Effective radiotherapy in palliating mammalgia associated with gynecomastia after DES therapy

Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy

PURPOSE

Several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons; the present study investigates the role of radiation therapy in this context.

METHODS

A systematic review was performed to evaluate the utility of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons.

RESULTS

Fifteen articles met the inclusion criteria for review. The mean incidence of gynecomastia was 70% in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Radiotherapy was shown to significantly reduce the incidence to a median of 23%, with all six randomized control studies assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. The median complication rate was 12.4% with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. While the efficacy of radiation therapy as a treatment modality for gynecomastia was also established, it was shown to be less effective than other available options.

CONCLUSIONS

Low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients; further studies are indicated within the common gynecomastia population managed by plastic surgeons to assess the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients.

Gynecomastia Due to Hormone Therapy for Advanced Prostate Cancer: A Report of Ten Surgically Treated Cases and a Review of Treatment Options

Aims and background

Gynecomastia is an abnormal increase in the volume of the male breast that is generally considered to be due to an increased estrogen/androgen ratio. Pathological causes of gynecomastia include organic diseases and therapy, such as the administration of estrogens and antiandrogens, which alter the ratio of circulating hormones. Hormone therapy for prostate cancer is generally well tolerated but often accompanied by the occurrence of gynecomastia and breast pain or tenderness. The increased use of antiandrogens as monotherapy is leading to an increase in the number of patients affected by gynecomastia. Treatments are available to alleviate or prevent the development of gynecomastia, including medical treatment with antiestrogens and aromatase inhibitors. Alternatively, mastectomy with excision of the gland, liposuction or an association of the two techniques have proved to be effective. Radiation therapy may provide effective relief from the breast pain associated with gynecomastia. In this paper we show the good results of mastectomy performed with a lower semicircular periareolar incision in men suffering from gynecomastia due to antiandrogen therapy for inoperable prostate cancer. In addition, we present a review of the various techniques used for the treatment of gynecomastia.

Methods and study design

During the period from September 1998 to May 2001, 10 patients receiving hormone treatment for metastatic or inoperable prostatic cancer were selected for the study if they had breast pain and bilateral gynecomastia. Five of these patients had been offered prophylactic radiotherapy before treatment but refused, while the remaining five patients had refused radiotherapy after hormone treatment. These patients were therefore given the option of surgical treatment. Before surgery all patients underwent clinical and ultrasound examination of the breast. All surgical samples were examinated histopathologically. During follow-up clinical examinations were carried out one week, one month, six months, one year and two years after surgery.

Results

The results were satisfactory in all patients especially from an aesthetic point of view. Moreover, breast pain disappeared about one week after surgery. After a follow-up of 6-36 months (average, 22.8 months) no recurrences were observed. Only a few immediate postoperative complications were recorded (hematoma in one case and seroma in another). Histological examination of the excised glands showed fibrosclerotic tissue and a small amount of fat.

Conclusion

Surgical liposuction can be considered an effective treatment for gynecomastia, in particular in the very early stages because the breast becomes irreversibly fibrous as the disease progresses. This surgical technique is simple and effective and is therefore to be considered favorable, especially because of the very short hospitalization and the absence of complications.

Treatment of gynecomastia in patients with prostate cancer and androgen deprivation

CONTEXT

Gynecomastia, defined as benign proliferation of glandular breast tissue has a prevalence of 32% to 72% in the male. In the urology setting, it is associated to patients with prostate cancer and hormone treatment with a prevalence of 15% in the case of complete hormone blockage and 75% in monotherapy. The different options of treatment in prostate cancer have changed in recent decades. Thus, we have focused on this subject to evaluate the different therapy options of hormone manipulation induced gynecomastia in prostate cancer patients.

OBJECTIVE

To synthesize the available evidence on the different therapeutic options in prostate cancer patients who develop gynecomastia due to the use of nonsteroidal antiandrogens and to generate a diagnostic algorithm and treatment.

ACQUISITION OF EVIDENCE

Using the PICO type structured search strategy (Patient or problem, Intervention, Comparison, Outcome or result) in the data bases of PubMed-Medline and Cochrane, identification was made of the relevant studies related to the treatment of gynecomastia in Prostate Cancer patients treated with nonsteroidal antiandrogens.

SYNTHESIS OF EVIDENCE

We have found 3 possible therapeutic options for the treatment of gynecomastia and mastodynia in patients with hormone deprivation therapy for prostate cancer. The 10Gy radiotherapy would be an option for the treatment of gynecomastia, although not all the patients need prophylactic treatment since only 50% report moderate-severe discomfort. Another option is the use of drugs such as tamoxifen 20mg/day that lead to a significant decrease in the mammary effects.

