Gynecomastia: pathophysiology, evaluation, and management

Surgical Technique Selection in the Management of Pediatric Gynecomastia

INTRODUCTION

Although the majority of pubertal onset gynecomastia is self-resolving in nature, persistent deformity may require surgical intervention. This study aims to identify patient factors associated with surgical technique selection and proposes an algorithm for the surgical management of pediatric gynecomastia.

METHODS

A retrospective analysis was performed of all surgically managed pediatric gynecomastia patients operated on at a single institution from 2012 to 2022. Charts and patient photos were analyzed for patient and operative demographics, endocrinologic comorbidities, complications, and outcomes. Data were analyzed using bivariate and logistic regression analysis.

RESULTS

Fifty-six surgically managed gynecomastia patients less than 18 years of age were included. The average age at surgery was 16.1 years old, with a mean BMI of 26.9. Most patients were overweight or obese (54.8%) and had Simon grade IIb or greater gynecomastia (55.4%) at presentation. All patients underwent 1 of 4 mastectomy techniques with or without liposuction: inferior periareolar (n=25, 44.6%), circumareolar (n=13, 23.1%), transverse with pedicled nipple (n=4, 7.1%), or free nipple graft (n=14, 25.0%). Bivariate and logistic regression analysis revealed significant differences in sternal notch-to-nipple distance, nipple-to-inframammary fold distance, breast resection weight, and gynecomastia grade between the 4 surgical techniques used in this study. An algorithm incorporating these factors was devised to guide surgical decision-making.

CONCLUSIONS

The proposed algorithm guides surgical technique selection for pediatric gynecomastia and is contingent upon the degree of ptosis and skin excess, anticipated resection weight, and skin quality.

Gynecomastia in adolescent males: current understanding of its etiology, pathophysiology, diagnosis, and treatment

Gynecomastia (GM) is a common and continuously evolving condition that commonly occurs during adolescence. It is the source of significant embarrassment and psychological stress in adolescent males. GM is characterized by enlargement of the male breast due to the proliferation of glandular ducts and stromal components. The main cause of GM during adolescence is physiological or pubertal GM, which is primarily attributed to an imbalance between estrogen and androgen activity. Physiological GM is typically transient and resolves within several months, although it may take several years to resolve. GM may also be caused by other pathological conditions and could be indicative of an endocrine disease. It is crucial to understand the pathogenesis of GM to distinguish it from normal developmental variants due to pathological causes. The aim of this review is to highlight the significance of GM during adolescence in terms of potential etiologies, clinical and laboratory diagnoses, and current management.

Gynecomastia on Thoracic Computed Tomography

Background and objective Gynecomastia is a benign proliferation of ductal epithelium in the retroareolar region in male patients. The aim of this study was to investigate the frequency of gynecomastia in male patients who underwent thoracic computed tomography (CT) imaging at our clinic, assess possible causes, highlight the imaging characteristics of gynecomastia, and compare our findings with the literature. Materials and methods Male patients over 18 years of age who underwent thoracic CT imaging in our clinic were included in the study. Patients were initially assessed based on age and the presence of gynecomastia. The patients with gynecomastia were evaluated in terms of age, gynecomastia localization (right, left, and bilateral), gynecomastia type (nodular, dentritic, and diffuse), and possible etiology. Results The study included 1500 patients with a mean age of 45.6±21.7 years, and 470 (31.3%) patients had gynecomastia. Gynecomastia was on the right side in 11.3%, on the left side in 11.1%, and bilateral in 77.7% of the patients. Gynecomastia was nodular in 52.1%, dendritic in 35.3%, and diffuse in 17.2% of the patients. The causative factor could not be identified in 44.3% of the patients with gynecomastia. Among cases where the etiology was identified (56.7%), the most common factors were cancer (23.4%), chronic kidney disease (CKD) (13.2%), and chronic hepatitis B (10.7%). Conclusion When evaluating thoracic CT, the breast area, in addition to the lungs, chest wall, and bone structures, should also be evaluated carefully. With the increased use of thoracic CT scans, incidentally detected gynecomastia in patients is also on the rise. Knowing the presence of gynecomastia is very important for the clinician to determine the etiology and treat the underlying disease. Therefore, detecting and reporting gynecomastia on thoracic CT can prevent unnecessary advanced breast imaging methods and play a very important role in treating the underlying etiology.

Gynecomastia

Enlargement of breasts among boys is termed gynecomastia. This could be due to an alteration in the androgen-estrogen ratio along with the effects of other hormones including growth hormone, insulin like growth factor 1, prolactin, and other factors affecting aromatase enzyme. The common causes of gynecomastia are pubertal gynecomastia, obesity, drugs and hypogonadism. Several other diseases including liver or renal failure, thyrotoxicosis, Klinefelter syndrome, tumors and environmental pollutants can cause gynecomastia. History and clinical examination will help formulate targeted investigations and management. The factors to be evaluated in these include examination of breasts and testes, in addition to other parts of systemic examination. Treatment of underlying disorders can improve gynecomastia, such as use of testosterone in hypogonadism. Some boys may not need any intervention as gynecomastia may resolve on its own. Medical management is useful in simple gynecomastia. Tamoxifen has been tried successfully in adolescents with gynecomastia. Other drugs including clomiphene, danazol, letrozole and anastrozole have not been consistently useful in this age group. In severe chronic gynecomastia, surgery is the treatment of choice.

A Retrospective Review of Arthroscopic Shaver Utilization in Adolescent Gynecomastia

Background

This study compares the arthroscopic shaver and liposuction with other established methods for treatment of adolescent gynecomastia.

Methods

Surgical management was via four operative techniques: open excision, open excision/liposuction, arthroscopic shaver/liposuction, or open excision and free nipple graft. Data were collected and compared using independent t tests, linear regression models, and one-way analysis of variance.

Results

Patients were stratified by Rohrich grades I -II (low) (N = 47) or III -IV (high) (N = 13). The groups were similar in age (P = 0.662) with lower BMI in the low-grade group (x̄ = 25.36 ± 2.1) vs. high-grade group (x̄ = 27.62 ± 4.0; P < 0.001). The low-grade group showed no significant difference in operative time across surgical techniques with decreased mean operative time in the high-grade group using the arthroscopic shaver technique (x̄ = 55.8 ± 7.56) compared with open excision (x̄ = 70.83 ± 11.02, P = 0.04), open excision plus liposuction (x̄ = 89.5 ± 24.93, P = 24.93), and open excision plus free nipple graft (x̄ = 81.67 ± 19.11, P = 0.05). There was no significant difference in complication (P = 0.84) or reoperation (P = 0.68) rates across surgical techniques regardless of grade.

