Danielle DeMulder, MD

50-year-old male presents with palpable lump in the left breast.


Bilateral mammogram: For the most part, demonstrates characteristic mammographic appearance of gynecomastia, left much greater than right. Flame-shaped, central subareolar mass with prominent linear projections radiating into deep adipose tissue. At inferior aspect on the left, there is a more-welldefined smoothly marginated, lobulated ovoid region, which is not typical for gynecomastia.


Targeted left breast ultrasound: In the left retro-areolar region, typical sonographic appearance of gynecomastia was seen with slightly hypoechoic tissue centered at the nipple, tapering posteriorly. In the area of palpable abnormality, there were multiple well-defined, anechoic structures without internal vascularity on color Doppler interrogation, consistent with multiple breast cysts.


Gynecomastia is defined as "benign proliferation of male breast grandular tissue."

Trimodal age distribution is neonatal, pubertal, and elderly males. It is usually due to an altered ratio of estrogens to androgens (ie, secondary to increased estrogen activity, decreased testosterone activity, or medication related).

Causes are linked to health conditions (hypogonadism, aging, tumors [including testes, adrenal glands, pituitary glands], hyperthyroidism, kidney failure and cirrhosis, malnutrition, and starvation. Medications, such as anti-angrogens (ie, for treatment of prostatic conditions), anabolic steroids and androgens, AIDS medications, anti-anxiety medications (eg, diazepam), tricyclic antidepressants, antibiotics, ulcer medications (eg, cimetidine), chemotherapy, heart medications (eg, digoxin, calcium channel blockers), and street drugs (amphetatimes, marijuana, heroin, methadone) and alcohol have also been linked as causes of gynecomastia.

Gynecomastia is a benign condition and is usually self-limited.

Further inquiry revealed that the patient reported noticing a "milky substance" associated with his palpable breast abnormality -- galactorrhea. This clinical history prompted initial laboratory evaluation, which included checking a prolactin level, revealing hyperprolactinemia. Prolactin level was elevated at 134 (normal range 4.0-15.2). One clinical note also revealed that the patient endorsed a history orf blurry vision. These findings prompted an MRI of the pituitary gland.[[{"type":"media","view_mode":"media_crop","fid":"41027","attributes":{"alt":"","class":"media-image","id":"media_crop_2826643534801","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4261","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":"Sagittal precontrast T1-weighted image reveals enlargement of the pituitary gland, as evidenced by superior convex border.","typeof":"foaf:Image"}}]]

New diagnosis: Gynecomastia secondary to pituitary adenoma (Prolactinoma)


In males, prolactinomas may be completely asymptomatic until there is galactorrhea, compression of the optic chiasm results in visual symptoms, or hypogonadotrophic hypogonadism results in loss of libido and impotence. Prolactinomas are the most common hormone-secreting pituitary tumors.
 

Treatment for gynecomastia secondary to prolactinoma depends on the underlying cause, the aim of treatment would be to reduce prolactin level to normal, reduce tumor size, and restore normal pituitary function.

Medications used to treat prolactinomas are bromocriptine (a dopamine agonist that decreases the synthesis and secretion of prolactin), and cabergoline (a long-acting, nonregot dopamine agonist, is usually better tolerated than bromocriptine, with superiod efficacy profiles). It has been reported that up to 70% of patients who do not respond to bromocriptine respond to cabergoline. Cabergoline has had fewer side effects reported than bromocriptine, but it is more expensive.

This patient was treated with cabergoline. Subsequent prolactin levels were found to be low-normal at 3.4. Follow-up mammogram (A–D) and breast ultrasound (E, F) performed following treatment revealed marked improvement in left gynecomastia, with only minimal residual gynecomastia by mammogram and ultrasound in the left retroareolar region, with resolution of previously seen breast cysts on the ultrasound (E, F).

1. Becker KL. Endocrinology of the Male. 

Principles and Practice of Endocrinology and Metabolism. 

