Male breast carcinoma: a review of 229 patients who presented to the Princess Margaret Hospital during 40 years: 1955-1996

Cancer du sein: l’homme est aussi concerné. Étude de 21 cas

Introduction

Le cancer du sein, première pathologie maligne chez la femme, reste une maladie rare chez l’homme. Il représente environ 1 % des cancers du sein et moins de 1 % de l’ensemble des néoplasies masculines. L’objectif de cette étude est d’analyser les caractéristiques cliniques, histologiques et thérapeutiques du cancer du sein chez l’homme.

Patients et méthodes

Les auteurs présentent une étude descriptive menée de manière rétrospective au service de radiothérapie-oncologie du CHU Ibn-Rochd de Casablanca, entre janvier 2006 et décembre 2007, concernant une série de 21 patients de sexe masculin présentant un cancer du sein.

Résultats

L’âge médian était de 70 ans (extrêmes: 39–84). Le délai médian de consultation était de huit mois (extrêmes: 2–24). Il s’agissait, dans 16 cas, d’une tumeur rétroaréolaire dont la taille médiane était de 35 mm (extrêmes: 15–80). Les tumeurs étaient classées T2 dans 12 cas et T4 dans sept cas. Le type histologique le plus représenté était le carcinome canalaire infiltrant (CCI) [18 cas]. Le grade SBR II a été retrouvé dans 13 cas. Le taux d’envahissement ganglionnaire axillaire prouvé histologiquement était de 38 % (huit patients) et dans 14 % des cas plus de trois ganglions étaient envahis. L’effraction capsulaire n’a été retrouvée que dans quatre cas. Les récepteurs hormonaux étaient positifs dans 19 cas. La prise en charge thérapeutique a consisté en une chirurgie radicale dans 14 cas avec une chimiothérapie associée à une radiothérapie dans cinq cas, 66 % des patients ont reçu une hormonothérapie. Après un suivi moyen de 23 mois, trois malades ont développé des métastases et six malades sont encore vivants sans maladie.

Conclusion

Le cancer du sein chez l’homme est rare. Son diagnostic se fait souvent à un stade tardif. Son traitement est similaire à celui de la femme avec un retard diagnostique retentissant sur le pronostic.

Poorer survival outcomes for male breast cancer compared with female breast cancer may be attributable to in-stage migration

BACKGROUND

Male breast cancer accounts for less than 1% of all breast cancers, yet males have a worse prognosis than females with breast cancer.

METHODS

Using the 1988-2003 Surveillance, Epidemiology, and End Results Program data, we conducted a retrospective, population-based cohort study to investigate stage-specific differences in breast cancer-specific and all-cause mortality between males and females. We calculated adjusted hazard ratios (aHR) and 95% confidence intervals (CI) using Cox regression models to compare breast cancer-specific and all-cause mortality by stage between males and females, controlling for potential confounding variables.

RESULTS

There were 246,059 patients with a first, single, primary breast cancer [1,541 (0.6%) male; 244,518 (99.4%) female]. Compared with females, males were more likely to be older, Black, married, diagnosed at more advanced stages, and treated with mastectomy (each P < 0.001). Males also were more likely to have lower grade and estrogen/progesterone receptor-positive tumors (each P < 0.001). After controlling for confounders, males were more likely to die from their breast cancer when compared with females, only if diagnosed with stage I disease (aHR 1.72, CI 1.15-2.61). For all-cause mortality, males were more likely than females to die at each stage of disease except stage IV.

CONCLUSIONS

Although all-cause mortality was higher for men than women at all stages of nonmetastatic breast cancer, higher male breast cancer-specific mortality was attributed to poorer survival in stage I disease. However, this statistical difference is unlikely to be clinically relevant and attributable to in-stage migration.

Pleomorphic lobular carcinoma in a male breast: a rare occurrence

Carcinoma of male breast is uncommon as it accounts for 0.7% of total breast cancer. The pathology of male breast cancer is remarkably similar to that of cancers seen in women. The same histological subtypes of invasive cancer are present, although papillary carcinomas (both invasive and in situ) are more common and lobular carcinomas are less common. The predominant histological type, in males, as in females, reported in large series has been infiltrating ductal carcinoma with scattered reports of infiltrating lobular carcinoma, all of them of classical type except for a single case of pleomorphic infiltrating lobular carcinoma. Herein, we describe a case of pleomorphic lobular carcinoma occurring in male breast.

Male breast cancer

Diagnosis and treatment modalities for female breast cancer have developed spectacularly in recent years. Unfortunately, this is not the case for male breast cancer. Because the disease is so rare, controlled clinical trials have almost never been performed and treatment is based on findings in women or small series of men. Similarly, while breast cancer in women is diagnosed at an increasingly early stage, male breast cancer is usually diagnosed late, when the chances of cure are diminished. This article reviews what is currently known about male breast cancer, with an emphasis on areas where evidence-based data are scarce. While it is possible that some recent developments in female breast cancer treatment could be applicable to men, but the way forward is to increase awareness of the disease, and for treatment centers to pool patients for inclusion in randomized clinical trials.