Conclusions

These findings suggest that the arthroscopic shaver is safe and effective for treatment of both low- and high-grade gynecomastia in adolescents. The results yielded a similar incidence of complications and reoperation across surgical techniques, and the arthroscopic shaver approach demonstrated a shorter operative time compared with other techniques for high-grade gynecomastia.

Is Breast Imaging in Male Patients With Benign Lumps Necessary? A Retrospective Study to Assess Concordance Between Clinical Diagnosis and Imaging Findings

Objective

Breast imaging for male patients is a controversial topic due to the high prevalence of gynecomastia compared to male breast cancer. Worldwide, men are undergoing more breast imaging despite the low incidence of male breast cancer. Gynecomastia is a benign condition, but the anxiety it causes and unnecessary medical costs are still high.

Materials and Methods

In accordance with Royal College of Radiology guidelines, a retrospective study was performed in two cycles to determine if mammography or ultrasound should be included in the workup of male patients who were referred to a breast care unit for a lump that was deemed benign by doctors.

Results

There was 100% concordance between clinical diagnosis and imaging findings.

Conclusion

In this population imaging was not necessary in cases of probable gynecomastia and benign conditions found during a clinical assessment. Standardised patient assessment methods can improve care and ensure accurate evaluation.

Changes in Health-related Parameters Associated with Sports Performance Enhancement Drugs

The purpose of this study was to evaluate changes in health-related parameters caused by the administration of anabolic-androgenic steroids and "fat-burning drugs" during a 6-month competition preparation period. The physiological, biochemical, and anthropometric parameters studied included serum cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, aspartate aminotransferase, alanine transaminase, bilirubin, body mass, and percentage of total body fat. Changes in the parameters studied were analyzed at monthly intervals during six months of preparation for competition. The study revealed a continuous increase in body mass, accompanied by a decrease in body fat percentage to the physiologically essential level. Total cholesterol levels remined in the desirable concentration range. The mean levels of triglycerides fluctuated between borderline high and high. Mean high-density lipoprotein cholesterol levels remained within the low range, while low-density lipoprotein cholesterol fluctuated between near-optimal / above-optimal, borderline high, and high levels. Serum levels of aspartate aminotransferase and alanine transaminase remained within the high concentration. The bilirubin concentration remained in the desirable range. The blood nitrogen urea concentration fluctuated between normal and elevated levels. Sports-enhancing drugs analyzed in this study do not have an immediate detrimental impact on the selected biochemical, physiological, and anthropometric parameters that define health.

Etiopathological Factors Associated with Gynecomastia Patients Seeking Surgical Correction in the South Indian Population

Background  Although several medical conditions are associated with gynecomastia, around 60% of cases are idiopathic. The role of endocrine testing in idiopathic gynecomastia is controversial. This study was done to determine the etiological and lifestyle factors associated with different grades of gynecomastia. Patients and Methods  This was a descriptive study conducted at the department of plastic surgery in a tertiary care hospital in South India between January 2014 and December 2016, among the patients seeking corrective surgery for gynecomastia. Results  A total of 73 patients were included in the study with a mean age of 22.56 years. The majority of the patients displayed Simon's Grade IIa gynecomastia (56.2%). The etiological factors identified in this study were hormonal abnormalities (47.95%), hypogonadism (2.7%), and drug intake (1.4%). The most common hormonal abnormality discovered was high estradiol values (15.1%) followed by decreased testosterone levels (13.7%). The chi-squared test revealed no statistically significant relationship between the hormonal values, type of food, body mass index (BMI), or physical activity and the grades of gynecomastia. Conclusion  Most of the patients (50.68%) in our study had idiopathic gynecomastia. The most common hormonal abnormality detected was high estradiol values. No correlation was found between the hormonal values, type of food, BMI, or physical activity and the grades of gynecomastia.

Efficacy and Safety of Cold-Induced Noninvasive Targeted Fat Reduction in Pseudogynecomastia

BACKGROUND

Treatment options for pseudogynecomastia are limited, and the demand for noninvasive breast fat reduction is increasing.

OBJECTIVE

We evaluated the efficacy and safety of a cold-induced lipolysis device for treating pseudogynecomastia.

METHODS

In this 16-week prospective trial, a total of 15 male patients with pseudogynecomastia were treated twice with cryolipolysis. The primary endpoint was a change in the chest circumference from baseline at posttreatment week 8. Secondary endpoints were changes in body weight, fat thickness assessed using ultrasonography, independent evaluator- and patient-rated improvement, and Simon's gynecomastia class (SGC) grading.

RESULTS

The primary assessment, a reduction of 3.05 cm in the mean chest circumference at 8 weeks post-treatment compared to baseline, was statistically significant. The treatment effect was cumulative, with a steady decrease in chest circumference and fat thickness over the 16-week study period. The mean pain score immediately after the first session of treatment was 2.0±1.36, based on a scale of 0~10, with a score of 10 being the worst pain ever experienced. The pain decreased substantially after the end of the procedure.

CONCLUSION

Cryolipolysis was demonstrated to be an effective and safe option for reducing breast fat in pseudogynecomastia. Male with mild to moderate breast enlargement without skin excess can be ideal candidates.

Prepubertal Idiopathic Unilateral Gynecomastia: Case Report and Literature Review

Introduction

Gynecomastia is a benign proliferation of the glandular tissue of the breast in males. Depending on the age, it can be considered a physiological condition. Prepubertal unilateral gynecomastia is a rare phenomenon. There are only a few case reports described through the last few years.

Case Presentation

We report the clinical appearance and management of prepubertal idiopathic unilateral gynecomastia in a 9-year-old boy. We further include a literature review of 14 cases from 2011 to 2021. In contrast to pubertal gynecomastia, prepubertal gynecomastia and especially unilateral prepubertal gynecomastia are extremely rare conditions. Most cases remain idiopathic.

Conclusion

Chromosomal and genetic testing, as well as oncological, endocrine diagnostic and tests for liver and kidney function should be performed. In case of idiopathic prepubertal gynecomastia, surgery is an important part of therapy since patients suffer from their atypical and rare phenotype.

Reversible Gynecomastia in HIV-Infected Man Treated With Triple Antiretroviral Therapy Containing Efavirenz: A Case Report

Gynecomastia is benign hypertrophy of male breast glandular tissue, either unilateral or bilateral, secondary to increased estrogen/testosterone ratio (elevated estrogen level, decreased testosterone levels, or both). The condition can be related to a medical disease or caused by some drugs.

Since the introduction of triple antiretroviral therapy (TAT), we have seen an improvement in the prognosis of human immunodeficiency virus (HIV) infection.

