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Patient APatient A 14M (BMI 24.7, Tanner stage II-III) with 2 years of L breast enlargement and tenderness, stable for the past several months Labs obtained by primary care: BUN 17, Cr 0.6 ALT 34 Total testosterone 25 ( Ref: 8-800 for Tanner II-III ) Free testosterone 0.4 ( No reference range for <16y/o ) Oestradiol 15 ( Ref: 3-14 for Tanner II-III ) CBC (WBC 7.3, Hb 39.8, Plt 266 ) To OR for subcutaneous mastectomy
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Patient BPatient B 16M (BMI 20.9, Tanner stage not documented) with tender L breast enlargement x2 years Labs obtained: CBC (WBC 8.6, Hct 40.6, Plt 197 ) TSH 1.95 ( Ref: 0.5 – 4.5 ) T4 5.1 ( Ref: 4.5 – 10.0 ) Testosterone 296 ( Ref: 190-680 ) Oestradiol 16 ( Ref: 5-37 for Tanner IV ) hCG <1 LH 1.5 ( Ref: 3-10 ) To OR for subcutaneous mastectomy; swelling and tenderness recurred; back to OR for repeat mastectomy, no evidence of re-recurrence at 1 month postop
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Gynaecomastia: The BasicsGynaecomastia: The Basics Physiologic : 3 peaks Neonatal 65-90% of neonates have breast tissue (transfer of maternal and placental oestrogen/progesterone), may persist for several months Puberty Up to 60% of boys at age 14 affected, usually resolved within 1-2 years Oestrogen concentrations increase 3x and peak earlier than testosterone concentrations (increase up to 30x) Relative delay in full testosterone production vs temporary increase in aromatase activity vs variable oestrogen sensitivity all implicated Senescence Free testosterone levels decline, obesity becomes more prevalent
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Gynaecomastia: The BasicsGynaecomastia: The Basics
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Nonphysiologic Pathologic Androgen insensitivity syndromes Congenital syndromes (Klinefelter) Genetic mutation in aromatase gene Neurologic disease (spinal cord injury) Primary or secondary gonadal failure Starvation/refeeding Systemic illness (hepatic, renal failure) Thyroid disease True hermaphroditism Tumors (adrenal, colon, lung, liver, pituitary, prostate, testicular (Leydig, Sertoli, germ cell))
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Gynaecomastia: The BasicsGynaecomastia: The Basics
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Nonphysiologic Pharmacologic ACE inhibitors Amiodarone Anabolic steroids or testosterone replacement Androgen receptor blockers Calcium channel blockers Cytotoxic chaemotherapeutics Gonadotropin-releasing hormone agents Oestrogen-containing creams or costmetics H2 antagonists, PPIs Isoniazid Ketoconazole Marijuana, heroin Metronidazole Phytoestrogens (soy products, beer) Spironolactone Theophylline Tricyclic antidepressants
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Laboratory EvaluationLaboratory Evaluation Serum creatinine Liver enzymes TSH (free T4/T3) Testosterone, LH, FSH, oestradiol, prolactin hCG Serum hehydroepiandosterone sulfate/urinary 17-ketosteroids
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Operative IndicationsOperative Indications Failure to regress (timing variable) Pain Emotional distress Suspicious lesions (diagnostic)
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Simon’s Grading ScaleSimon’s Grading Scale
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Surgical OptionsSurgical Options Standard of care: Subcutaneous mastectomy
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Surgical OptionsSurgical Options Liposuction (laser or ultrasound-assisted)
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Surgical OptionsSurgical Options Axillary approach with lighted retractor
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Surgical OptionsSurgical Options
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Endoscopic mastectomy
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Surgical OptionsSurgical Options Mammotome
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Surgical OptionsSurgical Options Reduction Mammoplasty
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Surgical OptionsSurgical Options Reduction Mammoplasty
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Complications Seroma and haematoma formation NAC or flap necrosis Epidermolysis Nipple hyperaesthesia or numbness No data for risk factors in adolescent patients Adults: BMI >25, resected tissue weight >40g associated with increased risk for postoperative complications ( P < 0.05)
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Recurrence No data
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Paediatric Male Breast Cancer 5 case reports of incidental DCIS in adolescent patients
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References Muramori K, Taguchi S, Taguchi T, et al. High Aromatase Activity and Overexpression of Epidermal Growth Factor Receptor in Fibrolamellar Hepatocellular Carcinoma in a Child. J Pediatr Hematol Oncol 2011;33:e195-e197. Wit JM, Hero M, Nunez SB. Aromatase Inhibitors in Pediatrics. Nat Rev Endocrinol 2012;8:135-147. Simon BE, Hoffman S, Kahn S. Classification and Surgical Correction of Gynecomastia. Plastic & Reconstr Surg 1973;51:48-52. Devalia HL, Layer GT. Current Concepts in Gynecomastia. Surgeon 2009;7:114-119. Fan L, Yang X, Zhang Y, et al. Endoscopic Subcutaneous Matectomy for the Treatment of Gynecomastia: A Report of 65 Cases. Surg Laparosc Endosc Percutan Tech 2009;19:e85-e90. Niewoehner CB, Schorer AE. Gynaecomastia and Breast Cancer in Men. BMJ 2008;336:709-713. McCloskey JJ, Germain-Lee, EL, Perman JA, et al. Gynecomastia as a Presenting Sign of Fibrolamellar Carcinoma of the Liver. Pediatrics 1988;82:379-382. Singer-Granick CJ, Granick MS. Gynecomastia: What the Surgeon Needs to Know. ePlasty 2009;9:e6. Morcos RN, Kizy T. Gynecomastia: When is treatment indicated? J Fam Pract 2012;61:719-725. Lemoine C, Mayer SK, Beaunoyer M, et al. Incidental finding of synchronous bilateral ductal carcinoma in situ associated with gynecomastia in a 15-year-old obese boy: case report and review of the literature. J Pediatr Surg 2011;46:E17-E20. Colombo-Benkmann M, Buse B, Stern J, et al. Indications for and Results of Surgical Therapy for Male Gynecomastia. Amer J Surg 1999;178:60-63. Koshy JC, Goldberg JS, Wolfswinkel EM, et al. Breast Cancer Incidence in Adolescent Males Undergoing Subcutaneous Mastectomy for Gynecomastia: Is Pathologic Examination Justified? A Retrospective and Literature Review. Plast Recon Surg 2011;127:1-7. Yavus M, Kesiktas E, Kesiktas NN, et al. Lighted Retractor-Assisted Transaxillary Approach in Gynecomastia Correction. Ann Plast Surg 2006;57:370-373. Wollina U, Goldman A. Minimally Invasive Esthetic Procedures of the Male Breast. J Cosmetic Dermatol 2011;10:150-155. Charlot M, Beatrix O, Chateau F, et al. Pathologies of the Male Breast. Diagn and Interventional Imaging 2013;94:26-37. Laituri CA, Garey CL, Ostlie DJ, et al. Treatment of Adolescent Gyaecomastia. J Pediatr Surg 2010;45:650-654.
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