Male Breast Disorders

Gynecomastia - Man Boobs Unmasked

• Benign proliferation of glandular breast tissue in males; imbalance of estrogen/androgen action.
• Types & Etiology:
  • Physiological: Neonatal, pubertal (usually resolves in 1-2 yrs), senile.
  • Pathological:
    • ↑ Estrogen: Testicular tumors (Leydig, Sertoli), liver cirrhosis, adrenal tumors, obesity (↑ aromatase).
    • ↓ Testosterone: Klinefelter syndrome (47,XXY), anorchia, testicular failure.
    • End-organ hypersensitivity.
  • Drug-induced: MOST COMMON CAUSE in adults.
    • 📌 Mnemonic: SACKED (Spironolactone, Alcohol, Cimetidine, Ketoconazole, Estrogens, Digitalis).
• Clinical Features:
  • Rubbery/firm, mobile, disc-like subareolar mass; often bilateral, can be unilateral/asymmetric.
  • Pain/tenderness may be present.
  • Differentiate from pseudogynecomastia (fat deposition, no glandular tissue).
• Evaluation: History, physical exam. Consider mammography/USG if suspicious for malignancy (eccentric, hard, fixed mass; nipple discharge; skin changes; axillary nodes).
• Management:
  • Observation if physiological/asymptomatic.
  • Treat underlying cause.
  • Medical: Tamoxifen, Danazol (limited efficacy).
  • Surgical: Subcutaneous mastectomy for persistent/symptomatic cases or cosmetic reasons.

⭐ Drug-induced gynecomastia is common; Spironolactone is a classic example.

Male Breast Cancer - Rare but Real Threat

• Rare (<1% of all breast cancers); median age 60-70 years. Affects ~1% of all male cancers.
• Key Risk Factors:
  • Genetic: BRCA2 (most significant), Klinefelter syndrome (XXY), CHEK2.
  • Hormonal: ↑Estrogen (obesity, liver disease), family history of breast cancer.
• Presentation:
  • Painless, firm, subareolar mass (most common, often eccentric).
  • Nipple changes (retraction, bloody discharge), skin ulceration/dimpling.
  • Axillary lymphadenopathy.
  • Often late presentation due to low awareness.
• Pathology:
  • Invasive Ductal Carcinoma (IDC) >85%. Lobular carcinoma rare.
  • ER/PR positive >80%; HER2 positive ~15%.
• Diagnosis:
  • Triple Assessment: Clinical exam, Imaging (Mammography/USG), Biopsy (Core Needle Biopsy).
  • Mammography: Eccentric, spiculated mass. Microcalcifications can occur.
• Management:
  • Surgery: Modified Radical Mastectomy (MRM) is standard; Sentinel Lymph Node Biopsy (SLNB).
  • Adjuvant Therapy: Tamoxifen (for ER+), chemotherapy, radiotherapy. Trastuzumab (for HER2+).
• Prognosis: Stage-for-stage similar to females; overall poorer due to delayed diagnosis and advanced stage.

⭐ BRCA2 mutation is the most significant genetic risk factor for male breast cancer.

Workup & Other Conditions - Sorting Swellings

• Key Workup Steps:
  • Thorough History: Onset, pain, discharge (esp. bloody), drug history (spironolactone, cimetidine, finasteride, anabolic steroids), family history (breast/ovarian Ca).
  • Clinical Exam: Differentiate gynecomastia (rubbery/firm, subareolar, often bilateral) vs. pseudogynecomastia (fatty, diffuse). Assess for malignancy signs (unilateral, hard, fixed, eccentric, skin/nipple changes, axillary nodes).
  • Imaging:
    • Mammography: Primary for suspicious unilateral mass (esp. age >25). Bilateral views.
    • Ultrasound (USG): Differentiates solid vs. cystic. Initial for <25 yrs or palpable abnormality with negative/equivocal mammogram. Guides biopsy.
  • Biopsy: Core Needle Biopsy (CNB) is standard for suspicious solid lesions. FNAC for cysts.

⭐ Unilateral breast mass in a male is suspicious for cancer until proven otherwise and warrants imaging.

High‑Yield Points - ⚡ Biggest Takeaways

• Gynecomastia, most common, often physiological (neonates, puberty, elderly) or due to drugs like spironolactone.
• Key causes of pathological gynecomastia: liver cirrhosis, Klinefelter syndrome, testicular tumors.
• Male breast cancer is rare (<1%), predominantly Infiltrating Ductal Carcinoma (IDC), often late presentation.
• BRCA2 mutations significantly ↑ risk for male breast cancer.
• Standard treatment for male breast cancer: mastectomy; tamoxifen if ER-positive.
• Pseudogynecomastia is fat deposition, not glandular tissue.