Gene expression analysis reveals a different transcriptomic landscape in female and male breast cancer

Male breast cancer (MBC) is a poorly characterized disease because of its rarity. Clinical management is based on results obtained from randomized trials conducted in women notwithstanding data in the literature suggesting relevant gender-associated differences in terms of biological and clinical behavior. However, a genome-wide characterization of MBC on a transcriptional level is lacking. In this study, gene expression profiles of 37 estrogen receptor positive (ER+) MBC specimens were compared to that of 53 ER+ Female Breast Cancer (FBC) samples similar for clinical and patho-biological features. Almost 1000 genes were found differentially expressed (FDR < 1%) between female and male patients and biological interpretation highlighted a gender-associated modulation of key biological processes ranging from energy metabolism to regulation of translation and matrix remodeling as well as immune system recruitment. Moreover, an analysis of genes correlated to steroid receptors and ERBB2 suggested a prominent role for the androgen receptor in MBC with a minor relevance for progesterone receptor and ERBB2, although, similarly to FBC, a genomic amplification could be observed. Our findings support the idea that breast cancer is a quite different disease in male and female patients and the underlying gender-related biological differences are likely to have clinical implications connected with different susceptibility to treatment.

Male breast cancer: a survey at the Helsinki University Central Hospital during 1981-2006

BACKGROUND

The purpose was to analyze the behavior of male breast cancer.

METHODS

Fifty-eight male breast cancer patients were treated at the HUCH during 1981-2006. Data on risk factors, tumor characteristics, clinical presentation, treatment and survival were obtained by chart review.

RESULTS

Presentation occurred at a median age of 63 years, most often due to a self-detected lump. The median size of the primary tumor was 1.8 cm and 14% were T4 tumors. Forty-seven percent had lymph node metastases and 4% distant metastases at diagnosis. Ductal carcinoma was the most common tumor type. All tumors with known receptor status were positive for estrogen receptor (ER) and 79% for progesterone receptor (PgR). Her-2 overexpression was found in 2/19 patients (11%). A family history of breast cancer, obesity, high alcohol intake and liver cirrhosis were the most often seen risk factors. Nineteen percent had one or two other malignancies, the most common second malignancy being prostate cancer in 7%. Ninety-seven percent were operated by mastectomy and 90% by axillary evacuation while sentinel node biopsy alone was done only in 7%. Sixty percent of the patients received radiotherapy, 64% adjuvant hormonal treatment, 20% adjuvant chemotherapy, and 2% adjuvant trastuzumab. Fourteen patients (25%) experienced a relapse of which 60% were distant, bone being the most common site. During follow-up 21 patients (37%) died, of whom nine of breast cancer and 12 due to other causes. The 5-year overall survival (OS) was 75%.

CONCLUSIONS

Male breast cancer behaves and is today treated in many respects like postmenopausal breast cancer. However, due to rudimentary breast tissue the symptoms, diagnosis and especially a higher amount of T4 tumors differ from that of females. Also the risk factor profile and histologic subgroups seem different. The 5-year OS of 75% is clearly higher than 44% reported at our institution in 1982.

A male patient from the West Indies with invasive ductal carcinoma in the right breast: a case report and literature review

BACKGROUND

Men with breast carcinoma have a poor prognosis, especially in the younger age group (30-40 years of age), because most breast enlargements in young men are dismissed as gynecomastia, resulting in an unnecessary delay in treatment.

OBJECTIVE

We describe the case of a young male patient with invasive ductal breast carcinoma.

CASE SUMMARY

In November 2005, a 30-year-old Afro-Caribbean man presented at St. Clair Medical Centre in Port of Spain, Trinidad, with a painless lump in the right breast. Diagnostic findings revealed that the patient had stage II invasive ductal carcinoma, for which he underwent a mastectomy with total axillary clearance.

CONCLUSION

Surgeons investigating unilateral breast swellings in young males should not dismiss them simply as gynecomastia, and should be wary of cancer.

Multidisciplinary meeting on male breast cancer: summary and research recommendations

Male breast cancer is a rare disease, accounting for less than 1% of all breast cancer diagnoses worldwide. Most data on male breast cancer comes from small single-institution studies, and because of the paucity of data, the optimal treatment for male breast cancer is not known. This article summarizes a multidisciplinary international meeting on male breast cancer, sponsored by the National Institutes of Health Office of Rare Diseases and the National Cancer Institute Divisions of Cancer Epidemiology and Genetics and Cancer Treatment and Diagnosis. The meeting included representatives from the fields of epidemiology, genetics, pathology and molecular biology, health services research, and clinical oncology and the advocacy community, with a comprehensive review of the data. Presentations focused on highlighting differences and similarities between breast cancer in males and females. To enhance our understanding of male breast cancer, international consortia are necessary. Therefore, the Breast International Group and North American Breast Cancer Group have joined efforts to develop an International Male Breast Cancer Program and to pool epidemiologic data, clinical information, and tumor specimens. This international collaboration will also facilitate the future planning of clinical trials that can address essential questions in the treatment of male breast cancer.

Pharmacologic treatment of male breast cancer

Male breast cancer is an uncommon condition. It often occurs in settings in which there is an imbalance between androgens and oestrogens. Genetics plays an important role, as many cases are associated with mutations in BRCA2 or other genes. Male breast cancer occurs at an older age than female breast cancer and is frequently diagnosed at a later stage. Tumors are predominantly oestrogen and progesterone positive. Prognosis is approximately equivalent to that of breast cancer in females when matched for age, stage and hormonal receptors. The recommended treatment for male breast cancer is similar to that for breast cancer in postmenopausal females. However, the presence of androgens in males has a strong effect on the hormonal milieu and the ability of male patients to respond to hormonal agents. When pharmacologic treatment is required, tamoxifen is effective for first-line therapy. Other hormonal approaches such as orchiectomy, aromatase inhibitors and androgen ablation may be useful in later lines of therapy.

Male breast cancer: 22 case reports at the National Hospital of Niamey-Niger (West Africa)

Background:

Male breast cancer (MBC) is rare. The objective of the study is to report clinicopathological characteristics, treatment patterns, and outcomes of MBC.

