Caracterización clínico-etiológica y bioquímica de pacientes con ginecomastia / Clinical- etiological and biochemical characterization of patients with gunecomastia

RESUMEN Introducción: La ginecomastia define el aumento benigno del tamaño de la glándula mamaria en el hombre. Objetivo: Determinar las características clínicas, etiológicas y bioquímicas de los pacientes con diagnóstico de ginecomastia atendidos en el servicio de Cirugía General. Método: Se realizó un estudio descriptivo de corte transversal en una muestra de 108 pacientes, mayores de 18 años, atendidos en el servicio de Cirugía General con diagnóstico de ginecomastia. El estudio se llevó a cabo en los Hospitales Mariano Pérez Balí y Celia Sánchez Manduley, entre septiembre 2015 y marzo 2017. Se determinó edad, características clínicas, etiología y perfil bioquímico de estos pacientes. Resultados: La edad media fue de 27,63 años siendo la afectación estética el principal motivo de consulta. Predominó la ginecomastia bilateral, el sobrepeso/obesidad, el grado IIa de la enfermedad, la etiología idiopática y el antecedente de ginecomastia puberal. La presencia de galactorrea, hiperprolactinemia, hipoandrogenismo e hiperestrogenemia fue mínima. Conclusiones: La ginecomastia bilateral de causa idiopática, en pacientes con sobrepeso/obesidad y niveles normales de hormonas hipofisarias y gonadales es la forma de presentación más frecuente de esta afección(AU)

ABSTRACT Introduction: Gynecomastia defines the benign increase of the mammary gland size in men. Objective: To determine the clinical, etiological and biochemical characteristics of patients diagnosed with gynecomastia attended at the General Surgery service. Methods: A descriptive cross-sectional study was conducted in a sample of 108 patients over the age of 18 years, attended at the service of General Surgery with a diagnosis of gynecomastia. The study was carried out in ´´Mariano Perez Bali´´ and ´´Celia Sánchez Manduley´´ Hospitals from September 2015 to March 2017. The age, clinical characteristics, etiology, and biochemical profile of these patients were determined. Results: The mean age was 27.63 years and the aesthetic affectations were the main reason for consultation. There was a predominance of bilateral gynecomastia, overweight/obesity, grade IIa of the disease, idiopathic etiology and the history of pubertal gynecomastia. The presence of hyperprolactinemia, galactorrhea, hypoandrogenism and hyperstrogenism was minimal. Conclusions: Bilateral gynecomastia of idiopathic cause, in patients with overweight/obesity and normal levels of gonadal and pituitary hormones is the most common presentation of this condition(AU)

Importancia de la anamnesis exhaustiva ante una ginecomastia unilateral inexplicada en un niño / Importance of the exhaustive anamnesis to an unexplained unilateral gynecomastia in a child

La ginecomastia es el crecimiento de la mama por un desequilibrio hormonal entre estrógenos y andrógenos. Un crecimiento importante y unilateral requiere descartar patologías subyacentes. Una causa poco frecuente es la traumática, que provoca aumento de tamaño por estimulación repetida. Se presenta el caso de un niño de 6 años con ginecomastia unilateral. Se destaca como único hallazgo en las pruebas complementarias hiperprolactinemia. Rehistoriando, se detecta una continua autoestimulación mamaria manual y oral a través de mordiscos de meses de evolución. Tras el cese del estímulo, se observa la involución de la mama y la normalización de los niveles de prolactina séricos.

Gynecomastia consists of breast enlargement due to a hormonal imbalance between estrogens and androgens. Unilateral and important breast growth requires ruling underlying pathologic disorders out. Mechanical cause is uncommon, causing enlargement by repeated stimulation. We report a 6-year-old boy with unilateral gynecomastia. Hyperprolactinemia is the only abnormal finding at laboratory tests. After repeated inquiries, a continuous breast selfstimulation is detected. Its relation with gynecomastia is verified because prolactin normalizes and breast regressed in further revisions, after stopping stimulus.

