Management of breast lesions in children and adolescents.

The records of 207 patients evaluated and treated for breast abnormalities during a 10-yr period were reviewed. Patients ranged in age from 1 wk through 16 yr. Seventy-eight per cent were female. Operative procedures were performed in 134 patients (64%). Most common diagnoses were fibroadenoma, premature thelarche, and precocious puberty in the females, and pubertal gynecomastia in the males. Age and sex separate patients into natural subgroups. In females beyond the neonatal period, premature thelarche and precocious puberty are the most likely cause of breast enlargement. Breast biopsy is only rarely indicated for a distinct mass lesion in the prepubertal breast. Mass lesions in the breast of adolescent females require excisional biopsy. In the male, pubertal gynecomastia is the most common form of breast enlargement and only occasionally requires subcutaneous mastectomy for cosmetic and psychologic reasons. Careful evaluation of all children with breast enlargement is indicated to uncover underlying causes and to avoid unnecessary operative procedures.     

Imaging Characteristics of Male Breast Disease

Abstract: The purpose of the study was to describe the imaging findings of male breast disease. One hundred and sixty‐four male patients, who underwent mammography and ultrasonography (US) between January 1999 and December 2008, were retrospectively evaluated. Seventy‐five patients (46%) underwent biopsy, and 89 patients (54%) were diagnosed radiologically. The radiologic and pathologic diagnoses in 164 cases of this series were 13 cancers (8%), including one ipsilateral and one contralateral breast cancers, 147 cases of gynecomastia (90%), one fibroadenoma (0.6%), two cases of fibrocystic disease of the breast (1.2%), and one epidermoid inclusion cyst (0.6%). Three mammographic patterns were adequate to describe all 147 cases of gynecomastia in our series: 53 patients (36%) had nodular gynecomastia, 46 patients (31%) had dendritic gynecomastia, and 48 patients (33%) had diffuse gynecomastia. Gynecomastia was unilateral in 65% of cases (n = 95), and bilateral in 35% of cases (n = 52). On physical examination, two of the malignant lesions had no clinic features of malignancy (15%). On mammography, 11 of 13 malignant masses were demonstrated (85%). A mass with microcalcifications was seen on mammograms in one case (9%). The contours of the masses were irregular in nine cases (82%), well‐circumscribed in two cases (18%). The location of the masses was retroareolar in seven cases (64%) and eccentric to the nipple in four cases (36%). The size of the masses varied between 0.5 cm and 5 cm (mean 2.4 cm). Nipple retraction was evident in five cases (45%), and skin thickening in four cases (36%). All of the malignant masses were demonstrated on ultrasound; however, one of them was seen retrospectively after mammography. All of the masses were hypoechoic and solid, the contours were well‐defined and smooth in two masses (15%), and irregular in 11 masses (85%), and five masses (39%) had posterior prominent shadowing. Axillary lymphadenopathia was detected in two cases (15%). One patient had a previous contralateral breast cancer, and one had an ipsilateral. On mammography, breast cancer characteristically exhibits an irregular subareolar mass, nipple retraction, and skin ulceration or thickening, but sometimes breast cancer has a well‐circumscribed contour and punctuated microcalcifications. Ultrasonography is essential and useful for further characterization and helpful for demonstrating lymphadenopathies of the axillary region.     

On the neglected entity of unilateral gynecomastia

Although there are many articles in the literature on the etiology, classification, and management of gynecomastia, the entity of unilateral gynecomastia has not received much attention. In this article, 15 consecutive males (seen over a 10-year period) with unilateral gynecomastia were retrospectively reviewed. The study showed the unique presentation in this group of patients. One third of the patients (n = 5) had "cancer phobia" and were worried either because of the presence of a mass (n = 2) or because of the unilaterality of their disease (n = 3). The study also showed the predominance of true (glandular) gynecomastia, and this has also been observed in other cases of unilateral involvement in the literature. All patients underwent preoperative mammography. Mammographic findings were consistent with gynecomastia in all patients, including the 2 patients with concurrent breast masses. All patients underwent subcutaneous mastectomy, and histologic examination confirmed the diagnosis. Finally, the literature on unilateral gynecomastia was reviewed.     