Method:

This study, which includes two parts (retrospective and prospective), focused on all hospitalized male patients with breast cancer during 17 years (1992–2008) with histological confirmation.

Results:

The series included 22 patients. The mean age was 52.8 years (range: 28–80 years). MBC represented 5.7% of all breast cancers. Most patients had an advanced disease with skin ulceration and inflammation T3 (31.9%) and T4 (59.1%). The majority of patients came from rural areas (63.6%). The duration of signs ranged from 1 to 7 years. Histology found infiltrating ductal carcinoma in 14 cases (63.6%), sarcoma in 3 cases (13.6%), papillary carcinoma in 2 cases (9%), and lobular carcinoma, medullar carcinoma, and mucinous carcinoma in 4.6% each of the others cases. The treatment had consisted of a radical mastectomy (Halsted or Patey) in 19 cases (86.4%) with axillary clearance and incomplete resection in 3 cases (13.6%). In the retrospective study follow-up of 14 patients, we lost sight of 13 patients 6 months after surgery. In the prospective study of 8 patients 10 to 36 months after mastectomy, 4 patients were deceased (50%), 4 were alive with 1 case having a local recurrence and pulmonary metastasis.

Conclusion:

The advanced clinical forms of MBC are most frequent with skin ulceration and nodal enlargement. The absence of radiotherapy and the low access of chemotherapy limited the treatment to radical mastectomy (Halsted) in the majority of cases.

Are males with early breast cancer treated differently from females with early breast cancer in Australia and New Zealand?

Breast cancer in males is much rare than in females so in practice, male breast cancer treatment is likely to follow the guidelines developed for female breast cancer patients. The objective of this study is to compare the characteristics and treatment pattern of male breast cancer patients with comparable subgroups of female breast cancer patients using data submitted to the National Breast Cancer Audit. This is a retrospective analysis of 151 male breast cancers diagnosed and treated between 2000 and 2008. Most of the male early breast cancer cases in this group were symptomatic ones in men aged >50 years with one invasive tumour. There was a similar proportion of lymph node positive cancer among males and females, although male breast cancer was more likely to be unifocal (P=0.007) and oestrogen receptor positive (P=0.001). Male breast cancer patients almost always underwent mastectomy and a significant proportion of them (11%) received no surgical treatment. There were no differences in axillary surgery although males were more likely to undergo a level 2 axillary surgery and less likely to have sentinel node biopsy. Male patients were significantly less likely to undergo radiotherapy, chemotherapy or hormonal therapy for oestrogen receptor positive tumours.

CONCLUSION

While the female oriented treatment guidelines are available, male patients with early breast cancer received different surgical and adjuvant treatment from comparable females.

The significance of nipple discharge of the male breast

Although male breast cancer typically presents as a palpable mass, failure to recognize the significance of other symptoms may lead to a delay in diagnosis. Here we present our experience with male patients presenting with a chief complaint of nipple discharge (ND). Using the ICD-9 code for "breast symptoms," we identified 2,319 patients without a current cancer diagnosis who presented to Memorial Sloan-Kettering Cancer Center for evaluation; 24 (1%) patients were male (1995-2005). Data were collected by retrospective review. Among 24 male patients presenting for evaluation, 14 (58%) presented with a chief complaint of ND, while the remaining 10 (42%) presented for evaluation of a palpable mass in the absence of ND. Among 14 patients presenting with ND, subsequent clinical breast examination identified a breast mass +/- nipple changes in 7 of 14 patients. In total, 8 of 14 (57%) patients had an underlying malignancy; two of seven patients with ND alone had DCIS (median interval from onset of ND to presentation 3 weeks, range 2-4 weeks), and six of seven patients with ND and a palpable mass had invasive disease (median interval between onset of ND and presentation 16 weeks, range 2-52). The remaining 10/24 patients presented with a painless palpable mass of whom 8 (80%) were found to have underlying invasive disease (median interval between onset of mass, and presentation was 4 weeks, range 2-20 weeks). All patients with invasive disease were node-positive. At 23.7 months median follow-up (range, 7.7-88.3 months), 14 of 16 cancer patients remain free of disease and two have died as a direct result of metastatic disease. The incidence of cancer among males presenting with ND was 57%. In the absence of additional clinical findings, ND may be a herald for early, non-invasive disease. Increased awareness of subtle features of malignancy may represent a window of opportunity for early diagnosis and improved outcomes for male breast cancer patients.

Clinicopathological study of male breast carcinoma: 24 years of experience

BACKGROUND AND OBJECTIVES

Because breast cancer in men is rare, few patients are available for prospective studies. To learn more about its epidemiology, risk factors, clinical features, genetics and pathology in our country, we conducted a retrospective study of all cases seen in recent decades at our institution.

PATIENTS AND METHODS

We identified each case of male breast cancer in the database at the Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India, between the years 1983 to 2007.

RESULTS

We identified only 32 cases of male breast cancer over the 24-year period. Male breast cancer accounted for 32 (2.8%) of 1141 resected breast specimens, which included all breast lesions and 32 (4.1%) of 780 breast cancer cases. Of the 32 cases, 20 (62.5%) had various associated risk factors. Invasive ductal carcinoma was seen in 30 cases (93.7%). Of 20 cases that underwent molecular studies, 16 (80%) patients had estrogen receptor positivity whereas 14 (70%) had progesterone receptor positivity. Six cases (30%) overexpressed HER2 and p53. The BRCA2 mutation was observed in 4 cases (40%) while no patient presented with the BRCA1 mutation.

