Male Breast Cancer

Case History: 54-year-old male presents with palpable right retroareolar abnormality. The patient reports that two years prior, he presented to a surgeon with unilateral bloody nipple discharge on the right. At that time, he underwent breast biopsy, with benign results. No nipple retraction or inversion by patient report or on physical examination.

Pathology report from biopsy February 10, 2012: Breast tissue with dense stromal fibrosis, mild focal duct hyperplasia, focal chronic inflammation, mild epithelial proliferation.

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Figure 1. Bilateral full field digital mammography with CC and MLO views demonstrate a lobulated mass in the right retroareolar region. Absence of breast parenchyma, expected in this male patient.

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Figure 2. Lobulated retreolar mass on the right.

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Figure 3. Spot compression CC and MLO views demonstrate persistence of lobulated right retroareolar mass.

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Figure 4. Grayscale transverse and longitudinal sonographic images (included with and without caliper measurements) in the right retroareolar region demonstrate lobulated, hypoechoic solid mas corresponding to the mammographic abnormality. Color Doppler interrogation of the mass does not reveal significant internal vascularity.

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Figure 5. The patient underwent core biopsy under ultrasound guidance. Sonographic images demonstrate accurate targeting, with the biopsy needle in the lesion.

Pathology: Invasive ductal carcinoma (strong estrogen and progesterone receptor positivity; HER2 – equivocal).

Discussion: The most common symptom of breast cancer in a male, as with females, is a hard, fixed, painless lump, which is present in 75 percent of cases. The palpable lump is usually subareolar. Other less common clinical features include nipple retraction or inversion, nipple discharge, axillary lymphadenopathy and skin changes (including retraction, skin thickening and even ulceration).

Men account for approximately 1 percent of all new breast cancer cases. Given rarity, lack of awareness and often low clinical index of suspicion from both the perspective of the patient and physician, there is often a delay in diagnosis, leading to progression of disease before presentation. This later stage of diagnosis results in an overall worse prognosis. Prognostic factors include size of primary tumor, histologic grade and lymph node status. Average age of diagnosis tends to be later than that of women, with range of 60-64 years.

There is a greater prevalence of male breast carcinoma in some ethnic groups, including African-American, Native African from Western nations, and men of Jewish and Icelandic ancestry.

Given the high frequency of genetic mutations (for example, BRCA-2 gene mutation, Klinefelter syndrome) in cases of male breast cancer, this diagnosis should prompt consideration of genetic counseling and testing, particularly if there is family history of relatives with breast and ovarian cancer.

Mammography in men with breast lesions has a reported sensitivity of 92 percent and specificity of 90 percent. On mammography, male breast cancer is typically manifested with a subareolar mass, which can be round, oval, irregular or lobulated in shape and the margin may be spiculated and ill-defined or well circumscribed. Calcifications are uncommon in male breast cancer. Ancillary features of skin retraction and ulceration are findings that portend a poor prognosis. Gynecomastia can mask a cancer.

Ultrasound typically demonstrates a hypoechoic solid, but can demonstrate a complex cystic mass.

The differential diagnosis for male breast cancer includes gynecomastia, fat necrois, pseduogynecomastia, granular cell tumor or extramammary metastasis to the breast.

Treatment: Treatment regimens are similar to those for female breast cancer.

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Figure 6. Treatment algorithm for operable male breast cancer (Fentiman 2006).

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Figure 7. Treatment algorithm for inoperable male breast cancer (Fentiman 2006).

References
Iuanow E, Kettler M, Slanetz P. Spectrum of Disease in the Male Breast. American Journal of Radiology. 2011;16:3.
Chantra P, et al. Mammography of the Male Breast. American Journal of Radiology. 1995;164:853-858.
Yang W, et al. Sonographic Features of Primary Breast Cancer in Men. American Journal of Radiology. 2001;176:2. Fentiman I, et al. Male Breast Cancer. Lancet. June 2006;367:1818.