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 Table of Contents  
POSTGRADUATE FORUM
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 115-118

Smoker with unilateral enlarged breast


Department of Respiratory Medicine, A.J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India

Date of Submission04-Jul-2021
Date of Acceptance23-Aug-2021
Date of Web Publication17-Aug-2022

Correspondence Address:
Dr. Vishnu M Sharma
Department of Respiratory Medicine, A.J. Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jalh.jalh_16_21

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  Abstract 


Intrathoracic tumors can present with paraneoplastic manifestations. We discuss a paraneoplastic manifestation as an interactive discussion. We have focused the discussion on clinical approach to the case.

Keywords: Bronchogenic carcinoma, causes of gynecomastia, gynecomastia, intrathoracic tumor, paraneoplastic manifestation


How to cite this article:
Sharma VM. Smoker with unilateral enlarged breast. J Adv Lung Health 2022;2:115-8

How to cite this URL:
Sharma VM. Smoker with unilateral enlarged breast. J Adv Lung Health [serial online] 2022 [cited 2022 Sep 25];2:115-8. Available from: http://www.jalh.com/text.asp?2022/2/3/115/353866




  History Top


A 59-year-old male patient presented with insidious onset of cough, occasional streaky hemoptysis since the last 3 months. He had scanty mucoid sputum. He had noticed enlargement of his left breast since the last 1 month. He had no history of chest pain, breathlessness, change in voice, wheezing, or stridor. He had no fever, weight loss, or recent weight gain. He had no cardiac symptoms, gastrointestinal symptoms or symptoms referable to other systems. He was a heavy smoker with smoking index of 819. No history of alcohol intake, drug addiction, liver disease, or any other chronic illness. He had type 2 diabetes since the last 3 months, on metformin tablet once daily. His diabetes was well controlled. He was not on any other long-term medications. He was married, has two children. No history of erectile dysfunction.

Question 1: Which of the following is the most likely cause for his symptoms?

  1. Bronchogenic carcinoma
  2. Pulmonary tuberculosis
  3. Mediastinal tumor
  4. Chronic obstructive pulmonary disease (COPD)
  5. Bronchiectasis.


Answer: A. Most common cause for chronic cough with streaky hemoptysis in an elderly smoker is bronchogenic carcinoma.[1] He has no symptoms such as fever, weight loss, or other systemic symptoms. Hence, pulmonary tuberculosis is less likely. Hemoptysis is an uncommon symptom in mediastinal tumor. Symptoms only since 3 months, without any history of breathlessness, and history of hemoptysis is less likely in COPD.


  Physical Examination Top


He had grade 3 clubbing [Figure 1]. He had no palpable cervical or peripheral lymph nodes. No thyroid swelling. He had no signs of chronic liver disease or chronic renal disease. His secondary sexual characters were normal. Testes and external genitalia were normal. His body mass index was 23.4 kg/m2.
Figure 1: Clubbing

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On inspection, he had enlargement of the left breast compared to the right breast [Figure 2]. Firm breast tissue could be palpated on the left side which was concentric with the nipple-areolar complex. There was no nipple retraction or discharge from the nipple. No breast tenderness on palpation. No palpable axillary lymph nodes.
Figure 2: Enlarged left breast

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Question 2: Which of the following is diagnostic of gynecomastia?

  1. Enlarged breast on inspection
  2. Palpation of firm breast tissue concentric with nipple-areolar complex
  3. Nipple retraction
  4. Hard irregular beast lump on palpation
  5. Breast lump with skin dimpling located outside the areola.


Answer: B. Other features (C, D, E) are suggestive of male breast carcinoma.[2] Pseudo gynecomastia and gynecomastia are the common cause for enlargement of male breast. Gynecomastia should be confirmed by palpation. Gynecomastia is characterized by glandular and stromal tissue in male breast. Pseudo gynecomastia is excess fat in breast which occurs due to obesity.[1] In pseudo gynecomastia, no breast tissue will be felt on palpation.

Respiratory system examination showed evidence of volume loss, and reduced breath sounds in areas corresponding to the right lower lobe. The abdomen and other systemic examination was normal.

Question 3: Which of the following is the most likely cause of gynecomastia in this patient?

