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A male breast lesion

1.  What is this male breast abnormality?
2.  What are the commonest ages at which it occurs?
3.  How should it be managed?

This patient has bilateral gynaecomastia. Palpable breast tissue is found in approximately one third of all adult males and in two thirds of pubertal boys. Localised discomfort may be the principle symptom but the cosmetic appearance is usually the main concern, particularly in adolescents.

Most cases of gynaecomastia occur at times of physiological hormonal change. Such physiological gynaecomastia occurs in the neonatal and pubertal periods and also in old age. Neonatal gynaecomastia is due to the trans-placental passage of maternal oestrogen and may be associated with a nipple discharge known as 'witch's milk'. It usually resolves during the first few weeks of life. Pubertal gynaecomastia is the commonest male breast lesion. It can be either unilateral or bilateral. Reassurance is often the only treatment that is required. The lesion will generally settle spontaneously but may persist for months or years. Senile gynaecomastia can be difficult to differentiate from the pseudo- gynaecomastia due to general adiposity increasingly seen in old age.

Only one third of patients with gynaecomastia will have a pathological cause. Gynaecomastia can be due to:

  • Primary testicular failure - anorchia, Klinefelter's syndrome or bilateral cryptorchidism.
  • Acquired testicular failure - mumps, irradiation.
  • Secondary testicular failure - hypopituitarism. isolated gonadotrophin deficiency.
  • Endocrine tumours - testicular, adrenal, pituitary.
  • Non-endocrine tumours - bronchial carcinoma, lymphoma, hypernephroma.
  • Hepatic disease - alcoholic cirrhosis, haemochromotosis.
  • Drugs - oestrogen agonists (spironolactone), hyperprolactinaemia (phenothiazines), Testosterone target cell inhibitors (cimetidine, cyproterone acetate)

The cause is often self evident from a full history and examination. The testes should always be examined. Useful investigations may include a chest x-ray, full blood count and liver function test. If there is suspicion of a testicular tumour then ultrasound should be requested. Hormonal assays may confirm endocrinopathies. Male breast cancer is rare accounting for only 1% of all breast tumours and 0.2% of all male malignancies. It should be considered in all unilateral breast lesions and fine needle aspiration cytology and male mammograms performed if there is any diagnostic doubt.

Most gynaecomastia is minor, does not require surgical intervention and the patient can be appropriately reassured. If it is painful or embarrassing surgery can be considered. The breast disc can usually be excised through a circumareolar incision along the lower border of the areola. The use of a suction drain is advisable to prevent post-operative haematoma formation. This can usually be removed after 24 hours. The concavity resulting from excision of the breast disc tends to fill over time but numbness of the nipple is not uncommon. Excision of all of the breast disc is required to prevent recurrence.

Recent papers

Colombo-Benkmann M,  Buse B,  Stern J,  Herfarth C.  Indications for and results of surgical therapy for male gynecomastia.  Am J Surg 1999;  178:  60-63.

Devalia H L.  Layer G T.  Current concepts in gynaecomastia.  Surgeon 2009; 7;  114-119.

Gasperoni C,  Salgarello M,  Gasperoni P.  Technical refinements in the surgical treatment of gynaecomastia.  Ann Plast Surg 2000;  44:  455-458.

Georgiadsis E,  Papandreou L,  Evanglopoulou C et al.  Incidence of gynaecomastia in 954 young males and its relationship to somatometric parameters.  Ann Human Biol 1994;  21:  579-587.

Hands L J, Greenall M J. Gynaecomastia. Br J Surg 1991; 78: 907-911.

Williams T G, Dawson P M. Gynaecomastia - presentation, aetiology and management. Curr Surg Pract 1992; 4: 105-109

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