Gynaecomastia, galactorrhoea, and lung cancer in a man

Abstract

In September, 2012, a 60-year-old man presented with right shoulder pain, productive cough, and dyspnoea of 3 months' duration, with 5 kg weight loss and anorexia. He was a manual labourer and had no history of chest pain, fever, or haemoptysis. He had smoked 20 bidis (thin hand-rolled cigarette-like tobacco wrapped in dried tendu leaf) per day for the past 40 years. He reported no other substance misuse or supplements intake. On examination, we noted no clubbing or lymphadenopathy. Testicular examination was normal. Bilateral gynaecomastia (see appendix) with watery discharge from nipple on squeezing was seen (see video). Radiography (figure A) and CT of the chest showed a mass lesion 9·9×9·4 cm in the right upper lung lobe, with loss of fat planes in the aortic arch and chest wall, multiple nodules in both lower lobes, and enlarged lymph nodes. Fibreoptic bronchoscopy showed a growth in right upper lobe bronchus. Endobronchial biopsy showed squamous cell carcinoma (see appendix). Immunohistochemistry for β-HCG (figure B) was positive, and negative for oestrogen and testosterone. Serum β-HCG was 20 000 IU/L (normal <5 IU/L). Serum 17-β oestradiol was 1160 pmol/L (normal 45–609 pmol/L). A urine pregnancy card test was positive. Liver and renal function tests, and serum concentrations of prolactin, testosterone, luteinising hormone, follicle stimulating hormone, thyroid stimulating hormone, and cortisol, were normal. Visual acuity, visual fields, and fundus examination were normal.