Incidental discovery of bilateral breast cancer in a 24-year-old man presenting with gynecomastia

We present a case of a 24-year-old man who was treated for gynecomastia with bilateral mastectomy and free nipple grafts with subsequent discovery of bilateral breast cancer in the submitted specimens. Surgical treatment of gynecomastia is becoming more popular with over 16,000 procedures of gynecomastia reduction performed in 2005, an increase of 17% compared with the previous year. This case underscores the rare but real possibility of detecting breast cancer in men who present with gynecomastia to plastic surgeons. We caution that male breast tissue should be regarded with the same oncologic principle as female breast tissue. In cases in which ultrasound-assisted suction lipectomy is used, the inability to analyze the breast tissue should be disclosed to the patient.     

锐性吸脂针腋皱襞入路肿胀抽吸法治疗男性乳房发育症

目的:改良目前治疗男性乳房发育症的手术方法,观察其效果。方法:术前应用高频超声探头选择脂肪和乳腺组织均有增生的男性乳房发育症患者18例,以腋皱襞前端为入路,单纯应用锐性吸脂针对增大的乳房进行肿胀抽吸治疗,吸出物送病理学检查。结果:乳房胸部塑形良好,无血肿、乳头乳晕感觉障碍等并发症。胸部无手术痕迹残留。随访3～18月无复发。病理检查结果显示吸出物中有增生的乳腺组织,病理特点符合男性乳腺发育症。结论:对于脂肪和乳腺组织均有增生的男性乳房发育症,锐性吸脂针腋皱襞入路单纯肿胀抽吸术是一种可选的有效手术方法。     

Periareolar-transareolar-perithelial incision for the surgical treatment of gynecomastia

Gynecomastia is an abnormal enlargement of the breast tissue in men. It is the most common disorder of the male breast. Surgical sharp resection of the excess breast tissue is still the mainstay of treatment when medical treatment modalities are proved to be ineffective. The authors believe that areolar incisions give the best results, especially for grades I and IIA gynecomastia. The authors review the ever-increasing areolar incision techniques that have been previously recommended, propose a classification for these techniques, and introduce an alternative technique for areolar resection of the enlarged gland in gynecomastia. An inferior pole, periareolar-transareolar-perithelial (PTP) incision was designed and 15 patients were operated successfully using this technique. Twelve cases were bilateral and 3 were unilateral (27 breasts). A 65-mm access port can be obtained from a 30-mm-diameter areola. No color changes or slough was observed in any of the patients. Areolar access incisions can be classified into 4 main groups: circumareolar, periareolar, transareolar, and circumthelial, and their subgroups. Like every incision proposed, the PTP incision cannot be recommended for every grade of gynecomastia. It is best suited for grades I, IIA, and IIB gynecomastia. Its wide exposure and potential advantage for areolar reduction makes this incision a good alternative to other areolar approaches.     

Surgical management of gynecomastia under endoscope

BACKGROUND: Gynecomastia is an abnormal enlargement of one or both breasts in men. Breast-reduction surgery can help those patients who feel anxious about their abnormal appearance. Surgical treatment of gynecomastia is to excise the excess glandular tissue, which can be performed alone or in conjunction with liposuction. With two successful cases, we proposed that the endoscopic removal of gynecomastia tissue is an innovative, effective surgical treatment. METHODS: Through three small incisions along the mid-axillary line, we surgically treated 2 young gynecomastia patients under an endoscope. The man first was 25 years old, with a developed right breast for 3 years, which was grade II, according to Simon's classification. The second patient was 24 and was diagnosed as bilateral gynecomastia of grade I for 10 years. RESULTS: The endoscopic removal of the glandular tissue was successfully completed. Only minor postoperative complications occurred. Both patients were satisfied with the cosmetic results of the surgery. CONCLUSIONS: Surgical treatment of gynecomastia under an endoscope is a new modality, which presents a satisfactory cosmetic result while leaving minimal and hidden scarring and seldom causes postoperative complications.     

