Gynecomastia+(Benign)

This condition can occur at any age in males. Estimates show that 60-90% of males at infancy have trasient gynecomastia due to high estrogen levels during pregnancy. During puberty the prevalence is 4-69%, and in older men the prevalence is 24-65%. 2 || The following etiologies in males seeking medical attention for gynecomastia include: -persistent pubertal gynecomastia -drugs -cirrhosis or malnutrition -primary hypogonadism -testicular tumors -secondary hypogonadism -hyperthyroidism -chronic renal insufficiency 2 || -a through history noting the age of onset and duration; ask about recent changes in the size of the nipples and the presence of pain or discharge from the nipples; inquire if the patient has any history of mumps, trauma to the testicles, alcohol use, drug use (eg. prescription, over-the-counter or recreational); note any family history of gynecomastia; evaluate the patient's history for sexual dysfunction, infertility or hypogonadism (impotence, decreased libido and strength). -physical with a through examination of the breasts, noting size and consistency and presence of discharge or axillary lymphadenopathy; differentiate between true gynecomastia and pseudogynecomastia; gynecomastia can be detected when the size of the glandular tissue exceeds 0.5 cm in diameter; examine the testicles, noting size and consistency; carefully look for the presence of nodules or asymmetry; note signs of feminization, including typical body hair distribution and eunuchoid habitus; check for any stigmata of chronic liver disease, thyroid disease or renal disease. -labs to include serum chemistry panel; free or total testosterone, luteinizing hormone (LH), estradiol, and dehydroepiandrosterone sulfate levels (used to evaluate possible feminization syndrome); thyroid-stimulating hormone (TSH) and free thyroxiine levels if hyperthyroidism is suspected. -imaging studies to include a mammogram (if breast cancer is suspect); testicular ultrasonogram if the serum estradiol level is elevated (if a testicular neoplasm is suspect). 2 || As this is a benign condition, grading/staging does not exist for this condition. However, Radiation Therapy is indicated as a way to prevent pain or growth of the mammary gland. Usually this is done for patients with prostate carcinoma undergoing hormonal therapy. 4 || As this is a benign condition, grading/staging does not exist for this condition. However, Radiation Therapy is indicated as a way to prevent pain or growth of the mammary gland. “This treatment can prevent pain or growth of the mammary gland…Radiotherapy cannot reverse gynecomastia.” 4 || In patients treated after estrogen therapy 20Gy in 5 fractions is recommended. 1 || || **References** 1. Chao KS, Perez CA, Brady LW. //Radiation Oncology - Management Decisions. //  2nd ed. Philadelphia: Lippincott, Williams & Wilkins, 2002: 677-688. 2. eMedicine. Gynecomastia. []. Accessed February 16, 2010. 3. American Cancer Society. What is breast cancer in men?[| http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_male_breast_cancer_28.asp]. Accessed February 17, 2010. 4. Gunderson and Tepper. Clinical Radiation Oncology. 2nd Edition. Philadelphia, PA: Churchill Livingstone. 2007. 5. Van Poppel H, Tyrrell C, Haustermans K, et al. Efficacy and Tolerability of Radiotherapy as Treatment for Bicalutamide-induced Gynaecomastia and Breast Pain in Prostate Cancer. //European Urology// [serial online]. May 2005;47(5):587-592. Available from: Academic Search Complete, Ipswich, MA. Accessed February 20, 2010. 6. Good Samaritan Regional Cancer Center. Corvallis, OR. Courtesy of Sheri Griffin.
 * Epidemiology: || "Gynecomastia occurs in as many as 90% of patients receiving estrogens or flutamide, compared with 8% of patients undergoing orchiectomy, 3%to 15% of those treated with luteinizing hormone-releasing hormone agonists, and 19% of those patients receiving a combination of flutamide and luteinizing hormone-releasing hormone agonists." 1 
 * Etiology: || Gynecomastia results from an altered estrogen-androgen balance, in favor of estrogen, or from increased breast sensitivity to a nomal circulating estrogen level.
 * Signs & Symptoms: || Gynecomastia is a benign enlargement of the male breast resulting from a proliferation of the glandular component of the breast. Gynecomastia is defined clinically by the presence of a rubbery or firm mass extending concentrically from the nipples. The condition known as pseudogynecomastia, or lipomastia, is characterized by fat deposition without glandular proliferation. Although gynecomastia is usually bilateral, it can be unilateral. 2 ||
 * Diagnostic Procedures: || <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">The workup for gynecomastia includes:
 * Histology: || Changes in ductal epithelium and connective tissue stroma. 2 ||
 * Lymph Node Drainage: || <span style="color: #008000; font-family: Arial,Helvetica,sans-serif;">Lymphatics of the male breast is similar to that of the female breast (drain laterally to the axillary nodes, medially to internal mammary nodes, of superiorly to supraclavicular and infraclavicular nodes). Lymph node drainage will not be affected by a diagnosis of gynecomastia; however if breast cancer develops, the cancer may spread via these lymphatics. <span style="color: #008000; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">3 ||
 * Metastatic Spread: || <span style="color: #008000; font-family: Arial,Helvetica,sans-serif;">Unless a breast cancer diagnosis occurs, the development of gynecomastia does not lead to metastases. <span style="color: #008000; font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">2 ||
 * Grading: || <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">
 * Staging: || <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif; font-size: 10pt;">
 * Radiation Side Effects: || The radiation side effects for treatment of gynecomastia are mild and short-lived. They inculde breast and nipple erythema, skin irritation, and fatigue. 5 ||
 * Prognosis: || Ultimately, the prognosis for these patients is excellent, as it is a benign condition. However, according to a study by Van Poppel et al., radiation therapy improves the intensity of bicalutamide-induced gynecomastia and/or breast pain in prostate patients in approximately 1/3 of patients. 5 ||
 * Treatments: || A single dose of 9 Gy or 4 to 5 Gy daily for three three treatments is effective.
 * TD5/5: || The TD5/5 of skin in a single dose is 15-20Gy and fractionated it is 30-40Gy. 1 ||
 * Planning Photos || Gynecomastia treatment DRRs. Pt was treated every other day 400 cGy per fraction to a dose of 2000 cGy using 6MV photons. 6