(Radiology. 2001;219:797-799.)
© RSNA, 2001
Diabetic Mastopathy in Men: Imaging Findings in Two Patients1
Susan P. Weinstein, MD,
Emily F. Conant, MD,
Susan G. Orel, MD,
Thomas J. Lawton, MD and
Geza Acs, MD, PhD
1 From the Departments of Radiology (S.P.W., E.F.C., S.G.O.) and Pathology (G.A.), University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104; and Division of Hospital Pathology, University of Washington Medical Center, Seattle (T.J.L.). Received May 22, 2000; revision requested July 2; revision received September 8; accepted November 9. Address correspondence to S.P.W.
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ABSTRACT
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The classic imaging findings of diabetic mastopathy, an uncommon entity manifesting in patients with a history of long-standing insulin-dependent diabetes mellitus, have been reported in the literature in women but not, to the authors’ knowledge, in men. Two men with diabetic mastopathy presented with palpable breast masses. The clinical histories of the men in whom this condition was diagnosed were similar to those reported for women with the condition. The mammographic findings in both men, at presentation, were suggestive of gynecomastia.
Index terms: Breast, male, 00.31, 00.75 • Breast neoplasms, male, 00.31, 00.75 • Gynecomastia, 00.75
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INTRODUCTION
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Soler and Khardori (1) described diabetic mastopathy in 1984 as a benign breast condition. Additional information has followed in the medical, pathology, and radiology literature. Diabetic mastopathy is an uncommon condition affecting women with a history of long-standing diabetes mellitus (2,3). At the time of presentation with breast symptoms, the patients often have associated complications of diabetes, such as retinopathy, nephropathy, and neuropathy (1,2). The pathogenesis of this condition has yet to be elucidated. This entity has been described in the radiology literature (3,4) only in women. The intent of this case presentation is to describe the imaging findings in two men with this condition.
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Case Reports
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Case 1
A 42-year-old man presented with a newly palpable left breast mass. At physical examination, the firm mass measured 4 x 5 x 3 cm. The patient had a 23-year history of insulin-dependent diabetes mellitus (IDDM) at the time of presentation. As the result of the IDDM, the patient had renal failure for which he underwent renal transplantation that subsequently failed. Other complications included a history of a pancreatic transplantation, neuropathy, retinopathy, and peripheral vascular disease requiring amputation of both lower extremities.
The mammogram revealed fibroglandular tissue in the subareolar regions bilaterally, more pronounced on the left than on the right (Fig 1). No suspicious mass lesions, microcalcifications, or architectural distortion were seen. The imaging findings were attributed to gynecomastia.
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Figure 1. Images in a 42-year-old man with a 23-year history of IDDM who presented with a new firm left breast mass. Medial lateral oblique mammographic views of both breasts show fibroglandular tissue (straight arrows) in the retroareolar regions bilaterally, more prominent on the left than on the right. There is a metallic marker (curved arrow) directly over the palpable area. The pathologic result obtained from the excisional biopsy of the left breast mass was consistent with diabetic mastopathy.
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The patient underwent excisional biopsy, as the clinical examination finding was a concern for malignancy. A fibrofatty specimen measuring 5 x 4 x 2 cm was removed and sectioned, revealing tan fibrous tissue. The histopathologic finding was consistent with diabetic mastopathy (Fig 2).
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Figure 2. Medium-power photomicrograph of lymphocytic ductitis shows lymphocytes and occasional plasma cells surrounding a mammary duct and invading the ductal epithelium. The stroma shows dense fibrosis with thick collagen bundles. (Hematoxylin-eosin stain; original magnification, x100.)
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Case 2
A 45-year-old man presented with a palpable left breast mass of 1-month duration in the retroareolar region. At physical examination, a firm mobile mass that measured 2 x 1 cm was present directly behind the nipple. No axillary adenopathy was appreciated.
IDDM was diagnosed in the patient at the age of 24 years. The only complications associated with diabetes included microangiopathy and neuropathy.
The mammogram revealed tissue in the retroareolar regions (Fig 3a). Ultrasonography (US) showed hypoechoic solid tissue in the region of the palpable breast mass without posterior acoustic shadowing (Fig 3b). The imaging findings were again attributed to gynecomastia.
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Figure 3a. Images in a 45-year-old man with a 21-year history of IDDM who presented with a mass behind the left nipple in 1992. (a) Bilateral medial lateral oblique mammographic views show fibroglandular tissue (straight arrows) in the subareolar regions, without suspicious masses, microcalcifications, or architectural distortion. A metallic marker (curved arrow) was placed over the palpable breast mass. (b) A sonographic image in the radial plane of the palpable region shows a hypoechoic mass (solid arrow). The pectoralis muscle is labeled with an open arrow. The imaging findings were believed to be due to gynecomastia. Excisional biopsy revealed diabetic mastopathy.
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Figure 3b. Images in a 45-year-old man with a 21-year history of IDDM who presented with a mass behind the left nipple in 1992. (a) Bilateral medial lateral oblique mammographic views show fibroglandular tissue (straight arrows) in the subareolar regions, without suspicious masses, microcalcifications, or architectural distortion. A metallic marker (curved arrow) was placed over the palpable breast mass. (b) A sonographic image in the radial plane of the palpable region shows a hypoechoic mass (solid arrow). The pectoralis muscle is labeled with an open arrow. The imaging findings were believed to be due to gynecomastia. Excisional biopsy revealed diabetic mastopathy.
