Case Competition 2023 Case 17 Surgical treatment of Bicalutamide-induced gynecomastia
Authors: Dominika Miklisova, med. student, Miroslava Verbat, med. student, Ema Sutakova, med. student, Zuzana Jelinkova, MD, Julia Bartkova, MD
A 67-year-old man presenting with gynecomastia was admitted to the Department of Burns and Plastic Surgery, for a bilateral mastectomy. This patient had undergone a radical retropubic prostatectomy (RRP) due to prostate cancer in 2013. Since 2015 he has been receiving adjuvant hormone therapy, to be more precise- androgen deprivation therapy (ADT). The medication of choice, bicalutamide (under the brand name Bicaluplex) administered daily, led to an excessive growth of mammary gland tissue, resulting in the development of gynecomastia. The patient expressed dissatisfaction with the appearance of his enlarged breasts and suggested that this condition has created difficulties in his daily activities. Being an active horse rider, he complained about discomfort during sports and even felt ashamed to go to the public swimming pool with his grandchildren in the summer because of his appearance. Therefore, the urologist advised him a surgical resolution. In terms of further anamnesis- the patient has an unsignificant family history, he is diagnosed with hyperlipidemia on medication (atorvastatin), is a non-smoker with an occasional use of alcohol, no allergies.
Before and after
During the initial physical examination, a significant bilateral gynecomastia was indentified, and the option of bilateral mastectomy was proposed to the patient. The patient underwent an internal preoperative examination and an anesthesiological assessment. Additionally, he was recommended to purchase a compression vest for a post-operative regime.
After the admission, pre-operative marking was performed while patient standing, to obtain a proper visualisation of the excess breast tissue. Lines were drawn for the semicircular and periareolar incisions, as well with the new final location of the nipple-areola complex (NAC).
Step 1: Liposuction
The solution of 0,5 l of saline with lidocaine was introduced into both breasts. The chosen approach was combination of liposuction with direct glandular excision in one surgery. The benefits of performing liposuction first are to facilitate the sculpting of the breast and adipose tissue elements of the chest wall and to contour the subcutaneous tissues. Next, the incisions were made, and approximately 200 ml of subcutaneous fat tissue was aspirated using 4 mm liposuction cannula.
Step 2: Incisions
Following the markings, the incisions were made using semicircular approach with the preservation of the NAC with periareoral incision. The new location of the NAC, approximately 2-3 cm above the original position, was identified and prepared with a circular incision.
Step 3: Mastectomy and NAC relocation
A bilateral mastectomy was performed, 180 g of tissue was removed from the right side and 231 g from the left side. Samples were sent for histopathological verification. After proper hemostasis, NAC was relocated into the new position on a preserved vascular pedicle. The subcutaneous tissue was sutured in layers. The skin was closed using running intradermal suture with polydioxanone resorbable fibre. After surgery, an elastic bandage was wrapped around the patient’s chest to provide a proper compression.
The patient was prescribed cefuroxime-axetil 500 mg antibiotics to be taken twice a day for a week. He was instructed to wear the compression vest throughout the day for the next 6-8 weeks, advised not to lean forward or carry heavy items. Regular check-ups were scheduled 4 days, 10 days, 4 weeks, and 6 weeks after surgery. The surgical wound was clean, and the hematomas and swelling gradually subsided. The patient was advised to moisturize and massage the scar for the best possible aesthetic outcome. The histological examination confirmed the diagnosis of gynecomastia with no detectable dysplasia of the mammary gland. We invited the patient for an additional check-up almost one year after the surgery (April 2023). The scars have fully healed with no detectable contractures. As we used preservation of the NAC on the vascular pedicle, there is still some residual volume of the breast tissue present. Despite these circumstances, the patient is very satisfied with the result. However, he is still worried, that his breasts will grow back while using bicalutamide. Therefore, he decided to lower the dosage by himself from daily use to every other day. Although he didn’t consult this step with his urologist, reportedly it doesn’t affect his laboratory results during oncological check-ups (tumor markers, prostate-specific antigen).
- Gynecomastia with or without breast pain (sometimes referred to as bicalutamide-induced breast events (BEs) (1)) is a well recognised side effect of bicalutamide, arising from an increase in the effective estrogen-to-androgen ratio in the breast. In the Early Prostate Cancer programme, the incidences of gynecomastia and breast pain were 68.3% and 73.6%, respectively, with symptoms developing within the first 6–9 months of bicalutamide therapy. BEs may cause some patients to withdraw from treatment (2).
- As you may have noticed in our case, gynecomastia is linked to negative psychological aspects, including body image concerns. The available research summarized in Body Image Journal in 2015 had also suggested the presence of depression, anxiety, low self esteem and disordered eating. Be aware if your patient shows any of these signs! (3).
- Combination of liposuction and mastectomy with NAC relocation on a vascular pedicle provides a well-contoured chest wall with a neurovascularly intact NAC.
- Surgeon uses the breast mound and the chest proportions as a guide to determine the final diameter of the areola. In order to create more masculine and natural appearance, superior and medial translocation of the NAC is crucial along with the use of inferolateral border of the pectoralis major muscle for nipple placement. These ascpects acknowledge the wider internipple distance of the male chest compared to the female one. To enhance the final aesthetic result, make sure to pay attention to this breast mound-areola proportion. (6)
- Make sure to do the pre-op drawing to prevent asymmetry of the breasts and secure the best aesthetic outcome possible!
- When choosing a vascular pedicle for the NAC relocation, inform the patient, there can be mammary gland residuum affecting the volume of the breast.
- A study published in the Aesthetic Plastic Surgery Journal in 2017 reported that only 12.5% of people who underwent glandular gynecomastia tissue removal experienced recurrence more than 10 years later. However, there is still no specific data concerning gynecomastia recurrence while being treated with bicalutamide (4).
- Fagerlund, A., Cormio, L., Palangi, L., Lewin, R., Santanelli di Pompeo, F., Elander, A., & Selvaggi, G. (2015). Gynecomastia in Patients with Prostate Cancer: A Systematic Review. PLOS ONE, 10(8), e0136094. https://doi.org/10.1371/journal.pone.0136094
- Giuseppe Di Lorenzo, Riccardo Autorino, Bicalutamide-Induced Gynaecomastia: Do We Have the Answer?, European Urology, Volume 52, Issue 1, 2007, Pages 5-8, ISSN 0302-2838,https://doi.org/10.1016/j.eururo.2007.01.063.
- D. Luis Ordaz, J. Kevin Thompson, Gynecomastia and psychological functioning: A review of the literature, Body Image, Volume 15, 2015, Pages 141-148, ISSN 1740-1445,https://doi.org/10.1016/j.bodyim.2015.08.004.
- Fricke, A., Lehner, G. M., Stark, G. B., & Penna, V. (2017). Long-Term Follow-up of Recurrence and Patient Satisfaction After Surgical Treatment of Gynecomastia. Aesthetic plastic surgery, 41(3), 491–498. https://doi.org/10.1007/s00266-017-0827-x
- Baumann K. (2018). Gynecomastia – Conservative and Surgical Management. Breast care (Basel, Switzerland), 13(6), 419–424. https://doi.org/10.1159/000494276
- Kornstein, A. N., & Cinelli, P. B. (1992). Inferior pedicle reduction technique for larger forms of gynecomastia. Aesthetic plastic surgery, 16(4), 331–335. https://doi.org/10.1007/BF01570696