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62-year-old man with a right breast mass
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A 62-year-old man with a breast mass underwent mammography. A right breast mass measuring 3.5 × 2.5 cm was noted behind the retracted right nipple. Multiple pleomorphic calcifications were also noted, and these findings were confirmed on sonography, which confirmed a 2.9 cm poorly marginated lobulated solid mass that was extremely suspicious for carcinoma. Biopsy was recommended, but the patient was lost to the follow-up.
The patient sustained minimal trauma to the right breast approximately six months later, noting right breast pain. There was right breast bleeding beginning about one month after trauma. The patient presented to the breast clinic about two months later.
On initial exam, he was complaining of moderate right breast pain, bleeding and right arm edema, which had been present for approximately three weeks. He denied fever, chills, night sweats, back pain, loss of weight, bone pain or any other metastatic symptoms. Two punch biopsies were performed that confirmed invasive ductal carcinoma. The tumor was moderately differentiated with invasion of dermal lymphatics, ER-positive 95%, PR-positive 5%, HER-2/neu 2+ by immunohistochemistry but FISH amplified at 2.3. The patient was immediately referred for palliative radiation for the bleeding right breast lesion.
FDG-PET/CT obtained shortly thereafter revealed a large ulcerated retroareolar mass in the right breast measuring approximately 34 × 36 × 33 mm associated with robust hypermetabolic activity (SUV 16.6). Hypermetabolic right breast skin thickening was consistent with the clinical history of inflammatory carcinoma. Hypermetabolic bilateral axillary lymphadenopathy was also present, larger on the left, 16 × 15 mm with an SUV of 9.3, suspicious for metastatic disease. There were also two lung nodules in the left lung measuring 2.5 mm and 4 mm that were too small to be characterized by functional imaging. Follow-up CT of the chest in three months was recommended. There was no anatomic or functional imaging evidence of metastatic disease to the neck, abdomen or pelvis and no evidence of osseous metastasis.
This patient was placed on tamoxifen and will begin palliative radiation shortly.
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Source: M. Ghesani |
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DISCUSSION
Breast cancer in men accounts for 0.7% of all breast carcinomas. The mean age of diagnosis is between 60 and 70 years, although men of all ages may be affected. The incidence increases with advancing age. Similar to breast cancer in women, the incidence has increased about 25% during the past 25 years. Risk factors include estrogen administration, radiation exposure and diseases like cirrhosis or Klinefelter’s syndrome, which are associated with hyperestrogenism. Other risk factors are undescended testes, congenital inguinal hernia, orchitis and infertility. There is evidence of definite familial tendencies with an increased incidence seen in men who have a number of female relatives with breast cancer. An increased risk for breast cancer in men has been reported in families with the BRCA2 mutation.
Infiltrating ductal carcinoma is the most common histologic subtype and is similar to the pathology of breast cancer in women. However, breast cancers in men are significantly more likely to express hormone receptors than breast cancer in women. In contrast, HER-2/neu is less likely to be expressed. Inflammatory carcinoma and Paget’s disease of the nipple have been described, but lobular carcinoma is rare. The pattern of spread and the staging system is also the same as for breast cancer in women.
The size of the lesion and presence or absence of lymph node involvement, like breast cancer in women, both correlate well with prognosis. ER and PR status and HER-2/neu gene amplification are also important.
Most cases present with a subareolar mass, nipple inversion or bleeding. The most common differential diagnosis is gynecomastia, which is present in 30% of healthy men. Overall survival rates are lower for men, but this is due to older age and more advanced disease at diagnosis.
There is abundant literature on staging of breast cancer in women with PET/CT, but little is known about its utility in men with breast cancer. One small retrospective study comparing 14 FDG-PET scans with CT scans done one to four weeks prior in the same patients found that patient-based sensitivity was the same for both modalities (100%). However, lesion-based sensitivity was 97% for PET and 74% for CT. Overall, as a result of adding PET to the work-up disease was upstaged in five of 14 scans and downstaged in one. Management was altered in three of 11 patients after PET.
The primary surgical treatment for breast cancer in men is a lumpectomy or modified radical mastectomy with sentinel lymph node biopsy or axillary dissection. Several case series have been published that establish the feasibility of sentinel lymph node biopsy in the men with breast cancer.
The decision for adjuvant therapy should be considered on the same basis as for women with breast cancer, because there is no evidence that responses are different. Despite limited data on adjuvant radiation in these patients, guidelines are generally similar to those in women. In men with N1 disease, chemotherapy plus tamoxifen and other hormonal therapy have been used and existing data supports similar survival outcome to women. At least one prospective study of adjuvant chemotherapy in men with breast cancer has been published and produced a projected five-year survival rate >80%, which was significantly better than historical controls. This data combined with several retrospective series suggest adjuvant chemotherapy decreases the risk for recurrence in men. Because of the rarity of this disease no controlled trials have compared adjuvant treatment options.
The majority of breast cancers in men are hormone positive; 85% are ER positive and 70% are PR positive. Hormonal therapy is recommended in all receptor-positive patients. However, tamoxifen can be difficult for men to tolerate due to adverse effects such as hot flashes and impotence. Responses are generally similar to those seen in women. The role for aromatase inhibitors in the adjuvant setting for men is limited due to sparse data.
In the metastatic setting, hormonal therapy, chemotherapy or a combination have been used in breast cancers in men. Since most breast cancers in men are ER positive, hormonal therapy is often the first approach. Options for hormonal therapy include tamoxifen, orchiectomy, luteinizing hormone-releasing hormone agonist with or without total androgen blockade, progesterone and aromatase inhibitors. Standard chemotherapy combinations are recommended in patients with hormone refractory disease or symptomatic visceral metastases. A smaller proportion of men than women are HER-2/neu positive, and although the effectiveness of trastuzmab (Herceptin, Genentech) in men is unproven, it seems prudent to consider this treatment given the strong evidence we have for efficacy in women.
Munir Ghesani, MD, is Associate Clinical Professor of Radiology at Columbia University College of Physicians and Surgeons and Attending Radiologist at St.Luke’s-Roosevelt Medical Center.
Carrie Wasserman, MD, is a second-year Hematology/Oncology Fellow at St. Luke’s-Roosevelt Hospital Center.
Andrew Evans, MD, is an Assistant Professor of Radiation Oncology, Albert Einstein College of Medicine and Attending in Radiation Oncology, St. Luke’s-Roosevelt Hospital Center.
For more information:
- Giordano SH. Oncologist. 2005;10:471-479.
- Karam M. Comparative performance of FDG PET scan and diagnostic CT in male patients with breast cancer. Presented at: Society of Nuclear Medicine 2008 Annual Meeting; June 14-18, 2008; New Orleans.
- National Cancer Institute. U.S. National Institute of Health. Male breast cancer treatment (PDQ) available online, Sept. 25, 2008. Last accessed April 15, 2009.