Here we report the case of a 53-year-old man receiving follow-up care in Internal Medicine for HIV infection receiving TAT (tenofovir/efavirenz/emtricitabine). After one year, the patient presented in the Department of Endocrinology, Diabetology, Metabolic Diseases, and Nutrition of Hassan II University Hospital Center, Fez, with bilateral gynecomastia. Hormonal exploration did not reveal any abnormality, so the gynecomastia was attributed to efavirenz use. The regimen was replaced by tenofovir, lamivudine, and dolutegravir. The gynecomastia was resolved within two months of discontinuing efavirenz.

In summary, we think that secondary gynecomastia should be suspected and screened in HIV patients receiving efavirenz-containing regimens.

Sonographic Features of Palpable Breast and Axillary Lesions in Adult Male Patients: A Pictorial Essay

The male breast is a non-functional and rudimentary organ, but similarly to the female breast, it can be affected by various diseases. In contrast to female breast cancer, male breast cancer has a low incidence, and there is no established breast cancer screening program for male patients. Therefore, the diagnostic evaluation is usually performed in male patients with symptoms such as palpability or pain in the breasts. Furthermore, most adult male patients who visit breast clinics sometimes present with not only breast symptoms but also axillary symptoms, and both the breast and axilla are usually examined during breast ultrasonography in daily clinical practice. The purpose of this pictorial essay was to present the sonographic features of various palpable breast and axillary lesions in adult male patients.

Prevalence of endocrine disorders among children exposed to Lavender Essential Oil and Tea Tree Essential Oils

Background

Lavender essential oil and tea tree essential oil have become popular ingredients in personal care and household products in recent decades. Questions regarding the safety of these oils in pediatric populations have been raised, proposing a link between these essential oils and endocrine disruption in children, specifically prepubertal gynecomastia. To date, no epidemiological studies have been conducted to evaluate this proposed link.

Methods

This is a cross sectional study conducted among parents of children in the United States to identify the prevalence of endocrine disruption in children aged 2-15 years old. This study also evaluates the potential for a relationship between the exposure of lavender essential oil and tea tree essential oil products and endocrine disrupting outcomes.

Results

In 556 children with a mean age of 6.33 (SD = 3.92), prevalence of endocrine disruption was .016 (SD = 0.13). No cases of prepubertal gynecomastia were identified in either group, and prevalence of precocious puberty, delayed puberty, growth hormone deficiency, and hypothyroidism were all consistent with population norms. Total risk of endocrine disorders among those exposed (0.0194) did not differ from the risk of those unexposed (0.0069). The risk ratio was 2.796 (95% CI: 0.352, 22.163, P = .458).

Conclusion

Children who were regularly exposed to lavender or tea tree essential oils experienced the same risk of endocrine disorders as those who were not exposed.

Safety, Efficacy, and Tolerability of Simultaneous Bilateral Cryolipolysis Using a Rapid Cycling Contoured Cup Applicator for Noninvasive Fat Reduction in the Enlarged Male Breast: A Pilot Study

BACKGROUND

A previous study using a parallel cooling plate cryolipolysis applicator demonstrated the efficacy of cryolipolysis for pseudogynecomastia. Although the procedure was safe and effective, treatment times were prolonged and anesthetic was needed to reduce treatment discomfort.

OBJECTIVE

To evaluate the safety, efficacy, and tolerability of a short cycle, reduced vacuum contoured cup cryolipolysis applicator for the treatment of pseudogynecomastia.

MATERIALS AND METHODS

Twelve male subjects received simultaneous bilateral treatment consisting of a 35-minute cryolipolysis cycle, followed by a short manual massage, and a second 35-minute cycle with 50% treatment area overlap in a single treatment visit. At the 6-week follow-up, a second treatment was performed with up to 2 overlapping cycles per side. Efficacy was assessed after the second treatment using transcutaneous ultrasound, standardized clinical photography, and subject surveys.

RESULTS

Ultrasound analysis showed a mean fat layer reduction of 5.1 ± 2.3 mm (p < .001). Blinded, independent reviewers correctly identified 97% of baseline/treatment photography results. Surveys revealed 100% subject satisfaction with 91% reporting visible fat reduction and 100% stating they would recommend treatment. Transient side effects included mild intratreatment discomfort, paresthesia, and tenderness.

CONCLUSION

A rapid cycling, reduced vacuum cryolipolysis applicator provides rapid, safe, effective, and tolerable treatment of pseudogynecomastia.

Assessing the Readability of Online Patient Education Resources Related to Gynecomastia

BACKGROUND

The Internet has a plethora of online patient education resources for many symptoms and diseases. National medical governing bodies recommend that patient education materials are written at or below the eighth-grade level, and the literature suggests that health literacy has been linked to increased adherence to treatment regimens and improved outcomes. The primary aim of the study is to assess the readability of online patient materials relating to gynecomastia and ascertain the availability of patient materials in non-English languages.

METHODS

The readability of patient education materials relating to gynecomastia for academic-based websites and nonacademic websites was assessed using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), and Simple Measure of Gobbledygook (SMOG). The prevalence of non-English patient education materials was assessed for both academic-based and nonacademic websites.

RESULTS

Fifty-eight documents were collected across academic websites. Overall median values were 10.7 for the FKGL, 47.0 for the FRE, and 11.4 for the SMOG. For the 10 nonacademic institutions, the overall median values were 10.6 for the FKGL, 45.2 for the FRE, and 10.8 for the SMOG. No appreciable differences were observed for readability when stratified by region or source. The prevalence of non-English patient materials was 19.1% across institutions. None of the noninstitutional materials had information in non-English languages.

CONCLUSIONS

The readability of patient education materials related to gynecomastia is at higher levels than recommended by national organizations. There are limited non-English patient education materials. Future efforts should focus on improving the readability and accessibility of patient materials.

Reoperation Because of Dissatisfaction with the Aesthetic Results of Gynecomastia Surgery: Technical Considerations

BACKGROUND

Gynecomastia is a common disease in male patients that is characterized by benign breast enlargement. Gynecomastia may involve fibroglandular tissue (FGT), supramammary fat tissue, and retromammary fat tissue (RMFT). Gynecomastia is usually treated surgically; however, some patients undergo reoperation because of dissatisfaction with the results of the first operation. This study aimed to analyze the breast conditions requiring reoperation and to identify factors requiring attention during the first gynecomastia surgery.

METHODS

We retrospectively evaluated 98 patients who underwent reoperation because of unsatisfactory esthetic outcomes from January 2014 to April 2020. According to the reasons for dissatisfaction, patients were divided into undercorrection and overcorrection groups. Patients with remnant breast tissue were assigned to the undercorrection group, while those in whom excess breast tissue was removed and was assigned to the overcorrection group.

