Gynecomastia: Differential diagnosis for male breast cancer
Breast cancer in males is uncommon, accounting for less than 0.8% of all breast cancers. However, there is some evidence to suggest that incidence rates are on the rise. Of course men do not develop milk-producing breasts, but they still have a small amount of breast tissue.
Thus, anyone who has breast tissue is at a small risk for breast cancer development. Men who ultimately have a breast cancer diagnosis tend to have tumors of a more advanced stage than women. A possible reason is that men may ignore the symptoms of breast cancer, or assume that the condition is benign like gynecomastia.
What is gynecomastia?
Essentially, gynecomastia is abnormally large breast development in males. (Recently this condition is known as ‘man boobs’. More specifically medics may define gynecomastia as an abnormal increase in the ductal and stromal elements of the male breast.
Men with gynecomastia may have a disc or button-like growth under the nipple and areola that is palpable and is sometimes also visible. The development of gynecomastia will be unique for each patient, depending on the patterns and sizes of the glandular tissues involved. Furthermore, the extent to which these tissues are intermixed with fibrous and adipose tissue also plays a role.
Well this page is getting a little old. We have recently created a new page with more up-to-date information on Gynecomastia.
Puffy nipples is a common symptom
Gynecomastia can be bilateral or unilateral and symmetrical or asymmetrical. But the most common and recognizable feature of early gynecomastia is a ‘concentric’ distribution of new fibroglandular growth located directly under the nipple.
A wide range of physically apparent ‘aesthetic’ abnormalities may arise. “Puffy nipples” is probably the most common manifestation of gynecomastia. Puffy nipples result from the accumulation of glandular tissue under and confined to the areola. Sometimes the abnormal growth extends just outside the areola, giving a characteristic ‘dome-shaped’ appearance.
Pure glandular gynecomastia is common in bodybuilders
The ‘pure glandular’ form of gynecomastia is common with lean men and bodybuilders Furthermore, it is sometimes brought on by the use of anabolic steroids.
Since the level of body fat (adipose tissue) is so low, the abnormal growth is purely of glandular tissues and not mixed with fat tissues. With ‘pure glandular’ gynecomastia, the only possible treatment is surgical excision of the abnormal breast tissue, which leaves the undesirable cosmetic result of a ‘flat nipple-areola complex’.
Phases of gynecomastia
Normally, the male breast has only major mammory ducts which almost never branch. True ‘acinar lobules‘ (berry-like glands) are usually absent.
But in early gynecomastia, sometimes called the ‘florid‘ phase, the breast ducts experience proliferative growth, which also causes a richly vascular (blood delivery) network of connective tissues to develop around them. As the condition progresses, the breast ducts involved dilate and lengthen, and increase in the number of branches. Epithelial hyperplasia is also typical at this stage.
Late ‘fibrous’ phase gynecomatia
In the late phase, sometimes called the ‘fibrous‘ phase, the breast duct structures become less defined as fibrosis and hyalinization gradually begin to take over. (‘Hyalinization‘ means that cell tissues gradually become glassy and ‘transparent’)
Collagen surrounds the breast ducts and becomes more and more densely packed, which essentially destroys the ducts.
In the image above one notes dilated breast ducts and ‘loose’ collagen along the right edge. Gradually the collagen becomes more densely packed around the breast ducts, damaging them. But in early stages it is termed ‘florid‘ gynecomastia.
In advance stages, such as in the image below, collagen becomes densely packed around the breast ducts, constricting them and eventually blocking them entirely. This is termed late-phase or ‘fibrous‘ gynecomastia.
There is another manifestation of gynecomastia in a ‘diffuse glandular‘ pattern, which is most commonly linked to patients who receive androgen therapy.
Certain age groups are more susceptible to gynecomastia
Suprisingly, gynecomastia actually affects about one third of males at some point in their lives. Sometimes a small percentage of males develop gynecomastia when they reach puberty. However, this is most often temporary and resolves on its own as the rest of the body ‘catches up’. But generally speaking, gynecomastia occurs most commonly with men in their mid sixties.
What are the Causes of Gynecomastia?
In cases of benign gynecomastia, researchers believe that a hormonal imbalance of some kind may be the cause of the condition. However, the condition may also arise as a result of breast tumor development, and this is why a full examination by your doctors is necessary. This usually involves an ultrasound and possibly a biopsy.
