Presentation
Patient with bilateral breasts in male (gynecomastia) for further evaluation.
Patient Data
The bilateral breasts fibro glandular parenchymal tissues are moderately diffusely prominent and heterogenous with multifocal discrete and variable sized, sizable anechoic thin-walled and posteriorly enhancing cystic lesions, the majority of which relatively conglomerates within the right lower inner breast quadrant and measuring 4.3 mm, 6.1 mm 4.2 mm and 5.9 mm in diameters for the largest cysts. No posterior acoustic shadowing or obvious calcifications. No gross duct ectasia or gross axillary lymphadenopathy.
Cytology report:
Gross appearance of needle aspirate: bloody,
Slides: PAP 6; H/E 4
Smear quality: Adequate
Cellularity: Low
Microscopic Description: Hemorrhagic smears with scant ductal epithelium
Diagnosis: Bilateral gynecomastia, Tanner stage 2
Category: Negative For malignancy
Laboratory hormonal profile
FSH = 3.36 mIU/mL: range (1.5-12.4)
LH 2 = 9.79 mIU/mL: range (1.7- 8.6)
Progesterone = 0.2 ng/mL: range (0.2- 1.4)
Estradiol = 57 pg/mL: range (11.3- 24.8)
2Gen Testosterone = 27.34 nmol/L: range (249-836)
Case Discussion
Symmetrical bilateral gynecomastia with fibrocystic breast changes (fibrocystic gynecomastia) supported and strengthened with laboratory hormonal ratios: follicle stimulating hormones (FSH), luteinizing hormones (LH), progesterone hormones and the estradiol levels as well as the fine needle aspiration cytology (FNA) findings.
Laboratory findings showed elevated estradiol levels, reduced testosterone levels and increased luteinizing hormone levels compared with the reference ranges given. Cytology depicts bilateral gynecomastia, Tanner stage 2 but with no malignancy.
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