RESULTS

The undercorrection and overcorrection groups comprised 81 and 17 patients, respectively. In the undercorrection group, 49 (60.5%) patients had residual FGT and fat tissue necessitating simultaneous FGT excision and liposuction, while 32 (39.5%) patients had no residual FGT and were treated with liposuction only. In the overcorrection group, 13 (76.5%) patients had undergone excessive removal of RMFT at the inferolateral aspect of the pectoralis major muscle margin and were treated by autologous fat grafting.

CONCLUSIONS

The most common cause of undercorrection was incomplete FGT removal, and the most common cause of overcorrection was excessive RMFT removal. Complete FGT excision and proper RMFT preservation can reduce the reoperation rate after gynecomastia surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Role of ultrasound in diagnosis of neonatal breast enlargement: a newborn case report

Neonatal breast enlargement is a hormone-related condition, mostly asymptomatic\physiological, with a well-recognizable sonographic appearance but limited data in the literature. It can be uni-or bilateral. Typically described in the first week of life, the transient lesion disappears spontaneously within 6 months. The main differential diagnosis is neonatal mastitis, a breast tissue infection that requires a specific antibiotic therapy. Knowledge of clinical and imaging findings is crucial, and ultrasound represents a reliable tool which allows a quick identification and an excellent examination of neonatal breast abnormalities. We aim to highlight sonographic classic features of benign neonatal breast enlargement showing how ultrasound rules out real breast masses helping to differentiate between it and mastitis when clinical and laboratory data are inconclusive. We describe a 2-day-old male with bilateral breast swelling more pronounced on the right side.

Imaging in gynecomastia

BACKGROUND

Gynecomastia (GM) is the benign proliferation of glandular tissue in the male breast. It is a common condition, which may occur physiologically and shows three age peaks during a male's lifespan: infancy, puberty, and senescence. An underlying pathology may be revealed in 45%-50% of adult men with GM, such as aggravating medications, systemic diseases, obesity, endocrinopathies, or malignancy.

OBJECTIVE

To discuss the role of imaging in the evaluation of GM and its contribution to therapeutic decision-making.

MATERIALS/METHODS

The current literature was reviewed through PubMed, Scopus, and CENTRAL electronic databases to identify the best available evidence concerning imaging modalities in patients with GM.

RESULTS

Most male breast lesions can be diagnosed on clinical grounds; however, in certain cases, when physical examination is inconclusive, imaging may be helpful.

DISCUSSION

The main purpose of evaluating a patient with GM is to establish the diagnosis and differentiate true GM from pseudogynecomastia, exclude breast cancer, and detect the possible cause. GM is seen in mammography as a subareolar opacity and three mammographic patterns of GM are described: nodular, dendritic, and diffuse, corresponding to florid GM of early onset, fibrous persistent GM, and GM due to exogenous estrogen administration, respectively. In ultrasound (US), florid GM is depicted as a disk-shaped, hypoechoic area underlying the areola, whereas echogenicity of the lesions increases as fibrosis develops. Data on the use of MRI in the evaluation of the male breast and GM are still limited. Imaging findings can be classified according to the BIRADS (breast imaging reporting and data system) based on their malignant potential.

CONCLUSION

Both mammography and US are sensitive and specific to diagnose GM and distinguish it from breast cancer. When clinical findings are suggestive of malignancy or imaging findings are inconclusive, a histological confirmation should be sought.

Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture

BACKGROUND

Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors' first report of pectoral etching in 2012, patients and surgeons became more aware about gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia.

METHODS

The authors reviewed their records on pectoral high-definition lipo sculpture between January of 2005 and October of 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years.

RESULTS

Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index.

CONCLUSION

Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy

PURPOSE

Several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons; the present study investigates the role of radiation therapy in this context.

METHODS

A systematic review was performed to evaluate the utility of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons.

RESULTS

Fifteen articles met the inclusion criteria for review. The mean incidence of gynecomastia was 70% in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Radiotherapy was shown to significantly reduce the incidence to a median of 23%, with all six randomized control studies assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. The median complication rate was 12.4% with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. While the efficacy of radiation therapy as a treatment modality for gynecomastia was also established, it was shown to be less effective than other available options.

CONCLUSIONS

Low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients; further studies are indicated within the common gynecomastia population managed by plastic surgeons to assess the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients.

Gynecomastia as a presenting symptom of Graves' disease in a 49-year-old man

SUMMARY

Gynecomastia is a symptom with a potential high disease burden. It has a variety of underlying causes, such as malignant, drug-related or hormonal. The presence of gynecomastia can be explained in thyrotoxicosis due to a concomitant disbalance of sex hormones. Interestingly, it rarely is the presenting symptom of Graves' disease. A 49-year-old man presented to our outpatient clinic with right-sided gynecomastia. After thorough history taking, more symptoms of thyrotoxicosis were present. Treatment was started with thiamazole and later levothyroxine. Three months after this treatment the gynecomastia and other symptoms resolved completely. A disbalance of sex hormones due to an increased expression of the protein sex hormone-binding globulin (SHBG) caused by thyrotoxicosis could result in gynecomastia. In vitro and in vivo research in mice suggest that the pathophysiology of thyrotoxicosis-associated gynecomastia is due to upregulation of hepatocyte nuclear factor-4α (HNF4A) in liver cells. Subsequent increase of SHBG results in a decrease of free testosterone levels.

LEARNING POINTS

Gynecomastia is a common finding (up to almost 40%) on physical examination in patients with hyperthyroidism. In gynecomastia, thyroid function tests should be examined on initial presentation because of the relative simple treatment. The pathophysiology of thyrotoxicosis-associated gynecomastia is well understood by a sex-hormonal disbalance due to an increased expression of SHBG. Due to the well explainable pathophysiology, reduction of symptoms can be expected after treatment. The underlying mechanism of an increased expression of SHBG is not well understood. However, in vitro and in vivo research in mice suggests that thyrotoxicosis causes an increased expression of HNF4A in liver cells. Thus, upregulating the expression of SHBG. Interestingly, HNF4A is suspected to play an important role in MODY. Future research will clarify the importance of this gene and might open up new insights for therapy.

Clinical features, presentation and hormonal parameters in patients with pubertal gynecomastia

Objective:

Gynecomastia is benign enlargement of breast in male. It is postulated that its development is primarily due to a mismatch in ratio of oestrogen and androgen at breast tissue. The aim of this study was to highlight the clinical features, presentation and hormonal parameters at the time of consultation.

Methods:

All adolescent patients who attended endocrinology department with the complaint of breast enlargement were taken into study. We analysed their thyroid function test, oestrogen, testosterone, prolactin, alpha-fetoprotein, follicle-stimulating hormone, luteinizing hormone, beta HCG (human chorionic gonadotropin) and liver function. Clinical features and anthropometry were recorded.

