Spectrum of Male Breast Lesions

Diagnosed by Fine Needle

Aspiration Cytology:
A 5-Year Experience at a Tertiary Care
Rural Hospital in Central India
Ranbeer Singh, M.D., Anshu, M.D., D.N.B., M.N.A.M.S.,*
Satish M. Sharma, M.D., and Nitin Gangane, M.D., D.N.B.

This study examines the spectrum of lesions in the male breast normal male breast contains both glandular and fat tissue.
at a tertiary care rural hospital in central India and explores The glandular tissue, in males, is typically made up of
the role of Fine Needle Aspiration Cytology (FNAC) in the diag-
nosis of these lesions. only ducts and located immediately under the nipple.2
Male breast lesions formed 5.89% (119 cases) of the 2017 Most patients present with gynecomastia, which is
breast lesions which were sent for FNA in the cytology section defined as enlargement of the male breast due to
over a period of 5 years (January 2005–December 2009). Of proliferation of both glandular and stromal elements.1,2
these, biopsy had been performed only on 37 (31.1%) patients.
Pseudo-gynecomastia refers to enlargement of male breast
Benign lesions comprised 102 (85.7%) cases, malignant lesions
comprised 14 (11.8%) cases and inflammation/abscess was by excessive deposition of fat, but with normal amount of
found in 3 (2.5%) cases. Gynecomastia was the commonest glandular breast tissue.3 Male breast cancer is extraordi-
benign lesion in 86 (84.3%) cases. The cytologic features of narily rare, and as it is associated with an aggressive clin-
gynecomastia included mild to moderate cellularity, cohesive ical course.1 It is important to differentiate male breast
sheets of bland cells, bipolar bare nuclei. Mild nuclear atypia cancer from gynecomastia and make a diagnosis without
was found in 19 cases. The cytologic features of malignancy
comprised of dyshesive groups of ductular cells with moderate delay.2 Clinically, the lesion in gynecomastia is usually
to severe degree of nuclear atypia and absence of bare nuclei. centered below the nipple—an important point in the dif-
Histology was done in 37 cases and diagnostic accuracy of ferential diagnosis with carcinoma, which tends to be
FNAC for gynecomastia was 100% and for malignancy 85.7%. located eccentrically.4 Although histologic examination is
This study showed that FNAC is a reliable tool for diagnosing a sure means of distinguishing gynecomastia from carci-
male breast lesions. We conclude that FNAC should be per-
noma, it is both impractical and unnecessary to perform a
formed as a standard procedure in the clinical evaluation of
male breast masses. Many unnecessary surgical biopsies for biopsy on all patients with gynecomastia.5 Studies show
histopathologic diagnosis can thus be avoided. Diagn. Cytopathol. that use of fine needle aspiration (FNA) can allow diagnosis
2012;40:113–117. ' 2010 Wiley Periodicals, Inc. to be made with a sufficient degree of confidence which can
spare the patient an invasive surgical procedure.2
Key Words: fine needle aspiration cytology; male breast; gyne- This diagnostic study was conducted in a tertiary care
comastia; breast neoplasms; breast cancer
rural hospital in Central India. We reviewed FNA smears
of 119 cases of lesions of the male breast reported in
Diseases of the male breast engender a tremendous emo- 5 years and correlated them with biopsy findings, where
tional response. Fortunately they are not common.1 The available. The objectives of this study were to determine
the diagnostic accuracy of fine needle aspiration cytology
(FNAC) in male breast lesions and to analyze the cytolog-
Department of Pathology, Mahatma Gandhi Institute of Medical
Sciences, Sevagram (Wardha), Maharashtra, India
ical features of these lesions.
*Correspondence to: Anshu, M.D., D.N.B., M.N.A.M.S., Department
of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram Methods
(Wardha), Maharashtra 442102, India. E-mail: dr.anshu@gmail.com
Received 5 May 2010; Accepted 3 July 2010 Setting
DOI 10.1002/dc.21507
Published online 12 November 2010 in Wiley Online Library This study was carried out at the Department of Pathology,
(wileyonlinelibrary.com). Mahatma Gandhi Institute of Medical Sciences (MGIMS)

' 2010 WILEY PERIODICALS, INC. Diagnostic Cytopathology, Vol 40, No 2 113
Diagnostic Cytopathology DOI 10.1002/dc
SINGH ET AL.