[Importance of the exhaustive anamnesis to an unexplained unilateral gynecomastia in a child]. / Importancia de la anamnesis exhaustiva ante una ginecomastia unilateral inexplicada en un niño.

Gynecomastia consists of breast enlargement due to a hormonal imbalance between estrogens and androgens. Unilateral and important breast growth requires ruling underlying pathologic disorders out. Mechanical cause is uncommon, causing enlargement by repeated stimulation. We report a 6-year-old boy with unilateral gynecomastia. Hyperprolactinemia is the only abnormal finding at laboratory tests. After repeated inquiries, a continuous breast selfstimulation is detected. Its relation with gynecomastia is verified because prolactin normalizes and breast regressed in further revisions, after stopping stimulus.

La ginecomastia es el crecimiento de la mama por un desequilibrio hormonal entre estrógenos y andrógenos. Un crecimiento importante y unilateral requiere descartar patologías subyacentes. Una causa poco frecuente es la traumática, que provoca aumento de tamaño por estimulación repetida. Se presenta el caso de un niño de 6 años con ginecomastia unilateral. Se destaca como único hallazgo en las pruebas complementarias hiperprolactinemia. Rehistoriando, se detecta una continua autoestimulación mamaria manual y oral a través de mordiscos de meses de evolución. Tras el cese del estímulo, se observa la involución de la mama y la normalización de los niveles de prolactina séricos.

Clinical and Etiological Aspects of Gynecomastia in Adult Males: A Multicenter Study.

OBJECTIVES: To evaluate the characteristics of presentation, biochemical profile, and etiology of gynecomastia in adults. METHODS: Medical records of 237 men aged 18-85 years with gynecomastia were evaluated. RESULTS: Highest prevalence of gynecomastia was observed between 21 and 30 years (n = 74; 31.2%). The most common presenting complaints were aesthetic concerns (62.8%) and breast pain (51.2%). 25.3% of the subjects had a history of pubertal gynecomastia. 56.5% had bilateral gynecomastia. 39.9% were overweight and 22.8% were obese. The etiology could not be identified in 45.1% of the cases; the most frequent identified causes were anabolic steroids consumption (13.9%), hypogonadism (11.1%), and use of pharmaceutical drugs (7.8%). Patients with bilateral gynecomastia had a longer history of disease, higher BMI, and lower testosterone levels. CONCLUSIONS: Patients with gynecomastia presented more often with aesthetic concerns and secondarily with breast pain. The most frequent final diagnosis was idiopathic gynecomastia, whereas the most frequent identified etiologies were anabolic steroids consumption, hypogonadism, and use of pharmaceutical drugs. Despite the low frequency of etiologies such as thyroid dysfunction or adrenal carcinoma, we emphasize the importance of a thorough assessment of the patient, as gynecomastia may be the tip of the iceberg for the diagnosis of treatable diseases.

Surgical Masculinization of the Breast: Clinical Classification and Surgical Procedures.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Surgical Masculinization of the Breast: Clinical Classification and Surgical Procedures.

INTRODUCTION: Aesthetic breast area improvements for gynecomastia and gender dysphoria patients who seek a more masculine appearance have increased recently. We present our clinical experience in breast masculinization and a classification for these patients. METHODS AND MATERIALS: From July 2003 to May 2014, 68 patients seeking a more masculine thorax underwent surgery. They were divided into five groups depending on three factors: excess fatty tissue, breast tissue, and skin. A specific surgical treatment was assigned according to each group. The surgical treatments included thoracic liposuction, subcutaneous mastectomy, periareolar skin resection in one or two stages, and mastectomy with a nipple areola complex graft. The evaluation was performed 6 months after surgery to determine the degree of satisfaction and presence of complications. RESULTS: Surgery was performed on a total of 68 patients, 45 male and 22 female, with ages ranging from 18 to 49 years, and an average age of 33 years. Liposuction alone was performed on five patients; subcutaneous mastectomy was performed on eight patients; subcutaneous mastectomy combined with liposuction was performed on 27 patients; periareolar skin resection was performed on 11 patients; and mastectomy with NAC free grafts was performed on 16 patients. The surgical procedure satisfied 94% of the patients, with very few complications. CONCLUSIONS: All patients who wish to obtain a masculine breast shape should be treated with only one objective regardless patient's gender: to obtain a masculine thorax. We recommend a simple mammary gland classification for determining the best surgical treatment for these patients LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ginecomastia / Gynecomastia

