Senger et al question the need for routine histopathologic exam of tissue removed for gynecomastia. The vast majority of patients have benign disease. While atypical ductal hyperplasia or cancer may be found, these are rare and the patients often have one or more risk factors for breast cancer.
Conditions that may be associated with a higher risk of breast cancer in a gynecomastia specimen:
(1) family history of breast cancer in a first-degree relative, including BRCA1 or BRCA2 mutation
(2) Klinefelter syndrome
(3) exposure to radiation, high occupational temperature or electromagnetic fields
(4) exposure to volatile organic compounds
(5) heavy alcohol use
(6) acute clinical onset with rapid progression or retroareolar pain
(7) suspicious features on the clinical examination (irregular hard mass, peau d'orange skin change, bloody nipple discharge)
(8) abnormal gross pathologic exam
The authors recommend that a patient with a large breast mass (> 6 cm) should have an MRI performed to look for findings suspicious for a malignancy.
Obtaining informed consent from the patient to defer an exam would probably be prudent.