Results:

Out of 50 patients enrolled, 34 (68%) had bilateral gynaecomastia while 16 patients (32%) had unilateral disease. Mastalgia was seen in 44 patients (88%). Psychological disturbance in the form of depression was seen in 60% of adolescent boys with gynecomastia. Tanner stage B had positive correlation with oestrogen to testosterone (E2/TTE) ratio (r = 0.47; P = 0.034). All other hormonal parameters were normal.

Conclusion:

Mastalgia was one of the presenting complaints in majority of patients and many had bilateral enlargement. Altered oestrogen to testosterone ratio is altered in majority of patients thus may be reason for pubertal gynecomastia.

Evaluation of pubertal and pathological gynaecomastia in children: A single-center experience

Gynaecomastia in adolescents is a benign glandular proliferation of the male breast. Secondary causes of gynaecomastia in adolescents are relatively rare and may result from a wide variety of rare pathological conditions. Among these, klinefelter syndrome, complete androgen resistance, adrenal tumours and oestrogen-secreting testicular tumours, hypogonadism, hyperthyroidism, kidney disease and medications play a role in aetiology. The aim of our study is to review the demographic characteristics, hormone profile, aetiological characteristics of paediatric gynaecomastia patients admitted to a single center and to determine the frequency of pathological gynaecomastia. Forty-three male patients with gynaecomastia who applied to the paediatric endocrinology outpatient clinic were included in our study. Demographic characteristics, physical examination findings, hormone profile, breast ultrasonography and karyotype results of the patients were recorded. There were 43 male patients in our study. Thirty-six (83.7%) of the patients were pubertal gynaecomastia, 7 (16.2%) were pathological gynaecomastia. Three of the patients with pathological gynaecomastia were prepubertal gynaecomastia, 2 had klinefelter syndrome, 1 had hypergonadotropic hypogonadism after acute lymphoblastic leukaemia treatment and 1 had gynaecomastia after spirololactone use. Careful evaluation of patients with gynaecomastia is especially important in detecting pathological types. We reported the rare prepubertal gynaecomastia and klinefelter frequency in our study.

Effect of atorvastatin on testosterone levels

BACKGROUND

Statins are one of the most prescribed classes of drugs worldwide. Atorvastatin, the most prescribed statin, is currently used to treat conditions such as hypercholesterolaemia and dyslipidaemia. By reducing the level of cholesterol, which is the precursor of the steroidogenesis pathway, atorvastatin may cause a reduction in levels of testosterone and other androgens. Testosterone and other androgens play important roles in biological functions. A potential reduction in androgen levels, caused by atorvastatin might cause negative effects in most settings. In contrast, in the setting of polycystic ovary syndrome (PCOS), reducing excessive levels of androgens with atorvastatin could be beneficial.

OBJECTIVES

Primary objective To quantify the magnitude of the effect of atorvastatin on total testosterone in both males and females, compared to placebo or no treatment. Secondary objectives To quantify the magnitude of the effects of atorvastatin on free testosterone, sex hormone binding globin (SHBG), androstenedione, dehydroepiandrosterone sulphate (DHEAS) concentrations, free androgen index (FAI), and withdrawal due to adverse effects (WDAEs) in both males and females, compared to placebo or no treatment.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomized controlled trials (RCTs) up to 9 November 2020: the Cochrane Hypertension Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; Embase; ;two international trials registries, and the websites of the US Food and Drug Administration, the European Patent Office and the Pfizer pharmaceutical corporation. These searches had no language restrictions. We also contacted authors of relevant articles regarding further published and unpublished work.

SELECTION CRITERIA

RCTs of daily atorvastatin for at least three weeks, compared with placebo or no treatment, and assessing change in testosterone levels in males or females.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the citations, extracted the data and assessed the risk of bias of the included studies. We used the mean difference (MD) with associated 95% confidence intervals (CI) to report the effect size of continuous outcomes,and the risk ratio (RR) to report effect sizes of the sole dichotomous outcome (WDAEs). We used a fixed-effect meta-analytic model to combine effect estimates across studies, and risk ratio to report effect size of the dichotomous outcomes. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included six RCTs involving 265 participants who completed the study and their data was reported. Participants in two of the studies were male with normal lipid profile or mild dyslipidaemia (N = 140); the mean age of participants was 68 years. Participants in four of the studies were female with PCOS (N = 125); the mean age of participants was 32 years. We found no significant difference in testosterone levels in males between atorvastatin and placebo, MD -0.20 nmol/L (95% CI -0.77 to 0.37). In females, atorvastatin may reduce total testosterone by -0.27 nmol/L (95% CI -0.50 to -0.04), FAI by -2.59 nmol/L (95% CI -3.62 to -1.57), androstenedione by -1.37 nmol/L (95% CI -2.26 to -0.49), and DHEAS by -0.63 μmol/l (95% CI -1.12 to -0.15). Furthermore, compared to placebo, atorvastatin increased SHBG concentrations in females by 3.11 nmol/L (95% CI 0.23 to 5.99). We identified no studies in healthy females (i.e. females with normal testosterone levels) or children (under age 18). Importantly, no study reported on free testosterone levels.

AUTHORS' CONCLUSIONS

We found no significant difference between atorvastatin and placebo on the levels of total testosterone in males. In females with PCOS, atorvastatin lowered the total testosterone, FAI, androstenedione, and DHEAS. The certainty of evidence ranged from low to very low for both comparisons. More RCTs studying the effect of atorvastatin on testosterone are needed.

Gynaecomastia in the Durban Breast Unit: A Comparison of HIV- and Non-HIV-Infected Individuals

BACKGROUND

The clinical profile of gynaecomastia patients, both in human immunodeficiency virus (HIV)-positive and HIV-negative patients, in resource-limited settings remains largely undocumented. The aim of this study was to compare and contrast these groups with a view to developing an appropriate treatment algorithm for the South African population.

METHODS

A retrospective chart review at the Durban Breast Unit for the period 2000-2015 was undertaken with ethics approval [BE012/16 (sub-study of BCA173/15)]. Statistical analysis was done with IBM SPSS version 25. A p value <0.05 indicated statistical significance.

RESULTS

One hundred and four patients were documented. The mean age was 37 years. Gynaecomastia was most commonly attributed to puberty, HAART, other medications or an idiopathic aetiology. HIV status was known in 49 patients. There was a 97% prevalence of HAART use in the HIV-positive subgroup (n = 31). Efavirenz was the most common inciting drug. Incidence of gynaecomastia correlated with duration of HAART use. Age, late presentation, advanced Simon grade and bilateral disease appear to necessitate surgical intervention more frequently.

CONCLUSION

Patients on HAART are advised to seek early advice upon noticing gynaecomastia. Drug cessation/change is likely to assist only upon early presentation resulting in static progression, and ultimate cure would still entail surgical excision. Extensive blood and imaging studies should be done only where clinically indicated and can be considered in cases of recurrence post-surgery. Management option must be discussed with patients, and surgeons are required to be familiar with the various surgical techniques necessary to treat gynaecomastia.

