-defined margins containing stippled calcifications typical of carcinoma (arrow). The skin is thickened and the nipple retracted, secondary to the desmoplastic reaction incited by the carcinoma. (Courtesy of Robert L. Egan, M.D.). B. Well-circumscribed carcinoma. A 72-year-old man had eccentric enlargement of the right breast for 3 months. Physical examination revealed a firm mass 3 cm in diameter, associated with skin retraction. Mammogram discloses a well-circumscribed homogeneous mass and a prominent duct between it and the thickened areola.
may be solitary or multiple (Fig. 3). Papillomatosis occurs in as many as 40 % of cases of florid gynecomastia (2) (Fig. 1, D). Carcinoma: Because the breast of males is smaller than that of females, a tumor within it is easier to palpate at a relatively smaller size. However, since a carcinoma anywhere within the male breast tends to be closer to the chest wall than in the female, earlier invasion of the chest wall is more likely to occur, resulting in a generally poorer prognosis (5). Fortunately, carcinoma of the male breast is rare, comprising less than 1% of all combined male and female breast carcinomas and fewer than 1.5 % of all cancers in men (4). Potential predisposing factors include Klinefelter's syndrome and therapeutic ionizing radiation to the chest wall during infancy or childhood (4, 6). The radiographic detection of breast cancer in the male
with gynecomastia is subject to the same pitfalls that pertain to the detection of breast cancer' in the female with mammary dysplasia. The diffuse increase in radiographic density accompanying florid gynecomastia may mask an underlying carcinoma. Moreover, even in a predominantly fatty breast a well-marqlnated mass, seemingly benign by mammographic criteria, may occasionally represent a carcinoma (Fig. 5, B), while a mass with an irregular, apparently infiltrating margin characteristic of carcinoma may turn out to be benign on microscopic examination (Fig. 4, A and B). The mammographic criteria for carcinoma of the male breast are the same as for the female. A carcinoma is usually eccentric in relation to the nipple, irregular or spiculated in outline, and may contain numerous tiny calcifications of angular or irregular shape (Fig. 5, A). Carci-
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noma may be associated with thickening of the skin and retraction of the nipple (Fig. 5, A and B). Males with Paget's disease of the nipple in association with underlying carcinoma, with inflammatory carcinoma or with simultaneous bilateral carcinomas, have been reported (3, 15, 17). Carcinoma of the male breast must be distinguished from gynecomastia. Bilateral, painful, central retro-areolar masses in a man less than 50 years of age most likely represent gynecomastia. Gynecomastia, however, may be unilateral, is occasionally eccentric, and may even cause nipple retraction. Moreover, gynecomastia and carcinoma may co-exist (2) (Fig. 5, A).
REFERENCES 1. Allen TS: Mammography in carcinoma of the male breast. Texas State J Med 60:47-48, Jan 1964 2. Bannayan GA, Hajdu SI: Gynecomastia: clinico-pathologic study of 351 cases. Am J Clin Path 57:431-437, Apr 1972 3. Coley GM, Kuehn PG: Paget's disease of the male breast. Am J Surg 123:444-450, Apr 1972 4. Crichlow RW: Carcinoma of the male breast. Surg Gynecol Obstet 134:1011-1019, Jun 1974 5. Crichlow RW, Kaplan EL; Kearney WH: Male mammary cancer: an analysis of 32 cases. Ann Surg 175:489-494, Apr 1972 6. Deutsch M, Altomare FJ, Mastian AS, et al: Carcinoma of the male breast following thymic irradiation. Radiology 116:413-414, Aug 1975 7. Forman M: Roentgenography of the male breast. Am J Roentgenol 88: 1126-1134, Dec 1962
January 1977
