Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Let's do our team timeout. Our patient today is still the breast module of the surgical curriculum and our operation or topic today is going to be male breast diseases. Specifically, I'm going to be covering gynecomastia and male breast cancer.
So let's get started with gynecomastia. Gynecomastia, by definition, is hyperplasia of the glandular breast tissue in the male and is usually thought to be driven by an alterational imbalance in the male estrogen to testosterone ratios. This is a non-cancerous increase in the size of the male breast tissue. Mostly this is thought of to be a manifestation of systemic
So systemic diseases that are changing that hormone ratio. And so investigation and most treatments will be focused on identifying and treating the underlying cause of the gynecomastia. So when we talk about the causes, I split them up into physiological, pharmacological, pathological, and idiopathic causes. Physiological causes are about
20% of presentations with gynecomastia. And these include basically those conditions where there is just a natural increase in the estrogen to testosterone ratio. This is commonly seen in neonates due to the placental transfer of estrogen. It's also seen commonly in puberty as the pubertal estrogen production.
will begin prior to testosterone production due to aromatase, changing peripheral testosterone into estrogen. So usually 90% of cases of this would regress as the... natural testosterone production picks up in puberty. And there's also another time when physiological imbalance is seen, and this is in elderly men, where a number of men over the age of 70 will have a reduction in their testosterone production, which is natural.
This will change that balance of estrogen to testosterone and can lead to gynecomastia. Our second group is pharmacological, and this will be 20% to 30% of presentations with gynecomastia. Feel free to look it up. There seems to be 100 different drugs that can cause this problem. But common ones are hormonal supplements. So if patients are taking estrogens, patients who are taking anabolic steroids.
Patients taking anti-androgens or androgen production blocking drugs and other drugs such as spironolactone that can block the androgen receptor. They can be drugs that cause hyperprolactinemia. So some of these include methyl dopa, tricyclic antidepressants, and metoclopramide. Some cytotoxic drugs, such as vincristine, can do this. Recreational drugs, including opiates, alcohol, marijuana, heroin, methadone, and amphetamines can cause gynecomastia. Cardiac drugs such as digoxin.
ACE inhibitors and amiodarone can do this, as well as anti-ulcer drugs such as H2 receptor blockers and PPIs. And some antibiotics such as ketoconazole, metronidazole and antiretrovirals can also do this. But like I said, there are many others. The interesting group, so the pathological group, and this is about 35% of presentations with gynecomastia.
So the one that we all worry about, which is a very rare form of gynecomastia, about less than 3% of cases of gynecomastia will be related to this, is where there is an increased estrogen production by a tumor. And these tumors can produce estrogen or androgens, aromatase or beta-HCG and lead to gynecomastia. And these can include hepatomas, testicular tumors, pituitary tumors.
adrenal tumors, or it can be a paraneoplastic syndrome associated with bronchial carcinoma. Other pathological causes include a relationship with systemic illnesses.
So liver disease is a common systemic illness that can lead to gynecomastia, and it's thought that there's decreased estrogen clearance by the liver in patients with cirrhosis. Other associations include renal failure, hyperthyroidism, which causes an increased aromatization of androgens into estrogen, malnutrition, HIV, and also obesity, which leads to increased aromatization as well. There are endocrine conditions that are associated with gynecomastia where...
there's a decreased natural testosterone production or primary hypogonadism. And the commonest case of this is in Klinefelter syndrome, which is a genetic abnormality with two X and one Y chromosomes. There can also be decreased testosterone production due to secondary hypergonadism, so that's where there's damage to the testes from mumps, orchitis, if there's bilateral cryptorchidism, or if there's an acquired testicular failure secondary to...
radiation therapy or hypopituitarianism. Acromegaly, a pituitary problem, is another cause of an endocrine dysfunction leading to gynecomastia and an androgen insensitivity. And in about 20 to 25% of cases, there is no cause found. So this is idiopathic gynecomastia. Some of the differential diagnoses to consider when a patient is presenting with a clinical presentation or referral with gynecomastia is making sure that you're not missing an underlying breast cancer.
Pseudogarnicomastia is another differential, and this is the accumulation of fat in the breast area. So fat not being glandular tissue, which is the definition of gynecomastia. And these patients don't need any further investigation.
It could be a lipoma, it could be a cyst such as a dermoid or a sebaceous cyst, and can also be fat necrosis, which is seen in women too. So when working up a patient who's been referred with gynecomastia, We would start with a history, and this should include a timeframe for the enlargement, whether there's any pain or tenderness.
Looking for a cause, so asking them about any prescribed drugs or recreational drug use, their alcohol consumption, whether they have any past history of systemic diseases such as liver. kidney, thyroid, hypogonadism, prostate or testicular diseases, if they've had any recent weight loss or gain. And also you should probe whether the patient is bothered by the breast enlargement or not.