Epidemiology of male breast diseases: A 10-year institutional review

OBJECTIVE

To review breast imaging utilization and epidemiology of breast diseases in male patients referred to our breast center.

MATERIAL AND METHODS

A retrospective analysis of all male patients who underwent breast imaging at our institution over a 10 year period (03/14/2008 to 03/13/2018) was performed. Patient history, imaging findings, biopsy reports, surgical interventions and follow-up data were reviewed.

RESULTS

Over the 10 year period, 143 male patients (0.1% of referred breast center patients) underwent breast imaging (versus 139,134 female patients). Mean age was 57.4 years (SD 19.7, median 59, range 21-92 years). The most common indication for referral was a palpable breast mass (98%). The most common diagnosis was gynecomastia (72%). Of the 20 (14%) patients who underwent core biopsy; 1 (0.7%) had breast cancer and the remaining 19 had benign pathologies. Follow-up imaging was recommended for 22 (15.4%) patients, of whom 15 (68%) were lost to follow-up. Two patients under the age of 25 years inadvertently underwent initial mammography instead of ultrasound.

CONCLUSION

The epidemiology of breast diseases in our male patient population mirrors that of the general male population worldwide; with an overwhelming 99.3% cases falling into benign category. Two-thirds of our male patients for whom short interval follow up was recommended were lost to follow-up, signifying the need for a more proactive approach in ensuring their compliance. It is important to increase awareness among referring clinicians and general radiologists regarding male breast imaging recommendations so that the appropriate imaging study is performed.

Gynecomastia in a Patient Taking Meloxicam-A Case Report

Gynecomastia is benign enlargement of glandular tissue in the male breast. It occurs due to an imbalance of estrogen and testosterone. It may be unilateral or bilateral. Physiologic gynecomastia commonly occurs in infants and during puberty and is self-limited. Gynecomastia may affect up to 50% of adult men over age 50 years old and can be related to underlying medical illness or caused by certain medications. Known causative agents include anti-androgenic and estrogenic drugs. Probable agents include alcohol and anti-ulcer, psychoactive, and antiretroviral medications. Non-steroidal anti-inflammatory drugs (NSAIDs) are not commonly associated with the development of gynecomastia. This case presents an instance in which the NSAID, meloxicam, was the only identified variable in a patient who developed unilateral gynecomastia. His breast tenderness and abnormal exam resolved spontaneously within 4 weeks of cessation of meloxicam therapy.

A Male Patient With Breast Hamartoma: An Uncommon Finding

Mammary hamartoma is a rare type of breast tumor that is composed of the same elements as normal mammary tissue. This condition is very rare in men. In current literature, there are fewer than five case reports on male breast hamartoma. This benign pathology is under-reported because of several reasons. Since breast tumors are still considered an exclusively female diagnosis and statistically proven to be gynecomastia when arising in men, they are often overlooked. In addition to the uncommon clinical presentation in men, insufficiency of definitive pathologic and radiologic characteristics can make an accurate diagnosis a challenging task. Mammary hamartoma is a benign condition with an excellent prognosis. The following case describes a rare instance of an enlarging mammary hamartoma in a male patient, highlighting the imaging features, pathohistological findings, and clinical management.

An Alternative Treatment of Pseudogynecomastia in Male Patients After Massive Weight Loss

BACKGROUND

There has been an increase in body contouring procedures following massive weight loss (MWL), including male breast reduction procedures. Treating male chest deformity after MWL using standard mastopexy techniques often leads to suboptimal results.

OBJECTIVES

The authors describe a technique to treat pseudogynecomastia using a modified elliptical excision and nipple-areola complex (NAC) transposition on a thinned inferior dermal pedicle as an alternative to conventional techniques.

METHODS

A retrospective chart review from January 2011 to January 2019 identified a total of 14 male patients who underwent excision of pseudogynecomastia using the described technique.

RESULTS

Patients were characterized by age, method of weight loss, pre-weight loss body mass index (BMI), post-weight loss BMI, total weight loss, grade of pseudogynecomastia, and concurrent procedures performed. Patients were followed for a period ranging from 3 months to 1.5 years (average, 8.1 months). Pre-weight loss BMI and post-weight loss BMI averaged 52.0 kg/m2 and 29.6 kg/m2, respectively. The average weight lost was 79.72 kg and the average total amount of tissue removed was 2615 g. All patients had concurrent procedures with an average operative time of 274 minutes. Four out of 14 patients (28.6%) experienced minor complications, which included asymmetry, delayed wound healing, seroma, and hyperpigmentation. There were no wound infections, hematomas, flap necrosis, or dysesthesia.

CONCLUSIONS

Due to several cosmetic advantages and low complication profile, our technique using a modified elliptical excision and NAC transfer on an inferior dermal pedicle is an attractive option for treating male chest deformity after MWL.

LEVEL OF EVIDENCE 4

Incidental Gynecomastia on Thoracic Computed Tomography in Clinical Practice: Characteristics, Radiologic Features, and Correlation With Possible Causes in South Korean Men

Gynecomastia is a common incidental finding on thoracic computed tomography (CT). This study aimed to retrospectively determine the prevalence, imaging characteristics, and possible causes of incidental gynecomastia on thoracic CT. Records of male patients who underwent thoracic CT in 2015 were reviewed. The size and morphologic types (nodular, dendritic, and diffuse) were recorded for patients with breast glandular tissue larger than 1 cm, and the cutoff value of gynecomastia was defined as 2 cm. Additionally, the possible causes of gynecomastia obtained by reviewing patients' charts were recorded. CT-depicted gynecomastia was identified in 12.7% (650 of 5,501) of patients. The median size of the breast glandular tissue was 2.5 cm (interquartile range 2.2-3.1), and 36.8% of patients (239 of 650) had unilateral gynecomastia. The age distribution provided a bimodal pattern with two peaks in the age groups from 20 to 29 years old and greater than 70 years old. Chronic liver disease (CLD; p < .001), all stages of chronic kidney disease (CKD; p < .001), and medications (p = .002) were significantly associated with gynecomastia. Gynecomastia did not correlate with body mass index (p = .962). The size of breast glandular tissue was identified to be correlated with the morphologic type of breast tissue and the severity of CLD or CKD. The prevalence of incidental gynecomastia seen on thoracic CT was 12.7%. CT-depicted gynecomastia is not associated with obesity but with CLD, CKD, and medications. When gynecomastia is detected on CT, further evaluations and management might be required for patients with a treatable cause.

