Transanal Endoscopic Microsurgery (TEM) by cz10mi1

VIEWS: 48 PAGES: 69

									Don’t forget the men !
  Gynaecomastia
    Professor Philip J Drew
                              Gynaecomastia

 “Man boobs” “Moobs”
           Increasing
                Actual

                Patient     Expectations
      Male         breast cancer
           1973  - 1998
           0.86 – 1.08 / 100,000 men


Giordano et al Cancer 2004
                         Gynaecomastia
Definition:
 Histologically:
       Benign proliferation of glandular tissue of the male breast
   Clinically:
       Rubbery firm mass extending concentrically from the nipple


   Pseudogynaecomastia:
       Fat deposition without glandular proliferation “lipomastia”
                            Gynaecomastia
   Pathophysiology: due to oestrogen / androgen imbalance
       Primary
       Secondary
   Decrease in androgen
       Actual / relative
            Increased binding to SHBG
            Receptor blockade
   Increase in oestrogen
       Direct / indirect (precursors)
                               Gynaecomastia
   Histology
       Early “florid” phase
       Oestrogen
            Ductal epithelial hyperplasia
            Ductal elongation and branching
            Proliferation periductal fibroblasts
       Later inactive senescent phase
            Dense fibrous tissue
            Breast enlargement may diminish
   Male / Female breast tissue
       Similar responsiveness
       No acinar development in men (progesterone)



                                     Wilson RL et al Adv Intern Med 1980
                        Gynaecomastia
   Aetiology
       Persistent pubertal gynaecomastia   25%
       Drugs                               10-25%
       Idiopathic                          25%
       Cirrhosis or malnutrition           8%
       Primary hypogonadism                8%
       Testicular tumours                  3%
       Secondary hypogonadism              2%
       Hyperthyroidism                     1.5%
               Primary Gynaecomastia
Prevalence: “Trimodal”

   Infants:      60% to 90%

   Pubertal:     30% to 60%

   Adults:       24% to 80%

                         Wise et al J Am Coll Surg 2005
                              Gynaecomastia
   Pubertal gynaecomastia
       Bilateral 50-60%
       Midpuberty
            Nydick et al
            1855 boy scouts
                  65% 14 yr olds
                  14% 16 yr olds
       Exact mechanism unknown
            Oestrogen increases before testosterone
       Most resolve spontaneously

                               Moore DC J Clin Endocrinol Metab 1984
                               Nydick et al J Am Med Soc 1961
                           Gynaecomastia
   Marked pubertal breast development
       10% endocrine abnormality
          Kleinfelter’s / XX maleness
          Primary testicular failure

          Androgen insensitivity

          Increase aromatase activity
                Autosomal dominant gene



                 Sher ES et al Clinical Paediatrics 1998
                          Gynaecomastia
   Age related “senescent” gynaecomastia
       Increases in normal men after 44yrs (57%)
            Histologically only 7% active phase
     Bilateral >90%
     Peak 50-69yrs (72%)

     Decreases 70-89 yrs (47%)



       >80% if BMI>25

                Nuttal FQ J Clin Endocrinol Metab 1979
                             Gynaecomastia
   Systemic Illness
       Liver disease
            Alcoholic cirrhosis
                 Direct effect on hypothalamic-pituitary-testicular system
                 SHBG increased – decreases free testosterone
       Thyrotoxicosis
          SHBG increased
          Increased peripheral aromatisation

          25-40% men with Grave’s disease
                        Gynaecomastia
   Chronic renal failure
       Dialysis patients: 50%
       Leydig cell dysfunction
   HIV
       Antiretroviral therapy
       Inhibition of cytochrome P450 enzyme
   Malnutrition
       “Refeeding” gynaecomastia
       Second puberty

