http://radiopaedia.

org/articles/gynaecomastia
Radiographic features
Mammography
May appear as an increased sub-areolar density, which may be flame-shaped.
Three mammographic patterns of gynecomastia have been described representing various degrees and
stages of ductal and stromal proliferation. They are:

nodular pattern

dendritic pattern

diffuse glandular pattern

Early nodular gynecomastia (florid phase) is seen in patients with gynecomastia for less than 1 year. At
mammography, there is often a nodular subareolar density.
Chronic dendritic gynecomastia (quiescent phase) is seen in patients with gynecomastia for longer than 1
year. Fibrosis becomes the dominant process and is irreversible. Mammograms this phase typically show
a dendritic subareolar density with posterior linear projections radiating into the surrounding tissue toward
the upper-outer quadrant.
Diffuse glandular gynecomastia is commonly seen in patients receiving exogenous estrogen. At
mammography, there is enlargement of the breast and diffuse density with both dendritic and nodular
features.

Breast ultrasound
Focal gynaecomastia can variably appear as a retroareolar, triangular, hypoechoic ( ~ 80% 2) mass.
In early nodular gynecomastia there can be subareolar fan or disc shaped hypoechoic nodule surrounded
by normal fatty tissue.
In diffuse glandular gynecomastia both nodular and dendritic features are seen surrounded by diffuse
hyperechoic fibrous breast tissue.
In chronic dendritic gynecomastia, there is a often a subareolar hypoechoic lesion with an anechoic starshaped posterior border, which can be described as fingerlike projections or "spider legs" insinuating into
the surrounding echogenic fibrous breast tissue.

See also

Abstract
Objective. The purpose of this study was to identify sonographic features of
gynecomastia. Methods. A retrospective analysis was performed on all male patients with breast
symptoms imaged with breast sonography over a 5-year period. Breast sonograms in 158 men
were jointly reviewed by 3 investigators. Sonograms were assessed for the presence or absence
of a mass: (1) if mass present, (a) location of the mass, (b) vascularity, (c), axis, (d) appearance
of posterior tissues, and (e) tissue echo texture; and (2) if mass absent, anteroposterior (AP)
depth at the nipple (increased if >1 cm). Results. Of the 237 men with breast symptoms, 79 with
only mammography were excluded. Of the 158 who had sonography with or without
mammography, 5 without gynecomastia were also excluded. A total of 153 men included in the
study presented with pain (n = 38), a lump (n = 95), both pain and a lump (n = 17), or nipple
discharge (n = 3). Nine of 153 with gynecomastia had a biopsy. A total of 219 sonographic
examinations were performed, which revealed 73 masses (33%): 20 (27%) nodular, 20 (27%)
poorly defined, and 33 (45%) flame shaped. All masses were retroareolar, with 57 (78%)
hypoechoic, 54 (73%) avascular, 60 (82%) parallel to the chest wall, and 47 (64%) without
posterior enhancement or shadowing. Of the 146 without masses (67%), 141 (97%) had
increased AP depth at the nipple. Conclusions. Gynecomastia is a clinical diagnosis, and
mammography is the primary imaging modality when indicated. However, if sonography is used
when mammography is declined or when mammography is inconclusive, it is important to
recognize the various described patterns of gynecomastia to avoid unnecessary biopsy based on
sonographic findings.

gynecomastia

breast

sonography
AP, anteroposterior

Gynecomastia is one of the most common diseases of the male breast. 1Palpable, painful, dense,
and mobile subareolar tissue in the male breast suggests the presence of gynecomastia. One
series showed palpable breast tissue in 57% of the male population older than 44 years. 2 Male
breast cancer is a rare entity, with incidence of less than 1%.3
There is considerable literature describing mammographic patterns of gynecomastia; however,
there is very little written about the sonographic patterns. Although prepubertal gynecomastia is
a clinical diagnosis,4sonography is a documented modality of choice in evaluation of prepubertal
male breast enlargement.5 However, very little is known about imaging features of gynecomastia
in adults. The most commonly described sonographic pattern of gynecomastia in adults is the
flame-shaped or triangular retroareolar density. 6,7 A study by Wigley et al8 described 2 patterns
of gynecomastia on sonography: focal, as a discrete triangular hypoechoic area in the
retroareolar region and diffuse, with a hyper-echoic increase in the amount of breast
parenchyma. The limitation of the study was that it included only 4 patients.
On reviewing the literature, it is unclear whether sonography is beneficial in diagnosis and
whether sonography alone or in combination with mammography should be used for evaluation
of gynecomastia. As a result, we decided to review the mammograms and sonograms of all
symptomatic male patients referred to our department during a 5-year period.