CONCLUSION

An incidence of 4.1% for male breast cancer indicates that this disease is not as uncommon as presumed in this part of the world. Breast cancer in men seems more frequently to be hormone receptor positive and the BRCA2 mutation confers a significant risk to men.

Male breast cancer

Male breast cancer (MaleBC) is a rare disease, accounting for <1% of all male tumors. During the last few years, there has been an increase in the incidence of this disease, along with the increase in female breast cancer (FBC). Little is known about the etiology of MaleBC: hormonal, environmental and genetic factors have been reported to be involved in its pathogenesis. Major risk factors include clinical disorders carrying hormonal imbalances, radiation exposure and, in particular, a positive family history (FH) for BC, the latter suggestive of genetic susceptibility. Rare mutations in high-penetrance genes (BRCA1 and BRCA2) confer a high risk of BC development; low-penetrance gene mutations (i.e. CHEK-2) are more common but involve a lower risk increase. About 90% of all male breast tumors have proved to be invasive ductal carcinomas, expressing high levels of hormone receptors with evident therapeutic returns. The most common clinical sign of BC onset in men is a painless palpable retroareolar lump, which should be evaluated by means of mammography, ultrasonography and core biopsy or fine needle aspiration (FNA). To date, there are no published data from prospective randomized trials supporting a specific therapeutic approach in MaleBC. Tumor size together with the number of axillary nodes involved are the main prognostic factors and should guide the treatment choice. Locoregional approaches include surgery and radiotherapy (RT), depending upon the initial clinical presentation. When systemic treatment (adjuvant, neoadjuvant and metastatic) is delivered, the choice between hormonal and or chemotherapy (CT) should depend upon the clinical and biological features, according to the FBC management guidelines. However great caution is required because of high rates of age-related comorbidities.

Etiologic factors for male breast cancer in the U.S. Veterans Affairs medical care system database

The etiology of male breast cancer is largely unknown, reflecting its relative rarity. Although a number of previous studies have suggested relationships with a variety of medical conditions, the results have largely derived from case-control studies and may reflect recall biases. Within the large U.S. Veterans Affairs computerized medical care system database, we had the opportunity to access 26 million hospital discharge records over the period 1969-1996 and to relate various documented medical conditions to the risk of subsequent male breast cancer. This allowed us to calculate relative risks (RR) and 95% confidence intervals (CI) for male breast cancer associated with conditions occurring one or more years after initial hospitalization, adjusted for age, race, calendar year, duration of follow-up, and number of hospital visits. Among 4,501,578 men aged 18-100 years, a total of 642 cases of primary male breast cancer were identified (523 among whites, 119 among blacks). Medical conditions that were significantly related to risk were diabetes (RR 1.30, 95% CI 1.05-1.60), obesity (1.98, 1.55-2.54), orchitis/epididymitis (1.84, 1.10-3.08), Klinefelter syndrome (29.64, 12.26-71.68), and gynecomastia (5.86, 3.74-9.17). Additionally, among black patients, cholelithiasis emerged as a significant risk predictor (3.45, 1.59-7.47). Diseases that have previously been related to male breast cancer risk that were not supported by our study results included thyroid diseases, smoking-related conditions, liver cirrhosis, prostatic hyperplasia, and fractures. After adjustment for obesity, the association with diabetes disappeared, but that with gynecomastia persisted. In multivariate models that simultaneously considered all important medical predictors of risk, significant risks were seen for Klinefelter syndrome (16.83, 6.81-41.62), gynecomastia (5.08, 3.21-8.03), obesity (1.91, 1.50-2.44), and orchitis/epididymitis (1.80, 1.08-3.01). These results support previous speculations that male breast cancer is influenced not only by tissue at risk, but also by hormonal and inflammatory factors.

Male breast cancer: a review

Male breast cancer (MBC) is rare, with the peak age of onset at 71 years. BRCA2 mutations are more frequent than BRCA1 with 20% of cases giving a family history. Risk factors for MBC are poorly understood and include working in high-ambient temperatures and exhaust fume exposure. MBC is associated with hyperoestrogenic states found in liver disease, Klinefelter's syndrome, gonadal dysfunction or obesity. Most information on treatment of MBC is derived from large randomized trials carried out in female patients. The small numbers of MBC seen in any unit annually has precluded significant trials being carried out.Diagnosis and treatment of MBC is similar to that of female patients, but men tend to be treated with mastectomy rather than breast-conserving surgery. The mainstay of adjuvant therapy or palliative treatment for advanced disease is endocrine, mostly tamoxifen. Prognosis of male patients is equal to that of stage-matched women, but men tend to fare worse because of delay in presentation, leading to a large proportion of patients presenting with stage III or IV disease. Increased input is needed for psychological support for male breast cancer patients. Specific therapeutic questions about MBC need international trials to obtain meaningful answers.

Male breast cancer: a retrospective analysis

BACKGROUND

To evaluate our results in the treatment of male breast cancer patients with respect to local control (LC), overall survival (OS) and possible prognosis factors for survival.

PATIENTS AND METHODS

Thirty-nine patients with male breast cancer have been retrospectively studied with the trial aim to evaluate the results of our practice. Among them, 94.8% had invasive ductal carcinoma (IDC), 2.6% invasive papillary carcinoma (IPC) and 2.6% invasive lobular carcinoma (ILC) and the distribution according to stage was found to be 12.8, 46.2, 30.7 and 10.3% in Stages I, II, III and IV, respectively. Among the patients, 7.7% received radiotherapy (RT) and hormonotherapy (HT), 22.8% received chemotherapy (CT), 61.8% received chemoradiotherapy (CRT) and HT and 7.7% received HT in addition to surgery.