at Sevagram in India. MGIMS is a 770-bedded tertiary Table I. Distribution of Cases According to Cytologic Diagnosis
care hospital, which predominantly caters to patients from Original cytologic Number of Age range
a rural background in Central India. Each year, *2500 diagnoses cases (years)
FNACs are performed in the Cytology section. Inflammation/abscess 3 26–75
Benign neoplasms 102
Cases Gynecomastia 86 12–80
Without atypia 67
During a period of 5 years, i.e., from January 2005 to De- With atypia 19
cember 2009, a total of 2017 FNACs were performed Benign breast disease/benign cells 9 15–45
Fibrocystic disease/benign cyst 5 25–45
from breast lesions of both male and female patients. Of Duct papilloma 1 39
these breast FNAs, 119 (5.89%) FNAs were from breast Lipoma 1 56
lumps in male patients, and these were included as the Malignant neoplasms 14 32–80
Duct carcinoma 11 22–80
cases in this study. ?Duct carcinoma, ?gynecomastia
Fine needle aspiration (FNA) was performed from with epithelial hyperplasia 1 35
breast lumps with a 24-gauge disposable needle and 10- Duct carcinoma with cystic change 1 65
Non Hodgkin’s lymphoma 1 32
ml disposable plastic syringe fitted to a Cameco syringe Total 119
pistol. Alcohol-fixed smears were stained with Papanico-
laou stain, and air-dried smears were stained with Giemsa.
Smears were screened for cellularity, and repeat aspiration ing from 5 days to 3 years. Of the 119 patients, 76 com-
was performed in few cases where adequate cells could plained of symptoms such as pain and/or tenderness in
not be obtained initially, until a satisfactory aspirate was the lump. Five patients presented with axillary lymphade-
obtained. For the purpose of this study, cytology smears nopathy, seven cases had nipple retraction, and two cases
of all cases were reviewed and assessed for cellularity, had ulcers over the lump. The clinical diagnosis was
cellular arrangement, presence or absence of myoepithe- gynecomastia in 68 (57.1%) cases and malignancy in 18
lial cells, bipolar bare nuclei, nuclear features, mitotic fig- (15.1%) cases. The remaining 33 (27.8%) cases were sent
ures, and stromal component. Accordingly the smears for FNA without a defined clinical diagnosis simply as
were classified as2: ‘‘breast lump,’’ ‘‘mass,’’ or ‘‘swelling.’’
Based on the original descriptions, the cytologic diag-
i. Virtually acellular smear. noses were grouped as: (i) conclusively benign, (ii) con-
ii. Mildly cellular smear (<2 groups per 10 hpf). clusive for malignancy, and (iii) inflammatory. Of the 119
iii. Moderately cellular smear (2–10 groups per 10 cases, 102 (85.7%) cases were diagnosed as benign neo-
hpf). plasms and 3 (2.5%) as inflammatory or breast abscesses.
iv. Rich cellularity (>10 groups per 10 hpf). The spectrum of cytologic diagnoses included: gyneco-
v. Proliferation without atypia. mastia, cystic lesions, inflammation, and lipoma. The
vi. Proliferation with atypia. cytologic diagnoses of malignancy were made in 14
vii. Benign breast lesions. (11.8%) of cases. Eleven cases were confirmed as ductal
viii. Suspicious of malignancy. carcinoma, one case was diagnosed as probably duct car-
ix. Malignancy. cinoma or gynecomastia with epithelial hyperplasia, one
case as duct carcinoma with cystic change, and one case
Other features observed were: presence or absence of was diagnosed as Non-Hodgkin’s lymphoma (plasmacy-
tall columnar cells, inflammatory component, and cyst toid type) (Table I).
macrophages in the background. The clinicians felt the Review of smears of the 119 cases showed that smears
need to perform excision biopsies in 37 of these cases, of gynecomastia had variable cellularity. On classifying
and their histopathology slides were reviewed. Relevant cases using Das et al.’s criteria2 mentioned above, smears
clinical information was further verified from patient from 21 cases were observed to be mildly cellular. We
records. observed moderate cellularity in 39 and rich cellularity in
26 cases of gynecomastia (Table II). Other features
Results observed were presence of cohesive cell groups, single
This study includes 119 cases of male breast lesions. The cells, bipolar bare nuclei, and tall columnar cells. Duct
ratio between male to female patients with breast lumps cell clusters, oval nuclei of myoepithelial cells, and frag-
was found to be 1:16.9. The mean age of the male ments of stroma were found in the more cellular smears.
patients was 32 years (range: 12–90 years). Lumps were Cytologic atypia was sometimes seen in smears with high
present in the left breast in 48 (40.4%) cases, in right cellularity and characterized by mild nuclear enlargement
breast in 39 (32.7%), and were bilateral in 32 (26.9%) with pleomorphism, nuclear overlapping, and deranged
patients. The lumps had been present for a duration rang- orientation (Fig. 1).

