What is the best approach to manage breast tenderness in an elderly male?

Management of Breast Tenderness in Elderly Men

The best approach to manage breast tenderness in an elderly male is to first determine if clinical findings are consistent with gynecomastia or if there are suspicious features, then proceed with appropriate imaging based on these findings, with mammography or digital breast tomosynthesis (DBT) being the recommended initial imaging for men age 25 and older with indeterminate findings. 1

Initial Assessment and Differential Diagnosis

Clinical Evaluation

• Determine if findings are consistent with gynecomastia:
  • Soft, rubbery, or firm mobile mass directly under the nipple
  • Pain or tenderness (more common in gynecomastia than cancer)
  • Bilateral involvement (occurs in approximately 50% of gynecomastia cases)

Common Causes in Elderly Men

• Gynecomastia (most common cause of male breast tenderness)
• Pseudogynecomastia (fatty tissue deposition without glandular proliferation)
• Medication side effects (common culprits include spironolactone and other medications)
• Hormonal changes associated with aging
• Chronic liver disease
• Breast cancer (rare but must be excluded, especially in men >60 years)

Imaging Recommendations

For Clinical Findings Consistent with Gynecomastia

• No imaging is routinely recommended if physical examination clearly indicates gynecomastia 1

For Indeterminate Physical Findings

• Mammography or digital breast tomosynthesis (DBT) is recommended as the initial imaging modality for men age 25 and older 1

  • Mammography has high sensitivity (92-100%), specificity (90-96%), and negative predictive values (99-100%) 1
  • Bilateral examination is routinely performed to assess for symmetry and detect asymptomatic contralateral abnormalities

• If mammogram is indeterminate or suspicious:

  • Ultrasound should be performed to assist in lesion characterization and potentially guide biopsy 1

Management Based on Findings

For Confirmed Gynecomastia

1. Address underlying causes:

   • Review and potentially discontinue medications that could cause breast enlargement (e.g., spironolactone) 2
   • Evaluate and treat any underlying conditions (e.g., hyperthyroidism, liver disease) 2

2. Symptomatic management:

   • Reassurance (important as most cases are benign)
   • Over-the-counter pain medications (NSAIDs)
   • Local application of heat or cold 3
   • Supportive garments if needed

3. For persistent cases:

   • Consider antiestrogen therapy in men with endogenous overproduction of estrogens 2
   • For hypogonadism, administration of androgens might be helpful 2
   • Surgical removal may be necessary when gynecomastia does not resolve with medical therapy 2

For Suspicious Findings

• Proceed with tissue biopsy if imaging suggests malignancy
• Note that breast cancer in males typically presents at a later age (median age 63 years) and often at an advanced stage 1

Important Clinical Considerations

Red Flags Suggesting Possible Malignancy

• Painless mass (patients with carcinoma typically present with painless lumps) 4
• Longer duration of symptoms before presentation (median 33 months for carcinoma vs. 3.4 months for gynecomastia) 4
• Personal history of cancer or family history of breast cancer 4
• Skin or nipple retraction, nipple discharge 1

Common Pitfalls to Avoid

• Assuming all breast tenderness requires imaging - for clear clinical gynecomastia, imaging may not be necessary 1
• Ignoring medication history - many medications can cause gynecomastia, but this should not prevent appropriate evaluation of suspicious masses 4
• Failing to consider extramammary causes of chest pain such as costochondritis or musculoskeletal conditions 3

By following this algorithmic approach, clinicians can effectively evaluate and manage breast tenderness in elderly men while appropriately identifying cases that require further investigation for potential malignancy.