Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver

Gynecomastia is the most common benign condition of the male breast. The authors present a new method of treatment for gynecomastia that combines traditional liposuction in conjunction with a shaver technique to effectively remove the fibrofatty and the glandular tissues of the male breast and avoid areolar incisions. Twenty-five patients were treated in this fashion, and each patient demonstrated a smooth, masculine breast contour with well-concealed scars in the inframammary folds, eliminating the stigma of breast surgery. The procedure is technically straightforward and provides consistent results. It is offered as an additional option for the treatment of gynecomastia.     

Gynecomastia: pathomechanisms and treatment strategies

Gynecomastia is common in adolescents and adults, and reflects an underlying imbalance in hormonal physiology in which there is an increase in estrogen action relative to androgen action at the breast tissue level. Most patients have persistent pubertal gynecomastia or breast glandular enlargement from medications, age-related reduction in testicular function, or idiopathic causes. Gynecomastia must be differentiated from pseudogynecomastia due to increased breast adipose tissue, as well as from breast carcinoma. The evaluation of the causes of gynecomastia can be accomplished through history, physical examination and a few laboratory tests. Painful gynecomastia of recent onset may respond to antiestrogen therapy. Surgical removal is the mainstay for long-standing gynecomastia or glandular enlargement that is unresponsive to medical therapy.     

Gynecomastia--pathogenesis, diagnosis and treatment

The aim of this review is to present the up-to-date information concerning the prevalence, pathogenesis, diagnosis and treatment of gynecomastia. Gynecomastia is a benign, unilateral or bilateral enlargement of the male breast due to the imbalance between the androgens and estrogens at the breast tissue level. This clinical condition is particularly common in boys during puberty and in aging men. The breast enlargement, especially with accompanying pain can cause serious psychological problem. At the present time there are no generally accepted procedures for the evaluation and treatment of patients with gynecomastia. In the article such recommendations were proposed. There are many studies conducted to find the safe and efficient medical therapy that could ameliorate the quality of life of the patients with gynecomastia. The information on the available treatment options were also presented.     

Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy

Gynecomastia is a benign enlargement of the male breast due to a physiological or pathological factor that interferes with the balance between estrogens and androgens in the serum. Gynecomastia itself requires no treatment unless the persistent enlargement of the male breast is a source of embarrassment and/or distress for the adolescent or adult man. The indications for the surgical treatment of gynecomastia are founded on two main objectives: (1) the restoration of male chest shape and (2) diagnostic evaluation of suspected breast lesions. The diagnostic evaluation begins with an adequate history and a thorough breast examination helped by laboratory tests and instrumental research. Several approaches for surgical treatment have been described in the literature. Some problems arise in patients who have significant enlargement and ptosis of the breast that will require skin reduction and in some patients requiring nipple-areola complex reduction. The authors believe that the complete circumareolar technique with purse-string suture creates the best aesthetic results, with fewer complications, in patients with moderate and severe ptotic glandular breast enlargements that have skin redundancy combined with areolar enlargement. From 1995 through 1999, a total of 10 male patients with moderate to severe gynecomastia were treated surgically using a complete circumareolar approach. All patients achieved a good aesthetic contour of the chest. Only two patients required a revision of the circumareolar scar to correct postoperative enlargement.     

Neither gynecomastia nor galactorrhea is a common side effect of neuroleptics in male patients