RESULTS

The distant metastases rate was 36% and the local recurrence rate was 5%. All the local recurrences and the distant metastases had occurred after the first two years. The five-year disease free survival (DFS) and OS rates were 65.8 and 80.1% respectively. In our series, univariate analysis for OS demonstrated statistical significance for lymph node metastases (p=0.00001), stage (p=0.0098) and age (p=0.03); while RT in the treatment modality (p=0.6849), and tumor size (p=0.4439) demonstrated no significance. The presence of lymph node metastases significantly impairs OS (p=0.004) and DFS (p=0.014) in multivariate analysis.

CONCLUSION

Postoperative radiotherapy was important in the management of male breast cancer to improve LC resulting in one local failure, but did not improve OS and DFS in our analysis. The presence of lymph node metastases significantly impaired OS and DFS.

Invasive Lobular Carcinoma of the Male Breast: A Rare Histology in an Uncommon Disease

SUMMARY: BACKGROUND: Breast cancer in men is an uncommon disease. Nearly all cases of male breast cancer originate in the terminal ductulolobular unit, with exceedingly rare reports of lobular carcinoma in men. Invasive lobular cancer is found in no more than 1-2% of male breast cancer cases. Most of what is known about this disease is in the form of approximately 30 case reports in the literature. CASE REPORT: We report the case of a 52-year-old man who presented at our institution with a lump in his left breast. Ultrasound-guided biopsy revealed an invasive lobular cancer. The rare histological type was confirmed by the result of the histological examination of the mastectomy specimen. The treatment was completed by dose dense chemotherapy, radiation, and endocrine therapy. CONCLUSION: Even though lobular structures are quite infrequent in the normal male, sporadic cases of invasive lobular breast cancer have been described. A short overview will be given in this case report.

Imaging, histology and hormonal features of five cases of male breast cancer observed in a single year: comparison with the literature

PURPOSE

The authors assessed mammographic and ultrasound (US) features and histological and biological characteristics of male breast carcinomas observed in five men (mean age 57.8 years) in a single year and compared the findings with the literature.

MATERIALS AND METHODS

All patients underwent history taking and bilateral mammography and US examination extended to the axillary region and complemented with colour Doppler US.

RESULTS

Three out of five patients had a family history of breast cancer, and all of them had an altered energy balance (mean body mass index 30.8). All subjects had a palpable mass, which was associated with bloody nipple discharge in two cases. Mammography identified all lesions as opacities with irregular margins (mean size 1.98 cm); in one case, it also revealed a nonpalpable contralateral lesion. US demonstrated the presence of inhomogeneously hypoechoic nodules with irregular margins and centrifugal vascular spots in 4/6 lesions. Histology diagnosed invasive ductal cancer (IDC) in 5/6 lesions (83.3%) and ductal carcinoma in situ (DCIS) in the contralateral lesion only.

CONCLUSIONS

The presence of symptoms warrants mammography, which is an accurate method for identifying male breast cancer. The frequency of invasive disease observed in our study was consistent with the literature (80%-90% IDC). The hormonal alterations induced by excess fat in our series appear to be correlated with the development of carcinomas with positive receptor status for both oestrogen and progesterone.

[Male breast cancer: a review of 52 cases collected at the Institute Bergonié (Bordeaux, France) from 1980 to 2004]

OBJECTIVES

To analyze the characteristics and to establish prognosis factors for 52 men suffering from breast cancer from 1980 to 2004.

PATIENTS AND METHODS

Men treated for breast cancer (invasive or in situ). A retrospective study analyzed clinical and histological characteristics, and treatment procedures. The probability of survival or recurrence was calculated using the Kaplan-Meier method. Prognostic factors were studied using the Log Rank test.

RESULTS

The mean age of our patients was 63.5 years old. In 73.1% of cases, subaerolar tumors were the initial symptoms, the average size was 30.31 mm. Among patients, 17 (32.7%) had T1, 19 (36.5%) T2, two (3.8%) T3 and 14 (26.9%) T4. The most represented histological type was the infiltrative ductal carcinoma (84.6%). The spread rate to axillary lymph nodes was 63.6%. The hormone dependency of these tumors was proven in 84.6% of cases. Overall survival rate were about 69% at five years and 32% at 10 years. The spread to lymph node and to derm, the clinical stage were significant factors influencing disease free survival. None of these factors had any significance regarding overall survival.

DISCUSSION AND CONCLUSION

Male breast cancer is a rare disease (about 1% of breast cancer) with a poor prognosis (32% 10 years disease free survival). An early diagnosis and better knowledge of the disease would certainly lead to improvement of prognosis.

Changes in Male Breast Cancer over a 30-Year Period

Male breast cancer is a rare clinical entity accounting for approximately 1 per cent of all breast cancers. The present study investigated changes in patient characteristics, disease patterns, treatment, and outcomes over a 30-year period. A retrospective chart review was performed on male breast cancer patients treated between 1975 and 2005 at Eastern Virginia Medical School, Norfolk, VA. Demographic, pathologic, treatment, and survival information was collected. To facilitate comparison of trends, the patients were divided into two groups: Cohort A (1972–1991, previously reported) and Cohort B (1992–2005). Both cohorts included 28 male patients. Comparing the cohorts, no statistical differences were noted in median age, ethnicity, presenting symptoms, or progesterone receptor status. In Cohort A, 70 per cent of patients were estrogen receptor positive, compared with 100 per cent of Cohort B ( P = 0.02). Her2/neu was positive in three of five patients in Cohort B. There was a trend toward more conservative surgery, with no radical mastectomy or orchiectomy performed in Cohort B. Only two patients had sentinel lymph node mapping, both from Cohort B. Infiltrating ductal carcinoma was more prevalent in Cohort B ( P = 0.04). For Cohort A and B, 5-year survival was 43 per cent and 51 per cent, respectively, which was not statistically significant. For male breast cancer, radical mastectomy is no longer a common treatment modality. Male breast cancer of today is more hormonally responsive which may have important implications for therapy. Survival has not significantly improved over the previous 30 years. Compilation of multi-institutional data of male breast cancer is needed to advance the treatment of this uncommon disease.