O objetivo deste trabalho foi observar na literatura dados referentes à etiologia da ginecomastia, seu diagnóstico e aspectos radiológicos. A metodologia adotada foi a pesquisa bibliográfica sistematizada para a produção de um artigo de revisão, de modo a responder ao objetivo proposto. A ginecomastia pode ser dividida em fisiológica (neonatal, puberal e senil) e patológica (resultante da diminuição da ação da testosterona, ou do aumento da ação estrogênica, por mecanismo de indução por drogas, idiopática ou secundária a outras causas). O diagnóstico deve ser realizado através do exame físico, investigação endócrina e exames radiológicos, como a mamografia e a ultrassonografia. O tratamento está baseado na orientação, medicamentos e, em último caso, cirúrgico.(AU)

The objective of this study was to observe data in the literature regarding the etiology, diagnosis and radiological aspects of gynecomastia. The methodology included a systematic literature search to produce a review article in order to meet the objective. Gynecomastia can be divided into physiologic (neonatal, pubertal and senile) and pathological (due to decreased action of testosterone, increased estrogen action, drug?induced, idiopathic or due to other causes). The diagnosis could be made by physical examination, endocrine and radiological investigation, as mammography and ultrasound. The treatment is based on the guidance, medication and, ultimately, surgery.(AU)

Klinefelter syndrome: an unusual diagnosis in pediatric patients.

OBJECTIVE: To identify clinical and laboratory data which differentiate Klinefelter syndrome (KS) patients according to age group. METHODS: The study included all cases of hypogonadism, gynecomastia and/or infertility whose karyotype was performed at a university hospital from January 1989 to December 2011, in a total of 105 subjects. The following data were retrospectively analyzed: age at first visit, ratio of arm span to height, pubic hair, gynecomastia, testicular volume, luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone (T), and spermiogram. RESULTS: During the study period, 33 patients were diagnosed with Klinefelter syndrome (KS+) and 72 were not (KS-). Out of all KS cases, only seven (21.2%) were diagnosed before 20 years old and two (6.1%) before 10 years old. Age at first consultation (in years) was similar in both groups (KS+ = 31.3±12.9 and KS- = 27.6±12.1), as were ratio of arm span to height and frequency of gynecomastia. However, in KS+ patients, pubic hair was less developed, testicular volume was smaller and testosterone levels were lower, while LH and FSH levels and frequency of azoospermia were higher. CONCLUSIONS: Klinefelter syndrome is both an under and late diagnosed condition. The most important data for diagnosis are testicular volume, hormone levels and presence of azoospermia in spermiogram, especially in puberty and adult life.

Síndrome de Klinefelter: diagnóstico raro na faixa etária pediátrica / Klinefelter syndrome: an unusual diagnosis in pediatric patients