  1. Bronchogenic carcinoma
  2. Hypogonadism
  3. Physiological
  4. Diabetes mellitus
  5. Metformin.


Answer: A. He was married and had two children. His secondary sexual characteristics were normal. He had no physical features of hypogonadism. He had no history of erectile dysfunction. Physiological gynecomastia occurs usually after the age of 60 years and is bilateral. Long-standing type 1 diabetes can lead to gynecomastia but not type 2 diabetes.[3] Gynecomastia as an adverse effect of metformin is not described in literature. History of smoking, age, and respiratory symptoms point toward the possibility of bronchogenic carcinoma. He had no other obvious cause for gynecomastia.

Question 4: Which of the following is not a common cause for gynecomastia?

  1. Medications
  2. Chronic liver disease
  3. Physiological
  4. Substance abuse
  5. Herbal product use.


Answer: E. Herbal products like plant oils, such as tea tree or lavender, used in shampoos, soaps, or lotions can rarely cause gynecomastia. This is probably due to their weak estrogenic activity.[3] Anti-anxiety medications such as diazepam, tricyclic antidepressants, Isoniazid, Metronidazole. Cimetidine, Anti-cancer drugs, Digoxin, calcium channel blockers. Metoclopramide is some commonly used medications which can lead to gynecomastia.

Question 5: Which of the following intrathoracic tumor is NOT associated with gynecomastia?

  1. Seminomatous germ cell tumors of mediastinum
  2. Teratoma
  3. Bronchogenic carcinoma
  4. Nonseminomatous germ cell tumors of mediastinum
  5. Carcinoid tumor.


Answer: E. Gynecomastia is not described in literature as a paraneoplastic manifestation in carcinoid tumors.[4]

Chest X-ray posteroanterior view was taken [Figure 3].
Figure 3: Chest X-ray posteroanterior view

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Question 6: What is the radiological abnormality?

  1. Encysted pleural effusion right side
  2. Partial collapse of right lower lobe
  3. Right lower lobe consolidation
  4. Right middle lobe collapse
  5. Right lower lobe collapse.


Answer: B. [Figure 3] shows volume loss on the right mid and lower zone due to an opacity causing silhouetting of a part of diaphragm suggestive of partial collapse lower lobe.

Question 7: Which of the following investigation will be least useful in diagnosis in this patient?

  1. Contrast-enhanced computed tomography (CT) scan of thorax
  2. Sputum cytology for malignant cells
  3. Bronchoscopy
  4. CT guided biopsy from the lesion
  5. Spirometry.


Answer: E. The patient has no symptoms or signs of obstructive airway disease. Hence, spirometry has no role in this patient as a diagnostic workup. Partial collapse of the right lower lobe indicates endobronchial obstruction by tumor which is likely to be visible on bronchoscopy. Contrast-enhanced CT scan of thorax prior to bronchoscopy will be useful to detect the extent of the tumor, mediastinal lymph nodes, if any. Sputum cytology may give a positive yield in up to 60% of central bronchogenic carcinoma. CT-guided biopsy can be considered if bronchoscopy does not show endobronchial lesion.

Bronchoscopy showed endobronchial lesion occluding the right intermediate bronchus. Bronchoscopic biopsy confirmed squamous cell carcinoma. The patient was referred to the oncology department for further management.

Question 8: Which of the following is the mechanism of gynecomastia in intrathoracic tumors?

  1. Increased production of human chorionic gonadotrophin (hCG)
  2. Increased production of alpha-fetoprotein
  3. Increased production of luteinizing hormone (LH)
  4. Increased production of estrogen
  5. Increased production of testosterone.


Answer: A. hCG acts as LH analog to stimulate leydig cells to produce more estrogen and less testosterone leading to gynecomastia. Gynecomastia occurs due to an increase in estrogen production, relative decrease in androgen production, or a combination of both.[2]

Hormonal estimation in this patient showed raised levels of hCG thus confirming the paraneoplastic etiology. The patient was referred to the oncology department for further management.


