In the evaluation of unilateral gynecomastia in a healthy 40-year-old male, the use of diagnostic tests such as mammography, ultrasound, or biopsy should be considered based on the clinical context and findings. The medical literature suggests that routine imaging for gynecomastia is generally not warranted unless there are suspicious abnormalities on physical examination.
The study by Lapid et al. highlights that malignancies in the male breast are rare, and the probability of finding cancer when performing imaging of clinically benign findings is negligible. Therefore, routine imaging of gynecomastia should be discouraged unless there are suspicious abnormalities.[1] Similarly, the American College of Radiology (ACR) Appropriateness Criteria recommend mammography or digital breast tomosynthesis (DBT) as the initial imaging modality for men with an equivocal physical examination, particularly when breast cancer is more likely due to age or other risk factors.[2] However, for men with a suspicious physical examination, mammography is recommended due to its high sensitivity and specificity in distinguishing benign from malignant disease.[2]
The Mayo Clinic study by Hines et al. found that mammography added little information to the initial evaluation of men with breast symptoms, as breast cancer was typically suspected based on the presence of a dominant mass or other suggestive findings on clinical examination.[3] Furthermore, the study by Muñoz Carrasco et al. demonstrated that while mammography and ultrasound have high negative predictive values, their routine use in the absence of suspicious clinical findings may lead to unnecessary procedures.[4]
In summary, while imaging can be useful in certain clinical scenarios, such as when there is a suspicious mass or other concerning findings, it does not generally improve the assessment of breast cancer risk in cases of clinically benign gynecomastia. Clinical observation remains a reasonable approach in the absence of suspicious findings.