114 Diagnostic Cytopathology, Vol 40, No 2

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MALE BREAST LESIONS DIAGNOSED BY FNAC

Table II. Categorization of Smears According to Cellularity and

Cytologic Pattern
Number of
Smear pattern Diagnoses cases
Virtually acellular smear — 00
Mildly cellular smear Gynecomastia 21
(<2 groups per 10 hpf)
Moderately cellular smear Gynecomastia 39
(2–10 groups per 10 hpf)
Rich cellularity Gynecomastia 26
(>10 groups per 10 hpf)
Proliferation without atypia Gynecomastia 67
Proliferation with atypia Gynecomastia 19
Malignancy 14
Benign breast lesions Benign breast cells 9
Suspicious of malignancy ?Duct carcinoma
?Gynecomastia
with epithelial
hyperplasia 1
Malignancy Ductal carcinoma 13
Fig. 2. Smear showing dyscohesive sheets of cells with presence of
intact cells with cytoplasm in a case of duct carcinoma of male breast
(Giemsa, 2003). [Color figure can be viewed in the online issue, which
is available at wileyonlinelibrary.com.]

Table III. Cyto-Histo Correlation of the 37 Cases where Biopsy was

Performed
Original cytologic Histopathologic
diagnosis diagnosis Number
Gynecomastia Gynecomastia 29
Duct carcinoma Invasive duct carcinoma 6
Lipoma Lipoma 1
Non Hodgkin’s High grade invasive
lymphoma duct carcinoma 1
Total 37

cases. All the 29 cases of gynecomastia were confirmed

on histology (Fig. 3). Thus cytology had a 100% positive
predictive value for diagnosis of gynecomastia. Six cases
Fig. 1. Smear showing cohesive clusters of bland cells in a case of of invasive duct carcinoma (grade I: two cases, grade II:
gynecomastia with mild pleomorphism and overcrowding and presence three cases, and grade III: one case) and one case lipoma
of bipolar bare nuclei (Giemsa, 2003). [Color figure can be viewed in
the online issue, which is available at wileyonlinelibrary.com.] were confirmed on histology (Fig. 4). One case was
reported as Non-Hodgkin’s lymphoma on cytology, while
on histology it turned out to be high grade (grade III)
The male breast carcinomas were cytologically distinct invasive ductal carcinoma.
from gynecomastia. Nine out of 14 cases of carcinoma
were highly cellular. Apart from cellularity, dyscohesive
cell groups with nuclear piling and anisonucleosis were Discussion
features favoring carcinoma. Absence of bare nuclei and Diagnosis of palpable breast masses by FNAC has gained
myoepithelial cells were valuable clues (Fig. 2). world-wide acceptance.6 Most of the studies have how-
Bipolar bare nuclei, which were present in most of the ever evaluated the usefulness of FNAC in the diagnosis
gynecomastia cases, were seen in only two cases of carci- of breast masses in females.6 The present study was
nomas which also showed benign cells in the smears. Co- undertaken to investigate the efficacy of FNAC in 119
lumnar cells were seen in 26 (30.2%) cases of gyneco- male breast lesions over a period of five years. The ratio
mastia and in none of the malignant cases. Mitotic figures of male breast lesions to female breast lesions was 1:16.9
were present in 19 (22.1%) cases of gynecomastia and 60 in our study which is similar to the findings of Mansoor
(69.8%) cases of carcinoma. et al.7 who found a ratio of 1:16.6. In their study of Saudi
Of the 119 cases, excision biopsies were received in 37 patients, male breast lesions constituted 6% of all breast
(31.1%) of cases in the histopathology section (Table III). lesions,7 which was higher than that reported by other
The cytologic diagnoses were confirmed in 36 (97.3%) studies in the USA and in South-East Asia.8–10 Their find-

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Fig. 3. Section showing features of gynecomastia (H&E, 103). Fig. 4. Section showing features of infiltrating duct carcinoma in
[Color figure can be viewed in the online issue, which is available at a male breast (H&E, 4003). [Color figure can be viewed in the
wileyonlinelibrary.com.] online issue, which is available at wileyonlinelibrary.com.]

