History: The patient is a 54 year old Asian male with a two month history of Gynecomastia diagnosed clinically by the patient's PMD. The pt claims that he began noticing an increase in his breast size without any other body changes. Mr. Wong denies any changes in weight, energy level, hair, or medications. He also denies any discharge or tenderness.
Radiological Findings: MLO and CC views of both breasts.
· Both breasts showed evidence of breast tissue extending behind the areola bilaterally.
o RT - Both CC and MLO views show mild breast tissue behind the areola without evidence of calcifications, densities/masses or soft tissue involvement.
o LT - Both CC and MLO views show a larger amount of breast tissue behind the areola without evidence of calcifications, densities/masses or soft tissue involvement.
Diagnosis: Gynecomastia (made clinically and confirmed through mammography)
PATHOLOGIC GYNECOMASTIA
A. Deficient production or action of testosterone
1. Congenital anorchia
2. Androgen resistance (testicular feminization and Reifenstein syndrome)
3. Defects of testosterone synthesis
4. Klinefelter syndrome
5. Viral orchitis
6. Trauma
7. Castration
8. Neurologic and granulomatous diseases
9. Renal failure
B. Increased estrogen production
1. Increased estrogen secretion
a. Testicular tumors
b. True hermaphroditism
c. Carcinoma of the lung and other tumors producing hCG
2. Increased substrate for extraglandular aromatase
a. Adrenal disease
b. Liver disease
c. Malnutrition
d. Hyperthyroidism
3. Increase in extraglandular aromatase
C. Drugs
1. Estrogens (diethylstilbestrol, birth control pills, digitalis, estrogen-containing cosmetics, estrogen-contaminated foods, phytoestrogens)
2. Drugs that enhance endogenous estrogen secretion (gonadotropins, clomiphene)
3. Inhibitors of testosterone synthesis and/or action (ketoconazole, metronidazole, alkylating agents, cisplatin, spironolactone, cimetidine, flutamide, etomidate)
4. Unknown mechanisms (busulfan, isoniazid, methyldopa, tricyclic antidepressants, penicillamine, diazepam, omeprazole, calcium channel blockers, angiotensin-converting enzyme inhibitors, marijuana, heroin, finasteride)
D. Idiopathic
Discussion:
Radiographic Findings (mammography):
· Early - nodular pattern with increased tissue focally in the subareolar area.
· Late - Fibrous phase with tissue radiating out from the nipple.
· Diffuse glandular pattern.
· Unilateral or asymmetric.
· If classic gynecomastia is seen with no microcalcifications or eccentric mass, biopsy may be averted unless the pt is symptomatic.
The incidence of active gynecomastia in autopsy series is between 5 and 9 percent. It may be difficult to distinguish true breast tissue from masses of adipose tissue without true breast enlargement (lipomastia); in such cases, true gynecomastia can be separated from lipomastia by mammography or ultrasonography. The incidence of gynecomastia may have increased (possibly due to exposure to environmental or plant estrogens), or the autopsy data may underestimate the frequency of palpable breast tissue. The finding of gynecomastia (distinct from lipomastia) may indicate underlying pathology or a normal variant.
Early gynecomastia is characterized by proliferation in the breast of both the fibroblastic stroma and the duct system, which elongates, buds, and duplicates. As gynecomastia persists, progressive fibrosis and hyalinization are associated with regression of epithelial proliferation and, eventually, a decrease in the number of ducts. When the cause of the gynecomastia is corrected early in the course, resolution occurs by reduction in size and epithelial content with gradual disappearance of the ducts, leaving hyaline bands that eventually disappear.
Growth of the breast in men, as in women, is mediated by estrogen and results from disturbances of the normal ratio of active androgen to estrogen. Estradiol formation in normal men occurs principally by the conversion of circulating androgen to estrogen in extraglandular tissues; the normal ratio of production of testosterone to estradiol in adult men is approximately 100:1 (6 mg versus 45 ug/day), and the normal ratio of the two hormones in plasma is about 300:1. Growth of the breast ensues in men when the normal ratio decreases as the result of diminished testosterone production or action, enhanced estrogen formation, or both processes occurring simultaneously.
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