A 14-year-old boy comes to the office with his mother for a well-child visit. He is in 9th grade and recently joined the football team. His diet is well-varied and includes fruits, vegetables, meat, and dairy. He had rhinorrhea and cough last week that resolved on its own. Otherwise, the patient has no medical problems and takes no medications. Height has increased by 7.5 cm (3 in) since his last physical, and he has gained 3.2 kg (7 lb); BMI is at the 65th percentile. The mother leaves the room while the patient undergoes physical examination and continued discussion with his health care provider. The boy is not sexually active. He drinks 1 or 2 beers on weekends and has never tried cigarettes or drugs. When asked if he would like to discuss any additional issues in private, the boy says, "This is so embarrassing, but I think something is wrong. My chest is getting bigger. I didn't want to tell my mom because my grandma died from breast cancer last year." Physical examination shows a nervous and alert boy. Palpation of the chest reveals a 3-cm (1.2-in), firm, mobile mass beneath the areola bilaterally. There is no skin dimpling or nipple discharge. The testes are descended bilaterally, and genital examination reveals Tanner stage III pubic hair. A 0.5-cm soft, mobile node is palpated on his right anterior cervical chain. The remainder of the physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 14-year-old boy comes to the office with his mother for a well-child visit.  He is in 9th grade and recently joined the football team.  His diet is well-varied and includes fruits, vegetables, meat, and dairy.  He had rhinorrhea and cough last week that resolved on its own.  Otherwise, the patient has no medical problems and takes no medications.  Height has increased by 7.5 cm (3 in) since his last physical, and he has gained 3.2 kg (7 lb); BMI is at the 65th percentile.  The mother leaves the room while the patient undergoes physical examination and continued discussion with his health care provider.  The boy is not sexually active.  He drinks 1 or 2 beers on weekends and has never tried cigarettes or drugs.  When asked if he would like to discuss any additional issues in private, the boy says, "This is so embarrassing, but I think something is wrong.  My chest is getting bigger.  I didn't want to tell my mom because my grandma died from breast cancer last year."  Physical examination shows a nervous and alert boy.  Palpation of the chest reveals a 3-cm (1.2-in), firm, mobile mass beneath the areola bilaterally.  There is no skin dimpling or nipple discharge.  The testes are descended bilaterally, and genital examination reveals Tanner stage III pubic hair.  A 0.5-cm soft, mobile node is palpated on his right anterior cervical chain.  The remainder of the physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bebc_d777_8f63_cbbae7a77900_MD0005_00 Physiologic gynecomastia is very common in pubertal boys due to relative excess estrogen production and resulting imbalance of estrogen and androgens. Patients present during mid-puberty (ie, Tanner stage III-IV) with a unilateral or bilateral mass or lump beneath the areola. This breast tissue is typically small (<4 cm), firm, tender, and disc-like in shape. Physiologic gynecomastia must be differentiated from pseudogynecomastia (deposition of fat in overweight or obese boys), which will not present as a palpable mass. Breast tissue may slowly increase in size, but pubertal gynecomastia resolves within a year in the majority of boys. Although gynecomastia can cause embarrassment and anxiety, medical intervention is not necessary and reassurance and observation are indicated at this time. (Choices A, B, and E) An evaluation is indicated for signs of pathologic gynecomastia. Breast cancer is exceedingly rare in this population, but skin dimpling, rapidly increasing mass size, or axillary lymphadenopathy warrant imaging (eg, ultrasound) and/or tissue biopsy. A serum prolactin level should be obtained in the presence of galactorrhea to evaluate for a prolactinoma. In addition, gynecomastia in a prepubertal boy warrants evaluation by an endocrinologist to assess for pathologic hormonal imbalance (eg, hyperthyroidism, hCG-secreting tumor). (Choice C) Many exogenous substances, including marijuana and anabolic steroids, can exaggerate the physiologic imbalance of estrogens and androgens and cause gynecomastia. Although this patient should be counseled on substances that can worsen his physiologic gynecomastia, a urine toxicology screen is not necessary in a patient with no history of substance abuse. Educational objective: Gynecomastia is a common physiologic finding in pubertal boys. Presentation includes a small, often tender, subareolar mass that may grow but typically resolves within a year. No treatment is required. References: Gynecomastia in adolescent males. Page(s): PMC3706045 (http://www.ncbi.nlm.nih.gov/pubmed/3706045) Gynecomastia: clinical evaluation and management. Page(s): PMC3987263 (http://www.ncbi.nlm.nih.gov/pubmed/3987263)

A 14-Year-Old Boy Comes to the Office with His Mother