8. Haagensen CD: Diseases of the Breast. Philadelphia, Saunders, 2d ed, 1971, pp 76-84 9. Hoeffken W. Lanyi 1'..1: Rontgenuntersuchung der Brust. Stuttgart, Thieme, 1973, pp 231-237 10. Kalisher L, Peyster RG: Xerographic manifestations of male breast disease. Am J Roentgenol 125:656-661, Nov 1975 11. Liszka VG, Kallo A, Decker I: Vergleichende radiologische und morphologische untersuchung der asdiposemastie. febrosomastie und gynakomastie. Rontgenfortsch 108:233-237, Feb 1968 12. Nicolis GL, Modlinger RS, Gabrilove JL: A study of the histopathology of human gynecomastia. J Clin Endocr Metab 32:173-178, Jan 1971 13. Robbins SL: Pathology. Philadelphia, Saunders, 3d ed, 1967, P 1191 14. Rosen IW, Nadel HI: Roentgenographic demonstration of calcification in carcinoma of the male breast. Radiology 86:38-40, Jan 1966 15. Treves N: Inflammatory carcinoma of the breast in the male patient. Surgery 34:810-820, Nov 1953 16. Williams MJ: Gynecomastia: its incidence, recognition and host characterization in 447 autopsy cases. Am J Moo 34:103-112, Jan 1963 17. Wolloch Y, Zer M, Dintsman M, et al: Simultaneous bilateral primary breast carcinoma in the male. Isr J Med Sci 8: 158-162, Feb 1972
Department of Radiological Sciences Diagnostic Division University of California School of Medicine Los Angeles, Calif. 90024
Diagnostic Radiology
Lee G. Michels, M.D., Richard H. Gold, M.D., and Rolf D. Arndt, M.D. 2 Mammographic features of 22 pathologically proved cases reflecting disorders of the male breast are described. Two patterns of gynecomastia were observed: a dendritic pattern seen in association with breast enlargement for 6 months or more, and a more florid triangular pattern, seen in association with breast enlargement of recent onset. Male breast carcinoma may be distinguished from gynecomastia by its eccentric location, spiculation, and, in some cases, calcification or involvement of the skin and nipple. Benign conditions simulating carcinoma included a case of drug-induced gynecomastia and a case of inflamed inclusion cyst. Breast, abnormalities. Breast, male. Breast neoplasms, diagnosis • Mammography
INDEX TERMS:
Radiology 122: 117 -122, January 1977
•
A LTHOUGH OCCASIONAL reports have stressed the M value of mammography in the detection of carcinoma
mammography. Gynecomastia has been characterized as the male analogue of female mammary dysplasia (13). The enlargement of the breast in gynecomastia is due primarily to the proliferation of stroma in which hypervascularity, fibroblasts, and hyalinization are prominent features and in which true acinar lobules are usually absent. Stromal and ductal proliferation progresses from an early florid stage characterized by intraductal epithelial hyperplasia and a loose, cellular stroma to a late stage characterized by hyalinized stroma (12). The extremes of this spectrum have been termed by Williams (16), Type I, or florid gynecomastia, and Type II, or quiescent, fibrous gynecomastia. The histologic characteristics of each type are related to the duration of the gynecomastia and not to its cause. Bannayan and Hajdu (2) found that patients with gynecomastia of up to 4 months duration manifested the florid type, while those with gynecomastia for a year or more manifested the fibrous type. These authors also noted that pubertal gynecomastia and hormone-induced gynecomastia tended to be bilateral, while idiopathic gynecomastia and gynecomastia induced by nonhormonal drugs were usually unilateral, findings which are in agreement with those of Haagensen (8). Nonhormonal drugs which may induce gynecomastia include digitalis, reserpine, ergotamine, diphenylhydantoin, pheonothiazine, spironolactone, and thiazide diuretics. The resultant gynecomastia is more frequently unilateral than bilateral. Causes of bilateral gynecomastia include exogenous estrogen administration, embryonal cell carcinoma or coriocarcinoma of the tetis, Klinefelter's syndrome, adrenal carcinoma, marijuana use, cirrhosis of the liver, and chronic renal dialysis. Forman (7) described two mammographic patterns of gynecomastia: a dendritic pattern featuring a retro-areolar soft-tissue shadow with prominent extensions radiating into
of the male breast (1, 7, 14), the mammogaphic features of gynecomastia and of benign diseases have been the subject of too few detailed reports (9-11). The purpose of this report is: (a) to describe the mammographic features of gynecomastia, (b) to review its radiological classification, and (c) to highlight the features of some benign and malignant lesions which, because they are found in the male breast, may present a radiological puzzle. MATERIALS AND METHODS
