Keywords: Gynecomastia, Saudi population, clinical manifestation, diagnostic work-up and therapeutic modalities.

Gynecomastia results from proliferation of the glandular breast compartment triggered by several endogenous, and occasionally by exogenous, factors [1]. Often, gynecomastia is the result of absolute imbalance between estrogen and androgen action at the breast tissue level. Estrogens stimulate and androgens inhibit breast glandular development [1, 2]. Most of the cases are benign whether in infancy, pre-pubertal, pubertal and even in adults. However, occasionally gynecomastia might be due to the underlying pathologic process of male breast cancer especially in the elderly population with prolonged exposure to female hormones, positive family history, or patients with reduced testicular function (Kleinfelter's Syndrome) [1, 2]. Age, family history, drug/medication history, clinical manifestation and specific diagnostic modalities remain crucial in differentiation and treatment. Presenting a case of gynecomastia among middle-aged Saudi men and reviewing related literature, we aim towards increasing the awareness of such a clinical entity and highlight the work-up and treatment when needed.

A 51 year old Saudi male presented to our out-patient clinic with mild pain and swelling of his right breast of 6 weeks' duration. He voluntarily expressed his reluctance to seek medical advice for the past few weeks saying, "I thought it would go away." Patient is a smoker (30 packets a year). Family history, past medical, surgical and drug history was unrevealing. Examination revealed a 2.5 cm x 1.5 cm firm, mildly tender sub-areolar mass with regular borders and free from underlying and overlying tissues, normal nipple and no lymph nodes were felt. TSH, liver function test, renal and chest X-ray were all normal. Mammography report noted: "2.9 cm x 1.3 cm retro-areolar right breast mass likely related to cancer." A fine needle aspiration by a general surgeon followed and the pathology report revealed "Few clusters of ductal cells with a few single epithelial cells." Afterwards, an open right breast excision was done and the pathology report noted the following: "Several ductular structures lined by hyperplastic ductal epithelium with papillary projections and micro-papillary formations embedded within connective tissue stroma featuring an area of basophilic myxoid stroma around ducts and intervening collagenous fibrillary stroma. No features of malignancy detected. The appearance is typical of gynecomastia." Fig 1,2

Gynecomastia is predominantly unilateral and quite prevalent among infants, pubertal and to a lesser extent amongst the elderly population. Female hormone estrogen is the main factor in breast glandular proliferation needed for breast enlargement in both sexes[1]. In males, estrogen is naturally counter-balanced by male hormones androgens. Changing the balance between the two sex hormones due to several causes (Table 1), enhanced sensitivity of breast tissue to estrogen and insensitivity to androgens lead to breast enlargement as well[1, 2]. Not all breast enlargements are due to hormonal imbalance. Many overweight and obese teens and adults have enlarged bilateral breasts due to increase fat and not breast tissue. This is called pseudo-gynecomastia and usually disappears only when individuals involved lose weight.

Neonatal and pubertal cases of gynecomastia remain the most common and usually resolve spontaneously in a couple of weeks to two years, respectively. Reassurance, patient and relative education of the physiologic basis of the condition and periodic follow-up is all that is needed.

However, gynecomastia in pre-pubertal [3] and elderly age groups [4, 5, 6] warrants further investigations as clinically indicated. Long-term direct or even indirect exposure to estrogen has been associated with some gynecomastia cases in pre-pubertal children. Testicular cancers, primary gonadal failure (Kleinfelter's Syndrome), secondary hypogonadism (mumps orchitis, orcheoctomy cases) can lead to gynecomastia due to decreased androgens. However, liver cirrhosis, lung cancer, hyperthyroidism and patients on dialysis have been associated with increased levels of free estrogen as a plausible cause of gynecomastia seen in some of these patients. Finally, drug and medication history should be reviewed as another cause of gynecomastia in adults [1, 7] (Table 1).

Male breast cancer, though very rare, does exist. It accounts for 0.2% of all cancers and 1% of all breast cancers [4, 5, 6]. Our patient had a negative family history and/or risk factors for male breast cancer. Physical exam was also reassuring; the mass felt concentric to the nipple without nipple changes, well delineated borders and not fixed to underlying tissues and overlying skin. Initial work-up was negative, and the mammography report was nonconclusive towards either diagnoses. Fine needle aspiration remains important in the diagnostic armamentarium of breast lumps, yet literature points to some false negative results [4]. Final diagnosis came through the pathology report of the excised breast tissue that ruled out malignancy and detailed the typical appearance of gynecomastia. The etiology behind our patient's gynecomastia might be explained on the basis of either increased estrogen sensitivity or decreased sensitivity of breast tissue to endogenous androgen.

Finally, open excision of breast tissue has been widely used for gynecomastia. Recently, new techniques in the surgical approach utilizing the hyper-tumescent power liposculpting have found to be successful in treating gynecomastia and leaves little scarring. Post-operative control of body weight and exercise is needed for long-term positive results and patient's self esteem [8].

Fig: 1 Low power featuring the hyperplastic irregular dilated ducts surrounded by fibrous stroma (Hematoxyline and Eosin stain X100). Fig: 2 High power showing Hyperplastic ducts with intraluminal micropapillary formation

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The author wishes to acknowledge the use of Saudi Aramco Medical Services Organization facilities for the data and the study, which resulted in this paper. The author is employed by Saudi Aramco during which the study was conducted and the paper written.