OBJECTIVE: Gynecomastia is known to be a side effect of neuroleptics. The authors investigated the prevalence of gynecomastia and galactorrhea in a group of regularly neuroleptic-treated male patients. METHODS: Gynecomastia was defined as a palpable, discrete button of firm subareolar tissue measuring at least 2 cm in diameter. The subjects were 100 male patients who were taking neuroleptic treatment regularly. Each patient gave informed consent for the research involved in this study. RESULTS: (1) Palpable gynecomastia was present in 2% of the patient group, but not at all in the normal group. (2) Galactorrhea was not present in either patient or normal group. (3) The mean level of the serum prolactin in the group of patients without gynecomastia (n = 53) was significantly higher than that in the normal group (n = 35), but there was no significant difference in blood luteinizing hormone, follicle-stimulating hormone, testosterone (T), estradiol (E(2)) or T/E(2) ratio between the groups. (4) The mean level of the T/E(2) ratio in the patients with gynecomastia tended to be higher than that in the group of patients without gynecomastia. CONCLUSIONS: Overall, these results seem to indicate that (i) gynecomastia is not common in the Japanese population, and (ii) in male patients neither palpable gynecomastia nor galactorrhea is a common side effect of neuroleptics. To clarify the relation between gynecomastia and neuroleptic treatment, large prospective studies are required.     

Gynécomasties

Gynecomastia is a frequent disorder, sometimes painful or psychologically disturbing. Many physiologic and pathologic conditions are considered to be associated with enlargement of the male breast (puberty, ageing, various diseases and certain medications) or it may be idiopathic. Excessive serum concentrations of estrogens and/or deficient levels of testosterone, resulting in an increased ratio of estradiol to testosterone appear to be the stimulus factor for this abnormal growth of male breast tissue. Production of estrogens by adrenal or testicular neoplasmes can also result in gynecomastia. Treatment of any primary disorder or discontinuation of responsible medication will often bring about resulution of the problem. However, for moderate to severe breast enlargement of for excessive pain, regardless of the cause, surgical intervention is frequently necessary.     

Specific expression of human pS2 gene in breast cancer

The hormone-dependence of some human breast cancers is well recognized. However, the molecular mechanisms responsible for the growth stimulation of these cancers by oestrogens are still poorly understood. With the hope of elucidating these mechanisms, we have recently cloned and studied the structure-function relationship of the human oestrogen and progestin receptors, and also undertaken a study aimed at characterizing genes whose expression is controlled by oestrogens in hormone-dependent breast cancers. We review here our findings concerning one of these genes and its expression products, the pS2 gene. We discuss also whether a systematic determination of pS2 gene expression in breast cancer biopsies could be useful to establish a new biochemical classification of these cancers which may be useful to improve the diagnosis of hormone-dependent cancers.     

Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction

Gynecomastia, or excessive male breast development, has an incidence of 32 to 65 percent in the male population. This condition has important physical and psychological impacts. Advances in elucidating the pathophysiology of gynecomastia have been made, though understanding remains limited. Recommendations for evaluation and workup have varied and are often arbitrary. A diagnostic algorithm is suggested, with emphasis on a comprehensive history, physical examination, and minimizing unnecessary diagnostic testing. Medical management has had limited success; surgical therapy, primarily through excisional techniques, has been the accepted standard. Although effective, excisional techniques subject patients to large, visible scars. Ultrasound-assisted liposuction has recently emerged as a safe and effective method for the treatment of gynecomastia. It is particularly efficient in the removal of the dense, fibrous male breast tissue while offering advantages in minimal external scarring. A new system of classification and graduated treatment is proposed, based on glandular versus fibrous hypertrophy and degree of breast ptosis (skin excess). The authors' series of 61 patients with gynecomastia from 1987 to 2000 at the University of Texas Southwestern Department of Plastic Surgery demonstrated an overall success rate of 86.9 percent using suction-assisted lipectomy (1987 to 1997) and ultrasound-assisted liposuction (1997 to 2000). The authors have found ultrasound-assisted liposuction to be effective in treating most grades of gynecomastia. Excisional techniques are reserved for severe gynecomastia with significant skin excess after attempted ultrasound-assisted liposuction.     

