I. Medizinische Klinik Klinikum Augsburg

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5 Case Report Gynecomastia: look beyond the obvious Thomas Pusl A 29-year-old man was referred to our clinic with a 4-week history of a tender predominant left breast enlargement without nipple discharge. Physical examination confirmed small palpable masses of tissue predominantly in the left breast. Ultrasound of the breast and mammography showed the typical appearance of gynecomastia without features of malignancy. Hormonal studies showed normal plasma levels of prolactin, TSH and cortisol. Testosteron was in the high-normal range and his estradiol was elevated, while the gonadotropins were suppressed. The tumor marker α-fetoprotein was normal, while HCG was elevated. Testicular ultrasonography revealed atrophy of the left testicle and a normal right testicle. Chest CT scan showed no abnormalities, cranial MRI also was normal. Abdominal computed tomography demonstrated a localized thickening of a bladder wall segment. Because of an episode of gross painless hematuria, he underwent cystoscopy. On cystoscopy, a small, unifocal bladder wall tumor was noted, followed by transurethral resection of the bladder tumor. Histology revealed grade 1 papillary cell carcinoma of the bladder with no invasion into the lamina propria (pta G1 N0 M0) with ectopic expression of HCG (Figure 1). Over the following weeks, HCG was no longer detectable, his sex hormones returned to normal, and gynecomastia completely regressed. Gynecomastia, uni- or more often bilateral enlargement of the male breast, occurs frequently in infancy, puberty and in middle-aged to older men with prevalence rates of %, % and 70 % respectively. Pathophysiologically, gynecomastia results from an estrogen-androgen imbalance, either because of increased production, bioavailabilty or responseivness of estrogen or reduced androgen concentrations or activity. Estrogen excess may result from exogenous estrogen exposure or endogenous estrogens derived from estrogen-producing tumors (feminizing adrenocortical tumors, Leydig-cell tumors, Sertoli-cell tumors). Human chorionic gonadotropin (hcg)-secreting tumors of gonadal or extragonadal germ-cell tissue or derived from nontrophoblastic origin increase aromatization of androgens to estrogens in Leydig cells leading to a relative increase in estrogen to testosterone production. Ectopic hcg-secretion from nontrophoblastic tumors has been observed in a wide variety of malignancies, including gastrointestinal, pancreatic, biliary, ovarian, renal, bladder, breast, head and neck cancers. The levels of hcg are usually only slightly increased and most tumors produce only the inactive free beta subunit of hcg, not the biologically active intact hcg. Gynecomastia is common and usually harmless, but - as our case shows vigilance and a structured workup is essential to rule out serious or treatable underlying disorders. A B FIGURE 1. Histology confirmed the diagnosis of papillary cell carcinoma of the bladder with expression of hcg (A, hematoxylin and eosin; B,C, immunhistochemical stain for hcg). Courtesy of Prof. Stömmer. C Herzzentrum

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8 Kardiotoxische Substanzen in der Onkolologie Was ist zu beachten? W. von Scheidt, I.Medizinische Klinik, Klinikum Augsburg Herzzentrum

9 Hyponatriämie Ursachen, Diagnostik, Differenzialdiagnostik Peter Gross, Thomas Pusl Herzzentrum