Male Breast Cancer

Breast cancer is a rare disease in men representing nearly 1% of the total breast cancer cases worldwide. Due to the low incidence, there are no randomized clinical studies giving information on the optimal diagnostics and therapy for male breast cancer patients. Therefore, treatment recommendations are derived from established guidelines for breast cancer in women. However, the lack of awareness of this disease leads to its detection at a later stage in men associated with a worse prognostic outcome. The gender-specific differences in breast cancer are among others related to the differing genetic and hormonal environment and the anatomic constitution in men. For example, males have a much higher percentage of hormone receptor-positive tumors but a significantly lower fraction of carcinomas overexpressing HER2. This review focuses on epidemiology, pathogenesis, and clinical findings of male breast cancer, and discusses current findings available to treat this disease. To optimize disease outcome and tolerability of treatment, these data should be considered to improve the therapeutic index of male breast cancer patients.

Male breast cancer: is the scenario changing

Background

The overall incidence of male breast cancer is around 1% of all breast cancers and is on the rise. In this review we aim to present various aspects of male breast cancer with particular emphasis on incidence, risk factors, patho-physiology, treatment, prognostic factors, and outcome.

Methods

Information on all aspects of male breast cancer was gathered from available relevant literature on male breast cancer from the MEDLINE database over the past 32 years from 1975 to 2007. Various reported studies were scrutinized for emerging evidence. Incidence data were also obtained from the IARC, Cancer Mondial database.

Conclusion

There is a scenario of rising incidence, particularly in urban US, Canada and UK. Even though more data on risk factors is emerging about this disease, more multi-institutional efforts to pool data with large randomized trials to show treatment and survival benefits are needed to support the existing vast emerging knowledge about the disease.

Breast conserving surgery with preservation of the nipple-areola complex as a feasible and safe approach in male breast cancer: a case report

Introduction

Breast cancer in men is rare. The evidence about treatment has been derived from data on the management of the disease in women. The usual treatment is for male patients to undergo modified radical mastectomy. There is insufficient experience of breast conserving surgery with preservation of the nipple. The management of patients who demand such an approach for personal reasons remains a challenge for both the surgeon and oncologist.

Case presentation

A 50-year-old man with a breast cancer was successfully managed with breast conserving surgery with nipple preservation combined with axillary clearance and postoperative radiotherapy, chemotherapy and hormone treatment. Since there are no similar cases in the literature, we discuss the feasibility, safety and possible indications of such an approach.

Conclusion

Despite the limited indications and evidence about the safety and efficacy of breast conserving surgery with nipple preservation in men with breast cancer, it is a feasible approach if other options are declined by the patient. More studies are necessary to reach firm conclusions about the safety of such an approach.

How to treat male breast cancer

The prevalence for breast cancer in males in Europe is estimated to be 1 or less per 100,000. Male breast cancer has a peak incidence at the age of 71 years. There are no randomized data giving information on the optimal therapy for male breast cancer patients, thereby limiting firmer conclusions. The preferred primary surgical therapy is modified radical/simple mastectomy, but breast-conserving surgery has also been used in males. Post-operative radiotherapy should be used on a more routine basis; as males have shorter breast-anatomical distances and males are diagnosed at a later stage compared with females. The so far preferred adjuvant therapy modality has been tamoxifen for patients with endocrine responsive disease. The use of aromatase inhibitors in males is more controversial, since they may not deplete the estradiol levels sufficiently. Different chemotherapy regimens have been used in the adjuvant and metastatic setting. The use of adjuvant therapy has in institutional and review comparisons been demonstrated to result in an improved outcome.

Pulmonary metastases in men: primary tumor in an unusual location

We report a case of breast cancer identified in a 72-year-old male as an accidental finding during the course of the investigation of a primary tumor and the search for pulmonary metastases. We address aspects related to the epidemiology, diagnosis, treatment and prognosis of this condition in males.

Breast conservation for male breast carcinoma

Male breast cancer in general is treated by modified radical mastectomy. Data have emerged supporting the replacement of the axillary lymph node dissection by a sentinel lymph node biopsy in the male patient with breast carcinoma. Local therapy in the breast continues to be primarily mastectomy. The reasons suggested for this include the central location of many of the male breast tumors and the paucity of breast tissue. Our experience with breast conservation over the last decade in male breast carcinoma and a review of the literature is outlined here. Between 1996 and 2006, seven men underwent breast conservation for breast carcinoma and to date with a median follow-up of 67 months, there have been no local recurrences. Breast carcinoma in males can be treated with breast conservation with acceptable local recurrence. Breast-conserving surgery in male breast cancer patients should be considered an option in patients without overt nipple/areolar involvement.

Some Aspects of the Endocrine Profile and Management of Hormone‐Dependent Male Breast Cancer

The management of hormone-dependent male breast cancer is insufficiently understood by practicing oncologists. This article provides a review of the endocrine profile of male breast cancer, and outlines the differences between hormone-dependent female and male breast cancers. A concise review of the past, present, and possible future management of hormone-dependent male breast cancer is presented. For a better understanding of this disease, more information on the natural history and biological behaviors of patients with male breast cancer is needed. This could be accomplished by the development of a specific multi-institutional tumor registry and execution of prospective clinical trials.