The diagnostic accuracy of mammography in the evaluation of male breast disease.

BACKGROUND: The role of mammography in the evaluation of male patients presenting with breast disease is controversial. This controversy is a function of the lack of specific data concerning the diagnostic accuracy of mammography when used in this clinical setting. The purpose of this study was to define the diagnostic accuracy of mammography in the evaluation of male breast disease. METHODS: One hundred and four prebiopsy mammograms from 100 patients with tissue diagnoses were read blindly by two independent radiologists, and placed into one of five predetermined categories: definitely malignant, possibly malignant, gynecomastia, benign mass, and normal. Radiologic/pathologic correlation was performed and the sensitivity (Sn), specificity (Sp), positive (Ppv) and negative predictive value (Npv), and accuracy (Ac) for each of the mammographic diagnostic category determined. RESULTS: The pathologic diagnoses were 12 cancers, including 1 patient with bilateral breast cancer, 70 cases of gynecomastia, 16 benign masses, and 6 normals. The accuracy data for the mammographic diagnostic categories are as follows: malignant (combined definitely and possibly malignant), Sn 92%, Sp 90%, Ppv 55%, Npv 99%, Ac 90%; and overall benignity (combined gynecomastia, benign mass, and normal), Sn 90%, Sp 92%, Ppv 99%, Npv 55%, Ac 90%. Six cancers (50%) coexisted with gynecomastia. CONCLUSIONS: Mammography can accurately distinguish between malignant and benign male breast disease. Although not a replacement for clinical examination, its routine use could substantially reduce the need for biopsy in patients whose mammograms and clinical examination suggest benign disease.     

Outcomes of surgical and sonographic assessment of breast masses in women younger than 30

Assessment of breast masses in young women is challenging due to normal glandular variance. Our purpose is to define the outcomes of specialized physical exam, selective breast sonography (BUS), and biopsy in women younger than 30. Five hundred forty-two patients younger than 30 referred with a palpable breast mass were studied. Patients' mean age was 24.8. Surgeon's physical exam confirmed a dominant mass in 44 per cent of cases. Thirty-seven per cent had normal clinical exams. Median tumor size was 2.2 cm. On multivariate analysis, a mass on surgeon's clinical exam (P < 0.0001), and BUS (P = 0.0001) predicted the presence of a true mass. Fifty-three per cent of self-detected abnormalities were true masses compared to 18 per cent when detected by the primary care provider (PCP) (P < 0.001). Most common diagnoses were fibroadenoma (72%), breast cysts (4%), or fibrocystic changes (3%). Malignancy occurred in 1 per cent. In summary, breast mass is a common reason for surgical consultation. Normal glandular nodularity is often mistaken for a mass. However, a judicious approach of physical exam by a surgeon using selective BUS and image guided core biopsy provides an efficient and safe approach for diagnosis. Breast malignancy is a rare but serious cause of breast mass in young women.     

Ultrasonographic assessment of male breast diseases

Although rare and accounting for less than 1% of all breast cancers, the incidence of breast cancer in men has increased by 26% over the past few decades. Very little has been reported on the sonographic appearance of benign and malignant male breast conditions. The aim of this study was to describe the ultrasonographic features of male breast disease and the value of ultrasound in the evaluation of male breast disease. Between December 2006 and October 2014, ultrasound examinations were performed in 560 male patients presenting with enlargement of, pain in, and/or a lump in the breast. One hundred and thirty‐six patients (24.3%) underwent surgical excision, and 424 patients (75.7%) were diagnosed by ultrasound. Their ultrasonographic features were retrospectively evaluated. The final diagnoses were gynecomastia (n = 537), primary breast cancer (n = 9), lipoma (n = 7), chronic mastitis (n = 6), and fibroadenoma (n = 1). Of the 560 lesions, 356 (63.6%) were classified as Breast Imaging Reporting and Data System (BI‐RADS) category 2, 191 (34.1%) were classified as BI‐RADS category 3, and 13 (2.3%) were classified as BI‐RADS 4 or 5. The sensitivity, specificity, PPV, NPV, and accuracy of the detection of malignant breast masses according to ultrasound were 100%, 99.3%, 69.2%, 100%, and 97.7% respectively. The sonographic patterns of gynecomastia were nodular (n = 131, 24.4%), dendritic (n = 50, 9.3%), and diffuse glandular (n = 356, 66.3%). Color Doppler flow imaging revealed hypervascularity in five of these malignant masses, moderate vascularity in two of the masses, and mild vascularity in the remaining two masses. Other diseases included in the study are also described. Ultrasonography (US) is useful in the diagnosis of male breast diseases, especially in differentiating cancer from benign lesions.     