Application of the probabilistic approach to reporting breast fine needle aspiration in males

OBJECTIVE: To apply the probabilistic approach to a series offine needle aspiration (FNA) samples of male breast lesions and determine the accuracy and reproducibility of this method of reporting in men. STUDY DESIGN: All male breast surgical specimens with a preoperative breast FNA at our institution from 1994 to 2005 were identified. The FNAs were blindly reviewed by 2 groups of observers and classified in 1 of 5 categories using published reporting guidelines: positive, suspicious, atypical, proliferative without atypia and unremarkable. The histologic and cytologic diagnoses were correlated. The interobserver variation was determined. RESULTS: A total of 138 FNAs were performed for 123 male patients. Histologic correlation was available for 23 satisfactory FNAs. A total of 11 of 11 carcinomas (100%) were classified as positive, suspicious or atypical. Of 12 benign masses, 11 (91.6%) were classified as proliferative without atypia or unremarkable. One case of gynecomastia was classified as atypical by 1 observer but deemed not atypical with consensus review. The kappa statistic for benign and atypical/suspicious/malignant categories was 0.90. CONCLUSION: Based on this series, the probabilistic approach can be applied to the reporting of FNAs of male breast lesions. Gynecomastia may result in an atypical cytologic diagnosis.     

The importance of thyroid hormone in experimental ovarian cyst formation in gilts

The role of the thyroid gland in ovarian cyst formation in farm animals and in women has rarely been considered. Experimental data on the induction of polycystic ovarian disease (PCOS) in rats indicates the importance of thyroid function to the mechanism of this disorder. The objective of this work was to prove the role of thyroid hormones in gonadotropin-induced cystic ovarian disease (COD) in gilts.In hypothyroid gilts (oral administration of 1 g of methylthioracyl (MTU) daily for 24 days), ovarian cysts were induced by injections of pregnant mares' serum gonadotropin (PMSG) (equine chorionic gonadotropin (eCG)) and human chorionic gonadotropin (hCG) (400 IU and 200 IU daily for 10 days, respectively). Gonadotropins were also injected into hyperthyroid gilts (400 μg of L-thyroxine daily for 24 days). Suitable control groups (no treatment, injected with gonadotropins, hypothyroid by application of MTU and hyperthyroid by administration of L-thyroxine) were set up. Thyroid function was monitored by estimating the total thyroxine in blood plasma using the radio-immunoassay (RIA) method. After treatment, all animals were laparatomized on Days 5–6 of the cycle and the blood samples from peripheral and utero-ovarian veins were collected by cannulation for 2–3 days following surgery. All gilts were then slaughtered and ovaries and other hormonal glands were excised, inspected and preserved for further analysis.The experimental results showed that thyroid hormones in gilts demonstrate an antagonistic influence on the cyst-formative action of gonadotropins. Hypothyroid status increased ovarian sensitivity to gonadotropin action. This was visualised by marked hypertrophy of the ovaries and multiple follicular cysts were also found in both ovaries. In contrast, the hyperthyroid animals showed a reduced sensitivity to the cyst-formative action of gonadotropins (decrease of ovarian dimensions, small numbers of cysts). The mechanism of antagonistic thyroid-gonadotropin relations may be based on negative interactions between thyroid hormones and gonadotropin receptors in the ovaries, and/or on central or peripheral interrelations between thyroid hormones and oestrogens.     

Phenotype of patients with gynecomastia

INTRODUCTION: Gynecomastia, a benign enlargement of the breast glandular tissue in men. The aim of the study was to evaluate the phenotype of patients with gynecomastia, in particular antropometric assessment, breast ultrasound examination and hormonal testing, as well as to estimate possible causes of gynecomastia in studied population. MATERIAL AND METHODS: Two hundred-twenty men were enrolled in the study: 126 patients with gynecomastia and 94 healthy volunteers as a control group. Detailed medical examination, breast ultrasound and hormonal assays for T, E2, LH, FSH, SHBG, S-DHEA, PRL and TSH were performed. Calculation of free testosterone concentration was done. RESULTS: The results of clinical and hormonal evaluation enabled to divide the cases into three groups: patients with idiopathic gynecomastia (58 subjects, 46%), with hypogonadism (34 subjects, 27%) and drug-induced or associated with other disorders gynecomastia (34 subjects, 27%). We found that men with gynecomastia, particularly associated with hypogonadism, had significantly higher BMI compared with control group. Ultrasound examination revealed the positive correlation between breast tissue volume and BMI, duration of gynecomastia and estradiol level, while negative correlation with testosterone level. We demonstrated significant differences in LH, T, SHBG, fT and S-DHEA levels between cases and controls. There were no differences in PRL, FSH and TSH levels among groups. Significant elevation of SHBG concentration in all groups of patients, including idiopathic gynecomastia cases, compared with controls, was remarkable. CONCLUSION: Clinical evaluation and hormonal profile can help to classify patient with gynecomastia into one of three groups: idiopathic gynecomastia, associated with hypogonadism, and drug-induced or associated with other diseases. Idiopathic gynecomastia - of unknown etiology is diagnosed in almost half of all cases (46%). We showed that apart from well known hormonal disturbances leading to gynecomastia, like hypogonadism or hyperestrogenism, also subtle hormonal alterations, such as sex hormone binding globuline (SHBG) level elevation may contribute to breast enlargement.     

