American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Gynecomastia: Look Beyond the Obvious

Histology confirmed the diagnosis of papillary urothelial carcinoma of the bladder with expression of human chorionic gonadotropin (hCG) [(A) Papillary urothelial carcinoma pTaG1, hematoxylin and eosin (H&E), 200×; (B) Distribution of hCG-expressing urothelial cells: irregular and focal expression, immunohistochemical stain (brown) for β-hCG, 300×; (C) Expression of hCG in urothelial carcinoma cells: intracytoplasmic and intranuclear expression, immunohistochemical stain for β-hCG, 400×].

Histology confirmed the diagnosis of papillary urothelial carcinoma of the bladder with expression of human chorionic gonadotropin (hCG) [(A) Papillary urothelial carcinoma pTaG1, hematoxylin and eosin (H&E), 200×; (B) Distribution of hCG-expressing urothelial cells: irregular and focal expression, immunohistochemical stain (brown) for β-hCG, 300×; (C) Expression of hCG in urothelial carcinoma cells: intracytoplasmic and intranuclear expression, immunohistochemical stain for β-hCG, 400×].

A 29-year-old man was referred to our clinic with a 4-week history of a tender predominant left breast enlargement without nipple discharge. He had been practicing bodybuilding regularly for years, but denied taking anabolic androgenic steroids. His past medical history was unremarkable apart from surgical treatment of undescended testes in childhood. His sexual desire and erectile function were normal. He had no family history of breast or testicular cancer.

Physical examination confirmed small palpable masses of tissue predominantly in the left breast.

Ultrasound of the breast and mammography showed the typical appearance of gynecomastia without features of malignancy.

Serum chemistry and complete blood count were all in the normal range. Hormonal studies showed normal plasma levels of prolactin, thyroid-stimulating hormone, and cortisol. Testosterone was in the high-normal range and his estradiol was elevated, while the gonadotropins were suppressed. The tumor marker α-fetoprotein was normal; human chorionic gonadotropin (hCG) was elevated. Laboratory values are summarized in the Table.

Testicular ultrasonography revealed atrophy of the left testicle and a normal right testicle. Chest computed tomography scan showed no abnormalities; cranial magnetic resonance imaging also was normal. Abdominal computed tomography demonstrated a localized thickening of a bladder wall segment. Because of an episode of gross painless hematuria, he underwent cystoscopy. On cystoscopy, a small, unifocal bladder wall tumor was noted, followed by transurethral resection of the bladder tumor. Histology revealed papillary low-grade superficial urothelial carcinoma of the bladder, with no invasion into the lamina propria (noninvasive papillary carcinoma pTa G1 N0 M0 according to the TNM Classification of Malignant Tumours, Eight Edition.1) with ectopic expression of hCG (Figure). Over the following weeks, hCG was no longer detectable, his sex hormones returned to normal, and gynecomastia completely regressed.

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-Thomas Pusl, MD, Peter Stoemmer, MD

This article originally appeared in the October 2017 issue of The American Journal of Medicine.

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