Management of gynaecomastia: an update

[Gynaecomastia and adipomastia on black skin: Clinical and surgical particularity]

AIM

Analyze the management of gynecomastia and adipomastia; and identify the peculiarities in black people in a general surgery department of the CHU Sylvanus Olympio in Lomé (Togo).

PATIENT AND METHOD

Descriptive retrospective study included 43 cases of gynecomastia and 5 cases of adipomastia (January 2014 to December 2020). The data taken into account were: epidemiological, clinical, paraclinical and the treatment (surgery and medical). The administration of hydrocortisone (solumedrol 120mg/day) for 3days immediately after surgery and the application of shea butter on the scar were performed.

RESULT

Patients consult for aesthetic discomfort, especially with bilateral lesions and fear of breast cancer for unilateral lesions. Morpho-types 3 and 4 are therefore the most frequent in 75% of cases. Age was over 30years in 87% of patients. We noted retro-areolar fibrosis. The etiology was dominated by idiopathic causes. The surgery was performed in 85% of the cases. The morbidities were 5 cases of hypertrophic scars without keloid.

CONCLUSION

Surgical difficulties on black skin are not only technical, but also scarring: hypertrophy and keloids. A delay in surgical management after 30years, and the prevention of unsightly scars would be a track for improving the aesthetic result.

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.

Surgical management of gynecomastia: experience of a general surgery center

AIM

Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia.

PATIENTS AND METHODS

Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study.

RESULTS

Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar.

CONCLUSIONS

Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

Gynecomastia and psychological functioning: A review of the literature

Gynecomastia is defined as excess glandular growth of breast tissue in males. It is a noticeable physical difference that commonly affects males in adolescence and old age. While often transient in nature, gynecomastia persists indefinitely in 10% of cases. Much of the literature on gynecomastia has focused on etiology and management. Little research has been done regarding the impact of gynecomastia on one's mental health and quality of life; however, some studies have suggested various psychosocial and psychological consequences related to gynecomastia. These consequences include but are not limited to depression, anxiety, disordered eating, body dissatisfaction, and reduced self-esteem. The aims of this paper are to review the current gynecomastia literature, bring awareness to an understudied but troubled population, and discuss directions for future work, including offering extant models of body image to guide researchers.

Gynecomastia induced by H1-antihistamine (ebastine) in a patient with idiopathic anaphylaxis

H1-antihistamine is generally a well-tolerated and safe drug. However, in resemblance with all other drugs, H1-antihistamines can also prompt adverse drug reactions (ADRs). We recently encountered the very unusual ADR of H1-antihistamine-induced gynecomastia. A 21-year-old man with idiopathic anaphylaxis was treated with ebastine (Ebastel), a second-generation H1-antihistamine, for the prevention of anaphylaxis. Three months later, the patient remained well without anaphylaxis, but had newly developed gynecomastia. Because anaphylaxis recurred after the cessation of H1-antihistamine, the preventive medication was changed to omalizumab. A few months later, his gynecomastia had entirely disappeared. Physicians should be aware of this exceptional ADR of H1-antihistamine.

Surgical Strategies in the Treatment of Gynecomastia Grade I-II: The Combination of Liposuction and Subcutaneous Mastectomy Provides Excellent Patient Outcome and Satisfaction

BACKGROUND

Gynecomastia (GM) is a benign condition with glandular tissue enlargement of the male breast. GM is classified into 4 grades of increasing severity. We describe a series of GM grade I-II, diagnosed, treated surgically and analyzed regarding feasibility, complication rate, and satisfaction.

METHODS

From 2005 to 2012, a chart review was performed for 53 patients. Preoperative examination included endocrine and urological examination and exclusion of other pathological conditions. The surgical technique consisted of liposuction through an inframammarian-fold incision and excision of the glandular tissue by a minimal periareolar approach.

RESULTS

A total number of 53 male patients with 104 breasts were available for analysis. By liposuction, a median of 300 ml (range: 10-1000 ml) was aspirated from each breast and 25.1 g (range: 3-233 g) gland tissue was resected. Surgery lasted between 25 and 164 min per patient (median: 72 min). 2 postoperative hemorrhages occurred (n = 2, 3.8%). 2 patients underwent re-operation due to cosmetic reasons (n = 2, 3.8%).

