2. 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

3. 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

4. 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

5. Gynaecomastia: The BasicsGynaecomastia: The Basics

6.  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))

7. Gynaecomastia: The BasicsGynaecomastia: The Basics

8.  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

10. Laboratory EvaluationLaboratory Evaluation  Serum creatinine  Liver enzymes  TSH (free T4/T3)  Testosterone, LH, FSH, oestradiol, prolactin  hCG  Serum hehydroepiandosterone sulfate/urinary 17-ketosteroids

11. Operative IndicationsOperative Indications  Failure to regress (timing variable)  Pain  Emotional distress  Suspicious lesions (diagnostic)

12. Simon’s Grading ScaleSimon’s Grading Scale

13. Surgical OptionsSurgical Options  Standard of care: Subcutaneous mastectomy

14. Surgical OptionsSurgical Options  Liposuction (laser or ultrasound-assisted)

15. Surgical OptionsSurgical Options  Axillary approach with lighted retractor

16. Surgical OptionsSurgical Options

17.  Endoscopic mastectomy

18. Surgical OptionsSurgical Options  Mammotome

19. Surgical OptionsSurgical Options  Reduction Mammoplasty

20. Surgical OptionsSurgical Options  Reduction Mammoplasty

21. 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)

22. Recurrence  No data

23. Paediatric Male Breast Cancer  5 case reports of incidental DCIS in adolescent patients

24. 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.

25. Thank you!Thank you!