Decreasing testosterone in elderly men may be a contributing factor
In elderly men, one of the main causes of gynecomastia is thought to be decreasing testosterone production. Medications a patient may have been taking over the years can also play a role.
Hormonal medications including:-
- anabolic steroids
can certainly help bring it on, but non-hormonal medications can also be a contributing factor. Of course, some of these ideas remain more in the category of ‘urban myths’. However, some studies suggest that the consumption of alcohol, marijuana use, and amphetamines may be the causes of gynecomastia.
Other drugs like
- tricyclic antidepressents
- thiazide diuretics
taken over many years, may contribute to the condition.
Causes of Gynecomastia: Endocrine-gland tumors
While uncommon, other causes of gynecomastia may also be tumors or diseases of certain endocrine (hormone-producing) glands or the liver, which increases estrogen production in men. (Estrogen is primarily a female hormone).
Treatments for gynecomastia will vary, but hormonal medications aimed at restoring hormonal balance are usually given. Depending on the amount of fat tissue involved, the condition might be treated (reduced) with liposuction, or surgically removal.
Differential diagnosis of gynecomastia versus breast cancer
Typical physical symptoms of male breast cancer may include:-
- nipple retraction
- nipple discharge
- redness and scaling of the breast skin or nipple
- a painful lump under the nipple
- skin dimpling or puckering
- breast swelling
For this reason, whenever there is gynecomastica the patient should have an mammogram and ultrasound to determine whether it looks like normal tissue or breast cancer. If those findings are uncertain or not in typical gynecomastia patterns, an excisional biopsy should be undertaken.
Male breast cancer tumors might include a hard, immobile mass
When the breast enlargement is the result of a breast cancer tumor, clinical signs might include a hard or immobile mass under the skin.
On a mammogram one might find a thickening of overlying skin layers, or an eccentric mass relative to the nipple, and possibly clustered microcalcifications.
Mammograms of males with gynecomastia might occasionally reveal a lipoma, with a thin capsule surrounding radiolucent lipomatous tissue. On ultrasound, this would appear as a solid, well-circumscribed and echogenic tumor.
Sometimes, inflamed fat lobules can make fat feel swollen, round, tender, and look like an isoechoic nodule on ultrasound. These tend to settle down and go away in about 3 to 6 months.
Treatment of male breast cancers is basically the same as for women
Treatment of male breast cancer will tend to follow the same recommendations as for the treatment of female breast cancers. For our full up-to-date post on male breast cancer survival rates please click here.
However, male breast cancer patients do appear to be more likley to have estrogen receptor-positive tumors, which is a good prognostic indicator for the successful treatment with chemical therapy.
Ongoing Genetic research on male breast cancer and gynecomastia
As breast cancer is essentially a genetic disease, research into the relationships and interactions caused by various gene expressions holds perhaps the most promise for ultimately curing and preventing breast cancer.
In the case of male breast cancer, one branch of current genetic research focuses on ‘micro-RNA‘s, (miRNA or micro Ribonucleic acid) which is a molecule in the category of ‘post-transcriptional regulator‘.
Genetic research into the ‘benignity’ of gynecomastia
By using gynecomastia as a potentially ‘benign counterpart‘ for abnormalities in male breast glands, studying the difference between miRNA gene expression profiles in men with breast cancer as opposed to men with gynecomastia might provide some insight into the potential genetic causes. Ultimately, it is hoped that such investigations may lead to genetically oriented treatments for male breast cancer.
Here are a few Q&A’s …
Gynecomastia – what causes it?
Some causes of gynecomastia include
- chronic liver disease
- exposure to anabolic steriod hormones
- exposure to estrogen hormones
- kidney failure and dialysis
- lack of testosterone
- marijuana use
- hormone treatment for prostate cancer
- radiation treatment of the testicles
When will my gynecomastia go away?
It usually goes away over a period of months.
When does gynecomastia occur?
If you have recent:-
- breast swelling
- enlargement in one of both breasts
- dark or bloody discharge from the nipples
- skin sores or ulcers over the breast
- lump under the nipple that feels hard or firm.
Call your health care provider if you experience any of these as soon as possible.
How gynecomastia can be reduced?
Stop taking all recreational drugs, such as marijuana, and stop taking all nutritional supplements or any other bodybuilding drugs. Apply cold compresses and use pain relievers as your health care provider recommends if swollen breasts are also tender.
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