(Radiology. 2000;214:553-555.)
© RSNA, 2000
Gynecomastoid Hyperplasia: Imaging Findings in Six Patients1
Donna-Lee G. Selland, MD,
Craig D. Korbin, MD,
Susan C. Lester, MD, PhD,
Mark H. Lerner, MD,
Julie A. Gulizia, MD,
Carolyn M. Kaelin, MD and
Jack E. Meyer, MD
1 From the Departments of Radiology (D.L.G.S., M.H.L., J.E.M.), Pathology (S.C.L.), and Surgery (C.M.K.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; the Department of Radiology, Milton Hospital, Mass (C.D.K.); and the Department of Pathology, University of Nebraska Medical Center, Omaha (J.A.G.). Received June 26, 1998; revision requested July 16; final revision received April 16, 1999; accepted July 28. Address reprint requests to D.L.G.S. (e-mail: dgselland@bics.bwh.harvard.edu).
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Abstract
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This case series describes the radiologic appearances of gynecomastoid hyperplasia of the breast in our experience. The clinical histories, breast images, and histopathologic findings in six women were reviewed. At mammography, there was no abnormality in two women, an enlarging asymmetric density in three women, and a nodule in one woman. Breast ultrasonography showed a hypoechoic nodule in one woman. Gynecomastoid hyperplasia has a varied radiologic appearance.
Index terms: Breast, abnormalities, 00.3199, 00.75 • Breast neoplasms, diagnosis, 00.3199, 00.75 • Gynecomastia, 00.75
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Introduction
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Gynecomastoid hyperplasia is a rare, benign process that affects the breast in women. The imaging features of this entity have not previously been described, to the best of our knowledge. Histologically, the findings may be confused with micropapillary ductal carcinoma in situ. We describe the findings in six women with gynecomastoid hyperplasia who underwent breast imaging prior to biopsy.
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Patients and Findings
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Patients
A total of 11 women with gynecomastoid hyperplasia who had undergone breast biopsy between 1992 and 1997 were identified at review of files in the pathology department at Brigham and Women's Hospital, Boston, Mass. Of these 11 women, six had undergone mammography. Five of these six had undergone breast ultrasonography (US) as well. These six patients form the basis of our case report.
Two authors (D.L.G.S., J.A.G.) reviewed the clinical information (one author gathered the data on five cases, and the other author gathered the data on one case). The clinical information was compared and compiled by the two authors together and was then shared with the remaining authors (C.D.K., S.C.L., M.H.L., C.M.K., J.E.M.). The clinical histories at the time of surgery were obtained by using the hospital computer information system's online ambulatory outpatient clinical notes. When all of the information was not available on the computer, the additional information was obtained from discussion with the primary care physicians. Tabulated were the age, obstetric and/or gynecologic history, endocrinologic abnormalities, breast lesion size, palpable or clinically occult lesions, and any symptoms (such as pain).
The mammograms and US images were reviewed simultaneously by two of the authors (D.L.G.S., J.E.M.) by using consensus opinion. At review of the imaging studies, the following items were assessed. The mammograms were evaluated for a mass, calcifications, distortion, and asymmetric density; if prior images were available, as was the case in three of the six patients, it was determined whether the finding was new or changed. The static US images were evaluated for the presence of a correlate to the palpable or mammographic finding. Characterization of the US abnormality (size, echogenicity, margins, and presence of posterior acoustic enhancement or attenuation) was performed.
Findings
Review of the clinical histories revealed varied backgrounds. Three women had no substantial gynecologic or medical problems, with reported normal, regular menses. One woman had Turner syndrome with secondary amenorrhea, was receiving hormone replacement therapy, and had hypothyroidism. A second patient had primary amenorrhea and severe growth retardation and had been receiving hormone replacement therapy continuously for 29 years. A third woman was infertile and was attempting in vitro fertilization.
The six women ranged in age from 33 to 54 years, with a mean age of 44.0 years. At presentation, three patients had a palpable mass that ranged from 0.7 to 4.0 cm. Only one palpable abnormality had a corresponding mammographic abnormality. The abnormality was in a woman with a normal prior mammogram (Fig 1a, 1b) who presented with a developing nontender right breast mass that corresponded to an enlarging 4.0-cm area of asymmetric density that encompassed the entire retroareolar region (Fig 1c, 1d).
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Figure 1a. Patient 4. Bilateral mammograms obtained in a 49-year-old nulliparous woman with primary amenorrhea and severely short stature who was receiving hormone replacement therapy and who presented with a new, palpable, retroareolar mass in the right breast. Biopsy revealed gynecomastoid hyperplasia. (a) Mediolateral oblique projections in 1996 show an asymmetric retroareolar density (arrows) in the right breast that was stable relative to the appearance on a mammogram obtained 2 years previously. (b) Craniocaudal projections from the same day as a show asymmetric retroareolar tissue (arrows) in the right breast. (c) Mediolateral oblique projections in 1997 demonstrate an enlarging asymmetric density (arrows) in the retroareolar region in the right breast that corresponds to the area of palpable concern (metallic skin BB). (d) Craniocaudal projections from the same day as c show an enlarging asymmetric density (arrows) in the retroareolar region of the right breast.
