Unilateral breast enlargement as a presenting feature of small cell carcinoma of the lung.

Abstract: Breast enlargement associated with carcinoma of the lung is most commonly a paraneoplastic manifestation of non-small cell carcinoma. Hormonally mediated proliferation of the glandular component of the breast leads to unilateral or bilateral enlargement. This report describes a patient with small cell carcinoma of the lung who presented with unilateral breast enlargement related to superior vena cava obstruction.

Key Words: breast enlargement, lung cancer, superior vena cava syndrome 

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Male breast enlargement may be unilateral or bilateral and can occur as benign enlargement caused by glandular proliferation or gynecomastia, or as a manifestation of an underlying local process. There are several well-described mechanisms for breast enlargement in lung cancer. (1) The most common type of lung cancer is non-small cell carcinoma (SCC) of the lung. Superior vena cava (SVC) syndrome presenting as unilateral breast enlargement is rarely described. In this report, we describe a patient with SCC of the lung who presented with unilateral breast enlargement related to SVC obstruction.

Case Report

A 66-year-old male had a 3-week history of dry cough and 12-pound weight loss. He also noticed facial swelling, dilated veins on his chest, and right-sided breast enlargement. He was a 90 pack-year smoker, and had significant ethanol abuse. His medical history was significant for hypertension, coronary artery disease, and chronic obstructive pulmonary disease. Medications at presentation included lisinopril, metoprolol, isosorbide, and simvastatin.

On examination, there was right-sided facial swelling, mild edema of the right arm more pronounced distally than proximally, jugular venous distention, and engorged veins over the neck, chest, and back. There was diffuse, nontender, asymmetric enlargement of the right breast without any mass lesions or discharge (Fig. 1). Breath sounds were decreased over the right hemithorax.

Blood tests were notable for sodium, 129 mmol/L; thyroid-stimulating hormone, 0.6 uIU/mL; follicle-stimulating hormone, 18.9 mIU/mL (normal, 1 to 15); testosterone, 629 mIU/mL (normal, 241 to 827); luteinizing hormone, 6.5 mIU/mL (normal, 1.5 to 9.3); estrogen, 104 pg/mL (normal, 40 to 115); estradiol, 39 pg/mL (normal, 12 to 72); and estrone, 34 pg/mL (normal, 12 to 72). Chest radiography demonstrated a right parahilar mass. Computed tomographic scan of the thorax demonstrated a 12-cm right suprahilar mass encasing the SVC with tumor (Fig. 2).

Thrombus was seen in the distal SVC. Doppler studies revealed thrombosis of the brachial and axillary veins. Bronchoscopic biopsy of the mass identified SCC.

The patient was started on anticoagulation therapy, and chemotherapy with cisplatin and etoposide was started, along with radiation. This resulted in resolution of the breast enlargement, and a decrease in the size of the mediastinal mass. Nine months after initial presentation, he was readmitted for pneumonia, and it was noted at that time that he had recurrent facial and arm swelling with bilateral breast enlargement accompanied by an increase in the mediastinal mass and recurrent SVC syndrome. A stent was placed across the obstruction in the SVC, which resulted in symptomatic relief. He died 1 year after his initial presentation.

Discussion

Breast enlargement in lung cancer is generally associated with an abnormal increase in stromal and ductal components of the breast, gynecomastia. (2) Our patient presented with unilateral breast enlargement, and it was initially unclear whether unilateral enlargement was a unilateral gynecomastia (hormonally mediated) or a structural phenomenon stemming from obstruction of the venous drainage to the breast. The findings from hormonal analysis, improvement with anticoagulation, chemotherapy, and radiation, and return of breast enlargement with recurrence of the SVC syndrome point to venous obstruction as the cause. The unilateral enlargement at initial presentation can be explained by the tumor and thrombus obstructing the flow from the right brachiocephalic vein to a greater degree than the left brachiocephalic vein.

The differential diagnosis of unilateral breast enlargement is extensive. Yet in most instances, careful physical examination and history-taking pertaining to the use of medication, drugs, (3,4) and alcohol, with specific questions about symptoms of hepatic dysfunction, testicular insufficiency, hyperthyroidism, and pulmonary abnormalities suggestive of lung cancer, are sufficient to uncover most of the conditions associated with breast enlargement. (2)

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Conclusion

Physicians should be aware of diagnostic clues such as unilateral gynecomastia in their male patients, and careful evaluation should follow, because of the possibility that breast enlargement may be a manifestation of an underlying lung malignancy.

Accepted April 7, 2004.

References

1. Sapone FM, Reyes CV. Unusual faces of lung cancer. J Surg Oncol 1985;30:1-5.

2. Braunstein GD. Gynecomastia. N Engl J Med 1993;328:490-495.

3. Garcia-Benayas T, Blanco F, Martin-Carbonero L, et al. Gynecomastia in HIV-infected patients receiving antiretroviral therapy. AIDS Res Hum Retroviruses 2003;19:739-741.

4. Ferrando J, Grimalt R, Alsina M, et al. Unilateral gynecomastia induced by treatment with 1 mg of oral finasteride. Arch Dermatol 2002;138:543-544.

RELATED ARTICLE: Key Points

* Breast enlargement in males should arouse suspicion of malignancy.

* Obstruction of the superior vena cava should be considered in the differential diagnosis of unilateral breast enlargement.

* Small cell lung cancer can be associated with unilateral breast enlargement.

Ravi K. Bobba, MD, Kishore Gaddipati, MD, Julian Bick, MD, and Edward L. Arsura, MD

From the Department of Internal Medicine, University of Virginia, Roanoke-Salem Program, Veterans Affairs Medical Center, Salem, VA.

Reprint requests to Dr. Edward Arsura, University of Virginia, Veterans Affairs Medical Center, 1970 Roanoke Blvd, Salem, VA 24153. Email: [e-mail]