Gynaecomastia (Fig 6.1)

This 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 Glnaecomastia (stonies)

Gynaecomastia is the commonest 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:

• Low testosterone (male sex hormone) levels as is seen after mumps affecting the testes (mumps viral orchitis). Testicular destruction such as tumours or syphilitic; gumma may be implicated.

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

• Drugs such as diuretics, digoxin, anti-hypertensive’s, alcohol, dagga, ecstasy, psychiatric medication and anabolic steroids.

• Repetitive trauma to the breast from jogging or wearing braces.

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

Gynaecomasltia may be bilateral (both sides) or unilatera.1 (one side). True gynaecomastla 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. FNA of that area can determine if the mass is malignant or not. Medical therapy is seldom of value except where a specific diagnosis has been made. Discontinuation of the causative drugs or improvement of the medical condition causing the gynacomastia often leads to breast regression. Investigations required are assessment of hormonal profiles, liver function tests, thyroid function tests, breast ultrasound, 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 problem 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. If you look at Africa the incidence of male breast cancer varies from 3% to 10% of all breast cancers.

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 increased in families who have the BRACA2 gene mutation. It increases in males who have Kleinefelters Syndrome (which is the chromosomal abnormali~ XXY). It seems to be increasing in men who work on electrical lines and factors such as ionizing radiation and electromagnetic fields have been implicated in male breast cancer.

Male breast cancer is almost always a ductal carcinoma. Very rarely a lobular carcinoma is seen and that is usually in association with Kleinefelters 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. 50% of them also 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% with a nipple discharge, about 20% with nipple changes, 4% with breast pain and 3% as metastatic 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 of these should raise suspicion in a man - any unilateral breast mass which is firm, fixed or ulcerated. The investigations that should be done are a mammogram and sonar. Sensitivity in mammograms is the same in males as it is in females. Needle biopsy will provide a diagnosis.

Treatment

Treatment for male breast cancer, as for female breast cancer, is multi-disciplinary. In other words it involves surgery, oncology which is chemotherapy and radiation therapy. The usual treatment is a modified radical mastectomy with a lymph node dissection followed by radiation treatment to the chest wall. This is then followed by adjuvant chemotherapy or endocrine therapy to improve survival. The principles of management are identical to that for female breast cancer.

There is a great propensity for local recurrence, so radiation treatment plays an important part of regional control. These tumours are mainly oestrogen receptor positive so endocrine therapy such as tamoxifen works incredibly well.

Adjuvant therapy, i.e. chemotherapy for tumours where there are positive lymph nodes or tumours which show signs of aggressiveness, have similar benefits to those seen in women. If more than ten lymph nodes are positive there is only a 10% chance of having a ten year disease free survival. If four to nine lymph nodes are positive, 25% of the patients will be disease free in ten years. If one to three of the lymph nodes are positive, 50% of the patients will be disease free in ten years. If no nodes are involved, 70% of the patients will be disease free in ten years. The prognosis for male breast cancer is directly related to the size of the tumour. So the prognosis is believed to be worse than in females, but it is actually identical to female breast cancer, stage for stage. Because men are 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, which are firm, to seek medical attention.