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Figure 1b. Patient 4. Bilateral mammograms obtained in a 49-year-old nulliparous woman with primary amenorrhea and severely short stature who was receiving hormone replacement therapy and who presented with a new, palpable, retroareolar mass in the right breast. Biopsy revealed gynecomastoid hyperplasia. (a) Mediolateral oblique projections in 1996 show an asymmetric retroareolar density (arrows) in the right breast that was stable relative to the appearance on a mammogram obtained 2 years previously. (b) Craniocaudal projections from the same day as a show asymmetric retroareolar tissue (arrows) in the right breast. (c) Mediolateral oblique projections in 1997 demonstrate an enlarging asymmetric density (arrows) in the retroareolar region in the right breast that corresponds to the area of palpable concern (metallic skin BB). (d) Craniocaudal projections from the same day as c show an enlarging asymmetric density (arrows) in the retroareolar region of the right breast.
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Figure 1c. Patient 4. Bilateral mammograms obtained in a 49-year-old nulliparous woman with primary amenorrhea and severely short stature who was receiving hormone replacement therapy and who presented with a new, palpable, retroareolar mass in the right breast. Biopsy revealed gynecomastoid hyperplasia. (a) Mediolateral oblique projections in 1996 show an asymmetric retroareolar density (arrows) in the right breast that was stable relative to the appearance on a mammogram obtained 2 years previously. (b) Craniocaudal projections from the same day as a show asymmetric retroareolar tissue (arrows) in the right breast. (c) Mediolateral oblique projections in 1997 demonstrate an enlarging asymmetric density (arrows) in the retroareolar region in the right breast that corresponds to the area of palpable concern (metallic skin BB). (d) Craniocaudal projections from the same day as c show an enlarging asymmetric density (arrows) in the retroareolar region of the right breast.
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Figure 1d. Patient 4. Bilateral mammograms obtained in a 49-year-old nulliparous woman with primary amenorrhea and severely short stature who was receiving hormone replacement therapy and who presented with a new, palpable, retroareolar mass in the right breast. Biopsy revealed gynecomastoid hyperplasia. (a) Mediolateral oblique projections in 1996 show an asymmetric retroareolar density (arrows) in the right breast that was stable relative to the appearance on a mammogram obtained 2 years previously. (b) Craniocaudal projections from the same day as a show asymmetric retroareolar tissue (arrows) in the right breast. (c) Mediolateral oblique projections in 1997 demonstrate an enlarging asymmetric density (arrows) in the retroareolar region in the right breast that corresponds to the area of palpable concern (metallic skin BB). (d) Craniocaudal projections from the same day as c show an enlarging asymmetric density (arrows) in the retroareolar region of the right breast.
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In the three patients with a nonpalpable abnormality, the mammogram demonstrated either an asymmetric density (n = 2) or a mass (n = 1) (Table). The first patient had a 4.0-cm asymmetric density in the upper outer quadrant of the right breast that developed over 15 months. In the second patient, the mammogram demonstrated a 2-cm density in the upper outer quadrant of the left breast that was determined to be new in a comparison of the current mammogram with a mammogram obtained 1 year earlier. The third woman, in whom no previous images were available, had a 1-cm, partially obscured, round, noncalcified nodule deep in the right breast at the 6-o'clock position (Fig 2a).
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Figure 2a. Patient 6. Images obtained in a 54-year-old postmenopausal woman receiving hormone replacement therapy who had a prior history of regular menses, gravida 3, para 3, and a family history of breast carcinoma (mother). (a) Right craniocaudal mammogram shows a 1-cm noncalcified nodule (arrows) deep in the right breast. (b) US image obtained at the same time as a at the 6-o'clock position shows a solid hypoechoic nodule (arrowheads). (c) Photomicrograph shows gynecomastoid hyperplasia. Small ducts with papillary hyperplasia (arrows) are surrounded by cellular stroma with a mild lymphocytic infiltrate. The area of gynecomastoid change borders on an area of adjacent adipose tissue (arrowheads). (Hematoxylin-eosin stain; original magnification, x125.)
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Figure 2b. Patient 6. Images obtained in a 54-year-old postmenopausal woman receiving hormone replacement therapy who had a prior history of regular menses, gravida 3, para 3, and a family history of breast carcinoma (mother). (a) Right craniocaudal mammogram shows a 1-cm noncalcified nodule (arrows) deep in the right breast. (b) US image obtained at the same time as a at the 6-o'clock position shows a solid hypoechoic nodule (arrowheads). (c) Photomicrograph shows gynecomastoid hyperplasia. Small ducts with papillary hyperplasia (arrows) are surrounded by cellular stroma with a mild lymphocytic infiltrate. The area of gynecomastoid change borders on an area of adjacent adipose tissue (arrowheads). (Hematoxylin-eosin stain; original magnification, x125.)