Male patients with unilateral breast symptoms: an optimal imaging approach

OBJECTIVES

To evaluate the usefulness of bilateral mammography in male patients with unilateral breast symptoms, including investigation of the diagnostic performance of unilateral and bilateral reviews and the average glandular dose (AGD) per exposure.

METHODS

Two hundred seventy-one consecutive male patients (mean age, 57 years) with unilateral breast symptoms underwent bilateral mammography. Image interpretation was performed in two ways, first with a unilateral review of the symptomatic breast and then with a bilateral review. A modified BI-RADS scale (from 1 to 5) was used. The diagnostic performance of unilateral and bilateral reviews was compared, and contralateral breast abnormalities and the AGD per exposure were recorded. We also analyzed ultrasound (US) results and compared them with mammography.

RESULTS

Of 271 male patients, 29 were pathologically diagnosed with breast cancer. There was no bilateral breast cancer. The sensitivity, specificity, positive and negative predictive values, and accuracy were 96.6%, 96.7%, 77.8%, 99.6%, and 96.7%, respectively, for unilateral review, and 96.6%, 95.9%, 73.7%, 99.6%, and 95.9% for bilateral review. Receiver operator characteristic analysis showed excellent diagnostic performance for both methods: the area under the curve (AUC) was 0.966 for unilateral review and 0.962 for bilateral review (p = 0.415). The mean AGD per exposure was 1.10 ± 0.29 mGy for symptomatic breast and 1.04 ± 0.30 mGy for contralateral breast (p < 0.001). Diagnostic performance parameters of US were not significantly different from bilateral or unilateral review of mammography.

CONCLUSION

The diagnostic performance of unilateral mammography is comparable with bilateral mammography in male patients with unilateral breast symptoms. Unilateral mammography also has the advantage of reducing radiation exposure.

KEY POINTS

• There is limited knowledge about standardized guidelines or recommendations for imaging the male breast. • Unilateral mammography for male patients with unilateral breast symptoms showed comparable diagnostic performance with bilateral mammography. • Both unilateral and bilateral mammography showed excellent diagnostic performance in the assessment of male patients with unilateral breast symptoms.

Combined surgical and medical treatment in an adolescent with severe gynecomastia due to excessive estradiol secretion: a case report

Background

Gynecomastia develops due to the reversed estradiol-to-Testosterone ratio in adolescence, and symptoms typically improve within 2 years. The causes vary widely, including estrogen excess and tumors, and surgical treatment is usually given in late adolescence because postoperative symptoms may recur in adolescents. This study reports a case of a pediatric patient with severe gynecomastia due to excessive estradiol secretion who showed a positive outcome after receiving surgical treatment combined with aromatase inhibitor administration.

Case presentation

A 9-year old boy visited to the Department of Pediatric Endocrinology for breast budding. At that time, the patient showed breasts at Tanner stage II and no abnormality on hormone tests. During a follow-up, both gynecomastia had progressed to Tanner stage III–IV at age 13. Tamoxifen 10 mg bid was administered; however, the condition rapidly progressed to Tanner stage V at 13.5 years. The evaluation of pathologic gynecomastia showed an increase of estradiol to 296 pg/mL with normal range 10 ~ 36 pg/mL and microlithiasis in both testes. As the condition worsened, total mastectomy was performed at the age of 13.5 years. Based on the assessment that elevated aromatase activity had induced breast budding, we changed the medication to anastrozole (Arimidex) 1 mg once a day, after which the estradiol level improved to 38.5 pg/mL and was maintained well in the two-year postoperative follow-up.

Conclusions

This case report shows a combined plastic surgery and appropriate medical management bring a positive outcome in severe gynecomastia patient.

Clinical and Biochemical Phenotype of Adolescent Males with Gynecomastia

OBJECTIVE

Gynecomastia is defined as a benign proliferation of male breast glandular tissue. Its prevalence during puberty varies between 50-60% and is also common in neonatal and elderly males. It develops mainly due to the disequilibrium between estrogen and androgen activity in breast tissue, where estradiol (E2) binds to estrogen receptors and stimulates ductal and glandular cells. The aim of this work was to investigate the relationship between sex hormone alterations and the natural history of gynecomastia.

METHODS

Participants in this study were young males referred to an outpatient clinic, between January 2011 and February 2016, with breast enlargement. Thyroid function, liver function, hormone concentrations and tumor markers were measured and anthropometric assessment was conducted.

RESULTS

Subjects comprised 93 males, aged 9 to 18 (mean±standard deviation age 13.8±2.6) years. In 63 of 93 (67.7%) the gynecomastia was confirmed and 28 were followed-up for a median period of three months. None of the boys showed any reduction in breast size during follow-up. There was no correlation between body mass index Z-score and breast size. Breast enlargement progressed in nine boys (32.1%). A positive correlation between estrogen to testosterone (E2/TTE) ratio and Tanner B stage (r=0.47; p=0.034) was observed.

CONCLUSION

The E2/TTE ratio may be a helpful tool in diagnosing gynecomastia. Altered E2/TTE ratio might be responsible for a proportion of cases described previously as idiopathic. Additionally, weight loss does not imply reduction of breast size in boys. Nonetheless it should be the first step in the management of prolonged gynecomastia.

Modified Benelli procedure for subcutaneous mastectomy in gynecomastia: A randomised controlled trial

BACKGROUND

Gynecomastia is defined as a benign glandular proliferation of the male breast tissue causing enlargement of the breast and a feminine appearance. Gynecomastia is usually treated surgically in some patients by different techniques.

AIM OF THE STUDY

is to allow ample excess during excision and to remove excess skin to allow for better cosmetic results using "modified Benelli technique" and to obtain good breast shape with better nipple areola complex position without any breast tension.

TYPE OF THE STUDY

Randomised controlled trial study.

PATIENTS AND METHODS

The study included 150 patients with gynecomastia (Grade II and III) for the period between January 2010 and January 2016 who attended private hospitals and Al-Kindy Teaching Hospital. The patients were divided into two groups according to the operative techniques used. Group A included 75 patients treated surgically with subcutaneous mastectomy using periareolar incision. Group B; included the other 75 patients who were managed by "modified Benelli technique".

RESULTS

The subcutaneous mastectomy using "modified Benelli technique" showed a significantly lower operating time due to ample access for excision of breast tissue. Excision of excess skin allowed the areola to retain a cosmetically more acceptable position. There was a lot of pleating of the skin compared to the other technique using the periareolar incision.

CONCLUSIONS

This technique namely the "modified Benilli technique" provides a relatively simple method with an aesthetically good outcome to treat gynecomastia with a low rate of complications and recurrences.

Barriers to the Effective Management of Gynecomastia in Adolescents

BACKGROUND

The aim of this study was to explore the impacts of gynecomastia on adolescents, explore the surgical and psychological success of mastectomy, and evaluate the adequacy of insurance guidelines and coverage.

