Tuesday, April 21, 2009


I walked into the family practice clinic at the Veteran's hospital.  At least I thought it was the family practice area - the VA is a complex geometrical maze of colored arrows on the floor and confusing signs on the wall.  Family practice was a less familiar haunt, during my cytology fellowship, than radiology or ENT, so I often got confused when called down to perform a needle biopsy on a patient in this area.  The cheerful desk attendant recognized me and guided me to the nurse practitioner's office, who re-iterated what she had already told me over the phone, as if I was someone new.  

"It's a breast mass.  Under his nipple.  You'll feel it.  I'm worried about it.  He says it's been there for a while, but better safe than sorry."

I hated getting called for male breast masses.  I have never known any cytologist under which I have trained that has yielded more interesting results than benign adipose tissue or the proliferation of benign glandular ducts that defines the condition of gynecomastia.  Male breast hypertrophy has many etiologies including drugs, prostate cancer therapy, low testosterone, or high estrogen states due to adrenal tumors, liver disease, or obesity, to name a few.  When the breasts hypertrophy they often develop vague, irregular nodules.  Sometimes, the patient becomes worried about a nodule, and a quick needle biopsy can reassure them that it is not cancer.  In other cases, the clinician palpates the mass and opts for a good night's sleep by calling a cytologist, to confirm benignity.  Men can get breast cancer, I don't want to downplay that possibility, but it is exceedingly rare.

Breast masses caused by gynecomastia are tough to hit and require aggressiveness to yield cellular material.  If you only get fatty tissue, without the benign glandular elements, it is "non-diagnostic" - which pleases no one.  A mass in the female breast is often easier to manipulate and stabilize within the fatty tissue, but I had only performed that once - the takeover of ultrasound guided core biopsies, a procedure performed by radiologists, had predated my fellowship.  A more likely call for a cytologist is a chest wall mass in a woman post-mastectomy to rule out (or in) recurrence of the breast cancer.  In this case, the cancer usually recurs in or on the muscle directly below the skin and scar.  Intuitively, a male breast mass would be easier to hit without all of the excess fat, but the irregular, dense nature of the lesion - think bumblebee trying to artfully gouge an large eraser - prevents easy access.

Cancer is not only easier to stick than benign entities - it is a hard, fixed lesion - it is also, generally speaking, much less painful.  Gynecomastia is by far one of the most subjectively painful procedures I had to perform.  Guys don't like it, and are often surprised at how much it hurts.  I have seen many men squeeze back tears and yelp in pain.  One flat out refused the second and third pass with the needle that are often required for any hope of diagnostic material.  I could hardly blame him.  

The nurse practitioner led me into the peach-colored clinic room.  A leather motorcycle jacket was slung over a low chair, and a tall, hulking man in a white t-shirt, jeans, and black work boots was perched on a flat examining table.  I had performed enough of these procedures during the year to learn that I liked the patient to lie down, but I briefly considered leaving him sitting - I couldn't possibly imagine him fitting comfortably in a supine state.  Then I pictured the multiple possible angles from which I could perform the procedure while he was sitting up -- all being terribly awkward -- so I walked over to the end of the examining table and pulled out the extended portion as far as it would go.  I asked him to take off his t-shirt and lie down.

I usually like to feel out a patient's propensity for chattiness -- many times engaging someone in conversation will distract and alleviate from the anxiety of the impending procedure.  But I am often relieved when my honest efforts aren't encouraged - I can just explain the procedure, get the consent, and concentrate on what I am doing.  This patient didn't require small talk, so I started working.  Examining a male breast is different than a female.  I remember the first time I did it I automatically pulled the modest, political correct female beast exam way of covering one while examining and/or performing a procedure on the other.  As I did it I felt silly - after all, men bare their chests all the time and probably don't care.  

I could feel the fibrotic nodule under the nipple.  I had never stuck a lesion directly under the nipple, and contemplated my approach.  I decided to go in directly outside of the areola and angle down and inward, so I could saw back and forth in a wide, sweeping arc.  I worried - from my own experience, the nipple is a pretty sensitive area, and I already knew that these lesions were painful.  I plunged in and started working, checking his face out of the corner of my eye for signs of distress.  There were none.  I performed the second and third pass quickly.  Before I pulled my needle out for the last time, I looked at his hands.  His fists were clenched, knuckles white.  I wondered about nail marks on his palms.

I thought of this yesterday when I was reading a dictation on a reduction mammoplasty - we get these all the time - I think reducing your breast size may be more popular than enhancing it - and the name was male.  Unusual, but not unheard of.  But it would be unusual, thank goodness, these days, for me to do a procedure for male gynecomastia - I haven't since my fellowship.  Maybe someone else is capturing that business, or maybe that was just the diagnostic trend at my training hospital.  Who knows.  But I am really glad they are in my past.  It's no fun to hurt people.


Anonymous said...

don't leave me in suspense!! was it cancer??

Gizabeth Shyder said...

No silly, gynecomastia!!! Was it EVER cancer for you?

trisha said...

well, i thought maybe this would be the exception case...ha,ha!

Gizabeth Shyder said...

Probably would have made for a better story, huh? There was only one guy I was ever really worried about - he had a big nodule in the upper outer quadrant, but also bad liver disease -- JUST GYNECOMASTIA.

Cosmetic Guru said...

Great post! Thanks for the informative and insightful view.

Anonymous said...

Gizabeth, I am having a very sore nodular like lump right under my areola under my nipple. It throbs and stings and my breast on the left side has gotten quite larger than the right. My right boob is fine. I have been on Nexium therapy and cimetidine tablets to treat heartburn for a long time. Do I have a liver that is secreting estrogen? Is it normal for a breast nodule or rubbery small mass to hurt like this?

Gizabeth Shyder said...

Go to a doctor and get it checked out!!