CONCLUSIONS

This analysis demonstrates that treatment of GM grade I-II can easily be performed by liposuction combined with subcutaneous resection of the glandular tissue as a minimally invasive and low-impact surgical treatment with a low rate of complications and excellent patient satisfaction. Preoperative workup is important to rule out specific diseases or malignancy causing the GM.

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.

A retrospective study of gynecomastia in male patients referred to Hatyai Hospital with breast lesions

Background: Gynecomastia is a common benign lesion of the male breast and accounts for up to 80% of male patients referred with beast lesions.

Objective: To examine the pattern of breast lesions in male patients who underwent breast biopsy.

Methods: All male patients referred to Hatyai Hospital with breast complaints were included in the study. Histopathology reports were retrospectively reviewed during 2004-2011.

Results: In 77 male patients diagnosed with breast lesions, the most common lesion was gynecomastia (49/77, 64%), followed by fibrocystic changes (7/77, 9%), and breast cancer (6/77, 8%). Gynecomastia was commonly found in male patients less than 40 years of age, while other breast lesions are seen in male patients over 40 years of age (P = 0.036, OR = 2.842, 95% CI = 1.085-7.447).

Conclusion: Gynecomastia was the most common diagnosis among breast lesions in male patients referred to the Hatyai Hospital during 2004-2011. Gynecomastia was more common in the patients less than 20 years old.

Surgical treatment of primary gynecomastia in children and adolescents

PURPOSE

Idiopathic gynecomastia is a common diagnosis in children and adolescents. Though medical treatments reveal potentially harmful side effects, surgical interventions are performable in numerous techniques. In children and adolescents, only minimal evidence exists. This retrospective study presents our experiences with two common surgical techniques, namely subcutaneous mastectomy and combination with liposuction.

PATIENTS AND METHODS

This retrospective study included all patients <18 years who underwent surgery due to idiopathic gynecomastia. Height, weight and grade of gynecomastia according to Simon's classification before surgery were reviewed in all patients' files. Additionally, duration of surgery, inpatient stay and postoperative complications were documented. Follow-up examinations were performed with assessment of scar formation, numbness and retraction of the nipple region. Furthermore, patients were asked to report on general satisfaction with surgery (satisfactory/not satisfactory) and esthetic outcome on a numeric scale (1 = good, 6 = bad).

RESULTS

37 patients underwent surgery for verified idiopathic gynecomastia. Grade of gynecomastia was I° in 13.5% (n = 5), II° in 40.5% (n = 15) and III° in 46% (n = 17) of cases. Subcutaneous mastectomy was applied in 11 patients (group I, 30%) and both subcutaneous mastectomy and liposuction in 26 patients (group II, 70.3%). Postoperative complications occurred in two patients. Long-term follow-up was performed in 32 patients after a median of 34 months (range 6-96 months). Hypertrophic scar formation was seen in one patient (3%) and nipple retraction in two patients (5%). Recurrence of gynecomastia occurred in two patients (5%). Patient rating was satisfactory in 9% of cases and esthetic outcome was received with a median of 2.0 (1-5). In comparing both surgical techniques, combination of mastectomy and liposuction revealed better results in every measure except for surgical duration (median 73 vs. 90 min).

CONCLUSION

Surgical correction of gynecomastia remains a purely elective intervention. In contrast to adults, skin in children and adolescents provides high retractability. Therefore, open reduction combined with minimally invasive liposuction was proven useful.

Gynecomastia: Clinical evaluation and management

Gynecomastia is the benign enlargement of male breast glandular tissue and is the most common breast condition in males. At least 30% of males will be affected during their life. Since it causes anxiety, psychosocial discomfort and fear of breast cancer, early diagnostic evaluation is important and patients usually seek medical attention. Gynecomastia was reported to cause an imbalance between estrogen and androgen action or an increased estrogen to androgen ratio, due to increased estrogen production, decreased androgen production or both. Evaluation of gynecomastia must include a detailed medical history, clinical examination, specific blood tests, imaging and tissue sampling. Individual treatment requirements can range from simple reassurance to medical treatment or even surgery. The main aim of any intervention is to relieve the symptoms and exclude other etiological factors.

[Male breast diseases]

Because andrology is relatively undeveloped in France, the dermatologist is often the doctor first consulted for diseases of the nipple in men. All dermatological diseases can in fact occur at this site. There are some specific nipple diseases such as gynaecomastia, congenital abnormalities, hyperplasia, benign tumours and breast cancer. All clinical examinations and laboratory examinations should focus on diagnosis of this type of cancer and its elimination.