Recognition of the beta-subunit of human chorionic gonadotropin and sub-determinants by target tissue receptors.

The beta-subunit of human chorionic gonadotropin, purified immunochemically to eliminate undissociated human chorionic gonadotropin, induced testosterone production by mouse Leydig cells at concentrations 400-fold higher than human chorionic gonadotropin. Steroidogenesis was also stimulated by a synthetic fragment of the beta-subunit of human chorionic gonadotropin conforming to the peptide sequence residues 39--71, whereas peptide sequence residues 39--56 and three C-terminal fragments (residues 115--145, 111--145 and 101--145) failed to cause steroidogenesis. These studies suggest the presence in the beta-subunit of human chorionic gonadotropin of determinants recognized by the tissue receptors, a part of these determinants residing between amino acid residues 57--71.     

Modification of sialyl residues of gonadotropic hormones by reductive amination. Influence on biological activity and circulating half-life

The sialic acid residues of human chorionic gonadotropin, human lutropin and human follitropin were quantitatively modified by introduction of an amino compound. In radioreceptor assays, the modified chorionic gonadotropin, lutropin and follitropin saturated the receptors. However, in the low nanogram range, the gonadotropic binding was higher for the control compared to the modified sample.The hormonal activity of the chorionic gonadotropin was testedin vitro. The modified preparations were four- to thirteen-fold less stimulatory compared to the control but elicited the same maximal response. The biological activity of follitropin was determinedin vivo. In this case, the modified preparations were four- to five-fold less stimulatory than the control. Both the modified chorionic gonadotropin and follitropin preparations were found to act as agonists. Modification of the gonadotropin hormones did not significantly alter the immune recognition of these glycoproteins.The apparent circulating half-life in rats of the modified chorionic gonadotropin and follitropin was increased six- to nine-fold compared to that of native hormones; this might be a consequence of resistance of the modified sialyl residues to sialidases and the resultant slower exposure of terminal galactosyl residues; the plasma half-life of modified lutropin remained the same as that of the native hormone.Abbreviations hCG human chorionic gonadotropin - hLH human lutropin or luteinizing hormone - hFSF human follitropin or follicle stimulating hormone - mala methyl ester of alanine - hCG(ala, mala, etc.) human chorionic gonadotropin modified on sialicacid by reductive amination with alanine, methyl ester of alanine, etc. - IRP-HMG intact rat prostrate-human menopausal gonadotropin     

Regulation of testicular LH receptors by homologous hormone: in vitro studies on receptor occupancy and receptor loss.

A method is described which makes use of 4M MgCl₂ to dissociate the testicular luteinizing hormone-receptor complex without altering either the binding capacity or binding affinity of the receptor. Using this method, it was demonstrated that $\text{in vitro}$ incubation at 4° of decapsulated rat testes with various concentrations of luteinizing hormone or with human chorionic gonadotropin resulted in a reduction in binding capacity. This reduction of binding capacity could not be completely accounted for by occupation of receptors by homologous hormone, suggesting that receptors were lost. Thus negative regulation of LH receptors by LH and hCG was observed. The reduction in LH binding capacity was specific for LH and hCG, dose dependent and time related. FSH, prolactin and growth hormone did not exert the same effect.     