腔镜联合脂肪抽吸术治疗男性乳房发育症

目的:探讨腔镜联合脂肪抽吸术治疗男性乳房发育症的手术效果。方法:在全麻下,应用腔镜和超声刀,切除发育乳腺;采用肿胀麻醉,负压抽吸方法,抽吸乳腺脂肪层,并放置引流,弹力绷带加压包扎。结果:共吸出脂肪组织150～700ml,切除乳腺组织30～160g。随访3个月,患者乳房形态自然良好,乳头乳晕感觉正常,弹性良好,乳房表面无瘢痕,患者对手术效果满意。结论:腔镜联合脂肪抽吸术是男性乳房发育较好的治疗方法,但因其对设备和技术要求较高,限制了其普及。     

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.     

An Ameliorated Approach for Sharp Resection in Gynecomastia Surgery

Surgery has become the accepted standard for the majority of patients with gynecomastia to get rid of feminine-looking breast enlargement. Many surgical techniques have been proposed according to grade of gynecomastia. The sharp resection of glandular tissues is a keystone for most of them. However, technical difficulties in application and inexperience in mastectomy often lead to poor cosmetic outcomes. Over excision and saucer-like deformity, under resection, and asymmetries are most common ones among them. The author presents an ameliorated subcutaneous mastectomy method to facilitate the learning curve and to improve the esthetic results avoiding saucer-like deformity and other breast contour deformities. This method consists of an en bloc tissue dissection via superior periareolar incision and excision of fatty glandular tissue in suprafascial plan, with slicing and trimming procedure. It is possible to adjust the degree of tissue reduction during surgery; hence, it may be labeled as a “cut-as-you-go” technique. Between 2008 and 2012, 23 male patients were operated with this technique. Medical photographs and drawings were used to describe the technique. The operation resulted in smooth, symmetric breasts befitting to men in all 23 patients. No major complications were observed in any of the cases. None of the patients reported a discomfort in sensation of nipple–areolar complex. The presented technique provides high degree of patient satisfaction and excellent esthetic outcomes and is a promising choice in gynecomastia surgery with extremely low recurrence rates and easy learning curve.     

The 3-layered ductal epithelium in gynecomastia

Gynecomastia is the most common abnormality in the male breast and has been associated with male breast cancer, but whether there is an etiological role remains unknown. In the present study we conducted an immunohistochemical investigation to further characterize gynecomastia. A total of 46 cases of gynecomastia were immunohistochemically stained on tissue microarrays for estrogen receptor (ER), progesterone receptor, HER2, androgen receptor, cytokeratins (CK5, CK14, CK7, and CK8/18), p63, E-cadherin, BRST2, cyclin D1, Bcl-2, p53, p16, p21, and Ki67. In addition, 8 cases of male ductal carcinoma in situ and normal breast tissue obtained from autopsies (n=10) and adjacent to male breast cancer (n=5) were studied. Normal ductal male breast epithelial cells were very often ER and Bcl-2 positive (>69%), and progesterone receptor and androgen receptor expression was also common (>39%). Gynecomastia showed a consistent 3-layered pattern: 1 myoepithelial and 2 epithelial cell layers with a distinctive immunohistochemical staining pattern. The intermediate luminal layer, consisting of vertically oriented cuboidal-to-columnar cells, is hormone receptor positive and expresses Bcl-2 and cyclin D1. The inner luminal layer is composed of smaller cells expressing CK5 and often CK14 but is usually negative for hormone receptors and Bcl-2. Male ductal carcinoma in situ was consistently ER positive and CK5/CK14 negative. In conclusion, for the first time we describe the 3-layered ductal epithelium in gynecomastia, which has a distinctive immunohistochemical profile. These results indicate that different cellular compartments exist in gynecomastia, and therefore gynecomastia does not seem to be an obligate precursor lesion of male breast cancer.     

