Breast Swelling

Gynecomastia, or breast swelling, refers to a noninflammatory enlargement of the male breast. It is defined histologically as a benign proliferation of the glandular tissue of the male breast and clinically by the presence of a mass extending concentrically from the nipple. Gynecomastia is common in infancy, adolescence, and in middle-aged or older adult males. Differentiate from lipomastia, which is swelling of the breast due to fatty tissue proliferation.

Differential Diagnosis

• Physiologic gynecomastia of puberty
• Persistent postpubertal/elderly gynecomastia
• Idiopathic
• Medications (e.g., estrogens, antiandrogens, spironolactone, nifedipine, digitalis, isoniazid, phenytoin, griseofulvin, cimetidine) or drugs (especially marijuana)
• Liver disease
  –Cirrhosis
  –Hepatitis
  –Hemochromatosis
• Chronic renal insufficiency
  –50% of men on dialysis have gynecomastia
• Hypogonadism (e.g., Klinefelter's syndrome, enzymatic defects, testicular trauma or infection)
• Thyroid disease
• Pituitary disease
  –Acromegaly
  –Chromophobe adenoma
• Neoplasms
  –Breast cancer
  –Testicular cancer
  –Adrenal cancer
  –Hepatocellular carcinoma
  –Lung cancer
  –Carcinoid
• Re-feeding after starvation
• Local irradiation

Workup and Diagnosis

• History and physical exam
  –Past medical history, family history, developmental and growth history, and medication history are important
  –If patient is an adolescent with normal physical examination, the diagnosis is likely pubertal gynecomastia; gradual improvement with age supports this diagnosis
  –Signs of breast cancer may include rubbery or firm mass, concentric or asymmetric, skin dimpling, nipple retraction, discharge, and axillary lymphadenopathy
• If gynecomastia is of recent onset, painful, or tender, initial laboratory evaluation may include β-hCG, LH, testosterone, TSH, estradiol, liver function tests, BUN/creatinine, prolactin, and DHEA-S
• Mammogram may be indicated to evaluate for cancer
• Ultrasound may distinguish normal glandular tissue from worrisome solid lesions
• Karyotype to diagnose Klinefelter's syndrome (XXY)

Treatment

• Many cases regress spontaneously without treatment
• Discontinue offending medications if possible
• Three types of medical therapies are available for elderly patients with severe pain, tenderness, or embarrassment
  –Androgens (e.g., testosterone, dihydrotestosterone, danazol)
  –Antiestrogens (e.g., clomiphene, tamoxifen)
  –Aromatase inhibitors (e.g., testolactone)

• Surgical therapy may be indicated if no response to medical therapy
  –Liposuction
  –Direct surgical excision

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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