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Gynaecomastia and tuberous breast

Gynaecomastia: Gynaecomastia is commonly described as benign ( Noncancer) proliferation of male breast tissue or persistant enlargement of male breast tissue.

Incidence

32 to 36% of males suffer from gynaecomastia, and as high as 65% in adolescent boys.

Bilateral disease is reported to occur in 25-75% of cases

Causes of Gynaecomastia

1.Idiopatic- exact cause is not known.

Oestrogen,androgens ad their receptors are thought to play a major role in the development of the condition

An imbalance in the concentrations of the hormone’s, with a relative increase in ostrogen, is thought to bring about breast tissue proliferation.

2. Physiological

1. Neonatal-no treatment required(Maternal Oestrogens through placenta)
2. Puberertal: transient development of breast tissue is common in adolescent boy.

A relative increase in plasma estradiol compared to testosterone is thought to cause pubertal gynecomastia.

1. Elderly : This is after age of 65 years. It is due to decrease testosterone level

In addition ,weight gain increases conversion of testosterone to ostrogen.

Pathological Gynaecomastia

Due to various metabolic and endocrine disorders

Aquired and congenital hypogonadal states leading to an increased overall estrogen state.

Pharmological Gynaecomastia

Drugs are major etiological factor

It occurs due to direct increase in ostrogen and decreased testosterone

Classification

Webster classification

1. Glandular
2. Fatty-glandular
3. Fatty

Bannayan and Hajdu

1. Florid-increased number of ducts
2. Intermediate-overlap of florid and fibrous types
3. Fibrous type- extensive stromal fibrosis with minimal ducts.

Simon(1973)

1. Grade 1:  small enlargement, no skin excess.
2. Grade2 a: Moderate enlargement with no skin excess.
3. Grade2 b:Moderate enlargement with skin excess.
4. Grade3: Marked  enlargement with  skin excess.

Rhorich (2003)

1. Grade I:Minimal hypertrophy(<250 grams of breast) without ptosis.
2. Grade II:Moderated hypertrophy(250 -500 grams of breast) without ptosis.
3. Grade III: Severe hypertrophy(>500 grams of breast) with ptosis.
4. Grade IV:Sever  hypertrophy with  grade II or III ptosis.

Cordova and Moschella

1. Grade I: Increase in diameter and protrusion limited to the areolar
2. Grade II: Hypertrophy of all the components, NAC is above the IMF.
3. Grade III: Hypertrophy of all the components, NAC is at the same height as or 1 cm below the IMF.
4. Grade III: Hypertrophy of all the components, NAC is at the more than 1 cm below the IMF.

Assessment

History

Clinical Examination

Opinion of Endocrinologist

Evaluation of liver,renal and thyroid function

Tumourmarkersfot testicular such as bhCG,alphaferoprotein and basal prolactin level(Prolactinoma)

Radioloagy:

X-ray chest to rule out ca lung

Mammmography: To rule out ca breast

CT head to rule out pituitary tumours.

Management

Medical: Tab Tamoxifen(anti-oestrogen), TabClomiphen( act on hypothalamic pituitary axis to increase LH & FSH) and Tab Danazole( acts on by suppressing pituitary –ovarian axis by inhibiting the out put of both LH & FSH)  can be used for spontaneous regression.

Surgical

The aim of surgical treatmentare volume reduction with or without retailoring of redundant skin.