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Figure 2c. Patient 6. Images obtained in a 54-year-old postmenopausal woman receiving hormone replacement therapy who had a prior history of regular menses, gravida 3, para 3, and a family history of breast carcinoma (mother). (a) Right craniocaudal mammogram shows a 1-cm noncalcified nodule (arrows) deep in the right breast. (b) US image obtained at the same time as a at the 6-o'clock position shows a solid hypoechoic nodule (arrowheads). (c) Photomicrograph shows gynecomastoid hyperplasia. Small ducts with papillary hyperplasia (arrows) are surrounded by cellular stroma with a mild lymphocytic infiltrate. The area of gynecomastoid change borders on an area of adjacent adipose tissue (arrowheads). (Hematoxylin-eosin stain; original magnification, x125.)
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US was performed in five of the six women. Only one mass was visible at US. This was a solid mass with indistinct margins (Fig 2b). The remaining US studies showed no discrete solid or cystic lesion.
Two of the six women underwent stereotactic core biopsy, which yielded gynecomastoid hyperplasia. One of the two women underwent subsequent wire localization and surgical excision, which resulted in confirmation of the diagnosis. The other four women underwent surgical excision; in two of these women, the lesion was nonpalpable and required wire localization. All surgery was performed within 1 month of mammography. In all women, histologic analysis revealed gynecomastoid hyperplasia.
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Discussion
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Gynecomastoid hyperplasia is a rare breast abnormality. To our knowledge, the imaging findings have not been previously described. At histologic analysis, gynecomastoid hyperplasia has a similar appearance as gynecomastia in men (1). Scattered ducts with papillary hyperplasia and without lobule formation in a myxoid stroma were the specific unique histologic characteristics identified to confirm this diagnosis (Fig 2c). The pathology literature identifies the association with palpable breast masses in women (2,3).
Gynecomastia in men typically manifests as a unilateral or bilateral tender palpable breast mass. Mammographically, gynecomastia appears as a triangular, flame-shaped, soft-tissue density that emanates from the nipples and extends posteriorly (4). The density has the appearance of normal glandular tissue.
In our series, gynecomastoid hyperplasia could manifest as a palpable mass or mammographic abnormality. It was visualized on the mammogram as a developing asymmetric density in three patients and as a focal nodule in one patient. In our small series, gynecomastoid hyperplasia manifested in women with and in women without hormonal imbalance.
At mammography and US, this benign process may mimic characteristics that are worrisome for malignancy. Likewise, at histopathologic analysis the pattern of proliferation may mimic ductal carcinoma in situ of the micropapillary type. However, benign histologic findings are confirmed with complete evaluation of the core biopsy or excisional biopsy specimens. Unlike other patterns of epithelial hyperplasia, such as atypical ductal hyperplasia, gynecomastoid hyperplasia is not associated with an increased risk of ductal carcinoma in situ (2).
Whether diagnosed at core or excisional biopsy, gynecomastoid hyperplasia represents a benign epithelial proliferation of the female breast with a variable appearance at mammography and US.
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Footnotes
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Author contributions: Guarantor of integrity of entire study, D.L.G.S.; study concepts, D.L.G.S., S.C.L., J.E.M.; study design, D.L.G.S.; definition of intellectual content, D.L.G.S., C.D.K., S.C.L.; literature research, D.L.G.S., S.C.L.; clinical studies, D.L.G.S., J.E.M.; data acquisition, D.L.G.S., J.A.G.; data analysis, D.L.G.S.; manuscript preparation, D.L.G.S.; manuscript editing, D.L.G.S., J.E.M.; manuscript review, C.D.K., S.C.L., M.H.L., J.A.G., C.M.K., J.E.M.
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References
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Rosen PP. Benign proliferative lesions of the male breast In: Rosen's breast pathology. 1st ed. Philadelphia, Pa: Lippincott-Raven, 1997; 612, 613.
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Tham KT, Dupont WD, Page DL, Gray GF, Rogers LW. Micro-papillary hyperplasia with atypical features in female breasts, resembling gynecomastia. In: Fenoglio-Preiser C, eds. Progress in surgical pathology. Vol 10. Blue Bell, Pa: Field & Wood, 1989; 101-109.
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Weidner N. Malignant breast lesions that may mimic benign tumors. Semin Diagn Pathol 1995; 12:2-12.[Medline]
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Kopans DB. Male breast In: Kopans DB. Breast imaging. 2nd ed. Philadelphia, Pa: Lippincott-Raven, 1998; 497-504.
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Abstract
Introduction