All mammograms of male patients performed in the Mammography Clinic of the UCLA Department of Radiology from 1970 through 1975 were reviewed. Of a total of 34 mammographic examinations, the findings in 22 received pathological correlation. These 22 mammograms form the basis for this report and include 19 cases of gynecomastia, 1 inflammatory process, 1 adenocarcinoma, and 1 case of papillomatosis. DISCUSSION
The normal male breast: Because it consists predominantly of fat and contains few secretory ducts, the normal male breast is homogeneously radiolucent with few if any strands of ductal or interlobular connective tissue and without suspensory ligaments of Cooper (Fig. 1, A). Gynecomastia: Gynecomastia is an abnormal increase in the stromal and ductal components of the male breast. Breast enlargement that results from an increase in fat, such as accompanies obesity, is not true gynecomastia. Gynecomastia and adiposity, although not always distinguishable by palpation (11), are easily differentiated by
1 From the Department of Radiological Sciences (L. G. M., R. H. G.), University of California, School of Medicine, Los Angeles, Calif. Accepted for publication in July 1976. 2 Current address: Radiology Department, St. John's Hospital, Santa Monica, Calif. elk
117
Fig. 1. Normal male breast compared to triangular and intermediate types of gynecomastia. Normal breast. Mediolateral view discloses almost complete absence of both retro-areolar stranding and fibroglandular density. Stromal connective tissue within the mammary fat has a delicate pattern. B. Intermediate type gynecomastia. An 18-year-old with gradual breast enlargement over 3 years. Contralateral breast (Fig. 1, A) was normal. No endocrinologic abnormality. MammographY discloses considerable breast enlargement with a pattern intermediate between dendritic and triangular. Fibrous changes are superimposed upon the early florid, nondendritic pattern usually associated with juvenile gynecomastia. C. Triangular gynecomastia. A 21-year-old man with progressive enlargement of the left breast for 6 months. A homogeneous increase in density extends throughout the breast. Endocrinologic evaluation was negative. Subcutaneous mastectomy revealed gynecomastia featuring legends for D-F are on page' 19 extensive stromal and ductal collagen promeration. A.
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Fig. 2. Dendritic gynecomastia. A. Dendritic gynecomastia of unknown origin. A 67-year-old man noted progressive chronic enlargement of both breasts with recent onset of tenderness on the right. Mammograms reveal a generalized increase in the retro-areolar fibrous component of both breasts. Although a biopsy was not performed, follow-up revealed no clinical change for 3 years. B. Bilateral dendritic gynecomastia of unknown origin. A 51-year-Old man with a 5-year history of bilateral breast enlargement. Endocrinologic studies were negative except for slightly increased urinary estrogen level. Mammogram reveals extensive dendritic gynecomastia. Similar changes were present in the other breast. C and D. Spironolactone-induced dendritic gynecomastia. A 65-year-old man receiving spironolactone for hypertension, noted unilateral breast enlargement 2 weeks before mammography. Radiographs reveal a retro-areolar mass with distinct margins which on palpation was freely movable.
...- Figure 1, A-F is on page 118. D. Intermediate type of gynecomastia. A 29-year-old man with gradual enlargement of the left breast for 4 years. Cephalocaudal view reveals increased density throughout most of the breast. The posterior margin of the density is ill defined. Pathology: Ductal hypertrophy, stromal fibrosis, with a single intraductal papilloma not detectable in the mammogram. E. Triangular, drug-induced gynecomastia. A 53-year-old man with diphenylhydantoin-induced progressive breast enlargement for 5 months. Cephalocaudal view discloses trlanqular gynecomastia with benign-appearing calcification (arrow). F. Bilateral triangular gynecomastia associated with cirrhosis. Chronic alcoholic, age 67, with tenderness and enlargement of the left breast over a span of 3 months. Nodularity was palpable beneath both areolae and was more prominent on the left. Mammogram reveals subareolar masses of indistinct outline and venous prominence. Similar changes were present contralaterally.
