Mastalgia and Gynecomastia

Duration of breast enlargement
Presence of breast pain or tenderness
Drug history
Sexual Function
Chagnes in virilization
Chagnes in weight
Symptoms of hypertyoidism

Laboratory evaluation
Serum creatinine
Liver enzymes
TSH, free T4
Testosteron, LH, FSH, Estradiol, prolatin
serum DHA or Urine 17-ketosteroids

Consulting and Coordination of Care
Causes and natural history of gynecomastia and mastalgia were discussed. While 20-25% of gynecomastia is drug-induced, even with detailed evaluation, there is no identifiable cause in 25% of cases. Other common causes of gynecomastia includes aging, renal failure and dialysis, cirrhosis of the liver, hyperthyroidism, stressful life events associated with increase serum cortisol and estradiol levels. Mr. «??» has been on androgen blockade for prostate cancer and it is the likely cause of his gynecomastia and mastalgia….

Drug-induced symptoms may regress with discontinuation of the offending-drug, but Mr. «??» continues to have symptoms despite being off of androgen deprivation therapy for «??» months.
— OR —
It would risk progression or recurrence of prostate cancer, Mr «??» were to discontinue his androgen deprivation therapy.

Treatments for gynecomastia and mastalgia are generally medical, radiation and surgery. In patients with prostate cancer, androgens would risk progression or recurrence of prostate cancer. Reducing estrogen levels could theoretically increase androgen secretion by blocking or decresing the negative feedback of estradiol on the hypothalamic-pituitary axis. When gynacomastia has been present for more than 2 years, medical therapy is not usually effective. Surgical techniques may be an option in these cases. however results are cosmetically unsatisfactory in up to 50% of patients, and some may have loss of nipple sensation. Radiation can be efficacious for prevention or treatment of established gynacomastia and mastalgia with ~70% resolution of symptoms. Radiation is associated with well-tolerated adverse events such as breast or nipple erythema and skin irritation which in general are short lived. (Perdona, Autorino Lancet Onc 2005).

Patient stated that he understood the various options, and he stated he would like to proceed with radiation treatment. The risks and benefits of radiation therapy were discussed in detail and all of his questions were answered to his satisfaction. We simulated him today on the treatment machine. The breast tissue was palpated and a cone encompassing the tissue was selected and placed. 12 MeV electron energy was chosen to treat to the depth of the breast tissue. Appropriate dosimetric calculations will be performed prior to starting therapy.

Thank you for asking us to see Mr. «??». It was our pleasure.

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