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.     

Role of testosterone and dihydrotestosterone in spontaneous gynecomastia of adolescents.

To test a possible hormonal mechanism of gynecomastia at puberty, a group of pubertal spontaneous gynecomastia (PSG) and healthy young volunteers (HYV), Tanner's stage II-V, were studied. Peripheral blood samples were obtained for measuring follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), testosterone (T), dihydrotestosterone (DHT), estradiol (E-2) and estrone (E-1). No difference was established in steroids in pituitary hormonal concentration when both groups were compared on a sexual stage-matched control basis, except for T 2 SD in 5/9 subjects of PSG and DHT 2 SD in all of PSG. The T:DHT ratio varied from 5.0 to 15.4 in PSG and from 0.42 to 2.224 in HYV. Whether spontaneous gynecomastia might exist in an enzimatic blockade of 5 alpha-reductase and whether a decrease in the T:DHT ratio might favor the estrogen action for the progression of breast enlargement deserve further analysis.     

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.     

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.     

Efavirenz-associated gynecomastia: report of five cases and review of the literature

The prognosis of HIV infection has improved dramatically since the introduction of highly active antiretroviral therapy (HAART). However, numerous adverse effects and limitations regarding tolerability remain a concern. Lipomastia (pseudogynecomastia), a breast enlargement due to central adiposity, may occur as part of a fat redistribution syndrome which has been associated with HAART regimens and several pathogenic mechanisms have been advocated in its development. Here we report an observational longitudinal study of five patients diagnosed of gynecomastia associated with efavirenz-based HAART regimens. All cases reached successful immunologic and virologic responses to HAART. The delay of appearance of gynecomastia from the beginning of HAART ranged between 4 to 15 months. In all five cases, gynecomastia regressed after efavirenz withdrawal (mean period of 5 months). In summary, we think that HAART induced gynecomastia should be suspected in HIV patients receiving efavirenz-containing regimens. Although pathogenesis is unclear, this study and a review of the English literature implicates two possible mechanisms: (a) immune restoration processes and (b) efavirenz mediated estradiol-like effects.     

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.     

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.     

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.     

Progressive spontaneous unilateral enlargement of the breast twenty-two years after prosthetic breast augmentation.

Late spontaneous enlargement of the breast is a rare complication after prosthetic breast augmentation. It has been intermittently described in the literature over the last 24 years but its exact aetiology remains unknown. Several possible aetiologies have been proposed. We present a case of a 46-year-old female who developed spontaneous asymmetrical breast enlargement 22 years post-bilateral breast augmentation without any known precipitating factors. Radiographic imaging revealed a periprosthetic collection occupying 70% of the volume inside the capsule. Initial recommendations for capsulectomy and removal of the breast implant were delayed for a year by the patient who subsequently represented with ongoing enlargement of the affected breast. Pathological findings revealed an intact silicone implant surrounded by laminated blood clot, similar in appearance to a chronic subdural haematoma. The literature is reviewed and the possible pathophysiological mechanisms of this unusual condition discussed.     

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.     

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.     

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.     

Concurrent Poland's syndrome and gynecomastia: a case report

Gynecomastia (enlargement of the male breast) is a common occurrence during puberty and usually resolves. Poland's syndrome or hypoplasia of the chest wall is a rare congenital anomaly associated with hypoplasia of the ipsilateral extremity. Simultaneous presentation of gynecomastia and Poland's syndrome in a 26-year-old man increased the extent of asymmetry and the perception of each deformity. Surgical reduction of the enlarged breast greatly reduced the asymmetry, giving a satisfactory result.     

Male reduction mammoplasty in serious gynecomastias

This article is a report on long-term followup of a total of 44 serious gynecomastia cases in the stages I–III (according to Deutinger). The treatment consisted of either a semicircular incision and subcutaneous mastectomy or a superiorly or an inferiorly based nipple transposition while performing male reduction mammoplasty. Aesthetically pleasing results could be obtained by a periareolar approach and mastectomy. This inconspicuous procedure is feasible even in massive gynecomastia cases (stage III) or in cases of male breast asymmetry. On the other hand, all cases with breast reduction plasty and nipple transposition resulted in wing-shaped, mainly broad scars, and subjectively unfavorable results. Consequently, we favor the semicircular approach in male reduction mammoplasty in treating serious gynecomastias. With regard to possible male breast cancer etiology, the histological specimen of the mammary gland in gynecomastia is excised prior to any additional liposuction for supplementary body contouring.     

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.     

Gynecomastia: complications of the subcutaneous mastectomy

Gynecomastia is a benign enlargement of the male breast secondary to gland proliferation. Subcutaneous mastectomy is performed for symptomatic patients and in those desiring cosmetic changes. The aim of this study was to assess the risk factors and complications associated with the operation. We retrospectively examined the records of all patients undergoing a subcutaneous mastectomy for gynecomastia. Ninety-one patients were identified. We conducted telephone interviews with 52 patients and performed 65 subcutaneous mastectomies on those 52 patients. Thirty of the 65 procedures (46%) developed complications. These included sensory changes, pain, seromas, scarring, breast asymmetry, hematomas, and wound infection. No preoperative risk factors were significant for postoperative complications. Eighteen of 22 cases with drains placed intraoperatively developed complications as compared with 12 of 43 cases without drains (P = 2.6 x 10(-7)). Specimens removed from the patients who had drains placed were significantly larger than those from patients who did not have drains placed (P = 1.5 x 10(-5)). However, specimen size was not an independent risk factor for development of a complication (P = 0.14). We found a relatively high complication rate in subcutaneous mastectomy for gynecomastia. Most complications are minor with no long-term effect. Drain placement was the only risk factor associated with postoperative complications.     

Incidental finding of synchronous bilateral ductal carcinoma in situ associated with gynecomastia in a 15-year-old obese boy: case report and review of the literature

Carcinoma of the breast is rarely encountered in the male population and is even less prevalent in the pediatric male population. Studies have suggested an association between male breast carcinoma and gynecomastia, but conflicting results have been shown. Only 3 cases of carcinoma in situ associated with bilateral gynecomastia during puberty have been described in the literature. Here, we present the case of a 15-year-old boy with bilateral gynecomastia who was found to have synchronous bilateral ductal carcinoma in situ.     

Inferior pedicle reduction technique for larger forms of gynecomastia

The treatment of larger types of gynecomastia is significantly different than that of less severe gynecomastias. Special concerns of the former include aerola enlargement, nipple-areola ptosis, and redundant skin. Many procedures have been described to address these issues, none of which is completely satisfactory; these are reviewed here. Unsatisfactory results may be due to residual breast hypertrophy, skin redundancy, complications related to nipple-aerola placement, form and viability, and cosmetically unacceptable scars. We describe a new technique that uses an inferior pedicle to reposition the nipple-aerola complex and to maintain its neurovascular integrity and form. A superiorly based chest wall flap in conjunction with suction-assisted lipectomy maximizes chest wall contour. There are no breast mound scars, only a periareolar and inframammary scar.     

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.     

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.