La gynécomastie,ses étiologies et sa prise en charge chirurgicale : y a-t-il une différence entre les cas bilatéraux et unilatéraux ?

Numerous excision and liposuction techniques have been described to correct bilateral male breast enlargement. Yet little attention has been directed towards the rare cases of unilateral gynecomastia which have frequently been suspected to be malignant. The purpose of this study was to investigate the results of surgical gynecomastia management and the roles of different treatment modalities in a large patient cohort with special attention to etiology, treatment and outcome in the cases of unilateral involvement.     

Overuse of Imaging the Male Breast—Findings in 557 Patients

Gynecomastia is the most common abnormality of the male breast. However, breast cancer may occur, albeit with a significantly lower incidence than in females. Imaging is often used as part of the diagnosis. The aim of this study was to assess the utilization and outcome of imaging with mammography or ultrasound of the male breast in a university hospital's department of radiology. A retrospective study assessing the imaging of the male breast in 557 patients over a 10‐year period. Referral was done mainly by general surgeons and general practitioners. The most common indication was enlargement of the breast, described as gynecomastia or swelling in 74% of patients, followed by pain in 24% and “lumps” in 10%. The modalities used were mammography in 65%, ultrasound in 51% and both in 26%. Most examinations, 519, were BI‐RADS 1 or 2, and 38 were BI‐RADS 3 or higher. Altogether 160 patients had additional fine‐needle aspiration or biopsy. Malignancies were diagnosed in five patients (0.89%). Imaging had a sensitivity of 80% and a specificity of 99%. The positive predictive value was 44% and the negative predictive value 99.8%. Malignancies are rare in the male breast. The probability of finding cancer when performing imaging of clinically benign findings in the male breast is negligible. Imaging is not warranted unless there are suspicious abnormalities. Routine imaging of gynecomastia should be discouraged.     

Clinical and surgical management of unilateral prepubertal gynecomastia

INTRODUCTION

Gynecomastia is the benign proliferation of the glandular tissue in the male breast. This condition is thought to be caused by the imbalance between estrogen action relative to androgen action at the breast tissue level. Bilateral gynecomastia is frequently found in the neonatal period, early in puberty, and with increasing age. Prepubertal unilateral gynecomastia in the absence of endocrine abnormalities is extremely rare, with only a few cases in literature.

PRESENTATION OF CASE

We present an otherwise healthy boy of 12 years old with unilateral breast masses. No abnormalities were found on ultrasonography and on all endocrine parameters. Treatment consisted in a new “modified” Webster technique.

DISCUSSION

The results confirmed validity of this technique in terms of esthetic and functional results, and patient satisfaction. Atypical presentations of gynecomastia are often not recognized. The main pathophysiology of gynecomastia is alteration in the balance between the stimulatory effect of estrogen and the inhibitory effects of androgens on the development of the breast. If there is no causal treatment, surgical resection is the therapy of first choice.

CONCLUSION

The exact mechanism of unilateral gynecomastia formation in our case is unclear. The evaluation of unilateral gynecomastia can therefore be complex. In conclusion, the surgical treatment of unilateral gynecomastia requires an individual approach, based on an appropriate diagnostic algorithm.     

How should gynaecomastia be managed?