OBJETIVO: Identificar dados clínicos e laboratoriais que diferenciam os casos com síndrome de Klinefelter de acordo com a faixa etária. CASUÍSTICA E MÉTODOS: Foram incluídos todos os casos de hipogonadismo, ginecomastia e/ou infertilidade avaliados em hospital universitário cujo cariótipo foi realizado entre janeiro de 1989 e dezembro de 2011, totalizando 105 pacientes. Foram avaliados: idade na primeira consulta, relação entre envergadura e altura, pilificação pubiana, ginecomastia, tamanho testicular, hormônio luteinizante (LH), hormônio folículo-estimulante (FSH), testosterona e espermograma. RESULTADOS: Foram diagnosticados três casos com síndrome de Klinefelter (SK+) e 72 sem a síndrome (SK-). Dos casos com síndrome de Klinefelter, apenas sete (21,2%) foram diagnosticados antes dos 20 anos e dois (6,1%) antes dos 10 anos de idade. A idade na primeira consulta (em anos) foi semelhante nos dois grupos (SK+ = 31,3±12,9 e SK- = 27,6±12,1), o mesmo ocorrendo com a relação entre envergadura e altura e a presença de ginecomastia. No entanto, a pilificação pubiana foi menor no grupo SK+, o mesmo ocorrendo com a média do volume bitesticular e a testosterona, enquanto que o LH e o FSH foram mais elevados neste grupo, o mesmo ocorrendo com a frequência de azoospermia. CONCLUSÕES: A síndrome de Klinefelter ainda é pouco e tardiamente diagnosticada em nosso meio, sendo os dados de tamanho testicular, LH, FSH, testosterona e presença de azoospermia no espermograma os mais importantes para o seu diagnóstico, principalmente na puberdade e na vida adulta.

OBJECTIVE: To identify clinical and laboratory data which differentiate Klinefelter syndrome (KS) patients according to age group. METHODS: The study included all cases of hypogonadism, gynecomastia and/or infertility whose karyotype was performed at a university hospital from January 1989 to December 2011, in a total of 105 subjects. The following data were retrospectively analyzed: age at first visit, ratio of arm span to height, pubic hair, gynecomastia, testicular volume, luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone (T), and spermiogram. RESULTS: During the study period, 33 patients were diagnosed with Klinefelter syndrome (KS+) and 72 were not (KS-). Out of all KS cases, only seven (21.2%) were diagnosed before 20 years old and two (6.1%) before 10 years old. Age at first consultation (in years) was similar in both groups (KS+ = 31.3±12.9 and KS- = 27.6±12.1), as were ratio of arm span to height and frequency of gynecomastia. However, in KS+ patients, pubic hair was less developed, testicular volume was smaller and testosterone levels were lower, while LH and FSH levels and frequency of azoospermia were higher. CONCLUSIONS: Klinefelter syndrome is both an under and late diagnosed condition. The most important data for diagnosis are testicular volume, hormone levels and presence of azoospermia in spermiogram, especially in puberty and adult life.

[Practical approach to management of gynecomastia: six questions to be answered by the paediatrician regarding a patient with gynecomastia]. / Enfoque práctico del manejo de la ginecomastia: Seis preguntas que debe responderse el pediatra ante un paciente con ginecomastia.

Pubertal gynecomastia is a common concern in the consultation of the adolescent. Usually, it is accompanied by an emotional component that can lead to changes in everyday attitudes of youth. The responsability of the pediatrician is to rule out other etiologies, to avoid unnecessary additional studies, to limit active therapeutic attitudes, and to reaffirm the variation of normality. We briefly describe six eminently practical questions to be answered by the physician.

Ectopic gynecomastia: repost of occurence in a male patient with type 1 diabetes

We report a case of breast tissue development at the usual insulin injection area, on both iliac fossa.There is no report in the literature that shows relation between hypertrophy, and/or increase ofin vivo breast tissue and insulin stimulus. To our knowledge, this is the first case of ectopic gynecomastia reported in the literature. Male patient, 52 years, diabetic, sought to the Emergency Department due to abdominal pain. Abdomen computed tomography scan incidentally indentified tissuewith the same morphological and attenuation characteristics of the breast in the subcutaneous of both iliac fossa, at the usual insulin injection site. The patient was also submitted to complementaryultrasound exam. Ectopic gynecomastia is a possible entity, considering embryology andhormone aspects, but literature has no record of such cases in men. Another intriguing point is thatthe preeminence of the breast tissue occurred only at the chronic insulin injection area, a stimulatinghormone, known to be mitogenic.