The use of monoclonal antibodies against human chorionic gonadotropin for immunoperoxidase staining of normal placenta, pituitary gland, and pituitary adenomas

A monoclonal mouse antibody to human chorionic gonadotropin (hCG) was used in a modified unlabeled antibody enzyme-bridge staining method to demonstrate the localization of hCG in normal human placenta, pituitary gland, and six pituitary chromophobe adenomas. Mouse ascitic fluid containing monoclonal antibody could be diluted up to 1:500,000 for detection of hCG in the syncytiotrophoblast, whereas no staining was observed in the pituitary or adenomas even with high antibody concentrations (dilutions from 1:500 upward). Nonspecific background staining was negligible. These results demonstrate that monoclonal antibodies are suitable for immunohistochemical localization of antigens in tissues.     

Estrogen and progesterone receptors in gynecomastia

The etiology of gynecomastia is unknown. There seems to be no increased incidence of malignancies in patients with idiopathic gynecomastia; however, patients with Klinefelter syndrome exhibit an increased incidence of malignancy. The authors reviewed the results of 34 patients with gynecomastia diagnosed in adolescence who, following initial evaluation, had a mastectomy. The estrogen and progesterone receptors were analyzed in these patients. Three of the patients were diagnosed with Klinefelter syndrome. These three patients exhibited elevated amounts of estrogen and progesterone receptors. None of the patients who were not diagnosed with this syndrome demonstrated significant elevation of their estrogen or progesterone receptors. The presence of elevated estrogen and progesterone receptors in patients with Klinefelter syndrome provides a potential mechanism by which these patients may develop breast neoplasms. The absence of elevated estrogen and progesterone receptors in patients with idiopathic gynecomastia may serve to clarify why these patients' disease rarely degenerates into malignancy.     

The porcine ovarian luteinizing hormone/human chorionic gonadotropin receptor II. Is the purified receptor an oligomer of identical subunits?

Purified porcine luteinizing hormone/human chorionic gonadotropin receptors were analyzed by sodium dodecyl sulfate/polyacrylamide gel electrophoresis following reduction and thermal denaturation and stained with Coomassie Brilliant Blue. A major protein of Mr = 77 +/- 4 X 10(3) and a minor protein of Mr = 66 +/- 4 X 10(3) were observed. Iodoreceptor proteins were resolved into a major component of Mr = 77 +/- 3 X 10(3) and a minor component of Mr = 62 +/- 5 X 10(3) after reduction and thermal denaturation. In the absence of reduction, the iodoreceptor had a major component of Mr 63 +/- 3 X 10(3). Purified human chorionic gonadotropin specifically transferred part of the iodoreceptor from the Mr = 63 X 10(3) species to an Mr = 110-120 X 10(3) species. Purified receptors were analyzed by nondenaturing polyacrylamide gel electrophoresis and identified by specific binding of iodo-human chorionic gonadotropin. Three binding species with approximate Mr = 60 X 10(3), 130 X 10(3), and 260 X 10(3) were identified. Iodoreceptors co-migrated with the Mr = 60 X 10(3) species under the same conditions. Similar results were obtained following renaturation of receptors separated by sodium dodecyl sulfate/polyacrylamide gel electrophoresis without reduction and thermal denaturation. These results suggest for the first time that the porcine corpus luteum luteinizing hormone/human chorionic gonadotropin receptor may be a hormone binding monomer of Mr = 60-65 X 10(3), and that the monomer may associate to form hormone binding polymeric receptor complexes.     