Background: The purpose of the present paper was to review the management of men referred to a breast clinic with presumed gynaecomastia. Methods: A retrospective analysis was carried out of 175 men over the age of 16 years who presented with breast enlargement and/or ‘lumps’, during a 7‐year period to a single‐surgeon. All patients had complete biochemical assessment (liver function tests, γ‐glutamyl transferase, prolactin, α‐fetoprotein, β‐human chorionic gonadotropin), and mammography and/or ultrasound with fine‐needle biopsy if indicated. Results: One hundred and seventy‐five men, median age 44 years (range: 18?89 years), were assessed. Thirty‐nine had bilateral true gynaecomastia and 88 had unilateral gynaecomastia (53% left). Carcinoma of the breast was diagnosed in eight, pseudo‐­gynaecomastia in 18, 13 had physiological pubertal changes only and nine had other diagnoses. Adverse drug reactions were possibly implicated in the aetiology of 47 patients, alcohol in seven patients, cannabis in one patient, testicular malignancy in four patients and hepatocellular carcinoma in one patient. Five patients were found to have hyperprolactinaemia. Twenty‐four per cent of patients were reassured without intervention; 18% failed to attend follow up. Sixteen per cent were treated with danazol, 15% underwent surgery and 28 were referred for management of their cause. Danazol was effective in 81%, and three patients required surgery when danazol was ineffective. One further patient developed testicular cancer 9 months after presentation. Conclusion: Men presenting to a breast clinic require clinical assessment to exclude diagnoses other than gynaecomastia. True gynaecomastia can be managed with exclusion of causative factors by non‐invasive investigation and examination. Many patients can be reassured as to the idiopathic nature of the condition and many will fail to attend follow up. Danazol is successful in some patients and surgery should be reserved for resistant cases.     

Changes in male breast cancer over a 30-year period

Male breast cancer is a rare clinical entity accounting for approximately 1 per cent of all breast cancers. The present study investigated changes in patient characteristics, disease patterns, treatment, and outcomes over a 30-year period. A retrospective chart review was performed on male breast cancer patients treated between 1975 and 2005 at Eastern Virginia Medical School, Norfolk, VA. Demographic, pathologic, treatment, and survival information was collected. To facilitate comparison of trends, the patients were divided into two groups: Cohort A (1972-1991, previously reported) and Cohort B (1992-2005). Both cohorts included 28 male patients. Comparing the cohorts, no statistical differences were noted in median age, ethnicity, presenting symptoms, or progesterone receptor status. In Cohort A, 70 per cent of patients were estrogen receptor positive, compared with 100 per cent of Cohort B (P = 0.02). Her2/neu was positive in three of five patients in Cohort B. There was a trend toward more conservative surgery, with no radical mastectomy or orchiectomy performed in Cohort B. Only two patients had sentinel lymph node mapping, both from Cohort B. Infiltrating ductal carcinoma was more prevalent in Cohort B (P = 0.04). For Cohort A and B, 5-year survival was 43 per cent and 51 per cent, respectively, which was not statistically significant. For male breast cancer, radical mastectomy is no longer a common treatment modality. Male breast cancer of today is more hormonally responsive which may have important implications for therapy. Survival has not significantly improved over the previous 30 years. Compilation of multi-institutional data of male breast cancer is needed to advance the treatment of this uncommon disease.     

Changing concepts in establishing the diagnosis of breast masses

Experience with 297 consecutive biopsies of breast masses for 235 benign lesions and 62 carcinomas over a thirty month period has been reviewed. The correct preoperative clinical diagnosis was made in 91 per cent of cases. Of patients with carcinoma, 66 per cent were suspected clinically, and 88 per cent of those clinically suspected were confirmed by needle biopsy alone. The mammographic diagnosis was correct in 89 per cent of cases with 6 per cent false-negatives. The clinical and mammographic diagnosis differed in 27 patients, with the clinical diagnosis being correct in 85 per cent. No patient thought to have cancer on both clinical and mammographic grounds had a benign lesion. These data indicate that the approach to establishing a tissue diagnosis in women with breast masses can be simple and inexpensive. Local anesthesia can almost always be employed, and the diagnosis of breast cancer can usually be confirmed with certainty by needle biopsy alone.     

