What is gynecomastia in the chest wall?

Gynecomastia in the Chest Wall

Gynecomastia is defined as the benign proliferation or enlargement of glandular breast tissue in men, which occurs in the chest wall area. 1 This condition must be distinguished from pseudogynecomastia, which is merely fatty tissue deposition without actual glandular proliferation.

Diagnostic Features

• In true gynecomastia, a solid tissue mass is palpable below the nipple-areolar complex 2
• The condition can be unilateral or bilateral 2
• Prevalence of asymptomatic gynecomastia is up to 65% in the general male population 2

Types and Causes

Physiologic Gynecomastia

• Common in newborns, adolescents, and older men 3
• Self-limited in most cases
• Results from normal hormonal fluctuations during these life stages

Pathologic Gynecomastia

Caused by:

1. Hormonal Imbalance:

   • Estrogen excess and/or androgen deficiency 4
   • Pre-existing hormonal imbalances increase risk 1

2. Medications:

   • Spironolactone (strongest association, ~10% of male patients) 1
   • Beta blockers (metoprolol, carvedilol) 1
   • Hormone replacement therapies 1
   • Antipsychotics 1
   • 5-α reductase inhibitors 1

3. Medical Conditions:

   • Liver disease
   • Renal insufficiency
   • Hyperthyroidism
   • Hypogonadism
   • Cirrhosis 3

4. Risk Factors:

   • Advanced age
   • Obesity
   • Concurrent use of multiple medications that can cause gynecomastia 1

Diagnostic Approach

• Most cases can be diagnosed based on clinical findings without imaging 1
• For males ≥25 years with breast pain, diagnostic mammography or digital breast tomosynthesis (DBT) is recommended as the initial imaging study 1
• Malignancy must always be ruled out, though breast cancer in men is much less common than benign gynecomastia 5

Management Options

1. Addressing Underlying Causes:

   • Discontinue contributing medications when possible 3
   • Treat underlying diseases 3
   • Consider medication adjustments (e.g., switching from spironolactone to eplerenone) 1

2. Pharmacological Treatment:

   • Tamoxifen may be considered at an early stage 2
   • For endogenous estrogen overproduction, antiestrogen therapy may help 5
   • For hypogonadism, androgen administration might be beneficial 5

3. Surgical Management:

   • For gynecomastia persisting over 12-24 months that doesn't respond to medication changes 1, 2
   • Options include liposuction, direct excision, or combined approaches 1

Important Considerations

• Regular physical examination is recommended to detect early breast tissue changes in high-risk patients 1
• Untreated hyperprolactinemia may lead to bone mineral density loss and increased risk of breast cancer 1
• Early treatment should be pursued to minimize emotional distress and physical discomfort 3

Gynecomastia is typically benign but may occasionally signal serious underlying conditions, making proper evaluation essential for appropriate management.