CONCLUSIONS

Gynecomastia and mastodynia, given their high incidence, make the physical examination a fundamental tool for all patients before initiating treatment with antiandrogens. The use of tamoxifen 20mg/day is the best treatment and prevention option against gynecomastia and mastodynia, while in the case of long-course established gynecomastia, surgery is the gold standard.

Low rate of clinician-scored gynecomastia induced by 6 months of combined androgen blockade in a randomized trial: Implications for prophylactic breast irradiation

PURPOSE

To determine the incidence and predictors of clinician-scored gynecomastia induced by 6 months of combined androgen blockade (CAB) in a randomized trial.

METHODS

We studied 94 men with intermediate or high-risk prostate cancer randomized to radiation plus 6 months of neoadjuvant CAB consisting of a gonadotropin-releasing hormone agonist and antiandrogen (flutamide). Patients were assessed for breast symptoms monthly as per protocol. Patients reporting breast tenderness or enlargement were then examined shirtless.

RESULTS

Median age at entry was 72.1 years. While 52 patients (55.3%) reported either breast tenderness or enlargement, only 9 patients (9.6%) were scored as having gynecomastia when examined shirtless by a single clinician. Four patients received radiation for self-reported breast tenderness or enlargement without clinician-scored gynecomastia. If these 4 had not been radiated, the total incidence of clinician-scored gynecomastia may have been as high as 13 of 94 (13.8%). No patient variable, such as age, body-mass index, and Adult Comorbidity Evaluation-27 score, or discontinuation of the antiandrogen, was associated with the development of gynecomastia.

CONCLUSIONS

While many patients self-reported breast tenderness or enlargement with short-course CAB, the incidence of breast enlargement noticeable to an examiner when the patient was shirtless was less than 15%, which is much lower than the 60% to 80% rates typically reported with antiandrogen monotherapy. Given that the long-term risks of prophylactic breast irradiation are not well characterized, these data suggest that prophylactic breast irradiation may not be as necessary in men receiving short-course CAB.

Radiation therapy in prostate cancer

Adenocarcinoma of the prostate is one of the most frequently diagnosed cancers of men in the Western hemisphere and is second only to lung cancer for male cancer mortality. Most patients are diagnosed in the early/clinically localized stage, which can be treated curatively with radiation therapy alone. Innovative methods such as brachytherapy, three-dimensional conformal radiotherapy (3D-CRT), and IMRT (intensity modulated radiotherapy) are able to deliver very high tumoricidal doses to the diseased prostate, with minimal side effects to the surrounding tissue. Radiation therapy combined with hormonal treatment can be curative in locally advanced disease. Radiation therapy is also very effective in alleviating symptoms of metastatic prostate cancer (bone metastases, spinal cord compression, and bladder outlet obstruction).

The role of radiation therapy in benign diseases

Although adequate prospective data are lacking, radiation therapy seems to be effective for many benign diseases and remains one of the treatment modalities in the armamentarium of medical professionals. Just as medication has potential adverse effects, and surgery has attendant morbidity, irradiation sometimes can be associated with acute and chronic sequelae. In selecting the mode of treatment, most radiation oncologists consider the particular problem to be addressed and the goal of therapy in the individual patient. It is the careful and judicial use of any therapy that identifies the professional. With an understanding of the current clinical data, treatment techniques, cost, and potential detriment, the goal is to provide long-term control of the disease while minimizing unnecessary treatment and potential risks of side effects. The art lies in balancing benefits against risks.

Management of gynaecomastia in patients with prostate cancer: a systematic review

Patients with prostate cancer are increasingly being offered treatment with non-steroidal antiandrogen monotherapy, which offers potential quality-of-life benefits compared with other treatment. Non-steroidal antiandrogens directly antagonise androgen action in breast tissue, and indirectly increase the oestrogen concentration. Thus, the most troublesome side-effects of monotherapy with these drugs are gynaecomastia and breast pain. Patients younger than 60 years of age, who might not have symptoms of prostate cancer, are probably more concerned about their body image and the development of enlarged breasts than are those older than 60 years. Clinicians who seek a treatment for prostate cancer need information on simple and well-tolerated options for the management of gynaecomastia and breast pain. In this review, management options for gynaecomastia caused by hormonal manipulation in patients with prostate cancer are discussed.