Previous SectionNext Section

Materials and Methods

Patients
The protocol was approved by the Beth Israel Deaconess Medical Centers Institutional Review
Board. Using medical records, all male patients with breast symptoms presenting for imaging
over a 5-year period from July 1, 1999, to June 30, 2004, were identified, and a retrospective
analysis was performed on all patients who had breast sonography. A total of 237 men presented
to our radiology department with breast symptoms over a 5-year period. Of these, 158 had
sonography with or without mammography, and 79 had only mammography. The 79 men with
only mammography were excluded, and 5 without gynecomastia as noted on the biopsy results
during data analysis (2 angiomyolipomas, 1 abscess, 1 hematoma, and 1 breast cancer) were
also excluded from the study. Therefore, only 153 patients were included in the study, 66 of

whom had sonography only and 87 of whom had both mammography and
sonography.
Study Design
All sonographic examinations were performed on an HDI 5000 machine (Philips
Healthcare, Bothell, WA) with a linear transducer (L10-5 or CL10-5) in a standard
supine position with arm above the head. A thick layer of gel or a true standoff pad
was used to better image the sub-areolar region. Three investigators jointly
reviewed each imaging study without knowledge of the clinical history or any
accompanying imaging study. The mammograms were reviewed separately from
the sonograms without knowledge of the clinical or correlative sonographic finding.
In cases where the reviewers did not agree on the pattern, a decision was made on
the basis of majority to reach a consensus.
Sonograms were assessed for the presence or absence of a mass. If a mass was
present, this was categorized as follows: (1) shape of the mass (nodular, poorly
defined, speculated, or flame shaped); (2) location of the mass (retroareolar or
other); (3) vascularity (absent, present, or not determined); (4) lesion orientation
(parallel or perpendicular to the chest wall or neither); (5) appearance of posterior
acoustic features (enhancement, shadowing, or neither); and (6) tissue echo texture
(isoechoic, hypoechoic, or hyperechoic). If there was no mass, the antero-posterior
(AP) depth of breast tissue at the nipple (from the skin surface under the nipple to
the anterior surface of the pectoralis muscle) was measured and categorized as
increased if the depth was greater than 1 cm. Data were analyzed for the
symptomatic breast as well as the imaged contralateral breast, even if
asymptomatic (contralateral breast categorized as asymptomatic).
Categories
Mammographic findings were categorized into 1 of 4 groups on the basis of the
parenchymal pattern as described by Appelbaum et al 9: dendritic, nodular, diffuse,
or combination. We categorized the sonographic findings as follows: (1) nodular
discrete round or oval hypoechoic area in the retroareolar region (Figure 1); (2)
poorly definedvague hypoechoic area in the retroareolar region (Figure 2); (3)
flame shapedirregular hypoechoic area with extensions into the surrounding
tissue (Figure 3); and (4) nonmass lesions, subdivided as follows: (a) increased AP
depth at the nipple, defined as greater than 1-cm depth of breast tissue at the

nipple (which may have been isoechoic, hypoechoic, or hyper-echoic; Figure 4);
and (b) a normal appearance with less than 1-cm depth of breast tissue at the
nipple and without any of the above criteria for a mass (Figure 5).

View larger version:

Figure 1.

In this page
In a new window

Images from a 54-year-old man who presented with a palpable tender mass in the
left breast. A, A discrete oval hypo-echoic mass (arrows) is shown in the retroareolar
region (nipple marked as N), consistent with nodular gynecomastia. B and C,
Mediolateral oblique and craniocaudal mammograms show a retroareolar mass,
consistent with nodular gynecomastia.