METHODS

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical database from 2010 to 2014 was evaluated for current procedural terminology codes 19300 and 19303, representing mastectomies for gynecomastia and complete mastectomies respectively to compare surgical site complications.

RESULTS

Of 1132 procedures for mastectomy for gynecomastia 1.5% of patients (n = 17) were associated with postoperative superficial surgical site complications. In the same timeframe, a total of 33,124 procedures for simple, complete mastectomy performed with a postoperative surgical complication rate of 2.2% (n = 721). Results of a Chi-squared goodness of fit χ (1, N = 34,997) = 2.10, P > 0.05 suggests no statistically significant difference between incidence of surgical site complications for a mastectomy for gynecomastia versus typical mastectomy.

DISCUSSION

High surgical success rate, coupled with significant improvements in psychosocial functioning suggests that mastectomy is a highly effective intervention for adolescents with gynecomastia. However, due to vague and inadequate coverage and evaluation criteria surgery is often not performed. This paper offers a framework for developing a quantitative system by which to evaluate surgical candidates by adopting well-established guidelines currently in use for reduction mammoplasties and suggests further analysis into a cost/benefit analysis for coverage of the procedure.

Analyzing a broader spectrum of endocrine active organic contaminants in sewage sludge with high resolution LC-QTOF-MS suspect screening and QSAR toxicity prediction

Endocrine active contaminants (EACs) in environmental samples can pose a range of toxicological threats to ecosystems, especially through their impacts on reproductive pathways mediated by the estrogen receptor. The physicochemical properties of known organic EACs vary greatly and typically require different sample preparation techniques to identify different classes of compounds. EAC sources are similarly diverse, including both endogenous compounds and anthropogenic chemicals found in personal care products, pharmaceuticals, and their transformation products, which are often disposed of to sewers at their end of use. Looking for EACs in sewage sludge proposes a bottom-up, or end-of-use and treatment approach to discover environmentally relevant EACs, since many EACs accumulate in sludges even after application of robust wastewater treatment processes. This study demonstrates an extraction and analytical method capable of detecting a broad spectrum of known and suspected EACs via High Resolution Liquid Chromatography Quadropole Time-of-Flight Mass Spectrometry (LC-QTOF-MS) suspect screening of fourteen California sewage sludge samples. Spike-recovery experiments were performed using twelve carefully selected surrogates to assess different extraction solvents, sample weights, extraction pH values, procedures for combining extracts with different extraction pH's, and solid phase extraction cartridges. Using LC-QTOF-MS, identifications of several other organic compounds in the samples were made, a goal unachievable with unit resolution mass spectrometry. Suspect screening of California sludge samples discovered 118 compounds including hormones, pharmaceuticals, phosphate flame retardants, recreational drugs, antimicrobials, and pesticides. Additionally, 22 of these identified compounds are predicted to interfere with estrogen receptors or other reproductive/developmental pathways based on the VEGA QSAR toxicity prediction model.

Puberty: Normal physiology (brief overview)

Puberty is a defining phase of human development where growth ends and the ability to reproduce begins. An understanding of the events leading up to puberty highlights the fact that this is the culmination of a process of skeletal and gonadal activity that has been ongoing since conception. Although there is natural variation in the timing of events in and around puberty the basic underlying processes are common to all healthy human beings. This chapter is intended to outline the mechanisms underlying normal growth and development before and during puberty. By understanding normality the pathological processes that give rise to abnormalities of pubertal development can be understood more easily.

Adverse events during testosterone replacement therapy in 95 young hypogonadal thalassemic men

Background:

Hormonal treatment of hypogonadism in thalassaemia major (TM) is a complex issue due to the co-existence of other contributing factors such as severity of iron overload, associated chronic liver disease and other endocrine complications.

Objectives:

Data about adverse events (AEs) of testosterone replacement therapy (TRT) in hypogonadal males with TM is scarce. We report the adverse events registered during TRT in 95 young patients with TM.

Results:

These AEs included gynecomastia, documented in 41/95 (43.1%) TM patients of mild to moderate severity (90%). Persistent pain in the injection site and local reactions to testosterone (T) skin patch occurred in a third of patients. Priapism was reported in 2 patients on treatment with intramuscular T enanthate. In both patients, substitution with T gel was successful, and no recurrence during the following 24 months was observed.

Conclusions:

Clinicians should exercise caution when considering TRT for hypogonadal men with TM. (www.actabiomedica.it)

Male DCIS diagnosed after use of over-the-counter hormonal supplement

INTRODUCTION

Male breast cancer is a rare disease. Although epidemiologic and genetic factors are associated with male breast cancer, hormonal factors may also play a role.

CASE PRESENTATION

We report the case of a 39-year-old BRCA negative male patient taking a sexual performance enhancement supplement who presented with worsening asymmetric gynecomastia and unilateral spontaneous bloody nipple discharge and was found to have ductal carcinoma in-situ.

DISCUSSION

The altered cellular environment related to the hormone contents of the supplement coincided with the rapid worsening of his gynecomastia and may have played a role in the development of the ductal carcinoma in-situ, or growth of an existing focus.

CONCLUSION

The use of hormonal male enhancement supplements can lead to higher levels of androgens in users. It is possible for this altered hormonal environment to cause the growth of tumor or promote the progression of an existing focus.

Atypical ductal hyperplasia in men with gynecomastia: what is their breast cancer risk?

PURPOSE

Atypical ductal hyperplasia (ADH) significantly increases the risk of breast cancer in women. However, little is known about the implications of ADH in men.

METHODS

Review of 932 males with breast pathology was performed to identify cases of ADH. Patients were excluded if ADH was upgraded to cancer on excision, or if they had contralateral breast cancer. Cases were reviewed to determine whether any male with ADH developed breast cancer.

RESULTS

Nineteen males were diagnosed with ADH from June 2003 to September 2018. All had gynecomastia. Surgical procedure was mastectomy in 8 patients and excision/reduction in 11. One patient had their nipple areola complex removed, and 1 required a free nipple graft. Median patient age at ADH diagnosis was 25 years (range 18-72 years). Of the 14 patients with bilateral gynecomastia, 10 had bilateral ADH and 4 had unilateral. Five cases of ADH were described as severe, bordering on ductal carcinoma in situ. No patient reported a family history of breast cancer. No patient took tamoxifen. At a mean follow-up of 75 months (range 4-185 months), no patient developed breast cancer.

CONCLUSION

Our study is the first to provide follow-up information for males with ADH. With 6 years of mean follow-up, no male in our series has developed breast cancer. This suggests that either ADH in men does not pose the same risk as ADH in women or that surgical excision of symptomatic gynecomastia in men effectively reduces the risk of breast cancer.