                            Biglia A et al Clin Infect Diseases 2004
                            Holdsworth et al N Engl J Med 1977
                            Smith SR J Clin Endocrinol Metab 1975
                               Gynaecomastia
Testicular neoplasms
       Germ cell tumours
            2.5-6% gynaecomastia at presentation
            hCG
            Leydig cell dysfunction
                  Inhibition of 17 alpha hydoxylase / 17,20 lyase enzymes
                  Increased CYP450 aromatase activity
                  Poor prognostic sign
            Same mechanism for other hCG producing tumours
       Leydig cell tumour
            2% testicular neoplasms
            Testosterone and oestrodiol
            6-10 yr olds
                  Precocious puberty
            26-35 yr olds
                  Testicular mass, impotence
            20-30% have gynaecomastia at presentation
                                   Gynaecomastia
   Other tumours
        Prolactinoma
              8%
              Hypogonadotrophic hypogonadism
        Large cell calcifying Sertoli cell (sex-cord) tumours
              Increased aromatase activity
              Sporadic
              Autosomal dominant
                    Peutz-Jehger’s syndrome
                    Carney complex
        Feminising adrenocortical tumours
              98% gynaecomastia
              58% palpable adrenal tumour
              50% testicular atrophy
        Pituitary / Hypothalamic tumours




         Braunstein GD Endocr Related Cancer 1999
                               Gynaecomastia
   True hermaphroditism
       Testicular and ovarian tissue
            Excessive oestrogen production
                  Direct affect
                  Suppression of intratesticular cytochrome P450
   Androgen insensitivity syndromes
       Defect or absence intracellular androgen receptor
       Spectrum
            Complete absence “testicular feminisation”
                  Phenotypic females
            Complete / partial insensitivity
                  Phenotypic males



                                      Quigley CA et al Endocr Rev 1995
                                 Gynaecomastia
   Primary hypogonadism
       Congenital
            Klinefelter’s syndrome
                  Lobular strutures
                  16 fold increase in breast cancer
            Acquired
                  Trauma
                  Infection
                  Infiltration
                  Vascular insufficiency
                  Age
            Decrease in testosterone
                  Increase in LH release
                  Increase in aromatisation of testosterone to estradiol
                      Gynaecomastia
   Secondary hypogonadism
       Prostate cancer treatment
         Combined androgen blockade        50%
         LH-RH analogue alone              25%
         Orchidectomy alone                10%
         Combined drug + orchidectomy      1-24%




              Dicker AP Lancet Oncol 2003
                              Gynaecomastia
   BPH
       Finesteride
          Type II 5 alpha – reductase inhibitor
          Blocks testosterone to DHT conversion

          Increase tesosterone – precursor to oestrodiol

          Oestrodiol increase leads to gynaecomastia

       But...increased risk of male (and female) breast cancer
        cannot be excluded
            Total data (MHRA Dec 2009):
                 90,000 pt/yr exposure, rate7.82 per 100,000 PYR
                 80,000 placebo / yr exposure, rate 3.84 per 100,000 PYR
                 P=0.328
                           Gynaecomastia
Anabolic steroids
      52% gynaecomastia
      57% testicular atrophy

      Self medicate with Tam or AI
       for gynaecomastia
      hCG for testicular atrophy
      Clomiphene / Nolvadex
      “PCT”
           Post cycle therapy
                            Gynaecomastia
   Other causes
       Diabetic mastopathy
            Not related to type of insulin
            Mimics gynaecomastia clinically
            Different histologically


       Occupational
            Morticians
       Very unusual causes
            Drinking female urine



              Vierhapper H Lancet 1999
                            Gynaecomastia
   Drug therapy
     Large number implicated
     Obvious association with hormonal agents
     Difficult to confirm for other agents
            Thompson & Carter
                 Probable
                     Ca channel blockers, chemotherapy, H2 blockers, ketoconazole,
                      spirinolactone
                 Inconclusive
                     Digitalis, neuroleptic agents and marijuana




        Thompson DF & Carter JR Pharmacotherapy 1993
                      Gynaecomastia
   Assessment:

   Clinical
   Imaging - ? mammogram / ultrasound
   Tissue ? Core biopsy
          Not FNAC – C3 result
                         Gynaecomastia

   Clinical assessment
       History
          Age of onset

          Duration

          Family history

                Aromatase excesss syndrome

                    Auto dominant

                    Chromosome 15

          Underlying disorders

                Hyperthyroidism

                Hepatic / Renal disease

          Loss of libido / impotence

          Drug history
                             Gynaecomastia
   Examination
        Swelling of the breast
        Tender
        Concentric
        Mobile
   Sinister findings
        Eccentric, unilateral, nipple retraction, skin dimpling, lymphadenopathy, nipple
         discharge
   Pseudogynaecomastia
        No resistance to apposition of fingers
   Abdominal / chest / ? testes examination
                    GYNAECOMASTIA –
                     CLASSIFICATION