A proposal for the repositioning of prophylactic breast radiotherapy of prostate cancer patients

Evaluation of: Perdona S, Autorino R, De Placido S et al.: Efficacy of tamoxifen and radiotherapy for prevention and treatment of gynaecomastia and breast pain caused by bicalutamide in prostate cancer: a randomized trial. Lancet Oncol. 6, 295–300 (2005). Patients with prostate cancer treated with small-molecular, nonsteroidal anti-androgens frequently develop mammalgia and gynecomastia. To avoid these unwanted effects, pretherapeutic radiation therapy of the male breasts is in common use. Recent findings on the effectivity of prevention and treatment of breast pain and gynecomastia, by both radiation therapy and tamoxifen, and a new comparative study, necessitate a re-evaluation of current prophylactic and therapeutic treatment options. An evidence-based treatment algorithm is derived that diverges from previous recommendations and redefines the role of preventive and therapeutic radiation therapy. For the propylaxis of gynecomastia and breast pain, tamoxifen is superior to single-dose radiation therapy with 10 Gy. Hence, if tamoxifen for this indication should prove to be safe on longer follow-up, radiation therapy would only be indicated in situations where tamoxifen therapy is impossible or contraindicated. The same is proposed for the treatment of early gynecomastia or breast pain except with tamoxifen treatment failure as an additional indication. Higher radiation doses of 4 x 5 Gy, which were shown to be effective in this setting, have not yet been evaluated against anti-estrogen therapy.

Efficacy and Tolerability of Radiotherapy as Treatment for Bicalutamide-induced Gynaecomastia and Breast Pain in Prostate Cancer

OBJECTIVE

To assess the efficacy and tolerability of localised radiotherapy for the treatment of bicalutamide ('Casodex''Casodex' is a trademark of the AstraZeneca group of companies.)-induced gynaecomastia and/or breast pain.

METHODS

This open-label, non-comparative, multicentre study included 51 patients receiving bicalutamide 150 mg for the treatment of non-metastatic prostate cancer (T1b-T4, Nx, M0). Patients who developed symptomatic gynaecomastia and/or breast pain received two 6-Gy fractions of external-beam radiation to the breasts and were then assessed at two 3-monthly follow-up visits.

RESULTS

37/51 (72.5%) patients experienced gynaecomastia and 41/51 (80.4%) experienced breast pain, typically within the first 6 months. Twenty seven and 38 patients, respectively, went on to receive breast irradiation. Following radiotherapy, gynaecomastia improved or resolved in 7/27 (25.9%) and 2/27 (7.4%) cases, respectively, and breast pain improved or resolved in 12/38 (31.6%) and 3/38 (7.9%) cases, respectively. No change was observed in 7 patients (25.9%) with gynaecomastia and 12 patients (31.6%) with breast pain, while 9 patients (33.3%) and 8 patients (21.1%), respectively, worsened. Radiotherapy-related adverse events, reported by 18/41 (43.9%) patients, were generally mild and short lived (median duration approximately 5 weeks).

CONCLUSIONS

Therapeutic radiotherapy, using two fractions of 6 Gy external-beam radiation to the male breast, improves the intensity of bicalutamide-induced gynaecomastia and/or breast pain in approximately one-third of patients. Adverse events were often mild and short lived.

Does prophylactic breast irradiation prevent antiandrogen-induced gynecomastia? Evaluation of 253 patients in the randomized Scandinavian trial SPCG-7/SFUO-3

OBJECTIVES

To examine the development of antiandrogen-induced gynecomastia and breast tenderness in the first 253 patients in a randomized Scandinavian trial (SPCG-7/SFUO-3) with a 12-month complete follow-up evaluation performed by both doctors and patients.

METHODS

In this study, the treating doctor and patient decided whether prophylactic irradiation (RT) of the breast should be given to prevent antiandrogen-induced gynecomastia. At each visit, the doctor evaluated the occurrence of gynecomastia and breast tenderness. Questions about gynecomastia and breast tenderness were also included in the study quality-of-life questionnaire (Prostate Cancer Symptom Scale).

RESULTS

Mammary RT with mostly single fraction (12 to 15 Gy) electrons was given to 174 (69%) of the 253 evaluated patients. At the 1-year follow-up visit, the doctor evaluations indicated some form of gynecomastia in 71% and 28% (P <0.001) of the nonirradiated (no-RT) and irradiated (RT) patients, respectively. The patient evaluations at 1 year showed some form of breast enlargement in 78% and 44% (P <0.001) of the no-RT and RT patients, respectively. The doctors reported some form of breast tenderness at 1 year in 75% and 43% (P <0.001) of the no-RT and RT patients, respectively. The patient evaluations of breast tenderness show an expected significant increase in the RT arm at the 3-month follow-up, which was probably due to skin reactions. At 1 year, significantly more patients who marked "very much" on the Prostate Cancer Symptom Scale were seen in the no-RT group. A weak correlation between the doctors' and patients' detection of breast problems was observed.

CONCLUSIONS

The results show that, with high significance, prophylactic RT of the breast decreases the risk of antiandrogen-induced gynecomastia and breast tenderness.