An examination should include examination of the breast tissue, the thyroid, visual fields, any evidence of hormonal problems or imbalances that you might be able to see on that patient. and also include an examination of the axilla and the testes. Some patients don't need any further investigation, and this includes adolescent males and...
The reason is in that group, it should be a self-limiting benign condition. So this is something that in the majority of these patients, it would go away within one to two years and they should be reassured and referred back if that does not occur. Elderly men with gynecomastia related to their age should also not be further investigated unless there's any clinical or history findings that make you suspicious for a more sinister underlying cause.
Men who have a drug-related cause don't need further investigation. You would simply stop that drug. And men with fatty pseudogynecomastia also don't need further investigation. Patients who... do need investigation are patients who are presenting with an eccentric hard mass, so eccentric not being just under the nipple, maybe off to one side. If it's hard, especially if it's unilateral and has rapid enlargement, then you should be concerned about a
underlying breast cancer. If there's recent onset in a very lean man who is more than 20 years old, then you would consider further investigation of those patients. Patients who have persistent painful gynecomastia or massive gynecomastia even in adolescents or adolescents who have persistent gynecomastia despite an 18 to 24-month period, then those patients need further investigation.
Investigation should be guided on your history and examination findings, but can include blood tests. So looking for a systemic illness. thyroid function tests, liver function tests, renal function tests can all be sent, as well as alpha-feta protein and beta-HCG, and a 9am testosterone test can also be taken.
If that testosterone test is abnormal, then further tests for luteinizing hormone, follicle stimulating hormone, sex hormone binding globulin, albumin, estradiol and prolactin should also be sent. If the patient has had headaches, seizures, diplopia, or visual field issues, then you should investigate for a pituitary cause with an MRI brain.
examination of the testes is abnormal, or if any of the blood tests looking at things such as the beta HCG, AFP, testosterone are abnormal, then that patient should undergo a scrotal ultrasound. older men, you could also consider a CT abdomen looking for adrenal causes or accessory testicular tissue, for example, that hasn't descended. In patients who have... a unilateral hard eccentric mass or if there's a discrete lesion you should
perform a breast ultrasound. This can also be helpful if you're not clear whether this is pseudogarnicomastia as they can differentiate whether the enlarged tissue is actually glandular tissue or whether this is just fat. And if there is a discrete lesion scene, this should be managed with triple assessment with a core biopsy.
There is a classification system for gynecomastia. I'm not sure that this would necessarily be required to be known, but it's pretty simple. It has to do with the amount of breast development and the amount of excess skin. And this classification is the Simon. Hoffman and Kahn gynecomastia classification. And there's grade 1, 2A, 2B and 3. Grade 1 is just small breast enlargement with no excess skin. 2A is moderate breast enlargement with no excess skin.
2B is moderate enlargement with excess skin. And 3 is marked enlargement with excess skin. The treatment of gynecomastia really depends on the underlying cause. So identifying that underlying cause and treating that, and that should lead to resolution of gynecomastia, especially if you're stopping a causative medication. However, this is... best done within two years after the commencement of gynecomastia, as if it's been going on for a long time, they may not get regression of that tissue.
There has been selective estrogen receptor modulators used as a treatment, such as tamoxifen or raloxifen, and this can be used for six months. However, there's often issues with side effects in men and compliance with treatment. And anastrazole has also been used to address the aromatase excess. There are operations that can be done for gynecomastia.
These include a subcutaneous mastectomy with resection of the glandular tissue, and this can be done with quite good cosmetic outcomes with a periareola incision. The principles of this operation are to maintain the nipple areola complex and to avoid a divot under the nipple areola complex. And the way that it's performed is that you make an incision around the areola, you raise skin flaps, and you excise excess tissue underneath the nipple areola complex to make it flat.
You don't go right down to the fascia because this is not a mastectomy. It's not a cancer operation, but you're trying to basically flatten the chest without leaving a defect there and to try to make it symmetrical to the other side. Liposuction can be... used and laser-assisted liposuction is a technique I've never seen before but has been described as an option for these patients. The complications of surgery are similar to that with all breast surgery with hematoma or infection.
Breast asymmetry or cosmetic issues, changes in sensation of the skin and nipple, necrosis of the nipple or areola, and also scarring. I hadn't come across this before, but apparently they can also do radiation therapy to glandular breast tissue in men who have prostate cancer and are receiving androgen deprivation therapy in order to prevent the development of gynecomastia. and breast pain in those patients. Moving on to male breast cancer.
This is very rare compared to female-associated breast cancer. 0.25% of malignancies in men is breast cancer, and about 1 in 100,000 men will be diagnosed with male breast cancer in their lifetime. It is more likely to be associated with an advanced stage at diagnosis, so therefore the overall prognosis is worse. Stage for stage, the prognosis is the same. And the majority of breast cancers in men are hormone receptor positive HER2 negative tumors.