Unilateral male breast masses: cancer risk and their evaluation and management

Breast cancer is an uncommon cause of breast enlargement in the adult male. Overall, it accounts for <1 per cent of all male cancers. Although most male breast carcinomas are clinically apparent, distinguishing early breast cancer from gynecomastia, the most common cause of male breast enlargement, is considered a difficult task. To overcome this difficulty, many surgeons proceed directly to surgery as their initial diagnostic test. Although appropriate in some cases, the infrequent occurrence of male breast cancer and the diagnostic accuracy of mammography and fine-needle aspiration cytology suggest a modification of our present management. The aim of this study was to assess the incidence of breast cancer in men with unilateral breast masses and to propose a treatment algorithm for unilateral male breast masses. The medical records of 36 male patients who underwent subcutaneous mastectomy for a unilateral breast mass at the Buffalo Veterans Administration Medical Center between 1989 and 1996 were retrospectively reviewed. Data was collected on a standard data form. The median age was 63-years-old (range, 22-82). Gynecomastia was diagnosed in 30 patients (83%), lipoma in 4 patients (11%), invasive breast cancer in 1 patient (3%), and melanoma in situ in 1 patient (3%). Of the 30 patients with gynecomastia, 60% (18 patients) gave a history of a medical condition or use of medications known to cause gynecomastia, compared with 16 per cent (1 of 6) of the patients without gynecomastia (P = 0.08). Half of the patients with gynecomastia presented with an asymptomatic mass compared with 67 per cent of the patients without gynecomastia (P = not significant). The median duration of symptoms for patients with gynecomastia was 3 months. Men with unilateral breast masses have a low incidence of breast cancer. A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical and mammographic findings does not require surgical biopsy unless other clinical indications prevail. Lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer.     

Multimodality gynecomastia repair by cross-chest power-assisted superficial liposuction combined with endoscopic-assisted pull-through excision

Numerous methods of gynecomastia repair have been described to accomplish removal of breast tissue. Our multimodality surgical approach for the treatment of gynecomastia combines the use of power-assisted superficial cross-chest liposuction with direct pull-through excision of the breast parenchyma under endoscopic supervision. Seventeen patients, aging 17-39, underwent this multimodality approach. According to Simon's grading, 3 patients had grade 1, 5 had grade 2a, 6 had grade 2b, and 3 had grade 3 gynecomastia. Power-assisted liposuction was performed with a 3- or 4-mm triple-hole cannula inserted through the contralateral periareolar medial incision to suction the contralateral prepectoral fatty breast. At the end of the liposuction, the fibrous tissue was easily pulled through the ipsilateral stab wound and excised under endoscopic control. Follow-up time ranged from 6 to 34 months. The amount of fat removed by liposuction varied from 100-800 mL per breast, and the amount of breast parenchyma removed by excision varied from 20-110 g. All patients recovered remarkably well. No complications were recorded. All patients were satisfied with their results. This technique enables an effective treatment of both the fatty and fibrous tissue of the male breast and avoids skin redundancy due to skin contraction. A smooth masculine breast contour is consistently achieved without the stigma of this type of surgery.     

Expression of Pepsinogen C in Gynecomastias and Male Breast Carcinomas

Pepsinogen C is a proteolytic enzyme involved in the digestion of proteins in the stomach; it is also synthesized by a significant percentage of female breast carcinomas. In addition, it has been demonstrated that pepsinogen C is one of the few proteins induced by androgens in breast carcinoma cells. Here we evaluate the expression of pepsinogen C by immunoperoxidase staining in normal breast tissue from 3 male patients, 15 gynecomastia tissues, 2 male in situ breast carcinomas, and 68 male invasive breast carcinomas. Pepsinogen C immunostaining values were quantified in male breast tumors using the HSCORE system, which considers both the intensity and the percentage of cells staining at each intensity. The results indicated positive immunohistochemical staining for pepsinogen C in all gynecomastia tissues, the two in situ ductal carcinomas, and 52 of 68 invasive breast carcinomas (76.4%). The three normal breast tissues analyzed showed negative staining for pepsinogen C, whereas invasive tumors showed clear differences among them with regard to the intensity and percentage of staining cells. In addition, pepsinogen C scores were significantly higher in well-differentiated (grade I, 188.7) and moderately differentiated (grade II, 145.8) tumors than in poorly differentiated (grade III, 98.5) tumors (p= 0.032). Similarly, significant differences in pepsinogen C content were found between estrogen receptor (ER)-positive tumors and ER-negative tumors (158.5 vs. 44.3, respectively; p= 0.009). Patients with pepsinogen C-positive tumors reached longer relapse-free and overall survival periods than did those with tumors with negative staining, but no statistical differences were observed between survival curves calculated for these two groups of patients. This results demonstrate expression of pepsinogen C by gynecomastias and by a high percentage of male breast carcinomas and may indicate an important role of pepsinogen C in the pathophysiology of male breast diseases.     