Psychosocial impact of adolescent gynecomastia: a prospective case-control study

BACKGROUND

The purpose of this study was to determine the physical and psychosocial impact of gynecomastia and its severity on adolescents seeking treatment as compared with healthy adolescent males.

METHODS

The following surveys were administered to adolescents with gynecomastia and healthy male controls, aged 12 to 21 years: Short Form-36 Version 2, the Rosenberg Self-Esteem Scale, and the Eating Attitudes Test-26. Demographic variables were compared between the two groups, and controls were administered a short chest symptoms survey. Linear regression models, unadjusted and adjusted for body mass index category, were fit to determine the effect of case status and graded severity of gynecomastia on survey score.

RESULTS

Forty-seven patients with gynecomastia and 92 male control subjects participated in this study. There was no difference in mean age between the groups, although patients with gynecomastia had a significantly higher body mass index. Gynecomastia subjects had three lower Short Form-36 domain and Rosenberg Self-Esteem Scale scores independent of body mass index category as compared with controls, although there was no difference in Eating Attitudes Test-26 scores between the groups. Graded gynecomastia severity had no effect on survey scores, all independent of body mass index category.

CONCLUSIONS

Gynecomastia has a significant negative impact on primarily the psychosocial well-being of affected adolescent patients, specifically in regard to social functioning, mental health, and self-esteem. Psychosocial impact was not affected by graded severity of disease. Health care providers and patients should be aware of the psychosocial impairments associated with gynecomastia and consider early treatment for adolescents suffering from this condition, regardless of severity.

[Laser-assisted lipolysis for gynecomastia: safe and effective skin retraction]

OBJECTIVES

To evaluate efficacy of laser lipolysis in the treatment of gynecomastia to correct breast volume, flaccidity and excess skin without its excision.

METHODS

Prospectively, 32 patients with gynecomastia under tumescent anaesthesia and sedation underwent laser lipolysis with 980 nm diode laser, 15W continuous emission and 8 to 12 kJ energy per breast. Externally cold air was used to protect the skin. No drainages were used but a compressive bandage. Patients evaluated results on a VAS scale. Two doctors evaluated results comparing before and 6 month after photographs and also measured the areola and chest diameter.

RESULTS

Twenty three patients considered results as Very Good, 7 Good and 2 Fair Cutaneous retraction of the areola was noticeable one month after the surgery and was maximum 6 months after. Evaluation by doctors was 26 Very Good, 5 Good and 1 Fair. There were no burns, ischemia or lesions in areolas or nipples.

CONCLUSION

Laser assisted liposuction is a simple and efficacious technique, barely traumatic and permits a rapid reincorporation to normal activities.

Drug-induced gynecomastia

Drugs account for about 20% of gynecomastia cases in men. As a number of factors can alter the estrogen:androgen ratio, several pathophysiologic mechanisms are associated with drugs causing this disorder. Antiandrogens, protease inhibitors, and nucleoside reverse transcriptase inhibitors are the most common drug causes of gynecomastia, whereas first-generation antipsychotics, spironolactone, verapamil, and cimetidine are less common causes. Other drugs have been reported rarely as causes. Treatment may involve switching to an alternative agent or may require surgery or irradiation if the causative agent cannot be discontinued. We reviewed the literature on drug-induced gynecomastia and provided another perspective by reviewing data from the United States Food and Drug Administration's Adverse Event Reporting System. Epidemiologic studies are needed to provide a more accurate description of the frequency of drug-induced gynecomastia.

Differential expression of estrogen receptor α and β transcripts in tissues and in primary culture cells from pubertal gynecomastia

BACKGROUND

Pubertal gynecomastia is a common problem occurring in up to 65% of adolescent boys. Gynecomastia comes at a time when self-image awareness is at its greatest and psychologically could be a psychologically disabling condition. Surgery is considered the mainstay of treatment for severe or persistent cases. A medical management aimed at altering the effective androgen/estrogen ratio has been suggested with inconstant results. Some promising results have been obtained by using anti-estrogens. Surprisingly there are no data on the estrogen receptor (ER) α and β RNA expression in gynecomastia.

