Case 4 Jane McNicholas Consultant Oncoplastic Breast Surgeon East Lancashire Hospitals

Case 4 27 year old man presents with a tender lump in his right breast for the last 3 months What features of his history and examination are most relevant?

Case 4 History of the lump Testicular lumps Liver disease Alcohol intake Drugs, prescribed and illicit

Case 4 On examination he has a 2 cm firm swelling behind the right nipple No evidence of liver disease, testicular swellings What investigations are appropriate?

Case 4 Mammogram - some units will do a mammogram in a male with a breast lump Ultrasound scan - showed typical features of gynaecomastia - U2 FNA - C2 What other tests are appropriate?

Case 4 Blood tests - LFT’s, U&E’s, Prolactin, αFP, β-HCG, testosterone

Gynaecomastia Due to a net excess of oestrogens (either actual increase in oestrogens or reduction in androgens) There are three physiological types of gynaecomastia - neonatal, pubertal and senescent The most common cause in older men is drug related A small number will be due to testicular disease, Klinefelter’s Syndrome, Adrenal disease, etc The majority of the rest are Idiopathic

Drugs That Cause Gynaecomastia PPI’s Digoxin Spironolactone ACE Inhibitors Calcium Channel Blockers Metronidazole Tricyclic anti-depressants Diazepam Metoclopramide Phenytoin Alcohol Cannabis Heroin Steroids Anti-androgens (Zoladex) Oestrogens

Case 4 Management depends on aetiology The natural history is that it often resolves over a period of a few months As far as is possible, it is conservative If it is drug related, withdrawal of the drug may cause resolution Medical management includes Danazol (only licensed medication) and Tamoxifen Surgery to excise gynaecomastia is sometimes useful but cosmesis can be difficult