The safety and tolerability of low-dose irradiation for the management of gynaecomastia caused by antiandrogen monotherapy

Gynaecomastia--a benign and often painful enlargement of the male breast--is a common side-effect of some therapies for prostate cancer, including non-steroidal antiandrogen monotherapy. Although gynaecomastia and breast pain are not harmful to the overall health of the patient, they can be serious enough to influence treatment decisions in the management of prostate cancer. Prophylactic low-dose irradiation can be effective in reducing the incidence and severity of both gynaecomastia and breast pain. In addition, irradiation may be effective in treating breast pain due to the development of gynaecomastia. Low-dose electron irradiation confers advantageous tissue dosing, is well tolerated, and has manageable side-effects, the most common of which is reversible skin erythema. Information on long-term safety after irradiation for gynaecomastia is limited at present, but trials are underway. Irradiation is likely to be an effective management option with an acceptable low risk of long-term complications for gynaecomastia associated with hormone therapy for prostate cancer.

Management options for gynaecomastia and breast pain associated with nonsteroidal antiandrogen therapy : case report series

OBJECTIVE

To present management options for gynaecomastia and mastodynia associated with nonsteroidal antiandrogen therapy, supported by relevant data and case studies.

BACKGROUND

Gynaecomastia (male breast enlargement) and breast pain/ sensitivity (mastodynia or mastalgia) are pharmacologically expected adverse effects of nonsteroidal antiandrogen therapy for prostate cancer. They are caused by proliferation of glandular tissue in response to an increase in the ratio of estrogen to androgen. Gynaecomastia and mastodynia are benign conditions, and many patients choose to tolerate them as acceptable, usually mild or moderate, adverse effects of therapy. Recent data show that nonsteroidal antiandrogen monotherapy significantly reduces disease progression in localised and locally advanced prostate cancer, a finding that may result in wider and more long-term use of this treatment. Therefore, both clinicians and patients may benefit from increased awareness of the options available for the management of gynaecomastia and mastodynia. Management options, data and case studies: Management options for gynaecomastia and mastodynia are illustrated in a schematic flow diagram. Options identified are: (1) risk reduction using pretreatment breast irradiation; (2) stopping antiandrogen therapy; (3) acceptance of gynaecomastia and/or mastodynia in the context of the significant clinical benefit of antiandrogen treatment; (4) prompt treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics); and (5) later treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics). Where available, relevant data are discussed and the options are illustrated by case studies.

CONCLUSIONS

The risk of developing gynaecomastia is lessened by prophylactic breast irradiation. Following the development of gynaecomastia, treatment options include readjustment of the estrogen-to-androgen ratio using antiestrogens, surgery in the form of liposuction or, for more advanced cases, breast tissue excision. Mastodynia may be controlled by post-treatment irradiation or analgesics.

Bicalutamide (Casodex) 150 mg as immediate therapy in patients with localized or locally advanced prostate cancer significantly reduces the risk of disease progression

OBJECTIVES

To investigate the efficacy and tolerability of bicalutamide (Casodex) as immediate therapy, either alone or as adjuvant to treatment of curative intent, in patients with localized or locally advanced (T1b-T4, any nodal status, M0) prostate cancer.

METHODS

This was a multicenter, prospective, randomized, double-blind, placebo-controlled trial in Europe, South Africa, Australia, and Mexico and is part of the Casodex Early Prostate Cancer program.

RESULTS

A total of 3603 men were randomized to receive bicalutamide (n = 1798) or placebo (n = 1805). The patient demographics were well balanced between the two groups. Prior therapy of curative intent had been given to 64% of the patients (prostatectomy [44%], radiotherapy [18%], and prostatectomy and radiotherapy [2%]) and 36% had been monitored with watchful waiting. After a median follow-up of 2.6 years and a median exposure to the study drug of 2.2 years, a significant 43% reduction in the risk of objective progression was observed for the bicalutamide group compared with the placebo group (hazard ratio 0.57, 95% confidence interval 0.48 to 0.69, P << 0.0001). The time to prostate-specific antigen doubling was significantly delayed for the bicalutamide group compared with the placebo group (hazard ratio 0.37, 95% confidence interval 0.32 to 0.43, P << 0.001). The survival data were immature, with 7.2% overall mortality. The most frequently reported adverse events with bicalutamide were gynecomastia alone (17.4%), breast pain alone (17.6%), and gynecomastia with breast pain (47.5%).

CONCLUSIONS

Bicalutamide 150 mg daily as immediate therapy, alone or as adjuvant to treatment of curative intent, significantly reduced the risk of disease progression in patients with localized or locally advanced prostate cancer. Longer follow-up is underway to assess any benefit in overall survival.