Symptoms of Unknown Origin: A Medical Odyssey

Chapter 14. Dr. Jim’s Breasts

108 14 Dr. Jim’s Breasts There is an old dictum that the patient will tell you what is wrong with him if you listen carefully. That rule was reinforced by my experience with Dr. Jim. I had known Dr. Jim for many years. He practiced in a small town not too far from Nashville, where I now saw patients alongside my teaching duties. He had sent me a number of patients through the years. Now seventy-six years old, he was complaining of breast enlargement. The enlargement had started in the right breast. Because the enlargement was unilateral, it was thought he might have cancer of the breast. The right breast had been removed surgically before Dr. Jim asked me to see him. Cancer of the male breast is not a common lesion, but it can be quite malignant when it does occur. Examination of the tissue did not show cancer but showed typical changes of gynecomastia (enlargement of the male breast). These changes are indicative of estrogen stimulation. (The normally dormant male breast can be converted to a fully functioning “female breast” if the proper mix of female hormones is present in the bloodstream.) The finding of unilateral gynecomastia was puzzling , and it was after that finding that Dr. Jim asked to see me. His left breast had now begun to enlarge. I was not too confounded by the initial unilaterality because I had seen that before. There is sometimes a lag in the response of Meador฀pagesFeb15.indd฀฀฀108 2/17/05฀฀฀5:35:11฀PM Dr. Jim’s Breasts 109 the breasts, and one will enlarge before the other even though the female hormone is available to both breasts. What did concern me was the appearance of gynecomastia at Dr. Jim’s age. It usually meant the presence of a malignant tumor of the testicle or the adrenal. The normal male at puberty secretes both female hormone and male hormone. Enlargement of the breasts in teenage boys is nearly universal if you palpate carefully. This early influence of the female hormone is soon replaced with the dominance of the male hormone, which is secreted in increasing amounts. The effect of the female hormone is inhibited, and the breast enlargement is suppressed. At any time in later life, this balance can be upset. If enough female hormone is present, breast enlargement will occur in a male of any age. In the adult male, there are only two endogenous sources of female hormones—the testicles and the adrenal glands. Both normally secrete very small amounts of estrogens. Both, however, can develop tumors that are capable of secreting large amounts of estrogens. That was my first concern, because these tumors are highly malignant, that is, they grow and spread rapidly. There is a very narrow window of time when surgical removal is still curative. (This was before effective chemotherapy was available for any of these tumors.) There is one other rare cause of estrogen secretion in the adult male: malignant tumors of various organs that curiously begin to make pituitarylike hormones that stimulate the adrenal or testicle to secrete estrogens. Lung cancer, for instance, can produce this bizarre biochemical aberration. Turning to the case of Dr. Jim, with these ominous and very serious possibilities of cancers in mind, I ordered all the tests that would identify the presence of estrogens or the hormones that can stimulate estrogen production. All the tests showed the very low and normal levels of estrogens typical for a man his age. What a surprise! Knowing that false negative results can occur, I repeated the tests. Again, the results came back within normal limits for a male. Meador฀pagesFeb15.indd฀฀฀109 2/17/05฀฀฀5:35:11฀PM 110 Symptoms of Unknown Origin My initial physical examination had been normal except for the easily felt gynecomastia of the remaining breast. I repeated the physical examination, this time giving extra time and attention to palpating Dr. Jim’s testicles for masses and pushing here and there in his abdomen trying to feel his deep-seated adrenals. My examination was normal again. (This case occurred before abdominal CAT scans were available.) Not satisfied with these normal results and still quite concerned that there was a malignant tumor hidden away somewhere, I began to do x-rays and other procedures to find a tumor. I reasoned that there are numerous compounds that...