The treatment of gynecomastia without sharp excision

A new suction cannula is described that is able to dissect and aspirate breast tissue. The cannula has proven effective in treating gynecomastia without surgical resection of breast tissue.     

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.     

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.     

Fibroadenomatoid hyperplasia of the male breast

A 69-year-old man with congestive heart failure who had been treated with digoxin for 27 years and spironolactone for 4 years developed bilateral gynecomastia. Excised tissue contained multiple nodules. Histologically, the nodules showed a structural pattern corresponding to fibroadenoma of the female breast. This lesion, called "fibroadenomatoid hyperplasia," is probably caused by treatment with spironolactone. The lesion has not previously been described in tissue from the male breast.     

Chest Lifting

The male chest has a female appearance in patients with gynecomastia and those who have experienced a huge weight loss. The disadvantages of reduction mammaplasty for men are the visible scars on the chest wall necessitated because of skin redundancy. The aims of the chest-lifting procedure are to reposition the breast, to create a male appearance by thinning the amount of glandular and fatty tissue, to avoid noticeable scars on the chest wall, and to hide the scar in the middle axillar line.     

Alternatives for the Surgical Correction of Severe Gynecomastia

Two surgical techniques available for the correction of severe gynecomastia in the male patient are described in detail. Severe gynecomastia complicates the plan for correction by presenting the same obstacles which are found in mastopexy or breast reduction for the female patient. These include: tissue resection, skin excision, and nipple-areolar complex elevation. The amount of each of these will determine which specific procedure should be used.     

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.     

Surgical treatment of gynecomastia: complications and outcomes

ABSTRACT: Gynecomastia is defined as the benign enlargement of the male breast. Multiple surgical options have been used to improve outcomes. The aim of this study was to analyze the surgical approaches to the treatment of gynecomastia and their outcomes over a 10-year period. All patients undergoing surgical correction of gynecomastia in our department between 2000 and 2010 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and revision rate. The surgical result was evaluated with self-assessment questionnaires. A total of 41 patients with 75 operations were included. Techniques included subcutaneous mastectomy alone or with additional ultrasound-assisted liposuction (UAL) and isolated UAL. The surgical revision rate for all patients was 4.8%. The skin-sparing procedure gave good surgical results in grade IIb and grade III gynecomastia with low revision and complication rates. The self-assessment report revealed a good level of overall satisfaction and improvement in self-confidence (average scores 9.4 and 9.2, respectively, on a 10-point scale). The treatment of gynecomastia requires an individualized approach. Subcutaneous mastectomy combined with UAL could be used as the first choice for surgical treatment of grade II and III gynecomastia.     

内镜乳晕小切口男性乳房肥大矫正术

目的探索减少男性乳房肥大整形术后瘢痕,使乳房切除更加精确,更有利于塑形,避免出血、血肿及支配乳头、乳晕感觉神经的损伤。方法对16例患者在内镜监视下,采用乳晕旁2~3.5cm切口,切除肥大的男性乳腺腺体组织,对于以脂肪增生为主者,先行肿胀吸脂术,后在内镜监视下进行残余肥大腺体切除。切除乳腺体组织量单侧为100~320g,平均为130g;吸脂量为20~130ml,平均为68ml,无血肿,切除组织病理检查为脂肪组织及腺体组织。结果术后无血肿,无皮肤坏死,乳头及皮肤的感觉良好,均获随访观察,时间为手术后5个月至3年,无复发。结论内镜外科技术能缩小乳晕切口,避免损伤乳头、乳晕,利于离乳晕较远范围的乳腺组织切除及乳房重新塑形,为男性乳房肥大矫正的一种良好选择。