[Breast cancer in men]

Breast cancer in men is rare and most often occurs at or after the age of 60 years. Prognosis is poor when it is discovered at a late stage, as it often is in men, although it should be easier to detect because men have so little breast tissue. The causal mechanism appears to depend on hormone metabolism abnormalities related to elevated estrogen or prolactin levels. A family history of breast cancer is found in 5-10% of cases. Infiltrating ductal carcinoma accounts for most cases (70-90%) of male breast cancers. In situ but not invasive carcinoma is exclusively ductal and accounts for 7% of cases. Spread to lymph nodes is observed in 50-75% of cases. Immunohistochemical analysis shows that tumors are positive for progesterone and estrogen receptors more frequently in men than women. Diagnosis is based on clinical examination, ultrasonography, and mammography. Aspiration cytology often makes it possible to confirm the malignancy. Excisional biopsy with an immediate intraoperative pathology examination confirms malignancy and makes wider excision possible during the same procedure. A modified radical mastectomy with removal of some lymph nodes (Patey's mastectomy) is the standard basic treatment. Locoregional radiotherapy is very often indicated. Hormone therapy is also a first-line treatment. Chemotherapy is reserved for young men with substantial lymph node invasion and negative for hormonal receptors. The prognosis of breast cancer in men remains uncertain because of the frequently late diagnosis, unpredictable course, and high potential for metastasis.

Male breast cancer in the veterans affairs population

BACKGROUND

The incidence of male breast cancer (MBC) continues to rise. The Veterans Affairs (VA) Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare the characteristics and outcome of patients with MBC and patients with female breast cancer (FBC) in the VA population.

METHODS

VACCR data were used to analyze the database of VA patients who had breast cancer diagnosed between 1995 and 2005. It includes 120 VA medical centers. Primary site codes were identified for breast cancer (500-508). Data were entered and analyzed using biostatistical software.

RESULTS

In total, 3025 patients' records were reviewed, and 612 patients who had MBC were compared with 2413 patients who had FBC. The mean age at diagnosis was 67 years for patients with MBC and 57 years for patients with FBC (P < .005). More patients with MBC were black, and patients with MBC presented with higher disease stage and more lymph node-positive disease. The dominant histology in MBC was ductal carcinoma. No difference in grade or laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Overall, patients with MBC received less chemotherapy, whereas no statistical difference was observed in the use of hormone treatment. The median overall survival for patients who had MBC was 7 years compared with 9.8 years for patients who had FBC (log-rank test; P < .005). There was no statistically significant difference in median survival for patients with stage III disease and stage IV disease. However, the median survival differed significantly for patients with stage I disease and stage II disease. In lymph node-negative patients, the median survival was 6.1 years for patients with MBC and 14.6 years for patients with FBC (P < .005), whereas the median survival did not differ significantly in lymph node-positive patients. Using Cox regression analysis age, sex, clinical stage, and lymph node status were independent prognostic factors for survival, whereas race, histology, and grade were not.

CONCLUSIONS

To the authors' knowledge, this is the largest series of MBC and FBC to date in the veterans population. The results suggested the presence of differences in the biology, pathology, presentation, ethnicity, and survival between patients with MBC and patients with FBC in the VA population. It is noteworthy that the survival of patients with MBC was inferior for those with early-stage disease and lymph node-negative tumors, suggesting that there are differences between the sexes in the pathogenesis and biology of breast cancer. In patients with hormone receptor-positive MBC, survival was inferior despite similar hormone treatment practices between MBC and FBC. This observational study calls for a better understanding of this disease that would allow new opportunities for specific therapeutic intervention.

Strategies in treating male breast cancer

Male breast cancer is rare. Median age at diagnosis is approximately 65 years, and > 35% of male breast cancers occur in elderly men. Retroareolar lump is the most frequent symptom, and 25-30% of tumours are T(4) lesions. Infiltrating ductal carcinoma represents almost 90% of the cases, and 10% are ductal carcinoma in situ. Axillary nodal involvement is present in 50-60% of the cases. Estrogen and progesterone receptors are positive in 75-92% and 54-77% of the cases. Mastectomy with axillary dissection remains the standard treatment. Sentinel lymph node biopsy could be proposed in small tumours (< or = 2 cm). Locoregional radiotherapy is very often indicated. Tamoxifen is the standard adjuvant treatment, but chemotherapy is proposed in young men with axillary nodal involvement and/or negative hormone receptors. Tumour size and, more particularly, histopathological axillary involvement are the strongest predictive factors for both locoregional recurrence and metastasis. Globally, the prognosis is similar to that in women (at identical stage), but the intercurrent death rate is higher due to the important impact of comorbidities and second neoplasm.

Clinical and pathological correlations in male breast cancer: intratumoral aromatase expression via tissue microarray

BACKGROUND

Male breast cancer (MBC) commonly expresses hormone receptors and there is anecdotal evidence of disease responsivity to aromatase inhibitors in the metastatic setting. Our objectives were to: (i) assess clinical-pathologic characteristics in a consecutive cohort of MBC (ii) evaluate intratumoral aromatase (ITA) expression via tissue microarray (TMA) and (iii) assess the prognostic impact of ITA METHODS: A retrospective review was conducted to identify all cases of MBC seen at the Nova Scotia Cancer Center between 1985 and 2005. Specimens were reviewed for standard pathologic characteristics and tumor blocks were incorporated into three TMA's (four 1 mm cores per tumor). Immunohistochemistry (IHC) for ER, PR, Her2-neu and ITA was performed blinded to clinical outcomes. ITA staining intensity was compared to control, benign hepatic tissue and if greater than or equal to liver was scored positive and if less than liver was scored negative. The log-rank test was used for survival comparisons and Kaplan-Meyer curves were used to estimate 3- and 5-year progression-free and overall survival probabilities.

