Ductal carcinoma in situ of the male breast presenting as adolescent unilateral gynaecomastia.

A 17 year old male patient was referred to the breast surgery service with a unilateral swelling of the left breast. Subsequent evaluation led to discharge with a diagnosis of adolescent gynaecomastia. Four years later the same patient was referred back to the breast surgery service and the referral was turned down without a consultation as the surgical treatment of gynaecomastia was not funded by the local Primary Care Trust (PCT). Three years following, this now 24 year old gentleman was referred to the Plastic surgery service at the Hospital Trust where he had been initially referred as a 17 year old. He underwent a nipple sparing mastectomy through a peri-areolar incision. The histology amounted to a diagnosis of ductal carcinoma in situ (DCIS). A literature review revealed the rarity of pure DCIS in the adolescent male. The variation in availability of treatments across the National Health Service in England has lead to a "postcode lottery" due to "rationing" decisions being made by individual Primary Care Trusts. "Action on Plastic Surgery", an NHS Modernisation Agency document, was designed as an aid to PCT's making funding decisions on Plastic Surgery patients in 2005. The case described in this report illustrates the difficulty in clinical diagnosis of a male breast lump. This persistent lesion was sampled on 2 separate occasions with fine needle aspiration, neither aspirate raising the possibility of DCIS. In conclusion this case describes a rare pre-malignant condition of the male breast. Complete histology of such a lump is the only conclusive investigation necessary and the limitations put upon the surgeon by the "rationing" of such treatment must be overcome on clinical grounds.