Regulation of infant and developing rat testicular gonadotropin and prolactin receptors and steroidogenesis by treatments with human chorionic gonadotropin, gonadotropin-releasing hormone analogs, bromocriptine, prolactin, and estrogen

Infant (5-day-old) male rats were treated with hormonal regimens to alter their exposure to gonadotropins, prolactin (Prl), and estrogen, and the response of testicular endocrine functions was measured. Human chorionic gonadotropin (hCG) or a potent gonadotropin-releasing hormone agonist analog (GnRH-A) resulted in a short-lived decrease of testicular receptors (R) for luteinizing hormone (LH), but no deleterious effects were found on testicular capacity to produce testosterone (T), which is a typical response of the adult testis. Only GnRH-A, through probable direct testicular action, induced a relative blockade of C21 steroid side-chain cleavage that was observed in vitro upon hCG stimulation. Human chorionic gonadotropin treatment, but not GnRH-A treatment, increased testicular Prl-R. GnRH antagonist analog (GnRH-Ant) treatment did not affect testicular LH-R, but decreased Prl-R and testicular T production. Decrease of serum Prl by bromocriptine had no effect on testicular LH-R or Prl-R, but slightly decreased T production in vitro. Ovine Prl increased binding sites for LH/hCG. The postnatal rats were insensitive to negative effects of diethylstilbestrol when monitored by testis weight, T, and LH-R. In conclusion, the responses to changes in the hormonal environment differed greatly between infant and adult testes. Mainly positive effects of elevated gonadotropin and Prl levels were seen on infant rat Leydig cell functions. Likewise, decreased tropic hormone levels, and exposure to estrogen, were ineffective in bringing about the inhibitory actions seen in the adult.     

Effects of prolactin on progestin secretion by human granulosa cells in culture

Concentrations of human prolactin (hPrl) greater than or equal to 600 ng/ml produced inhibition of progestin production in cultures of granulosa cells pooled from follicles of women stimulated with clomiphene citrate-human chorionic gonadotropin (hCG). However, cells collected from follicles of human menopausal gonadotropin (HMG)-hCG-treated patients did not demonstrate a significant reduction in progestin secretion in response to hPrl. We conclude that high concentrations of hPrl can result in inhibition of steroidogenesis, but the expression of the inhibitory effects of Prl depends upon the hormonal treatments used to stimulate follicular growth.     

Effect of super-ovulatory doses of pregnant mare serum gonadotropin and human chorionic gonadotropin in blastocyst implantation in golden hamsters

The effect of super-ovulatory dose of pregnant mare serum gonadotropin and human chorionic gonadotropin on ovulation, advancement of ovulation, subsequent embryo development and implantation were studied in the hamster. Groups of hamsters received pregnant mare serum gonadotropin injection on day 1 of the estrous cycle followed by human chorionic gonadotropin injection either at 56 or 76 h later, pregnant mare serum gonadotropin alone on day 1 or human chorionic gonadotropin alone on day 3.The combination therapy (pregnant mare serum gonadotropin and human chorionic gonadotropin) resulted in super-ovulation (an average of 40 mature ova/animal) while human chorionic gonadotropin alone yielded an average of 10 mature ova/animal. Ovulation was advanced by 24 h by giving human chorionic gonadotropin at 56 h instead of 76 h after pregnant mare serum gonadotropin. Subsequent embryo development and implantation occurring under different hormonal regimens were studied. The ova obtained by giving human chorionic gonadotropin injection at 56 h were poorly fertilizablein vivo and hence the pregnancy rate was low (6 %). These ova however, were fertilizablein vitro, suggesting that the low fertilization rate and developmental failure may be due to inhibition of sperm capacitation/transport because of premature human chorionic gonadotropin administration. In the group receiving human chorionic gonadotropin alone on day 3 there was fertilization and cleavage, but no implantation occurred due to failure of functional corpora lutea. However, administration of progesterone and estrone from day 2 of gestation resulted in 80% implantation and sustenance of pregnancy. On the other hand, the pregnant mare serum gonadotropin and human chorionic gonadotropin combination therapy resulted in super-pregnancy. The number of fetuses present at term was higher in the group receiving pregnant mare serum gonadotropin alone than in the group receiving the combination therapy. Embryo resorption however was higher (37%) in the latter group compared with the former (9.5%). However, preimplantation embryos were found to be viable as evidenced by fluorescein diacetate staining.