A 77-year-old man presented to a primary care clinic with a complaint of pain and tenderness in his left nipple for 6 to 8 months. He had noticed recently that the areola was swollen, and his wife told him that she felt a hard area on his breast.
History
The patient had no history of breast abnormalities. He denied past injury to the breast, recent illness, hormone replacement therapy, or supplement use. He denied family history of breast or ovarian cancer. He had not noticed any nipple discharge. Medical history included hypertension and hyperlipidemia. Surgical history was significant for repair of the right meniscus 3 months ago. Medications included quinapril 10 mg/d, hydrochlorothiazide 25 mg/d, and rosuvastatin 40 mg/d. His last visit to the clinic was approximately 1 year earlier.
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Physical Examination
The patient’s height was 5 ft 10 in and his weight was 223 lb, with a body mass index of 32 kg/m2. Vital signs included a heart rate of 80 beats per minute, blood pressure of 138/70 mm Hg, respirations at 16 breaths per minute, and a temperature of 98.4°F.
Upon examination, the left nipple was inverted, with redness noted at the 6 o’clock position. A firm, immobile, and painful 1×1-cm mass was palpated at the 5 o’clock position. Examination of the remainder of the left breast and the right breast was unremarkable. No axillary lymphadenopathy was noted. A left breast ultrasound was ordered and the patient was immediately sent to the radiology center.
Diagnostic Studies
Ultrasound of the left breast revealed a 1×0.8×1-cm retroareolar/areolar complex. The area was hypoechoic with posterior shadowing and had irregular margins and increased vascular flow. These findings were noted to be suspicious for an aggressive process, and a biopsy was recommended.
Diagnosis
On the basis of the findings on ultrasound, the patient underwent a core biopsy, which revealed chronic inflammation. The mass was excised 1 week later, at which point a diagnosis of nodular gynecomastia of the breast was made.
Discussion
This case demonstrates the lack of knowledge that men can have in regard to breast health. This patient had a known breast problem for up to 8 months before reporting to the clinic.
Gynecomastia is the proliferation of mammary glands secondary to an imbalance between androgen and estrogen, resulting in dense tissue.1,2 It is the most common male breast disease, occurring in up to 57% of men.1 It is often seen in newborns, teenagers, and men aged >50 years.3 Common causes include gonadal failure, testicular cancer, hyperthyroidism, renal disease, liver disease, certain tumors, and other diseases that result in androgen resistance.2 In some instances, gynecomastia can be idiopathic.2
A thorough history should be taken from the patient, including recent medications and supplements.1 Agents associated with gynecomastia include spironolactone, digoxin, cimetidine, marijuana, heroin, and amphetamines, as well as alcohol.2 In this case, the patient had no history of gynecomastia-inducing diseases or medications.
Gynecomastia occurs in 3 stages: nodular, dendritic, and diffuse.4 It often presents as a subareolar mass that is palpable, firm, and mobile.3 Although characteristics of the disease are often found in both breasts, it can occur unilaterally.3 In this case, the mass was immobile, fixed, and hard.
Diagnostic Imaging
The need for diagnostic imaging is determined based on physical examination findings. If a hard, immobile mass is noted, imaging is recommended to rule out malignancy.3 Imaging studies can be performed via mammogram or ultrasound, with ultrasound the preferred recommendation for gynecomastia.1,3 Similar to this case, ultrasound of nodular gynecomastia often reveals a hypoechoic subareolar mass that may exhibit increased vascular flow.4 If imaging studies are suspicious for malignancy, fine-needle aspiration or biopsy is required.1
Figure. Laboratory testing recommendations.3
Laboratory Testing
Multiple laboratory tests are recommended to determine the underlying cause of gynecomastia (Figure). Laboratory testing should be chosen according to the suspected underlying cause.3 Because of the suspicious presentation of the breast mass in this case, the patient was immediately sent for diagnostic imaging, and laboratory assessment was not conducted.
If the condition is causing pain and/or distress, pharmacologic, radiologic, and surgical options are available.2 It is important to remember that psychological distress is often reported and needs to be addressed in the management plan.3
