1. Case 4 Jane McNicholas Consultant Oncoplastic Breast Surgeon
East Lancashire Hospitals

2. 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?

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

4. 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?

5. 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?

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

7. 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

8. 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

9. 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