AIM

We studied ER RNA subtypes in pubertal gynecomastia.

METHODS

ERα and β RNA were determined by real time RT-PCR in 50 mammary samples from pubertal boys with idiopathic gynecomastia subjected to reductive mammoplasty. To study ERα and β pattern of expression, epithelial and stromal primary cell cultures were set up from fresh tissues.

RESULTS

These analyses indicated that in all stromal cells ERβ was expressed at higher level than ERα and in epithelial cells both ERα and ERβ were barely detectable.

CONCLUSIONS

Our data suggest that also stromal cells are involved in the pathophysiology of pubertal gynecomastia. The high level of expression of ERβ seen in pubertal gynecomastia adds new insight on validation of ERβ as a target for candidate diseases and exploration of ERβ as a marker for clinical decision-making and treatment in pubertal gynecomastia. This could drive to search for new and selective anti-estrogen drugs for medical treatment of pubertal gynecomastia with a particular attention to the ERβ-selective ligand.

Gynecomastia in German soldiers: etiology and pathology

BACKGROUND

We found a high incidence of patients with gynecomastia in the German Ministry of Defense Guard Battalion in Berlin. For this reason, we conducted the present study to investigate etiological and pathological aspects of this condition.

METHODS

Within six years, a total of 211 patients underwent surgery for gynecomastia. We compared this group of patients with a control group of healthy males without signs or symptoms of gynecomastia. The two groups were matched for median age.

RESULTS

The groups showed significant differences (p<0.05) in serum testosterone, free triiodothyronine (fT3), LH (luteinizing hormone) and prolactin levels and in body mass index (BMI). In addition, there was a highly significant correlation between left-sided gynecomastia and membership in the Guard Battalion.

CONCLUSIONS

We found differences in hormone blood levels between gynecomastia patients and a control group. Moreover, gynecomastia was predominantly seen on the left side in guard soldiers. A possible explanation is the mechanical impact of the carbine against the left side of the body during rifle drills.

Surgical correction of gynecomastia in thin patients

BACKGROUND

Gynecomastia refers to a benign enlargement of the male breast. This article describes the authors' method of using power-assisted liposuction and gland removal through a subareolar incision for thin patients.

METHODS

Power-assisted liposuction is performed for removal of fatty breast tissue in the chest area to allow skin retraction. The subareolar incision is used to remove glandular tissue from a male subject considered to be within a normal weight range but who has bilateral grade 1 or 2 gynecomastia.

RESULTS

Gynecomastia correction was successfully performed for all the patients. The average volume of aspirated fat breast was 100-200 ml on each side. Each breast had 5-80 g of breast tissue removed. At the 3-month, 6-month, and 1-year follow-up assessments, all the treated patients were satisfied with their aesthetic results.

CONCLUSIONS

Liposuction has the advantages of reducing the fat tissue where necessary to allow skin retraction and of reducing the traces left by surgery. The combination of surgical excision and power-assisted lipoplasty also is a valid choice for the treatment of thin patients.

Surgical treatment of gynecomastia by vacuum-assisted biopsy device

BACKGROUND

Gynecomastia is a benign clinical condition that is the unilateral or bilateral enlargement of the male breast, but sometimes it causes serious psychological and physical stress in young men and brings about phobia of malignancy in elderly men. Minimally invasive and functional therapy represents an inevitable trend in breast surgery. We investigated the feasibility and safety of vacuum-assisted biopsy device in treating gynecomastia.

METHODS

From January 2006 to January 2010, 20 male patients with gynecomastia were treated by an 8-gauge vacuum-assisted biopsy device. The average age was 24.7 years (range, 18-47 years).

RESULTS

The operation was successfully performed in all 20 patients with a mean operating time of 51 minutes and a hospital stay of 4 days. Postoperative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. No other operation-related complications were observed. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6-48 months.

CONCLUSIONS

Treatment of gynecomastia by the Mammotome device is distinctive, practicable in manipulation, safe, and can achieve excellent cosmetic results. The Mammotome procedure simply represents another novel treatment option for gynecomastia.

Laser lipolysis with pulsed 1064 nm Nd:YAG laser for the treatment of gynecomastia

BACKGROUND

Lipolysis using laser is currently widely used for reducing localized fat. A 1064 nm neodynium-doped yttrium aluminum garnet (Nd:YAG) laser lipolysis was investigated in this study to evaluate its efficacy and safety in the treatment of gynecomastia.