The risk factors for development of breast cancer in men is the same as for the development of breast cancer in women. The older you are, the higher the risk of development of breast cancer. higher the estrogen exposure over your lifetime, the higher the risk. So this includes hyperestrogenic states or androgen deficient states. So Klinefelter syndrome, which is, we briefly mentioned, extra chromosome.
X, so two X chromosomes, one Y chromosome is the highest risk factor for the development of male breast cancer with a 20 to 50 times higher risk than the general population. Testicular dysgenesis or cryptochism is where you get a congenital or acquired testicular dysfunction leading to an androgen deficiency. So you have a higher estrogen to testosterone ratio.
obesity with increased aromatization of testosterone to estrogen, alcoholism and liver impairment, as we've just mentioned, and prostate cancer treatments. In addition, previous chest irradiation such as in Hodgkin's lymphoma and some genetic causes including BRCA mutations increase your risk of development of male breast cancer. up to 20% of men with breast cancer.
will have a first degree relative with breast cancer. And BRCA2 mutations are the most commonly observed mutation in men with breast cancer. They'll have a 5% to 15% lifetime risk of developing breast cancer. The clinical presentation is also the same patients. Usually they will present.
clinically because they don't have a screening program for men and they'll present with a painless mass usually eccentrically placed and there may be early involvement of the nipple areola complex due to the lack of breast tissue they can also have enlarged nodes in the axilla. The way that we work up breast cancers in men is the same as the way that we work up breast cancers in women so we would do a triple assessment. So this includes history and examination. which...
would be a mammogram and ultrasound. And these would show the same changes in a male breast cancer as in females. So mammogram may show calcifications. You may see an eccentrically placed mass with speculated margins. And an ultrasound would find a hypoechoic solid mass with speculated margins and posterior acoustic shadowing. It can be difficult.
to see a breast cancer if there is gynecomastia with dense breast tissue. And also an ultrasound should have a look at the axilla in the same way it would in women. The last step is obviously tissue biopsy, which should be done with a core biopsy of the mass and FNA or core of any potentially suspicious involved lymph nodes. Differential diagnosis of a mass in a male breast include garnicomastia, which we've talked about, pseudogarnicomastia, infectional abscess, lipoma.
Pseudoangiomatous stromal hyperplasia or PASH, which we talked about in the Benign Breast Diseases podcast. Other tumors such as desmoid tumor, granular cell tumors, schwannomas.
It can be a hemangioma or a metastasis to the breast or other non-breast cancer primaries such as sarcomas, although these are very rare. Management of male breast cancer involves... MDT discussion as you probably know by now but in terms of surgery most men would have a total mastectomy and sentinel lymph node biopsy if the axilla is negative.
is higher involvement of chest wall muscles because there's less breast tissue, so therefore higher incidence of local invasion. And this should be investigated if there's any suspicion for this on imaging. If there is involvement of the axilla, then these patients need formal staging with CT, chest, abdo, pelvis, and bone scan, and will also, exam answer-wise, require an axillary lymph node dissection.
Men can also have other treatments, so radiotherapy treatment can be indicated, especially if there's any high-risk features or poor prognostic signs, such as a very large tumour, local invasion, auxiliary nodes involved, or high-grade disease. Chemotherapy can also be given and the same chemotherapy given to women can be given to men. And this would be indicated if there were positive lymph nodes, a large tumor, if there was inflammatory breast cancer.
We would also consider endocrine therapy in men if they have a hormone receptor positive tumour, which is the most common tumours in men. So they can have tamoxifen and this will give them improved survival. It's not well tolerated in men, and this can lead to issues with compliance. Some of the side effects include decreased libido, weight gain, hot flushes, mood alteration, depression, insomnia, and an increased risk of thrombosis.
Patients who have HER2 positive tumors, which are very rare, these patients, although there's not great data, would also be offered trastuzumab in the same way that women are. And the guidelines for staging of these tumors is that you would use the same AJCC staging guidelines for men as you do for women. The other thing is that a man who develops breast cancer should be referred for genetic counselling and investigation about whether there is an underlying genetic cause of their breast cancer.
Well, that was short but sweet. Obviously, there isn't as much to go through because we have gone through all of this in detail in our recent episodes on early breast cancer.
I might just take this opportunity to mention that I also wrote a book about the general surgical interview. So if you are an unaccredited registrar applying for the program or if you know of any unaccredited registrar, applying for the program let them know to have a look on amazon for my book which is entitled general surgery set interview the ultimate preparation guide it has absolutely
everything you could possibly need to prepare for this interview. It's chock full of practice questions, model answers and frameworks for answering questions about the interview. The other thing that's worth mentioning to them is that you only find out you get the interview a few weeks beforehand. But this is something that's worth the most out of any part of the application. And really, I studied for this like an exam for six months. And if people are serious.
about trying to get onto the program, that's really what needs to be done. So encourage them to start preparing early, which is the key to getting onto the program. And once again, Please rate, review and subscribe so that other people can find this podcast. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback... send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!