ings are similar to ours—we found that 5.8% of our As our findings show, fine needle aspirates of gyneco-
breast aspirates were from male patients. Gupta et al.8 mastia can have variable cellularity ranging from virtually
reported 99 male breast lesions amongst a total of 7321 acellular to richly cellular smears.2 Virtually acellular
(1.4%) breast aspirates, while Das et al.2 reported 188 smears were seen in more mature lesions, where sclerosis
male patients amongst 2573 breast aspirations (7.3%). had overtaken proliferation. Cytologic atypia was seen in
Adolescents and elderly individuals frequently present smears with high cellularity. However the more cellular
with gynecomastia. In our study, 23 cases of gynaecomas- smears had a pattern very similar to that of fibroadenoma.
tia were adolescents, and 27 cases were in senescence Duct cell clusters, oval nuclei of myoepithelial cells, and
(>50 years). Majority of the patients (36 cases) were fragments of stroma were the three main components
between 20 and 50 years. Gynecomastia caused by transi- found in these smears.2 Mild nuclear atypia in gyneco-
tory hormonal changes, as in puberty, often regresses after mastia has also been observed by other authors.2,6 The more
1 or 2 years.6 A study by Ersek et al showed that in 33% cellular aspirates represent actively proliferative lesions. The
of pubertal cases, the condition subsided on its own cytologic diagnosis of gynecomastia and carcinoma is diffi-
within 1 year, and in 93% of cases, the condition subsided cult in such cases. One important clue to the correct diagno-
in 3 years.3 Gynecomastia results from different factors sis is epithelial cohesiveness in smears of gynecomastia,
that induce a benign proliferation of the duct epithelium with presence of very few single atypical cells.2
and increased periductal deposition of collagen.11 These The male breast carcinomas were easily distinguished
different causes share a background of relative on cytology from gynecomastia on the basis of high cellu-
increase in estrogenic activity and decrease in andro- larity, dyshesive cell groups with nuclear piling and ani-
genic activity or both.4,12 The aetiological factors sonucleosis.2 These features were observed in almost all
causing gynecomastia in adolescents are: weight gain cases of carcinoma of male breast. Absence of bipolar
and fat deposition in the breast area, estrogen-androgen bare nuclei was an important clue and only two cases of
imbalance in puberty, psychological stress, hypogonad- carcinoma showed benign cells accompanying malignant
ism or abnormalities of pituitary (loss of blood supply, cells. In the present study, we found that benign and ma-
infection, steroid producing tumors), systemic causes lignant cases were cytologically distinct, except in one
such as adrenal genital syndrome, cirrhosis, renal case, which was initially diagnosed as gynecomastia with
failure, thyrotoxicosis (estrogen and testosterone bind- hyperplasia or probably carcinoma. On review, we found
ing changed) or congenital (Klinefelter syndrome, that the smear contained both benign and malignant cells,
androgen resistance syndrome, etc.) or idiopathic.4 and on histology it was diagnosed as duct carcinoma
Causes of gynecomastia in later years may be: hormo- grade I. Besides this case, there was another case in
nally active tumors (Leydig cell tumor of testis, hCG- which the initial cytological diagnosis was non-Hodgkin’s
secreting germ cell tumors, lung carcinoma or others), lymphoma. On histology, it was diagnosed as high grade
cirrhosis, medications (digitalis, reserpine, Dilantin, and (grade III) invasive duct carcinoma. The misdiagnosis
others) or idiopathic.13 occurred due to completely dispersed cell population with

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MALE BREAST LESIONS DIAGNOSED BY FNAC

cells showing eccentrically placed nuclei, lending a plas- 5. Nuttal FO. Gynecomastia as a physical finding in men. J Clin Endo-
crinol Metab 1979;48:338–340.
macytoid appearance to the cells.14 The poorly differenti-
6. Lilleng R, Paksoy N, Vral G, Langmark F, Hagmar B. Assessment
ated breast carcinoma with a completely dispersed cell of fine needle aspiration cytology and histopathology for diagnosing
population may closely resemble large cell lymphoma male breast masses. Acta Cytol 1995;39:877–881.
(immunoblastic/plasmablastic).15 This pattern is most of- 7. Mansoor I, Jamal A. The value of fine needle aspiration cytology
ten seen in aspirates of ductal carcinoma from older indi- in the diagnosis of male breast lesions. Kuwait Med J 2001;33:
216–219.
viduals.14 Except these two cases, the remaining 29 cases 8. Gupta RK, Naran S, Dowle CS, Simpson JS. The diagnostic impact
of gynecomastia and seven cases of carcinoma, where of needle aspiration cytology of the breast on decision making with
biopsies were available, showed excellent cyto-histologic an emphasis on the aspiration diagnosis of male breast masses. Diagn
Cytopathol 1991;7:637–639.
correlation. The biopsy rate was only 27.6% amongst the
9. Russin VL, Lachowicz C, Kline TS. Male breast lesions: Gyneco-
benign lesions subjected to FNAC. mastia and its distinction from carcinoma by aspiration biopsy cy-
FNAC is a reliable, sensitive, and specific technique tology. Diagn Cytopathol 1989;9:243–247.
which helps to avoid unnecessary surgery in lesions of 10. Joshi A, Kapila K, Verma K. Fine needle aspiration in the manage-
ment of male breast masses: Nineteen years of experience. Acta
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of male breast masses. Many unnecessary surgical biop- breast cancer: A clinicopathologic study of 97 cases. Ann Surg
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