METHODS

Five male patients diagnosed with gynecomastia were enrolled in this study, which was designed as a controlled split-breast trial. One breast of each patient was subjected to laser lipolysis and was then compared with a contralateral breast. Photographs and clinical assessments were obtained before the lipolysis, and at the fourth and eighth weeks thereafter. Computed tomography (CT) scan and ultrasound (US) imaging were used to evaluate the changes in the breasts' thicknesses.

RESULTS

The mean chest circumference was found to have been significantly reduced 8 weeks after the laser lipolysis. The clinical outcomes of the laser lipolysis were considered favorable by both the patients and clinicians. The CT and US scans showed that the thicknesses of the treated right breasts reduced more than those of the left breasts were 8 weeks after the laser lipolysis. The side effects (pain, edema, and ecchymosis) were minimal and disappeared shortly after they first manifested. Limitations The limitations of this study are that it employed small treatment groups and short-term follow-up.

CONCLUSION

This study demonstrated that gynecomastia can be treated effectively and safely through 1064 nm Nd:YAG laser lipolysis.

Gynaecomastia and scrotal rhacosis: two aesthetic surgical operations for men in Byzantine times

BACKGROUND

Nowadays, as in the past, much attention is paid to aesthetic operations in women, while only infrequently have such operations been referred to in males. Generally, male aesthetic surgery was introduced to surgical practise during the 19th century. In this study, we analysed the practise of such operations in Byzantine times and in other ancient cultures with surgical knowledge, i.e. ancient India and China

METHODS

The sixth book of Paul of Aegina's "Epitome of Medicine" was studied for description of aesthetic operations in males in the Byzantine period, since this book is completely devoted to surgery and is generally considered to be the most important reference for surgery in Byzantine times. The original text and its excellent translation by Francis Adams were used. References concerning aesthetic operations for males were identified. Accordingly, historical work and reviews on plastic surgery in ancient India and China were studied.

RESULTS

Mainly, two aesthetic surgical procedures for males in the Byzantine period were identified. These two procedures comprise gynaecomastia and rhacosis (scrotal relaxation). Two different techniques were reported for the surgical management of gynaecomastia, through sub-mammary or supra-mammary access. Two procedures were noted for rhacosis, for which Paul of Aegina reproduced the respective chapters from Leonides' and Antyllus' works. Evidence supporting male aesthetic surgery in ancient India and China or elsewhere was not found.

CONCLUSIONS

Despite the dubious aesthetic result, the existence of different aesthetic surgical techniques in males substantiate the advanced level of surgery achieved by physicians in the Byzantine period.

A Clinicopathological Evaluation of Male Patients with Breast Cancer

BACKGROUND

Although male breast cancer constitutes only 1% of all breast cancers, its incidence is increasing and it is becoming an important public health issue. The present study aims to present the clinicopathological characteristics of surgically treated male breast cancer patients from multiple centers.

PATIENTS AND METHODS

Twenty-one male patients operated on for breast cancer were retrospectively examined in terms of clinical presentation, pathological characteristics, TNM staging status, and type of surgical treatment.

RESULTS

The mean age of the 21 patients was 62.3 years (range 38-94), with the majority being in the range of 50-69 years (61.9%). The most frequent finding was breast mass (85.7%). Most patients underwent modified radical mastectomy (76.1%), and the most prevalent histological type was invasive ductal carcinoma (85.7%). The majority of patients had stage II or III disease, and estrogen receptors were positive in 18 (85.7%) of the patients.

CONCLUSION

Since male breast cancer is a rare condition, it is challenging to conduct prospective randomized trials. Currently, there is a lack of comprehensive data on the diagnosis and management of this condition. Thus, further studies and the implementation of specific guidelines or protocols for this subgroup of patients will aid better management.

A Clinicopathological Evaluation of Male Patients with Breast Cancer

Background

Although male breast cancer constitutes only 1% of all breast cancers, its incidence is increasing and it is becoming an important public health issue. The present study aims to present the clinicopathological characteristics of surgically treated male breast cancer patients from multiple centers.

Patients and Methods

Twenty-one male patients operated on for breast cancer were retrospectively examined in terms of clinical presentation, pathological characteristics, TNM staging status, and type of surgical treatment.