   Simons et al ( 1973 )

I. Minor breast enlargement
   without skin redundancy
                          Gynaecomastia
   Investigation
       Teenager with otherwise normal examination
            Re-examine to establish whether persistent


       Adult or persistent/marked pubertal gynaecomastia
          BCP, Prolactin, LH, Oestrogen, Testosterone, hCG
          Consider genetic causes
                         Gynaecomastia

                                     hCG, LH,
                               Testosterone, Estrogen

                          Increased LH
                                                        Increased LH and
         Increased hCG     Decreased                                          Normal
                                                           Testosterone
                          Testosterone


Testicular                   Primary                                         Idiopathic
                                              Check TSH
ultrasound                hypogonadism                                     gynaecomastia


           Normal-                                        Normal –
            CXR /                                         Androgen
         abdominal CT                                     resistance
                        Gynaecomastia
   Imaging / biopsy
       Mammography
           Negative predictive value for malignancy: 99%


     Ultrasound +/- core biopsy
     Imaging for clinical gynaecomastia no longer supported by
      RCR



                          Evans et al Am J Surg 2001
                       Gynaecomastia
Primary gonadal failure
       “Hypogonadism”
       “Andropause”

   Consider endocrinology referral
   Testosterone Replacement Therapy?
         No mature data from large trials
                      Gynaecomastia
   TRT
       Potential benefits / drawbacks
          Bone density
          Cognition

          Muscle mass / body composition

          Mood

          Erythropoiesis

          Libido
                              Gynaecomastia
   TRT
       Potential harm
            ?Cardiovascular disease
                  Putative relationship
                  Studies actually show favourable effect
            Prostate risks
                  Mild increase in volume
                  Theoretical cancer risk




                   Snyder PJ J Clin Endocrinol Metab 2000
           Treatment of Gynaecomastia
   Indications
       Pain
       Tenderness
       Embarrassment interfering with normal activity

   Options
       Medical

       Surgical
                            Gynaecomastia
   Non-surgical treatment
       Reassure and observe
            Painful for 6-12 months during florid phase
            Revue medication
            Correct obesity / lifestyle
   Medication
       Little good data
       End points difficult to assess
            Tends to resolve anyway
            Pain is self limiting
                   Gynaecomastia
   Medical therapy
     Clomiphene
     Danazol

     Tamoxifen

     Aromatase Inhibitors
                            Gynaecomastia
   Clomiphene 50-100mg day
       Evaluated in adolescents
       Unproven efficacy especially at 50mg
       May achieve up to 64% resolution
       Adverse effects rare

   Danazol 400mg day
       Evaluated in adolescents (200mg day)
       Objective response 20-76%
       Side effects common
            Weight gain, acne, abnormal LFT’s


        LeeRoith et al Acta Endocrinol 1980
        Jones DJ et al Ann RCS Eng 1990
                               Gynaecomastia
   Tamoxifen
        Not evaluated in adolescents
        Generally poorly designed trials and audits
             Total of 136 patients in 5 trials
             Only 113 studied prospectively
             No randomised controlled studies
             Doses of 10, 20 & 40mg used
             From this “evidence” in adults
                   Reduces pain: 70-100%
                   May decrease lump:         50-80%
        Amoxifene
                   4-OH Tam gel
                   No significant systemic level
                   Trial in design stage (Hull / Cardiff)




    Plourde PV et al J Clin Endocrinol Metab 2004
    Kahn HN, Blamey RW BMJ 2003
                            Gynaecomastia
   Aromatase Inhibitors
       One RCT in adolescents
          Pain reduced
          No effect on lump

       Theoretical risks
          Bone health
          LH increases leading to peripheral aromatisation
                Not use AI’s for male breast cancer
                         Gynaecomastia
   Prostate cancer therapy
     Bicalutamide
     Dose dependent response to Tamoxifen prohylaxis
          8.8% on 20mg/day
          96.7% placebo

          No increase in PSA

       Alternatives
            Low dose irradiation


    Fradet, Yves, Egerdie et al Europ Urol. 2007 52(1): 106-114
             Gynaecomastia - Surgery
   Glandular enlargement with no/little excess skin
     ?liposuction alone – will not remove glandular
      element
        Ultrasound assisted
           Risk of thermal damage