Relatamos o caso de paciente masculino, em que foi identificadotecido mamário no local habitual de aplicação de insulina, nas fossas ilíacas. Não há na literatura nenhuma relação estabelecidaentre hipertrofia e/ou aumento do tecido mamário in vivo e estímulo de insulina, sendo este, ao nosso conhecimento, o primeiro caso documentado na literatura de ginecomastia ectópica. Paciente do sexo masculino, 52 anos, diabético, atendido no Pronto Atendimento devido a dor abdominal. Tomografia computadorizada de abdome total identificou, incidentalmente, tecido com as mesmas características morfológicas e de atenuação do tecido mamário no subcutâneo de ambas as fossas ilíacas, no local habitual de aplicação de insulina. Foi feita complementação com ultrassonografia direcionada. A ginecomastia ectópica é uma entidade possível, tendo em vista a embriologia e os fatores hormonais,porém não há na literatura casos descritos em homens. Outro fator intrigante é a proeminência do tecido mamário somente no local de injeção crônica de insulina, um hormônio estimulante, conhecidamente mitogênico.

Disseminated blue naevus and malignant blue naevus associated with excessive aromatase syndrome.

We report a case of a 17-year-old boy who had a giant congenital blue naevus with multiple satellite pigmented lesions. Later the patient developed melanoma arising in the pre-existing lesion. He also had gynaecomastia and was diagnosed as having aromatase excess syndrome. To our knowledge, the association of these two rare conditions has not been previously reported. Further studies should be performed to investigate this unusual combination, which may have a genetic, endocrine or local cutaneous link leading to its occurrence.

True hermaphroditism in a phenotypic male without ambiguous genitalia: an unusual presentation at puberty.

True hermaphroditism usually appears with ambiguous genitalia requiring extensive evaluation during the neonatal period. There have been occasional cases with better differentiation of external genitalia, leading to delays in diagnosis. We report the case of an adolescent boy with true hermaphroditism who presented with normal external genitalia and no sexual ambiguity. He was referred due to progressive gynecomastia and arrest of puberty. He presented at the age of 16 years for gynecomastia of rapid progression with normal penile development and both gonads in scrotum and normal testosterone and increased gonadotropin levels. Gonadal ultrasound scan was compatible with testicular and ovarian tissues in scrotum, and the karyotype showed two cellular lines (46,XX/46,XY). Gonadal histology revealed bilateral ovotestes. A genotype polymerase chain reaction mediated analysis using seven microsatellite markers did not confirm chimerism. Clinical findings and mechanism of generation are discussed.

Ginecomastia (Estudio retrospectivo sobre 54 casos operados) / Gynecomastia: retrospective study of 54 cases surgically treated

Se realiza un estudio retrospectivo de 54 casos operados en el Hospital de Endocrinología y Metabolismo Dr. Arturo Oñativia de Salta. Entre los años 1987 y 2001 fueron intervenidas 63 ginecomastias que representan el 5,58 por ciento de los diagnósticos anátomo-patológicos y el 7,18 por ciento de los informes benignos. Sobre 54 pacientes con historias clínicas presentes se detallan aspectos epidemiológicos, formas de presentación, estudios practicados, diagnóstico causal, características anátomo-patológicas y se intenta cursar una guía para el estudio de la ginecomastia como así también para el tratamiento médico y quirúrgico. Por último se realiza determinación de receptores hormonales por inmunomarcación en 19 casos observando pisitividad nuclear epitelial para estrógenos en el 68,42 por ciento y de progesterona en el 47,36 por ciento.(AU)

Ginecomastía: aproximación clínica y terapeútica / Gynecomastia: clinical and therapeutic approach