View larger version:

Figure 2.

In this page
In a new window

Images from a 69-year-old man with known prostatic cancer who presented with
right breast pain. A, A poorly defined vague hypoechoic mass (arrow) is shown in
the retroareolar region (nipple marked as N), consistent with irregular
gynecomastia. B and C, Mediolateral oblique and craniocaudal mammograms show
retroareolar dendritic breast tissue.

View larger version:

Figure 3.

In this page
In a new window

Images from a 42-year-old man who presented with painful nodularity in the left
breast. A, An irregular hypoechoic area with extensions into the surrounding tissue
(arrow) is shown in the retroareolar region (nipple marked as NIP). This is the flameshaped appearance of gynecomastia. B and C, Mediolateral oblique and
craniocaudal mammograms show retroareolar dendritic breast tissue.

View larger version:

Figure 4.

In this page
In a new window

Images from an 84-year-old man who presented with right breast enlargement for 1
month. He had been receiving antihypertensive medication for 15 years. A, There is
no discrete mass; however, the tissue depth at the nipple (N) is greater than 1 cm.
This pattern of increased AP depth is another sonographic appearance of
gynecomastia. B and C, Mediolateral oblique and craniocaudal mammograms show
retroareolar dendritic breast tissue.

View larger version:

Figure 5.

In this page
In a new window

Images from a 35-year-old man who presented to our department with pain in the
left breast and an asymptomatic right breast.A, Normal AP thickness of less than 1
cm at the nipple (N) is shown (measured between the arrows). B andC, In the right
asymptomatic breast, mediolateral oblique and cranio-caudal mammograms of the
right breast show a relatively fatty breast (nipple marked by a BB).
Previous SectionNext Section
Results
There were 153 patients included in our study population, who presented with pain
(n = 38), a lump (n = 95), pain and a lump (n = 17), or nipple discharge (n = 3).
The age range was 18 to 97 years (median age, 58 years). A total of 219 breast
sonographic examinations were performed, 66 bilateral (n = 132 breasts scanned)
and 87 unilateral breasts. Of the 219 breast sonographic examinations, 191 were for
the symptomatic breast, and 28 were for the asymptomatic breast.
These revealed 73 of 219 (33%) with masses and 146 (67%) without masses. Of the
73 with masses, 20 (27%) were nodular; 20 (27%) were poorly defined; and 33
(45%) were spiculated or flame shaped. All 73 masses (100%) were retroareolar,
with 57 (78%) hypoechoic, 54 (73%) avascular, 60 (82%) parallel to the chest wall,
and 47 (64%) showing no enhancement or shadowing. Of the 146 without masses,
141 (97 %) had increased AP depth at the nipple, and 5 (3%) had no increased AP
depth at the nipple (normal). The largest category that showed increased AP depth
at the nipple without a mass had an isoechoic tissue echo texture (76 of 141 [54%]),

followed by hypoechoic (61 of 141 [43%]) and hyperechoic (4 of 141 [3%]) echo
textures.
The pattern of gynecomastia differed in symptomatic and asymptomatic breasts.
Masses were seen in 16 symptomatic and 9 asymptomatic breasts. Increased AP
depth was seen in 64 symptomatic and 15 asymptomatic breasts. Sonographic
findings were normal (without gynecomastia) in 1 symptomatic and 4 asymptomatic
breasts. Ninety-five percent of patients with a nodular mass and 85% with a flameshaped mass were symptomatic; 89% of patients with increased AP depth were also
symptomatic (Table 1).
View this table:

In this window
In a new window

Table 1.
Patterns of Gynecomastia in Symptomatic and Asymptomatic Patients
In our study population there were 3 patients receiving highly active antiretroviral
therapy treatment, 2 patients with a history of insulin-dependent diabetes mellitus,
and 1 patient with a known case of Klinefelter syndrome. The 3 patients with nipple
discharge in our series were receiving antiandrogens for prostate cancer, and the
nipple discharge was bilateral, spontaneous, and attributed to the medication.
There were no intraductal filling defects, and the discharge subsided in 3 to 5
months; hence, it was not persistent, and no further evaluation was done.
Intervention (sonographically guided core needle biopsy with a 14-gauge springloaded biopsy device; Bard Biopsy Systems, Tempe, AZ) was performed in 9
patients. In these 9 patients with proven gynecomastia, biopsy was recommended
by the radiologist: in 3 patients for eccentric densities on the mammograms and in
6 for the presence of microlobulated margins, which remained suspicious for cancer.
Of the remaining 144 patients who did not have a biopsy, 2-year follow-up was
available for 136 patients with a clinical and imaging diagnosis of gynecomastia.
Eight patients were lost to follow-up after the first visit.
Mammography was performed in 87 of the 153 patients. Fifteen patients had
unilateral mammograms, and 72 had bilateral mammograms (159 breasts imaged
mammographically). Of the 159 breasts examined with mammography, we found
39 dendritic, 51 nodular, 24 diffuse, and 7 combination patterns. Most patients had
a bilateral mammogram even if they were symptomatic on one side. Fifteen patients
did not have a mammogram of the asymptomatic side. Negative (fatty)
mammographic findings were seen in 38 breasts, and 35 of these 38 were
asymptomatic. Only 5 of these 38 breasts with negative mammographic findings
had a sonographic evaluation for comparison with the normal side, showing normal
AP thickness at the nipple (Figure 5). The remaining 33 fatty breasts were not
evaluated with sonography. Note that sonographic evaluations performed in 28
asymptomatic contralateral breasts showed imaging features of gynecomastia on
mammography as well as sonography, indicative of subclinical gynecomastia. Of the
87 patients in whom mammography was performed, sonographically detected

masses were seen in 5 with dendritic, 17 with nodular, 9 with diffuse, and 5 with
combination patterns.
Previous SectionNext Section
Discussion
Gynecomastia is a benign proliferation (hypertrophy) of ductal and glandular
elements in the male breast. Physiologic gynecomastia occurs in neonates, at or
before puberty, and with aging. Many cases of prepubertal gynecomastia are
idiopathic (25%).4 Potential pathologic causes of gynecomastia are medications
including hormones, increased serum estrogen, decreased testosterone production,
androgen receptor defects, chronic kidney disease, chronic liver disease, human
immunodeficiency virus treatment,10 and other chronic illness. Gynecomastia as a
result of spinal cord injury and refeeding after starvation has also been reported. 11
Some would argue that gynecomastia is solely a clinical diagnosis, with which we
agree; however, when clinical suspicion of gynecomastia is less certain, imaging is
often used. Mammography is sufficient for diagnosis in most cases; however, it may
be insufficient when there is asymmetric nodular gynecomastia or a cluster of
subareolar ducts, which can form a convex margin simulating a mass (Figure 6).
Some men refuse mammography, and sonography may be occasionally used.
Knowledge of the various sonographic features and patterns of gynecomastia is
especially important in these cases.

View larger version:

Figure 6.

In this page
In a new window

Images from a 31-year-old man who presented with a hard palpable mass in the left
breast. A, A discrete oval hypo-echoic mass, is shown (arrows), more readily
diagnostic of nodular gynecomastia. B and C, Mediolateral oblique and craniocaudal
mammograms show an asymmetric mass forming a convex margin, marked with
the more posterior BB, separate from the dendritic tissue under the nipple, marked
with the anterior BB. Biopsy based on the mammographic interpretation of
suspicious features showed gynecomastia.

Imaging findings of our patients with gynecomastia could be categorized into 1 of 4

