A 14-year-old boy is brought to the office due to a breast lump. For the last 2 months, he has felt a mass under his right nipple. The patient has no medical conditions and smokes 1 or 2 cigarettes per day. He takes no medications and does not use alcohol or illicit drugs. His grandmother developed breast cancer at age 64. The patient's height and weight are at the 60th and 40th percentiles, respectively. Physical examination reveals tender, glandular, right subareolar breast tissue that is 3 cm (1.2 in) in diameter. There is no overlying erythema or warmth, and no discharge can be expressed from the nipple. The left chest wall is flat without palpable breast tissue. He has Tanner 3 genitalia, including normal testicular volume. What is the most appropriate next step in the management of this patient?

Question

A 14-year-old boy is brought to the office due to a breast lump.  For the last 2 months, he has felt a mass under his right nipple.  The patient has no medical conditions and smokes 1 or 2 cigarettes per day.  He takes no medications and does not use alcohol or illicit drugs.  His grandmother developed breast cancer at age 64.  The patient's height and weight are at the 60th and 40th percentiles, respectively.  Physical examination reveals tender, glandular, right subareolar breast tissue that is 3 cm (1.2 in) in diameter.  There is no overlying erythema or warmth, and no discharge can be expressed from the nipple.  The left chest wall is flat without palpable breast tissue.  He has Tanner 3 genitalia, including normal testicular volume.  What is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d66c_475f_bc81_dd3333a5935b_MD0003_00 Pubertal gynecomastia is a benign, physiologic condition characterized by gradually enlarging, glandular breast tissue in adolescent boys. It most commonly occurs in boys age 12-14 during midpuberty (Tanner stage 3-4) due to transiently increased testicular production of estrogen compared with testosterone and peripheral conversion of prohormones to estrogen. Patients typically have a small (<4 cm), firm, unilateral or bilateral, subareolar mass that may be tender to the touch. Laboratory and radiologic evaluation are unnecessary in patients without pathologic features (eg, nipple discharge, axillary lymphadenopathy, rapidly enlarging mass). Management of pubertal gynecomastia includes reassurance and observation because it usually resolves within a year. (Choice A) Breast biopsy is indicated in patients with suspected cancer, which is extremely rare in adolescent boys. Presentation includes a nontender, fixed mass, overlying skin changes, nipple discharge/bleeding, and lymphadenopathy. (Choice B) Breast ultrasound can be used to identify breast masses such as cysts, which are typically located peripherally. This patient's subareolar breast tissue is classic for pubertal gynecomastia. (Choice C) Karyotype is indicated in patients with suspected Klinefelter syndrome, a condition that occurs in males born with an extra copy of the X chromosome (47,XXY). It usually presents with small, firm testes and bilateral gynecomastia. This patient's normal testicular volume and unilateral gynecomastia make Klinefelter syndrome unlikely. Klinefelter syndrome (Choice E) A prolactinoma, a prolactin-producing pituitary tumor, can lead to hypogonadotropic hypogonadism (ie, suppressed testosterone production) in males. Symptoms may include bilateral gynecomastia and galactorrhea. This patient's unilateral breast tissue without discharge makes further evaluation with a serum prolactin level test unnecessary. (Choice F) Urine toxicology screening can identify certain substances (eg, anabolic steroids, marijuana, alcohol) that, if chronically abused, can lead to bilateral gynecomastia. This patient has unilateral breast tissue and does not use alcohol or illicit drugs. Educational objective: Pubertal gynecomastia is common in adolescent boys during midpuberty due to transiently increased estrogen. Breast tissue can be present unilaterally or bilaterally and is often tender. The condition usually resolves within a year. References: Adolescent gynecomastia. (http://www.ncbi.nlm.nih.gov/pubmed/28613047) Gynecomastia and hormones. (http://www.ncbi.nlm.nih.gov/pubmed/27145756)

A 14-Year-Old Boy Is Brought to the Office Due to a Breast