     Minimally     invasive gland excision +/- liposuction
                USS Guided Intervention
   VABD
       Initially diagnostic
            Burbank, Parker, Fogarty Am J Surg 1996
       Therapeutic
            Zannis, Aliano Am J Surg 1998
                         VABD
   Breast vacuum biopsy system
   Hand held
   Multiple sampling through a single incision

   Introduction of 8-gauge probe
      Therapeutic procedures
Mammotome® Technique
             Gynaecomastia - VABD
   Hull Breast Unit
   Patients
     59 men
     Mean age 38 (range 21-80)


   Grade
     Grade 1/2
     14 unilateral
                         Gynaecomastia
   Complications
       Haematoma n=2
          Spontaneously resolved
          (“Bruising” inevitable)

       Recurrence n=2
            Re-mammotome




             Iwuagwu O et al Annals of Plastic Surgery 2004
                     Gynaecomastia
   Operating time
       50 min (range 20-60 min)
   Patient satisfaction: 8-9/10
   Cosmesis:             9-10/10
Gynaecomastia
        Gynaecomastia - Surgery

Excess skin +
  Consider staged operation
      Liposuction
      +/- skin excision
  Periareolar breast reduction

Excess skin +++
  Consider Wise pattern, vertical scar etc.
     Beware hypertrophic scars
  Repeated periareolar operations
                 SURGICAL TECHNIQUE




   Pre-operative markings – standing

   Operative patient position : semi-sitting

   Infiltrate breast with adrenaline solution
    ( 1 litre Ringers, 1ml 1: 1000 adrenaline , LA )
       GYNAECOMASTIA ASSESSMENT –
            NIPPLE POSITION


                                 B


                                     A



   A = ( 0.19 chest circumference ) + 2.192 cm

   B = ( 0.12 height ) – 2.782 cm


    •Shulman et al PRS 2001
     CIRCUMAREOLAR
CONCENTRIC SKIN REDUCTION
     CIRCUMAREOLAR
CONCENTRIC SKIN REDUCTION
     CIRCUMAREOLAR
CONCENTRIC SKIN REDUCTION
CIRCUMAREOLAR CONCENTRIC SKIN
         REDUCTION
     CIRCUMAREOLAR
CONCENTRIC SKIN REDUCTION
     CIRCUMAREOLAR
CONCENTRIC SKIN REDUCTION
CIRCUMAREOLAR CONCENTRIC SKIN
         REDUCTION
Pseudo-gynaecomastia after massive
           weight loss
VERTICAL SCAR REDUCTION TECHNIQUE
VERTICAL SCAR REDUCTION TECHNIQUE
VERTICAL SCAR TECHNIQUE
GYNAECOMASTIA SURGERY –
    SKIN REDUCTION
GYNAECOMASTIA SURGERY –
    SKIN REDUCTION
GYNAECOMASTIA SURGERY –
    SKIN REDUCTION
GYNAECOMASTIA SURGERY –
    SKIN REDUCTION
    GYNAECOMASTIA SURGERY –
        SKIN REDUCTION




Gusenoff et al   Plas. Recon. Surg. 122: p1301, 2008
                         Gynaecomastia
   Surgical complications
     Scarring and adherence to underlying muscle
     Excessive resection
           Contour deformity
   Solutions
     Local dermoglandular flaps
     Lipomodelling
           Autologous fat injections
                       Gynaecomastia
   Summary
     Usually “normal” or iatrogenic
     Occasional underlying disease

     Consider primary gonadal failure in the mature male

     Investigate
         Persistent or extreme cases in adolescents
         Adults
                                Gynaecomastia
   Summary
       Treatment
            Medical
                  Little good data
                  Tamoxifen in adults only
            Surgical
                  Do the least required to achieve patient’s desires
                  Not supported by PCT unless “exceptional”
            Grade 1/2a
                  Minimally invasive plus liposuction
            Grade 2b/3
                  Aesthetic techniques
                    Gynaecomastia
   Conclusion
     Common benign condition
     ? Normal part of ageing

     No licensed effective medication

     Trial needed

     ?Minimally invasive surgery operation of choice if
      appropriate

								
To top