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Paper text:
gynecomastia is an over - development of the glandular tissue of the breast region in males .
it occurs in young boys during puberty and in older men and results from an imbalance in the hormone levels .
coexistence of gynecomastia and ductal carcinoma , though rare , has been reported in literature .
a 62-year - old caucasian male presented with a complaint of pain and swelling in the retroareolar right breast .
the patient denied any family history of breast cancer and had no history of trauma to the breast .
the patient underwent a bilateral digital diagnostic mammogram with mediolateral oblique ( mlo ) and craniocaudal ( cc ) views of both breasts ( hologic lorad selenia ) .
there was a flame - shaped density within the retroareolar right breast consistent with mammographic gynecomastia .
further evaluation with ultrasound was recommended for confirmation and to evaluate for any underlying mass .
additional magnification views of the left breast were performed for regional retroareolar pleomorphic and linear microcalcifications extending to the upper outer quadrant [ figure 2 ] .
these microcalcifications were suspicious , and given the regional distribution , further evaluation with ultrasound was recommended to evaluate for any associated mass .
there were no additional suspicious masses , microcalcifications , or areas of architectural distortion in either breast .
medial lateral oblique and craniocaudal views of the bilateral breasts show flame - shaped gynecomastia of the right breast .
the left breast shows microcalcifcations ( arrows ) for which magnification views have been performed .
medial lateral and craniocaudal magnification views of the left breast show suspicious microcalcifications in the retroareolar region extending to the upper outer quadrant ( arrows ) .
an ultrasound examination of both breasts was performed utilizing a 12 mhz transducer ( toshiba alplio mx ) .
the area of pain and retroareolar density in the right breast seen on mammogram corresponded to vague heterogeneous glandular tissue , consistent with gynecomastia , by ultrasound [ figure 3 ] .
no sonographic abnormality was noted in the area of regional microcalcifications in the left breast .
the patient subsequently underwent stereotactic core biopsy ( 9 gauge suros eviva ) of the suspicious microcalcifications in the left breast .
pathology results showed ductal carcinoma in situ grade ii , with intermediate nuclear grade features in multiple core fragments [ figure 4 ] .
the patient was treated with left total mastectomy and sentinel lymph node biopsy , which was negative .
surgical pathology confirmed dcis nuclear grade ii ( intermediate ) , with all surgical margins uninvolved by dcis .
( a ) ductal carcinoma in situ with intraductal proliferation of small , monomorphic cells , forming secondary microlumina , with clustered microcalcifications ( hematoxylin and eosin stain ) ( 4 ) .
( b ) punctate necrosis is present in some involved ducts ( hematoxylin and eosin stain ) ( 4 ) .
( c ) microcalcifications are present within the ducts and stroma ( hematoxylin and eosin stain ) ( 10 ) .
most cases of male dcis present with symptoms on the affected side , such as , palpable mass or bloody nipple discharge .
our case is unusual in that the patient presented with symptoms of gynecomastia in the right breast , and the cancer was an incidental finding in the asymptomatic left breast .
the patient was completely asymptomatic on the left with no pain , palpable mass or nipple discharge .
other authors have reported cases of concurrent gynecomastia and dcis in the same breast , in male patients.[26 ] ductal carcinoma in situ of the male breast is rare , accounting for only about 7% of all male breast cancer cases . of all patients ( male and female ) with dcis , 30 - 50% develop invasive cancer in the following 10 - 20 years ,
a vast majority of male breast cancers are ductal , and usually present late , with approximately 40% having stage iii or iv disease .
men are less likely than women to be diagnosed in the early stages , but diagnosis at the non - invasive stage has increased .
this increase in early diagnosis may be due to improved awareness of male breast cancer .
factors that increase the risk of male breast cancer include high estrogen states , klinefelter 's syndrome , family history , brca 2 gene , hyperprotactinemia , and prior radiation .
no increased breast cancer risk associated with gynecomastia in males has been found . the exact cause of dcis in males in unknown , as they lack the terminal duct lobular units where dcis often originates in women .
it is hypothesized , however , that dcis originates in the duct epithelium in men .
mammography for male breast cancer has a reported sensitivity of 92% and specificity of 91% .
malignant calcifications in the male breast often have a more benign appearance and can be more scattered or round .
management of male breast cancer is largely based on studies that deal with female breast cancer .
typical treatment for males with dcis is total mastectomy without axillary node dissection . in a series of 31 cases of pure dcis in men by cutuli et al .
recurrence of male dcis following total mastectomy has yet to be described . in the same series of 31 cases of male dcis , cutuli et al .
, described only four recurrences , none of which were in patients treated with total mastectomy .
no further adjuvant therapy is necessary , and prognosis for dcis in males is excellent .
our case emphasizes that the contralateral breast should also be imaged in males presenting with unilateral breast symptoms .
ductal carcinoma in situ ( dcis ) in males is rare and usually presents with symptoms on the affected side , such as , palpable mass or bloody nipple discharge . 
 even as dcis has been reported in conjunction with gynecomastia in the same breast , we report an unusual case of a 62-year - old caucasian male , with no family history of breast cancer , who presented with symptomatic side gynecomastia , and was incidentally found to have dcis in a completely asymptomatic left breast . to the best of our knowledge 
 , this case is the first report in literature of asymptomatic , incidentally discovered dcis in a male patient .