patterns on sonography: (1) nodulardiscrete round or oval hypoechoic area in the
retroareolar region (Figure 1); (2) poorly definedvague hypoechoic area in the
retroareolar region (Figure 2); (3) flame shapedirregular hypoechoic area with
extensions into the surrounding tissue (Figure 3); and (4) increased AP depth at
the nipple, defined as greater than 1 cm depth of breast parenchyma at the nipple
(which may have been isoechoic, hypoechoic, or hyperechoic; Figure 4).
Carcinoma of the male breast is an unusual lesion with a frequency equaling only
about 0.9% of the occurrence of female breast cancer 12 and 0.2% of all
malignancies in men. The peak incidence is in the fifth and sixth decades.
Gynecomastia may not always be readily differentiated from carcinoma; however, a
typical sonographic feature of cancer is an irregular mass with microlobulated
margins (Figure 7). Axillary nodal involvement is frequent in about 47% of
patients.13 The lesion may be central or peripheral. The central location is frequent,
and nipple involvement and ulceration of the overlying skin are common. 12,14 An
eccentric location of a lesion should be viewed with suspicion; rarely, some degree
of eccentricity may be present in gynecomastia, although this is more pronounced
in carcinoma. When correlated with lesions of similar stages in women, the overall
prognosis is the same in men. Mammography should still be performed as a primary
imaging modality. It better detects calcifications, especially microcalcifications, in
men of an age at which cancer is a possibility. The pattern of calcifications is
generally not as classic in men as in women, 14 and the calcifications in male breast
cancer often appear benign.

View larger version:

Figure 7.

In this page
In a new window

Images from a 68-year-old man who presented with tenderness in the left breast
and whose physician felt a retroareolar mass. A, A hypoechoic mass with
microlobulations is shown (arrows), which is slightly taller than wide and suspicious
for breast cancer (nipple marked as N). B andC, Mediolateral oblique and
craniocaudal mammograms show a retroareolar mass with microlobulations
(arrows), which is suspicious for cancer. In addition, strands of retroareolar dendritic
tissue (arrowheads) are shown, which accompany gynecomastia. Biopsy based on

the suspicious mammographic and sonographic features showed invasive breast

cancer. The patient had negative breast cancer gene (BRCA) test results.
We understand the drawbacks of our study. The first is that the category of
increased AP depth at the nipple, defined as greater than 1 cm, was based only on
our observation, without references. It may be difficult to completely differentiate
gynecomastia from negative fatty breasts on the basis of sonography; however, this
appearance rules out suspicion of cancer. The increased AP depth suggests the
presence of gynecomastia in patients who have a small amount of retroareolar
breast tissue seen on mammography (Figure 4), which cannot be delineated as a
retroareolar hypoechoic area on sonography because of nipple shadowing, and
these only show the increased thickness at the nipple. If patients only have fatty
tissue, which flattens out, the hypothesis is that it presents with less thickness
under the nipple (Figure 5). We acknowledge that the arbitrary value of greater
than 1 cm for defining increased AP depth needs validation and are working on a
study to gather more data.
A second limitation was that not all patients in our study were imaged with both
mammography and sonography (66 of 153 patients had only sonographic
evaluations). The protocol followed was that if a mammogram was not requested or
the patient declined or was resistant to mammography, breast sonography was
performed as the initial imaging test. If the sonography showed no suspicious
findings or findings suggestive of gynecomastia, mammography was not performed.
None of these patients had new or worsening breast symptoms over a 2-year
clinical follow-up. Many of these patients were evaluated by our experienced
radiologists (>10 years in breast imaging) with expertise in sonography, who were
thus confident in identifying and distinguishing sonographic features of
gynecomastia with more certainty than others with less experience and expertise.
After reviewing data from this study, we have standardized our protocol to obtaining
a mammogram as the initial imaging examination in all male patients older than 30
years with breast symptoms. Once the mammogram is reviewed by the radiologist,
sonography is performed if necessary for diagnostic clarification. Sonography is
used as the initial examination for patients younger than 30 years. This protocol is
what we recommend.
In conclusion, gynecomastia is a clinical diagnosis, and mammography is the
primary modality when imaging is indicated. However, if sonography is used as a
primary imaging tool when mammography is declined or in combination with
mammography, and when mammography is inconclusive, it is important to
recognize the various described patterns of gynecomastia to avoid unnecessary
biopsy based on the sonographic findings. A sonographic mass can be seen in up to
33% of gynecomastia cases. The presence of a taller-than-wide lesion with
microlobulations or an eccentric lesion away from the retroareolar region should
raise the suspicion for breast cancer.

http://www.jultrasoundmed.org/content/29/4/539.full