Results

The mean age of the 21 patients was 62.3 years (range 38-94), with the majority being in the range of 50-69 years (61.9%). The most frequent finding was breast mass (85.7%). Most patients underwent modified radical mastectomy (76.1%), and the most prevalent histological type was invasive ductal carcinoma (85.7%). The majority of patients had stage II or III disease, and estrogen receptors were positive in 18 (85.7%) of the patients.

Conclusion

Since male breast cancer is a rare condition, it is challenging to conduct prospective randomized trials. Currently, there is a lack of comprehensive data on the diagnosis and management of this condition. Thus, further studies and the implementation of specific guidelines or protocols for this subgroup of patients will aid better management.

Onset of male gynaecomastia in a patient treated with sunitinib for metastatic renal cell carcinoma

Sunitinib is an orally administered multitargeted tyrosine kinase inhibitor that has demonstrated substantial antitumour activity in patients with metastatic renal cell carcinoma. The more common grade 3 or 4 adverse effects of sunitinib include hypertension, fatigue, hand-foot syndrome, elevated lipase and lymphopenia. We report the case of a 69-year-old patient with metastatic renal clear-cell carcinoma, treated with nephrectomy and three lines of therapy (interleukin-2 plus interferon-alpha2a, vinorelbine plus gemcitabine, and capecitabine), who started a fourth-line therapy with oral sunitinib because of disease progression. At the end of his fifth cycle of sunitinib therapy, the patient complained of the development of abnormally large mammary glands associated with pain and peri-areolar erythema. After 2 weeks' off therapy, a partial reduction in mammary gland enlargement, local pain and erythema was observed. However, re-initiation of sunitinib treatment was followed by bilateral breast enlargement again. The mechanism by which sunitinib induces gynaecomastia is thought to be associated with an unknown direct action on breast hormonal receptors. To the best of our knowledge, this is the first report of an association between sunitinib and gynaecomastia.

Non-classical 21-hydroxylase deficiency in boys with prepubertal or pubertal gynecomastia

This report describes two boys who were evaluated for the first time at the ages of 9.8 (patient 1) and 13.4 years (patient 2), due to either prepubertal or pubertal gynecomastia. The diagnosis of non-classical (NC) 21-hydroxylase deficiency (21-OH-D) was substantiated by the finding of increased baseline and adrenocorticotropic hormone (ACTH)-stimulated 17-hydroxy-progesterone levels and was supported by molecular analyses of the CYP21A2 gene, which revealed V281L homozygosis in patient 1 and V281L/P30L compound heterozygosis in patient 2. In both boys, gynecomastia completely regressed 5-8 months after the institution of glucocorticoid substitutive treatment. We conclude that it is mandatory to suspect NC 21-OH-D in the clinical evaluation of either prepubertal or pubertal gynecomastia, since this association might be more frequent than reported so far, and that it is important that diagnosis is made by the first months after gynecomastia development, since a longstanding gynecomastia is unlikely to respond completely to medical therapy.

Gynecomastia in adolescents

PURPOSE OF REVIEW

Gynecomastia is a common finding in adolescent men. The primary care provider should feel equipped to thoroughly evaluate this condition and to differentiate physiologic from pathologic breast enlargement. The present review focuses on the epidemiology, pathogenesis, evaluation, and treatment of gynecomastia during adolescence.

RECENT FINDINGS

While gynecomastia has long been attributed to an imbalance between estrogen and androgen concentrations, recent literature has begun to illuminate other potential mechanisms for breast development in adolescent men. Increased leptin levels, as well as human chorionic gonadotropin and luteinizing hormone receptors on male breast tissue, may play a role. Newer treatment strategies, such as the antiestrogen raloxifene, have shown promising results; however, further studies are needed to determine long-term efficacy. As a result of the limited pharmaceutical treatment options, many more adolescents are seeking surgical intervention.

SUMMARY

Gynecomastia is frequently encountered in the primary care setting. During adolescence, male breast enlargement is most often benign and rarely represents a pathologic mechanism. Careful attention should be paid to both the breast and testicular examination. A detailed history should include an inquiry regarding the use of illicit substances, anabolic-androgenic steroids, herbal products, and medications. The impact of gynecomastia on the adolescent's mental health should be assessed. A workup for pathologic causes is rarely required. Reassurance remains the standard of care for physiologic gynecomastia.