Surgical Management of Gynecomastia—a 10-year Analysis

Background Gynecomastia is defined as the benign enlargement of the male breast. Most studies on surgical treatment of gynecomastia show only small series and lack histopathology results. The aim of this study was to analyze the surgical approach in the treatment of gynecomastia and the related outcome over a 10-year period. Patients and methods All patients undergoing surgical gynecomastia corrections in our department between 1996 and 2006 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and histological results. Results A total of 100 patients with 160 operations were included. Techniques included subcutaneous mastectomy alone or with additional hand-assisted liposuction, isolated liposuction, and formal breast reduction. Atypical histological findings were found in 3% of the patients (spindle-cell hemangioendothelioma, papilloma). The surgical revision rate among all patients was 7%. Body mass index and a weight of the resected specimen higher than 40 g were identified as significant risk factors for complications (p < 0.05). Conclusions The treatment of gynecomastia requires an individualized approach. Caution must be taken in performing large resections, which are associated with increased complication rates. Histological tissue analysis should be routinely performed in all true gynecomastia corrections, because histological results may reveal atypical cellular pathology.     

Use of breast imaging-reporting and data system (BI-RADS) ultrasound classification in pediatric and adolescent patients overestimates likelihood of malignancy

Background/Purpose: Breast masses in the pediatric population cause patient and family concern, partially driven by public awareness of adult breast cancer. However, the spectrum of breast masses in children differs greatly from that in adults, and malignancy is exceedingly rare. The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) ultrasound-based classification system is the diagnostic standard, yet no study has validated BI-RADS in pediatric patients. This study compares BI-RADS classification with histologic diagnoses to evaluate BI-RADS validity in pediatric patients.Methods: Multicenter retrospective evaluation of breast masses in patients under 21 years. Ultrasound reports were compared with histologic diagnoses.Results: There were 283 patients with breast pathology results after excluding clinical diagnoses of gynecomastia. Mean age was 16.9 (SD 2.3), ranging 10–20 years. 227 had pre-operative ultrasounds, and 84% (191/227) were assigned a BI-RADS category. BI-RADS 4 was the most frequent category (55%, n = 124), by definition predicting 2 – 95% likelihood of malignancy. However, pathology was benign in all patients.Conclusions: The current BI-RADS categorization system overestimates cancer risk when applied to pediatric patients. BI-RADS scores should not be assigned to pediatric patients, and BIRADS-defined recommendations for biopsy should be disregarded. A pediatric-specific classification system could be useful.     

Die plastische chirurgische Therapie der Gynäkomastie nach antihormoneller Therapie bei Prostatakarzinom

Gynecomastia is a potential side effect of hormone therapy for prostate cancer. In large, randomized, placebo controlled studies approximately 50% or more of patients with prostate cancer experienced gynecomastia attributable to various mechanisms. Although it is mostly reported as mild to moderate, gynecomastia is one of the reasons most frequently cited for premature discontinuation of such treatment. Prophylactic radiotherapy and prophylactic tamoxifen have been shown to decrease the incidence of hormone-induced gynecomastia; nevertheless, there are still cases of refractory gynecomastia, and in these plastic surgery is needed for correction.Gynecomastia is a benign enlargement of the male breast, requiring no treatment unless it is a source of embarrassment and/or distress for the adolescent or man affected. The indications for surgical treatment of gynecomastia are founded on two main objectives: restoration of the male chest shape and diagnostic evaluation of suspected breast lesions. The authors believe that the complete circumareolar technique with no further scarring creates the best aesthetic results with fewer complications. When this is used in combination with liposuction very pleasing aesthetic results can be achieved.     

Post-traumatic onset of secondary progression of gynecomastia

Gynecomastia is a benign enlargement of the male breast which can be a source of significant anxiety and embarrassment for the patients. A great variety of etiologic factors have been investigated and discussed. However, only few studies in the literature have accentuated on the possible role of the chronic tissue trauma for the de novo development of gynecomastia. Nevertheless, the exact mechanism of its onset in such cases remains unclear. The authors report on a case of posttraumatic unilateral progression of preexisting stable gynecomastia. The possible role of a single episode of acute trauma as a trigger mechanism for the new onset of the breast enlargement is discussed.Level of Evidence: Level V, risk/prognostic study.     

Male breast cancer: a clinicopathologic study of 97 cases.

