Gynecomastia and Systemic Mastocytosis

Valerie L Ward, MD
Christine M Denison, MD

September 3, 1996

Presentation

Imaging Findings

This man's mammogram demonstrates a focal opacity (arrow) in the central retroareolar region of the left breast. The more typical mammographic appearance of gynecomastia is a flame-shaped opacity which extends and expands posteriorly from the nipple. This flame-shaped opacity is better demonstrated on a craniocaudal mammogram from another patient (arrow). (The lead marker denotes the nipple.)

This man's diffusely dense bones are demonstrated on a plain radiograph of the pelvis. A magnetic resonance image (MRI) of his humerus shows diffusely hypointense T1-weighted signal (arrows) in the bone marrow caused by the presence of innumerable mast cells.

Differential Diagnosis

Diagnosis

Discussion

Etiologies for gynecomastia include side effects of drugs and states of elevated serum estrogens. Drugs associated with gynecomastia include cimetidine, spironolactone, digitalis, isoniazid, reserpine, marijuana, and exogenous estrogens. Increased circulating estrogens are seen in cirrhosis, adrenal carcinoma, estrogen-secreting testicular tumors, and Klinefelter's syndrome. Further questioning of this patient revealed that he was on cimetidine, a histamine blocker, as gastrointestinal prophylaxis for peptic ulcer disease. Gynecomastia was a side effect of his therapy. Peptic ulcer disease is a manifestation of this patient's underlying condition of systemic mastocytosis.

Systemic mastocytosis is a rare disorder of mast cell proliferation in the skin and other organs. In the gastrointestinal tract, histamine release by mast cells leads to histamine-mediated acid secretion and ultimately to peptic ulcers. Hence, prophylaxis with histamine (H2) blockers like cimetidine is common. In addition to the mammographic findings of gynecomastia, other radiographic findings related to this patient's systemic mastocytosis include diffuse osteosclerosis and bone marrow infiltration. Osteosclerosis is due to mast cell proliferation in the skeletal tissues. Mast cells also infiltrate the bone marrow and replace the normal adult yellow marrow. In summary, several manifestations of systemic mastocytosis can be demonstrated radiographically and have a cause and effect relationship.

References

2. Edelman R, Hesselink J. Clinical magnetic resonance imaging. Philadelphia: Saunders, 1990.

3. Kopans D. Breast imaging. Philadelphia: Lippincott, 1989.

4. Resnick D. Bone and joint imaging. Philadelphia: Saunders, 1989.

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