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Fig. 3. A 64-year-old man with bloody discharge from the right nipple for 15 months. Physical examination revealed mild bilateral gynecomastia. Mammography reveals a slight increase in density (arrows) deep to the prominent nipple, compatible with mild gynecomastia. Fig. 4. Benign lesions masquerading as carcinomas. A. Drug-induced gynecomastia resembling carcinoma. A 54-year-old man under treatment for hypertension with spironolactone for 5 months, with a 3-week history of a nontender mass. Mammogram reveals a poorly marginated, slightly spiculated mass (arrows) beneath the areola and apparent skin thickening. B. Inflammatory lesion masquerading as carcinoma. A 52-year-old man with a 1-month history of a progressively enlarging, nontender subareolar mass. Mammogram discloses a homogeneous subareolar density. the margin of which is, in part, poorly delineated. Pathology revealed a ruptured epidermal inclusion cyst associated with fibrosis, chronic inflammation, and a foreign-body reaction.
the deeper adipose tissue, and a triangular, nondendritic pattern featuring a retro-areolar soft-tissue density with few, if any, radiating extensions. The dendritic pattern, present in four of our patients, could be correlated with the typical pathological features of the Type II or fibrous pattern and with gradual breast enlargement over a long duration (Fig. 2). The triangular pattern was present in 15 of our patients, usually those whose breast enlargement was of recent onset and featured Type I or florid pathological changes (Fig. 1, C, E, and F). Of these 15, 12 manifested breast enlargement for 6 months or less. Two patients with
breast enlargement of many years' duration featured combined pathological and mammographic features of both types (Fig. 1, B, and D). Other benign conditions: Inflammatory disease of the breast may present a difficult differential diagnostic problem both clinically and mammographically. Spiculation of the periphery of a lesion, nipple retraction, and thickening of skin may result either from the desmoplastic response incited by an underlying carcinoma, or from the scarring associated with an inflammatory process. Papillomas may result in a bloody discharge from the nipple and
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Fig. 5. Carcinoma. A. Scirrhous carcinoma and co-existent gynecomastia in a 58-year-old man. Mammography reveals a 3-cm by 4-cm central mass with iII-defined margins containing stippled calcifications typical of carcinoma (arrow). The skin is thickened and the nipple retracted, secondary to the desmoplastic reaction incited by the carcinoma. (Courtesy of Robert L. Egan, M.D.). B. Well-circumscribed carcinoma. A 72-year-old man had eccentric enlargement of the right breast for 3 months. Physical examination revealed a firm mass 3 cm in diameter, associated with skin retraction. Mammogram discloses a well-circumscribed homogeneous mass and a prominent duct between it and the thickened areola.