RESULTS

Fifty-four cases were identified with a median age of 64 (31-85 years). Median tumor size was 2.6 cm (0.3-8.0 cm) and 22(41%) had nodal metastases. Forty-five cases had tissue available for IHC. Of these, 40 (89%) were ER and 33 (73%) were PR positive. Her2-neu was overexpressed in four cases (10%) and 12 (27%) were positive for ITA expression. ITA positive tumors were less likely to be grade 3, have lymphovascular invasion or nodal metastases and were more likely to be of favorable histology compared to ITA negative tumors. In univariate analysis strong (versus weak) ITA expression was associated with improved 5 year overall (92% vs. 49%, P = 0.038) but not progression-free (82% vs. 76% P = 0.44) survival rates.

CONCLUSIONS

Tumors with strong ITA expression may have a less aggressive phenotype compared to those with negative/weak ITA expression. Further investigation of ITA as a relevant prognostic factor as well as a potential therapeutic target in MBC is warranted.

Male breast cancer: a gender issue

The incidence of male breast cancer (MBC) is rising; however, mortality due to MBC has not changed, unlike female breast cancer. This lack of change is mostly attributable to a lack of major progress in the understanding and treatment of the disease. The treatment of MBC has been extrapolated from the knowledge of female breast cancer, despite the multiple differences in the pathogenesis, biology and genetics of these two disease entities, especially the differences with regard to the role of male hormones as well as estrogens in MBC compared with female disease. Although major advances in hormonal manipulation for the treatment of breast cancer are being developed, an improved understanding of the potential differences between male and female breast cancer is essential, as this would provide new opportunities for therapeutic intervention and probable improved outcome for MBC. This review aims at highlighting the major differences between male and female breast cancer with an emphasis on hormonal therapy, and discusses some of the recent advances in MBC.

Male breast cancer metastasis presenting as submandibular swelling

This case report deals with the case of an 86-year-old man who was admitted to our hospital with an submandibular swelling after mastectomy for breast cancer one and a half year ago. Histopathological examination after surgical resection evaluated metastasis of a mixed-type breast carcinoma. Further treatment was palliative chemotherapy. This is the first description of a male breast carcinoma metastasis located in the submandibular region.

Invasive carcinomas of the male breast: a morphologic study of the distribution of histologic subtypes and metastatic patterns in 778 cases

The current investigation was conducted to evaluate the proportional distribution of the various histologic subtypes (including newly recognized variants) of male breast carcinomas, to determine whether any histologic subtypes occur with a frequency that is markedly discordant with the expected frequencies from published data on parallel female breast tumors. We also aimed to document the distribution of malignancies metastatic to the breast. Seven hundred fifty-nine archived cases of primary invasive carcinoma involving the male breast were retrieved and subcategorized into histologic subtypes according to contemporary criteria. Six hundred forty-three (84.7%) tumors were pure infiltrating ductal carcinoma (IDC) not otherwise specified. The most common of the remainder included papillary carcinoma with invasion in the form of IDC (n = 34), mixed IDC and mucinous carcinoma (n = 26), and pure mucinous carcinoma (n = 21). In 19 cases, metastases from other sites involved the breast, most commonly (58%) cutaneous melanoma. Invasive carcinoma of the male breast appears to display a morphologic spectrum and distribution of histologic subtypes that is comparable to those of the female breast, with some expected variation. Compared with published experience on their female counterparts, there is a two-fold increase in the frequency of invasive papillary carcinoma in the male breast. Finally, the most common tumor metastatic to the male breast in this series was cutaneous melanoma.

A prospective study of adjuvant CMF in males with node positive breast cancer: 20-year follow-up

PURPOSE

To determine the long-term overall survival of male patients with stage II node positive breast cancer treated with adjuvant chemotherapy.

PATIENTS AND METHODS

Between 1974 and 1988, 31 male breast cancer patients were prospectively enrolled on study MB-82 in the National Cancer Institute. Following mastectomy, patients were treated with 12 cycles of cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy.

RESULTS

Median patient age was 61 years (38-74 years). Twenty-one patients (68%) had 1-3 positive axillary lymph nodes while ten patients (32%) had four or more positive nodes. Estrogen receptor status was positive in 22 (71%), negative in 1 (3%), and unknown in 8 (26%) tumors. Progesterone receptor status was positive in 18 (58%), negative in 3 (10%), and unknown in 10 (32%) tumors. Median potential follow-up for all patients is 22.5 years with a median survival of 16.3 years. Twenty-one of 31 patients have died; one from a treatment-related complication, nine patients from recurrent breast cancer, five from other cancers, one from non-cancer related causes, and five from unknown causes. Ten patients remain alive at a median of 19.2 years. The overall survival probability at 10 years is 64.5% (95% CI: 46.9-78.9%), at 15 years is 51.6% (95% CI: 34.8-68%), and at 20 years is 42.4% (95% CI: 25.8-60.8%).

CONCLUSION

To our knowledge, 20-year prospective data with adjuvant chemotherapy in male breast cancer has never been reported. Adjuvant chemotherapy may benefit male breast cancer patients with positive nodes.