Wednesday, December 8, 2010

Gynecomastia: Is Pathologic Examination Justified?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Most medical centers routinely perform or require that breast tissue be sent to pathology for histologic examination.  The authors of the article (referenced below) question whether this is useful when the breast tissue excised comes from an adolescent male with gynecomastia considering the benign nature of the condition.
Furthermore, the authors point out male breast cancer is rare and when it does occur it is most often in older males, not adolescent males.
In 2009, there were an estimated 1,910 new cases and 440 deaths related to male breast cancer, accounting for just 0.25% and 0.15% of all new cases of cancer and cancer deaths for males in the entire United States, respectively, with historical cohorts demonstrating that the peak incidence of male breast cancer occurs at approximately 71 years of age.  More significantly, breast cancer becomes increasingly uncommon among younger age groups.
To look at the issue, the authors did a retrospective chart review  of their patients younger than 21 years of age who had undergone subcutaneous mastectomy for gynecomastia between 1999 and 2010.  A review of the literature was done, as was an informal survey of major children's hospitals regarding their practice of histologic examination for adolescent gynecomastia.
The authors had  81 patients during the time period.  All cases were negative for malignancy, with only one case of cellular atypia.
The literature review found only 36 articles which discussed cases of adolescent gynecomastia and the associated pathologic results, resulting in data for 615 individuals.  Of these 615 individuals, there have been six cases of cancer and five cases of ADH.  The average age of patients involved was 17.4 years (range 16-20 years) and 43% of cases presented with unilateral gynecomastia. 
Of twenty-two survey respondents, all either routinely performed or required histologic examination of breast tissue excised for gynecomastia. The out-of-pocket costs for self-pay patients to perform pathologic exam has been quoted at $1,268 for bilateral cases.
The authors conclude:
The incidence of malignancy or abnormal pathology associated with gynecomastia tissue in the adolescent male is extremely low, and given the costs associated, the histologic examination of breast tissue excised for gynecomastia in individuals 21 years of age or younger should be neither routinely performed nor required, but should be performed only when desired by either the patient, patient's family, or managing physician.

Breast Cancer Incidence in Adolescent Males Undergoing Subcutaneous Mastectomy for Gynecomastia: Is Pathologic Examination Justified? A Retrospective and Literature Review; Koshy, J. C.; Goldberg, J. S.; Wolfswinkel, E.; Ge, Y.; Heller, L.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 23 September 2010; doi: 10.1097/PRS.0b013e3181f9581c


Kate said...

I found you from Dona Nobis Pacem. I love your site. I’m going to poke around a little bit, but don’t worry I’ll put everything back where I found it!!

Gizabeth Shyder said...

How interesting! Are you goading me:)

A few months back, I found ADH (atypical ductal hyperplasia) in a case of gynecomastia. I showed it to a partner - since it was a first for me. He pointed out a reference in Rosen, which I quoted in the comment, saying that ADH does not carry the same risks in men as it does in women.

I wonder who in the heck is getting $1268 for bilateral path exam of gynecomastia. We charge 88305 - this CPT code gets about $80-$100 in global fees for Medicare - 60% technical and 40% professional. Doesn't add up. I get about two to three gynecomastia cases a year, so we are certainly not padding our pockets with benign male breasts.

You also have me thinking if this argument could be stretched to other areas - gallbladders, skin margins, herniated discs, etc. I like to think that by examining tissue, we are a sort of a check for the surgeon. Yes, there is pathology here. There was a reason for the excision. And once in a blue moon, that fracture was pathological (neoplastic). There is CLL in that node adjacent to the benign gallbladder. If we weren't confirming disease, couldn't you surgeons just run rampant (not you of course) and take out whatever you want, citing any excuse? Ugly, yes, but it could happen.

A lot of dermatologists read their own path, and this scares me for the same reason that I worried when a cardiothoracic pediatric surgeon was doing his own autopsies. "Yes, I know I cleared those margins." "Cause of death was as I predicted." A little too biased, I think.

Thanks for making me think! Looking forward to getting together on Saturday.

rlbates said...

I wasn't trying to goad you but was hoping for your opinion. The reimbursement did sound high but needed you to tell me for sure. Thanks for commenting