What are the treatment options for male breast conditions like gynecomastia or breast cancer?

Treatment Options for Male Breast Conditions

For male breast conditions, treatment should be tailored based on the specific diagnosis, with gynecomastia requiring different management than breast cancer, which requires aggressive multimodal therapy similar to female breast cancer treatment. 1

Gynecomastia Management

Diagnostic Approach

• Most men with gynecomastia can be diagnosed based on clinical findings without imaging 1, 2
• Gynecomastia presents as a soft, rubbery, or firm mobile mass directly under the nipple and is often painful, especially when present for less than 6 months 1, 2
• Gynecomastia is bilateral in approximately 50% of patients 1, 2
• Differentiate true gynecomastia from pseudogynecomastia (fatty tissue deposition rather than glandular tissue enlargement) 1, 2

Imaging Recommendations

• For men with clear clinical findings of gynecomastia, no imaging is routinely indicated 1
• If clinical differentiation between benign disease and breast cancer is uncertain, imaging is indicated 1
• For indeterminate breast masses:
  • Men younger than 25: Ultrasound is the initial recommended imaging study 1
  • Men 25 and older: Mammography or digital breast tomosynthesis is recommended 1

Treatment Options for Gynecomastia

1. Watchful Waiting

   • Recommended after treating underlying pathology or discontinuing substances associated with gynecomastia 3
   • Pubertal gynecomastia resolves spontaneously in >90% of cases within 24 months 3

2. Medical Treatment

   • Testosterone treatment should only be offered to men with proven testosterone deficiency 3
   • Selective estrogen receptor modulators (SERMs), aromatase inhibitors, and non-aromatizable androgens are not generally recommended 3, 4

3. Surgical Treatment

   • Recommended for patients with long-lasting gynecomastia that doesn't regress spontaneously or following medical therapy 3, 5
   • Surgical options include:
     • Mastectomy with excision of the gland 5
     • Liposuction (especially effective in early stages) 5
     • Combination of both techniques 5
   • Surgery has shown good aesthetic results with minimal complications 5

Male Breast Cancer Management

Diagnostic Approach

• Male breast cancer is rare (accounting for <1% of all breast cancers) but should be ruled out, especially in older men (median age 63 years) 1
• Suspicious findings include: palpable lump, skin or nipple retraction, nipple discharge 1

Treatment Recommendations

1. Primary Surgery

   • The approach to primary surgery should be the same as for women with breast cancer 1

2. Adjuvant Therapy

   • Adjuvant chemotherapy and radiation therapy approaches should follow the same principles as for women 1
   • Tamoxifen is effective for the treatment of male breast cancer 6
   • For hormone receptor-positive breast cancer, endocrine therapy is recommended 1

3. Advanced/Metastatic Disease

   • Endocrine therapy should be offered as first-line therapy for hormone receptor-positive, HER2-negative breast cancer, except in cases of visceral crisis or rapidly progressive disease 1
   • Targeted therapy guided by HER2, programmed death ligand 1, PIK3CA, and germline BRCA mutation status may be used with the same indications as for women 1

4. Genetic Considerations

   • All men with breast cancer should be offered genetic counseling and testing for germline mutations 1
   • BRCA2 mutations are particularly common in male breast cancer patients 1

Surveillance Recommendations

• Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy 1
• Contralateral annual mammogram may be offered to men with a history of breast cancer and a genetic predisposing mutation 1
• Breast MRI is not recommended routinely in men with a history of breast cancer 1

Common Pitfalls to Avoid

• Unnecessary imaging in clear cases of gynecomastia can lead to additional unnecessary benign biopsies 2
• Assuming gynecomastia is a premalignant condition (it is not) 3
• Failing to consider underlying pathologies in adult gynecomastia, which may be present in 45-50% of cases 3
• Overlooking the possibility of breast cancer in older men with breast symptoms 1