La Ginecomastia es una condición frecuente especialmente en la pubertad y edad adulta, no obstante en ocasiones produce en el paciente un importante grado de ansiedad y discomfort social. Si bien la mayoría de las veces no representa un desafío clínico diagnóstico, puede ser la manifestación inicial de un gran numero de condiciones médicas de mayor importancia para el pronóstico del paciente. De capital importancia es el diagnóstico diferencial con el cáncer de mama masculino, que si bien es de presentación mas bien excepcional, puede ser resuelto con un tratamiento precoz. El presente articulo es una revisión de los aspectos más trascendentes a considerar en el enfrentamiento clínico y terapéutico de esta condición.

Lipoaspiração ultrassônica em ginecomastia / Ultra-sound assisted liposuction in gynecomastias

A lipoaspiração ultrassônica vem se tornando bastante indicada no tratamento das ginecomastias, devi- do à boa qualidade dos resultados obtidos. O presente estudo relata 11 casos de ginecomastia glandular e glândulo-gordurosa, no período de 1999 a 2002, submetidos à lipoaspiração ultrassônica e lipoaspiração convencional complementar, com cânulas de médio e pequeno calibres. Foi utilizado o equipamento Lisonix 2000, numa amplitude de 5, ou seja, 50 da potência do aparelho, com cânulas de 32 cm de comprimento e 3 mm de diâmetro. O volume médio aspirado, pela lipoaspiração ultrassônica, foi de 222 ml na mama direita e de 225 ml na mama esquerda, enquanto que o volume aspirado por lipoaspiração convencional foi de 200 ml e de 205 ml, respectivamente, totalizando em média, 852 ml por paciente. O tempo médio de lipoaspiração ultrassônica foi de 7 minutos e 12 segundos. Podemos concluir que, a lipoaspiração ultrassônica tem sua indicação, tanto em ginecomastia gordurosa quanto glandular, com uma evolução pós- operatória mais rápida, sem a necessidade de uma incisão na aréola e ressecção cirúrgica da glândula ma- mária.

The ultrasound assisted liposuction is becoming more popular in treating gynecomastias. This paper reports 11 cases of fatty-glandular breasts treated from 1999 to 2002 at private clinic, which were undertaken to ultrasound-assisted lipoplasty and complementary conventional liposuction, with small and medium canulas. Lisonix 2000 was used with 32 cm length canulas and diameter of 3 mm.The medium volume aspirated by ultrasound- assisted lipoplasty in the right breast was 222 ml and 225 ml were aspirated from the left breast, while the volume aspirated by conventional liposuction was 200 ml and 205 ml, respectively, with a total of 852 ml per patient. The medium time of liposuction for each side was 7 minutes and 12 seconds. The ultrasound-assisted lipoplasty is indicated either in fatty or glandular gynecomastia, with better results when compared with conventional liposuction. It has a faster recovery period without the need for glandular tissue resection.

Ginecomastia transitória näo puberal: relato de três casos / Transient not pubertal gynecomastia: report of three cases

Os autores relatam os casos de 3 meninos com ginecomastia pré-puberal, de etiologias incomuns. No primeiro caso, ginecomastia bilateral teve início aos 5 anos e 10 meses de idade e foi relacionada com realimentação após doença celíaca. No segundo caso, ginecomastia unilateral foi constatada aos 8 anos e 5 meses de idade, após a introdução de análogo do GnRH, utilizando para tratamento de puberdade precoce verdadeira idiopática diagnosticada aos 5 anos. No terceiro caso, ginecomastia bilateral surgiu aos 5 anos e 9 meses e foi associada à contaminação com estrógeno de origem não estabelecida. Nos três casos, a evolução clínica foi benigna com regressão da ginecomastia. A apresentação dos casos confirma que, nesta faixa etária, a ginecomastia, embora rara, apresenta com freqüência dificuldades diagnósticas em relação ao processo desencadeante.