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The patient underwent excisional biopsy on the basis of clinical suspicion. The histopathologic diagnosis revealed diabetic mastopathy (Fig 4).
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Figure 4. Low-power photomicrograph shows mononuclear vasculitis with lymphocytes surrounding several small vessels. The stroma shows scattered epithelioid fibroblasts with round to oval vesicular nuclei and abundant cytoplasm arranged as individual cells embedded in dense fibrosis with thick collagen bundles. (Hematoxylin-eosin stain; original magnification, x40.)
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Histopathologic Findings
The histopathologic findings were similar in the two men. Gross examination revealed firm, white, trabeculated, fibrotic tissue. Histologic examination showed prominent lymphocytic ductitis and perivasculitis. The inflammatory infiltrate was composed of small round lymphocytes and scattered plasma cells, which surrounded and invaded the ductal epithelium (Fig 2) and small vessels (Fig 4). The stroma showed dense fibrosis with thick bundles of collagen with keloid-like features. Numerous scattered epithelioid fibroblasts with abundant cytoplasm and vesicular nuclei were present in the stroma, separated from each other by dense collagen (Fig 4). The constellation of the features just described was diagnostic of diabetic mastopathy (6). There were no pathologic changes of gynecomastia seen within both specimens.
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Discussion
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Diabetic mastopathy is a relatively uncommon condition that has been described in women. At our institution, there were 12 documented cases, 10 in women and two in men, from 1991 to 1998. The women typically present with firm, mobile breast masses that may be irregular in contour (2–4). On the basis of the physical examination findings alone, it is often difficult to exclude a malignancy (2,4,5). The size of the masses may vary considerably from 5 mm to 6 cm (3,5). The two men in our case report also presented with firm breast masses. Although the mammographic findings suggested gynecomastia, the physical examination findings were suggestive of malignancy. Therefore, excisional biopsy was performed in both men.
Mammograms in women classically show dense breast tissue, and, because of the density, a focal breast mass may not be seen (1,3,4). The US finding has been described (3,4) as dense posterior acoustic shadowing. Therefore, the imaging findings often increase the level of clinical suspicion of a breast malignancy. In the two men, the mammographic findings were suggestive of gynecomastia. As noted, sonographic evaluation in one of the men revealed a hypoechoic solid mass without posterior acoustic shadowing.
Diabetic mastopathy is associated with long-standing IDDM, with duration of diabetes reported (1–3) to be from 6 to 37 years at the time of diagnosis. Similarly, IDDM was diagnosed in the two men 21 and 23 years ago.
The pathogenesis of diabetic mastopathy is not known. Soler and Khardori (1) postulated that an autoimmune reaction resulting from abnormal cross linking of collagen might be responsible. Others (2,6,7) have also concurred with an autoimmune hypothesis. It has been proposed (1,2) that the disease process causing diabetic mastopathy is likely a part of the spectrum responsible for the multiple complications in diabetes. This would account for the fact that this condition occurs primarily in patients with a long history of IDDM and when there are other associated complications.
In men with a history of IDDM who present with clinically suspicious breast masses and mammographic findings suggestive of gynecomastia, surgery may be avoided. Logan and Hoffman (3) successfully followed up a group of women with a high clinical suspicion of diabetic mastopathy with serial clinical evaluation and fine-needle aspiration. This approach may also be useful to avoid surgery in men who fit the appropriate clinical description, as this population is at increased risk for surgical complications compared to the general population.
In conclusion, diabetic mastopathy may affect men as well as women with long-standing IDDM, and, in the appropriate clinical setting this diagnosis should be entertained in men presenting with discrete palpable breast masses and mammographic findings suggestive of gynecomastia. The medical histories of the men in whom diabetic mastopathy was diagnosed were similar to those reported in the literature for women.
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FOOTNOTES
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Abbreviation: IDDM = insulin-dependent diabetes mellitus
Author contributions: Guarantor of integrity of entire study, S.P.W.; study concepts, E.F.C., S.P.W., T.J.L.; study design, S.P.W.; literature research, S.P.W.; clinical studies, S.P.W., T.J.L., G.A.; data acquisition, T.J.L.; data analysis/interpretation, T.J.L., G.A.; manuscript preparation and definition of intellectual content, S.P.W.; manuscript editing, S.P.W., T.J.L., S.G.O., E.F.C.; manuscript revision/review and final version approval, all authors.
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REFERENCES
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Logan WW, Hoffman NY. Diabetic fibrous breast disease. Radiology 1989; 172:667-670.[Abstract/Free Full Text]
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Garstin WIH, Kaufman Z, Michell MJ, Baum M. Fibrous mastopathy in insulin dependent diabetics. Clin Radiol 1991; 44:89-91.[Medline]
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Tomaszewski JE, Brooks JS, Hicks D, Livolsi VA. Diabetic mastopathy: a distinctive clinicopathologic entity. Hum Pathol 1992; 23:780-786.[Medline]
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Morgan MC, Weaver MG, Crowe JP, Abdul-Karim FW. Diabetic mastopathy: a clinicopathologic study in palpable and nonpalpable breast lesions. Mod Pathol 1995; 8:349-354.[Medline]
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ABSTRACT
INTRODUCTION