From 1949 through 1976, 97 men have been treated at Memorial Hospital for primary operable breast cancer. Seven per cent had intraductal carcinoma. Of the patients with invasive carcinoma 30% were pathologic stage I, 54% stage II, and 16% stage III. Fourty-six per cent had pathologically negative axillary lymph nodes. The most common type of tumor was infiltrating duct carcinoma. Fourty per cent of the patients had microscopic gynecomastia. None of the eight patients with intraductal or intracystic carcinoma died of cancer. Survival of the entire group of men with invasive carcinoma was 40% after ten years. The ten year survival for men with negative nodes was 79%, for men with positive nodes 11%. Comparison with a series of 304 women with breast cancer operated on at Memorial Hospital in 1960 revealed no difference with regard to incidence of positive axillary lymph nodes or stage of disease. There was, however, a significantly lower survival rate for men. This poorer prognosis was limited to those men with pathologically positive axillary nodes.     

Enlarging unilateral breast mass in an adolescent male: an unusual presentation of intraductal papilloma

Breast masses presenting in adolescent boys are rare and are almost uniformly owing to gynecomastia. Although surgical referral for breast masses in adolescent boys is common, intervention is typically for cosmesis. We report the case of a 14-year-old boy who presented with an enlarging unilateral breast mass, which was found to be owing to an intraductal papilloma at the time of surgical excision.     

The significance of breast complaints as correlated with age and breast cancer.

A review is presented of 2,000 consecutive new, patients with breast complaints. Emphasis is placed on the specific complaint as correlated with patient age and the incidence of breast cancer. The initial complaints were a lump (50%), an abnormal mammogram (32%), other complaints (8%), breast pain (6%), and nipple discharge (4%). Follow-up information was available for 1,889 patients. The majority of the patients (68%) were under 50 years of age. Of 831 patients to whom a biopsy was recommended, 720 ultimately had a biopsy and 147 cancers were identified. Sixty-five per cent of the cancers were in women aged 50 years or greater. Of the patients aged 50 years or older, 16.1 per cent had breast cancer, while only 4.0 per cent of the patients less than 50 years and 0.8 per cent of the patients less than 30 years of age had breast cancer. The author concludes that the overwhelming majority of patients (92%) referred to a breast surgery practice do not have malignancy. Thus, primary physicians undoubtedly see even a smaller per cent of breast complaints ultimately result in the diagnosis of breast cancer. There is a need to better inform the public as to the significance of breast complaints and to establish more specific criteria for biopsy, particularly in the young, professional, liability threats not withstanding.     

Laser-assisted lipolysis in the treatment of gynecomastia: a prospective study in 28 patients

Gynecomastia is the most common breast pathology. Numerous excisions and liposuction techniques have been described to correct bilateral male breast enlargement. Recently, there has been a shift from the open approach to minimally invasive techniques. This article reports a 5-year experience using laser-assisted lipolysis (LAL) to treat gynecomastia, and describes the surgical technique. Between January 2006 and December 2010, a total of 28 patients with bilateral gynecomastia were treated with LAL. Patients had a mean age of 36.5 years (range 24 to 56 years). LAL was performed with a 980-nm diode laser (continuous emission, 15 W power, 8–12 kJ total energy per breast) after tumescent anesthetic infiltration. The breast was evaluated objectively by two physicians who compared chest circumference and photographs. Patients were also asked to score the results using a visual analogue scale: 75 to 100 (very good), 50–74 (good), 25 to 49 (fair) and 0 to 24 (poor). The postoperative period for all patients was incident-free. After 6 months, 18 patients (64.3%) scored the results as “very good”, 6 as “good” (21.4%), 3 as “fair” (10.7%) and 1 “poor” (3.6%). Mean chest circumferences pre- and postoperatively were, respectively, 117.4?±?11.1 cm and 103.3?±?7.5 cm (p?<?0.001), corresponding to a mean difference of 14.1 cm. Physicians scored the photographs as “very good” in 22 patients (78.6%), as “good” in five patients (17.9%), and as “fair” in one patient (3.6%). LAL in gynecomastia is safe and produces significant effects on fatty tissue, with a reduction in breast volume, together with significant skin tightening. Provided an appropriate amount of energy is delivered by an experienced operator, the results are both significant and consistent.