  Discussion Top


Gynecomastia can affect one or both breasts, sometimes unevenly. Newborns, during puberty and elderly men may develop gynecomastia as a result of physiological changes in hormone levels. When physiological, it usually does not lead to any symptoms.[2] Gynecomastia can lead to embarrassment and psychological stress. Occasionally, it can cause pain in the breast. Pathological gynecomastia leads to five-fold greater risk for developing male breast cancer when compared with the general population.[2] The hormonal changes (relative increase in estrogens, lower levels of androgens) that produce gynecomastia in adult men increase the risk of developing breast cancer.

Causes for gynecomastia

Physiological

Newborns, during puberty, and elderly men.[2]

Pathological

Medications, drug abuse and addictions, chronic diseases, neoplasms, starvation, stressful life events,[2] long-standing Type 1 diabetes mellitus.

Medications

Anti-androgens which are commonly used to treat an enlarged prostate and prostate cancer can lead to gynecomastia. These drugs include flutamide, finasteride, and spironolactone.[2] Anabolic steroids and androgens, which are prescribed by doctors for certain conditions or sometimes used illegally by athletes to build muscle and enhance performance, can lead to gynecomastia.

HIV medications

Gynecomastia can develop HIV-positive men receiving highly active antiretroviral therapy. Efavirenz is more commonly associated with gynecomastia than are other HIV medications.

Anti-anxiety medications, such as diazepam, tricyclic antidepressants, INH, Metronidazole. Cimetidine, and Anti-cancer drugs, Digoxin, calcium channel blockers. Metoclopramide are some of the commonly used medications which can lead to gynecomastia.

Substance abuse such as alcohol, amphetamines, marijuana, heroin, and methadone can lead to gynecomastia.

Hypogonadism

Conditions that interfere with normal testosterone production, such as Klinefelter syndrome or pituitary insufficiency.

Aging

Hormone changes that occur with normal aging can cause gynecomastia, especially in men who are overweight.

Tumors

Tumors of the testes, intrathoracic tumors such as bronchogenic carcinoma, teratoma and germ cell tumors, adrenal glands or pituitary gland, can produce hormones that alter the male-female hormone balance.

Hyperthyroidism

Due to excess thyroxine, several chronic illnesses can cause gynecomastia by imbalance of hormones.

Chronic kidney disease

About half the people being treated with dialysis experience gynecomastia due to hormonal changes.

Chronic liver disease and cirrhosis

Changes in hormone levels due to liver disease and cirrhosis medications are associated with gynecomastia.

Malnutrition and starvation

During starvation, testosterone levels drop while estrogen levels remain the same, causing a hormonal imbalance.

Herbal products

Plant oils, such as tea tree or lavender, used in shampoos, soaps, or lotions have been associated with gynecomastia. This is probably due to their weak estrogenic activity.

Gynecomastia is reported in 2.4% of patients with lung cancer as a paraneoplastic manifestation.[5] In some patients, gynecomastia may appear before the onset of symptoms and signs of lung cancer. Hence, a focused history, physical examination, and appropriate investigations are essential in all patients with gynecomastia to find out the underlying cause. Gynecomastia may regress if the underlying cause is treated.

Learning points

Gynecomastia can be a paraneoplastic manifestation of underlying bronchogenic carcinoma. Focused history, physical examination, and appropriate investigations to find out any physiological cause, hormonal imbalance, medication use, substance abuse, underlying chronic illness, intrathoracic tumors will lead to prompt diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cuhaci N, Polat SB, Evranos B, Ersoy R, Cakir B. Gynecomastia: Clinical evaluation and management. Indian J Endocrinol Metab 2014;18:150-8.  Back to cited text no. 1
    
2.
Barros AC, Sampaio Mde C. Gynecomastia: Physiopathology, evaluation and treatment. Sao Paulo Med J 2012;130:187-97.  Back to cited text no. 2
    
3.
Magro G, Gangemi P, Villari L, Greco P. Deciduoid-like stromal cells in a diabetic patient with bilateral gynecomastia: A potential diagnostic pitfall. Virchows Arch 2004;445:659-60.  Back to cited text no. 3
    
4.
Birring SS, Peake MD. Symptoms and the early diagnosis of lung cancer. Thora×2005;60:268-9.  Back to cited text no. 4
    
5.
Wu R, Fang W, Lin L. The clinical analysis of lung cancer with paraneoplastic syndrome as initial symptom. Zhongguo Fei Ai Za Zhi 2003;6:204-5.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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