What is the approach for outpatient management of a male breast lump?

From the Guidelines

The approach for outpatient management of a male breast lump begins with a thorough clinical assessment including history and physical examination, and diagnostic imaging typically starts with ultrasound in men younger than age 25, and mammography or digital breast tomosynthesis in men age 25 and older, as recommended by the American College of Radiology 1. The patient should be asked about duration of the lump, associated pain, nipple discharge, skin changes, family history of breast cancer, medication use (particularly hormonal medications), and any systemic symptoms. Physical examination should document the size, location, consistency, mobility, and tenderness of the lump, as well as any skin changes or lymphadenopathy. Most male breast lumps are benign gynecomastia, but malignancy must be excluded. Some key points to consider in the management of male breast cancer include:

• The use of tamoxifen for an initial duration of five years in men with hormone receptor–positive breast cancer who are candidates for adjuvant endocrine therapy, as recommended by the American Society of Clinical Oncology 1
• The consideration of genetic counseling and germline genetic testing of cancer predisposition genes in all men with breast cancer 1
• The importance of follow-up and surveillance, including ipsilateral annual mammogram in men with a history of breast cancer treated with lumpectomy, regardless of genetic predisposition 1 For suspicious findings, a core needle biopsy should be performed, and any confirmed malignancy requires prompt referral to a breast specialist. If gynecomastia is diagnosed, management includes addressing underlying causes such as discontinuing contributing medications (spironolactone, finasteride, anabolic steroids), treating hormonal imbalances, and weight loss if appropriate. For persistent, painful, or cosmetically concerning gynecomastia, referral to surgery may be considered. Follow-up should be arranged based on the specific diagnosis and management plan, with clear instructions to the patient about warning signs that should prompt earlier reassessment.

From the Research

Outpatient Management of Male Breast Lump

The approach for outpatient management of a male breast lump involves a combination of clinical evaluation, imaging, and laboratory tests to determine the underlying cause of the lump.

• The initial step is to rule out pseudogynecomastia by careful history taking and physical examination 2.
• Gynecomastia is the most common cause of male breast enlargement, and it is usually caused by increased estrogen activity, decreased testosterone activity, or the use of numerous medications 2.
• Imaging studies such as mammography and ultrasound are useful in evaluating male breast lumps, with mammography showing a typical appearance of gynecomastia in most cases 3, 4.
• Fine-needle aspiration cytology (FNAC) may not be necessary in cases where mammography shows classical gynecomastia, as it does not change the diagnosis and contributes to unnecessary costs 3.
• In some cases, treatment with antiestrogenic medications such as tamoxifen may be effective in reducing the size of gynecomastia and alleviating symptoms 5.

Diagnostic Approach

• A male patient with a palpable unilateral breast mass consistent with gynecomastia on the basis of historical, physical, and mammographic findings does not require surgical biopsy unless other clinical indications prevail 6.
• The diagnostic approach should involve a stepwise evaluation, including imaging and laboratory testing to exclude neoplasms and endocrinopathies, and to facilitate cost-effective diagnosis 2.
• Men with unilateral breast masses have a low incidence of breast cancer, and a lack of symptoms (pain) related to the mass is probably not helpful in deciphering gynecomastia from breast cancer 6.

Treatment Options

• Treatment of gynecomastia may involve antiestrogenic medications such as tamoxifen, which has been shown to be effective in reducing the size of gynecomastia and alleviating symptoms in some cases 5.
• In cases where gynecomastia is caused by an underlying medical condition or medication use, treatment of the underlying condition or discontinuation of the offending medication may be necessary 2.
• Surgical treatment may be considered in cases where gynecomastia is severe or persistent, or where breast cancer is suspected or confirmed 6, 3.