2. Johnson RE, Murad MH. Gynecomastia: patholphysiology, evaluation, and management. 

3. Seidenwurm DJ. Neuroendocrine imaging. 

Poll

50-year-old male presents with palpable lump on the left breast.

Image IQ: 50-year-old Male, Palpable Lump on Left Breast

 54-year-old male presents with palpable right retroareolar abnormality. The patient reports that two years prior, he presented to a surgeon with unilateral bloody nipple discharge on the right. At that time, he underwent breast biopsy, with benign results. No nipple retraction or inversion by patient report or on physical examination.

Pathology report from biopsy February 10, 2012: Breast tissue with dense stromal fibrosis, mild focal duct hyperplasia, focal chronic inflammation, mild epithelial proliferation.

 Bilateral full field digital mammography with CC and MLO views demonstrate a lobulated mass in the right retroareolar region. Absence of breast parenchyma, expected in this male patient.

 Spot compression CC and MLO views demonstrate persistence of lobulated right retroareolar mass.

 Grayscale transverse and longitudinal sonographic images (included with and without caliper measurements) in the right retroareolar region demonstrate lobulated, hypoechoic solid mas corresponding to the mammographic abnormality. Color Doppler interrogation of the mass does not reveal significant internal vascularity.

 The patient underwent core biopsy under ultrasound guidance. Sonographic images demonstrate accurate targeting, with the biopsy needle in the lesion.

 Invasive ductal carcinoma (strong estrogen and progesterone receptor positivity; HER2 – equivocal).

: The most common symptom of breast cancer in a male, as with females, is a hard, fixed, painless lump, which is present in 75 percent of cases. The palpable lump is usually subareolar. Other less common clinical features include nipple retraction or inversion, nipple discharge, axillary lymphadenopathy and skin changes (including retraction, skin thickening and even ulceration).

Men account for approximately 1 percent of all new breast cancer cases. Given rarity, lack of awareness and often low clinical index of suspicion from both the perspective of the patient and physician, there is often a delay in diagnosis, leading to progression of disease before presentation. This later stage of diagnosis results in an overall worse prognosis. Prognostic factors include size of primary tumor, histologic grade and lymph node status. Average age of diagnosis tends to be later than that of women, with range of 60-64 years.

There is a greater prevalence of male breast carcinoma in some ethnic groups, including African-American, Native African from Western nations, and men of Jewish and Icelandic ancestry.

Given the high frequency of genetic mutations (for example, BRCA-2 gene mutation, Klinefelter syndrome) in cases of male breast cancer, this diagnosis should prompt consideration of genetic counseling and testing, particularly if there is family history of relatives with breast and ovarian cancer.

Mammography in men with breast lesions has a reported sensitivity of 92 percent and specificity of 90 percent. On mammography, male breast cancer is typically manifested with a subareolar mass, which can be round, oval, irregular or lobulated in shape and the margin may be spiculated and ill-defined or well circumscribed. Calcifications are uncommon in male breast cancer. Ancillary features of skin retraction and ulceration are findings that portend a poor prognosis. Gynecomastia can mask a cancer.

Ultrasound typically demonstrates a hypoechoic solid, but can demonstrate a complex cystic mass.

The differential diagnosis for male breast cancer includes gynecomastia, fat necrois, pseduogynecomastia, granular cell tumor or extramammary metastasis to the breast.

 Treatment regimens are similar to those for female breast cancer.

 Treatment algorithm for operable male breast cancer (Fentiman 2006).

 Treatment algorithm for inoperable male breast cancer (Fentiman 2006).


Iuanow E, Kettler M, Slanetz P. Spectrum of Disease in the Male Breast. 

y. 2011;16:3.
Chantra P, et al. Mammography of the Male Breast. 

y. 1995;164:853-858.
Yang W, et al. Sonographic Features of Primary Breast Cancer in Men. American Journal of Radiology. 2001;176:2. Fentiman I, et al. Male Breast Cancer.

Articles

Case History: 54-year-old male presents with palpable right retroareolar abnormality.