Male Problems
Problems benign | pain | discharge | lumps | male problems

 

Male Breast Problems

 

Gynaecomastia
Gynaecomastia refers to breast enlargement in the male. About one third of normal adult males have mild gynaecomastia. About two thirds of normal boys at puberty have mild gynaecomastia (stonies). Gynaecomastia is the most common condition affecting the male breast. It is due to an enlargement of ductal and stromal tissues that is structurally different from the surrounding subcutaneous fat. It may be physiological as in neonatal, pubertal and senescent hypertrophy which is due to relative excesses of oestrogen in relation to testosterone.


Causes of gynaecomastia include:

Bullet

Low testosterone (male sex hormone) levels as is seen after mumps affecting the testes (mumps viral orchitis), testicular destruction by tumours or syphilitic gumma may also be implicated.

Bullet

Liver insufficiency (e.g. alcohol or hepatitis), where the damaged liver cannot metabolise oestrogen efficiently and oestrogen levels are therefore elevated.

Bullet

Drugs such as diuretics, digoxin, anti-hypertensives, alcohol, marijuana, ecstasy, psychiatric medication and anabolic steroids.

Bullet

Repetitive trauma to the breast from jogging or repetitive sports movements wearing braces.

Bullet

Breast enlargement (unilateral) in the male may be due to breast cancer (yes, breast cancer can occur in males).

 

Gynaecomastia may be bilateral (both sides) or unilateral (one side). True gynaecomastia is always central in the breast (under the nipple) whereas breast cancer is often eccentric (not directly under the nipple). The presentation is usually a tender enlargement of the breast. Patients may be concerned about the cosmetic appearance, tenderness, pain or the fear of an underlying cancer.

 

Sonar can determine if there is a suspicious area. A core biopsy of that area can determine if the mass is malignant or not.

Discontinuation of the causative drugs or improvement of the medical condition causing the gynacomastia often leads to breast regression.

Investigations that are required are assessment of hormonal profiles, liver function tests, thyroid function tests, breast ultrasound and mammography and testicular ultrasound.

Medical management involves the use of low dose SERMs (tamoxifen or fareston) for at least six months.

Surgical treatment is indicated for unilateral breast enlargement, cosmetic or psychological problems or for failure of medical treatment. Subcutaneous mastectomy is performed through elevation of periareolar or inframammary flaps.

Male breast cancer

The incidence of male breast cancer varies throughout the world. In the United Kingdom it counts for about 0.7% of all breast cancers. There seems to be an increasing incidence in the USA, especially amongst black males, with about a thousand cases being diagnosed per year. The mean age of breast cancer in the USA is about sixty years of age. The incidence of male breast cancer varies from 3% to 10% of all breast cancers in sub-Saharan Africa.

Risk factors for male breast cancer are interesting; it is definitely not associated with benign male breast lumps (gynaecomastia). There does however appear to be an inherited component. The lifetime risk of a male to get breast cancer if his mother and his sister had breast cancer is about 2.5%.

Male breast cancer is more common in families who have the BRACA2 gene mutation and in males who have Kleinefelters Syndrome (which is the chromosomal abnormality XXY). It seems to be increasing in men who work on electrical lines. Factors such as ionising radiation and electromagnetic fields have been implicated in male breast cancer.

A male breast cancer is almost always a ductal carcinoma. Lobular carcinoma is rarely seen in men and when it is it is usually in association with Kleinerfelters Syndrome. Any variation of ductal carcinoma can be seen in male breast cancers including Paget’s disease. 80% to 90% of male breast cancers are oestrogen receptor positive. Less than 10% are progesterone receptor positive and 50% of them contain androgen receptors.

The disease parallels female breast cancer but tends to present in an older age group. It also usually presents at a more advanced stage and this is due to the decreased amount of breast tissue found in men. So it is more frequent to see skin and chest fixation.

90% of all male breast cancers present as a breast lump and it is usually a painless mass.14% present with a nipple discharge, about 20% with nipple changes, 4% present with breast pain and 3% as metastic disease, (the breast cancer spreads to other organs).

Breast cancers usually present as an asymmetrical eccentric firmness either with fixation or ulceration of the breast. Any unilateral breast mass that is firm, fixed or ulcerated should raise suspicions in a man. The investigations that should be done are a mammogram and sonar. Sensitivity in mammograms is the same in males as it is in females. An ultrasound is also of benefit to obtain the diagnosis. A needle biopsy will provide the diagnosis.

 

Treatment
Treatment for male breast cancer, as for female breast cancer, is multi-disciplinary. In other words it usually involves surgery, oncology (chemotherapy and hormone therapy) and radiation therapy. The usual treatment is a modified radical mastectomy with a lymph node dissection, followed by adjuvant chemotherapy if necessary. Radiation treatment to the chest wall is used if necessary while endocrine therapy can improve the survival if the cancer is hormone sensitive. The principles of management are identical to that for female breast cancer.

 

There is a higher incidence for local reccurrence in males so clear surgical margins and radiation treatment (should the tumour be greater than 2 cm) play an important part of loco-regional control. These tumours are mainly oestrogen receptor positive so endocrine therapy (Tamoxifen) is part of systemic treatment.

Adjuvant chemotherapy is used for node positive tumours or biological aggressive tumours. Tumours that are greater than 2cm have twice the risk of relapse than those where the lesions are less than 1cm.

 

While the prognosis is believed to be worse in male breast cancer than in female it is actually identical stage for stage. Because men are often diagnosed at a later stage relative to the size of breast tissue they have, it gives the impression of a worse prognosis. It is important for men with unilateral breast masses, that are firm, to seek medical attention.