may be solitary or multiple (Fig. 3). Papillomatosis occurs in as many as 40 % of cases of florid gynecomastia (2) (Fig. 1, D). Carcinoma: Because the breast of males is smaller than that of females, a tumor within it is easier to palpate at a relatively smaller size. However, since a carcinoma anywhere within the male breast tends to be closer to the chest wall than in the female, earlier invasion of the chest wall is more likely to occur, resulting in a generally poorer prognosis (5). Fortunately, carcinoma of the male breast is rare, comprising less than 1% of all combined male and female breast carcinomas and fewer than 1.5 % of all cancers in men (4). Potential predisposing factors include Klinefelter's syndrome and therapeutic ionizing radiation to the chest wall during infancy or childhood (4, 6). The radiographic detection of breast cancer in the male
with gynecomastia is subject to the same pitfalls that pertain to the detection of breast cancer' in the female with mammary dysplasia. The diffuse increase in radiographic density accompanying florid gynecomastia may mask an underlying carcinoma. Moreover, even in a predominantly fatty breast a well-marqlnated mass, seemingly benign by mammographic criteria, may occasionally represent a carcinoma (Fig. 5, B), while a mass with an irregular, apparently infiltrating margin characteristic of carcinoma may turn out to be benign on microscopic examination (Fig. 4, A and B). The mammographic criteria for carcinoma of the male breast are the same as for the female. A carcinoma is usually eccentric in relation to the nipple, irregular or spiculated in outline, and may contain numerous tiny calcifications of angular or irregular shape (Fig. 5, A). Carci-
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noma may be associated with thickening of the skin and retraction of the nipple (Fig. 5, A and B). Males with Paget's disease of the nipple in association with underlying carcinoma, with inflammatory carcinoma or with simultaneous bilateral carcinomas, have been reported (3, 15, 17). Carcinoma of the male breast must be distinguished from gynecomastia. Bilateral, painful, central retro-areolar masses in a man less than 50 years of age most likely represent gynecomastia. Gynecomastia, however, may be unilateral, is occasionally eccentric, and may even cause nipple retraction. Moreover, gynecomastia and carcinoma may co-exist (2) (Fig. 5, A).
REFERENCES 1. Allen TS: Mammography in carcinoma of the male breast. Texas State J Med 60:47-48, Jan 1964 2. Bannayan GA, Hajdu SI: Gynecomastia: clinico-pathologic study of 351 cases. Am J Clin Path 57:431-437, Apr 1972 3. Coley GM, Kuehn PG: Paget's disease of the male breast. Am J Surg 123:444-450, Apr 1972 4. Crichlow RW: Carcinoma of the male breast. Surg Gynecol Obstet 134:1011-1019, Jun 1974 5. Crichlow RW, Kaplan EL; Kearney WH: Male mammary cancer: an analysis of 32 cases. Ann Surg 175:489-494, Apr 1972 6. Deutsch M, Altomare FJ, Mastian AS, et al: Carcinoma of the male breast following thymic irradiation. Radiology 116:413-414, Aug 1975 7. Forman M: Roentgenography of the male breast. Am J Roentgenol 88: 1126-1134, Dec 1962
January 1977
8. Haagensen CD: Diseases of the Breast. Philadelphia, Saunders, 2d ed, 1971, pp 76-84 9. Hoeffken W. Lanyi 1'..1: Rontgenuntersuchung der Brust. Stuttgart, Thieme, 1973, pp 231-237 10. Kalisher L, Peyster RG: Xerographic manifestations of male breast disease. Am J Roentgenol 125:656-661, Nov 1975 11. Liszka VG, Kallo A, Decker I: Vergleichende radiologische und morphologische untersuchung der asdiposemastie. febrosomastie und gynakomastie. Rontgenfortsch 108:233-237, Feb 1968 12. Nicolis GL, Modlinger RS, Gabrilove JL: A study of the histopathology of human gynecomastia. J Clin Endocr Metab 32:173-178, Jan 1971 13. Robbins SL: Pathology. Philadelphia, Saunders, 3d ed, 1967, P 1191 14. Rosen IW, Nadel HI: Roentgenographic demonstration of calcification in carcinoma of the male breast. Radiology 86:38-40, Jan 1966 15. Treves N: Inflammatory carcinoma of the breast in the male patient. Surgery 34:810-820, Nov 1953 16. Williams MJ: Gynecomastia: its incidence, recognition and host characterization in 447 autopsy cases. Am J Moo 34:103-112, Jan 1963 17. Wolloch Y, Zer M, Dintsman M, et al: Simultaneous bilateral primary breast carcinoma in the male. Isr J Med Sci 8: 158-162, Feb 1972
Department of Radiological Sciences Diagnostic Division University of California School of Medicine Los Angeles, Calif. 90024
