Male breast cancer

Breast Cancer Screening in High-Risk Men: A 12-year Longitudinal Observational Study of Male Breast Imaging Utilization and Outcomes

Background Male breast cancer incidence is rising. There may be a potential role in selective screening in men at elevated risk for breast cancer, but the effectiveness of such screening remains unexplored. Purpose To evaluate patterns of male breast imaging utilization, to determine high-risk screening outcomes, and to delineate risk factors associated with cancer diagnosis. Materials and Methods This retrospective study reviewed consecutive male breast imaging examinations over a 12-year period (between 2005-2017). Examination indications, biopsy recommendations, and pathologic results were correlated with patient characteristics. Fisher exact test, Mann-Whitney test, Spearman correlation, and logistic regression were used for statistical analysis. Results A total of 1869 men (median age, 55 years; range, 18-96 years) underwent 2052 examinations yielding 2304 breast lesions and resulting in 149 (6.5%) biopsies in 133 men; 41 (27.5%) were malignant and 108 (72.5%) were benign. There were 1781 (86.8%) diagnostic and 271 (13.2%) screening examinations. All men undergoing screening had personal or family history of breast cancer and/or genetic mutations. There was a significant increase in the number of examinations in men relative to the number of examinations in women over time (Spearman correlation, r = 0.85; P < .001). Five node-negative cancers resulted from screening mammography, yielding a cancer detection rate of 18 per 1000 examinations (95% confidence interval [CI]: 7, 41), with cancers diagnosed on average after 4 person-years of screening (range, 1-10 person-years). Mammographic screening sensitivity, specificity, and positive predictive value of biopsy were 100% (95% CI: 50%, 100%), 95.0% (95% CI: 93.1%, 98%), and 50% (95% CI: 22.2%, 77.8%). Older age (P < .001), Ashkenazi descent (P < .001), genetic mutations (P = .006), personal history (P < .001), and first-degree family history (P = .03) were associated with breast cancer. Non-first-degree family history was not associated with cancer (P = .09). Conclusion There is potential benefit in screening men at high risk for developing breast cancer. Such screening may have increased over time. © RSNA, 2019.

The role of BRCA1/2 in hereditary and familial breast and ovarian cancers

BACKGROUND

BRCA1/2 pathogenic variants have become associated with familial breast and ovarian cancers, and hereditary cancer-predisposition syndrome. With advances in molecular biology, BRCA profiling facilitates early diagnosis and the implementation of preventive and therapeutic strategies. The genes exhibit variable prevalence among different individuals and moderate interpretation complexity. BRCA deficiency is instrumental in cancer development, affects therapeutic options and is instrumental in drug resistance. In addition, BRCA1/2 profile is diverse across different groups and has been associated with the "founder effect" in certain populations.

METHODS

In this review, we aim to detail the spectrum of BRCA1/2 variants and their associated risk estimates.

RESULTS

The relationship between BRCA1/2 and hereditary and familial cancers is indisputable, yet BRCA screening methods are beset with limitations and lack clinical confidence.

CONCLUSION

This review emphasizes the importance of screening BRCA genetics, in addition to their clinical utility. Furthermore, founder variants are anticipated in the Saudi population.

Morbidity Profile of Cases Attended Oncology Center of Mansoura University (OCMU), Egypt: A Cross-Sectional Study

Objectives

In Egypt, the National Cancer Registry Program integrates hospital-based data from multiple Egyptian governorates to obtain representative rates. Unfortunately, Dakahlia (one of the largest Egyptian governorates) was not integrated in the National Cancer Registry Program. This research aimed to acquire malignancy rates from the Oncology Center of Mansoura University, which is one of the two oncology centers present in Dakalia Governorate in Egypt.

Methods

Electronic records of patients who attended the Oncology Center of Mansoura University during 2016 were accessed with permission. Analysis was performed to extract diagnostic categories (age, gender, and geographic distribution of cases).

Results

Most commonly diagnosed malignancies were breast cancer which represented about 10% of cases in the Oncology Center of Mansoura University during 2016. This was followed by leukemia (3.80%), lymphoma (3.59%), and liver cancer (3.44%). Diagnoses encountered included benign and malignant tumors as well as non-tumor diagnoses. The Mansoura district had the highest proportionate rate of breast cancer cases. Females in the age group ≥ 35 < 60 years had the highest incidence of malignancy cases across all diagnoses.

Conclusion

The burden of breast cancer in Mansoura district is high. Risk factors need further evaluation with a recommendation to perform an environmental risk assessment.

Development and Validation of a Nomogram for Predicting Survival in Male Patients With Breast Cancer

Male breast cancer (MBC) is rare, and most patients are diagnosed at an advanced stage. We aimed to develop a reliable nomogram to predict breast cancer-specific survival (BCSS) for MBC patients, thus helping clinical diagnosis and treatment. Based on data from the Surveillance, Epidemiology, and End Results (SEER) database, 2,451 patients diagnosed with MBC from 2010 to 2015 were selected for this study. They were randomly assigned to either a training cohort (n = 1715) or a validation cohort (n = 736). The Multivariate Cox proportional hazards regression analysis was used to determine the independent prognostic factors, which were then utilized to build a nomogram for predicting 3- and 5-year BCSS. The discrimination and calibration of the new model was evaluated using the Concordance index (C-index) and calibration curves, while its accuracy and benefits were assessed by comparing it to the traditional AJCC staging system using the net reclassification improvement (NRI), the integrated discrimination improvement (IDI), and the decision curve analysis (DCA). Multivariate models revealed that age, AJCC stage, ER status, PR status, and surgery all showed a significant association with BCSS. A nomogram based on these variables was constructed to predict survival in MBC patients. Compared to the AJCC stage, the C-index (training group: 0.840 vs. 0.775, validation group: 0.818 vs. 0.768), the areas under the receiver operating characteristic curve of the training set (3-year AUC: 0.852 vs. 0.778, 5-year AUC: 0.841 vs. 0.774) and the validation set (3-year AUC: 0.778 vs. 0.752, 5-year AUC: 0.852 vs. 0.794), and the calibration plots of this model all exhibited better performance. Additionally, the NRI and IDI confirmed that the nomogram was a great prognosis tool. Finally, the 3- and 5-year DCA curves yielded larger net benefits than the traditional AJCC stage. In conclusion, we have successfully established an effective nomogram to predict BCSS in MBC patients, which can assist clinicians in determining the appropriate therapy strategies for individual male patients.

Male occult triple-negative breast cancer

Male breast cancer is a rare but important condition accounting for only 1% of breast cancer worldwide and less than 1% of all male malignancies. Occult male breast cancer is an extremely rare type of male breast cancer that manifests as axillary metastases without an identifiable breast lesion. We report a case of triple-negative occult male breast cancer who underwent modified radical mastectomy.

A Case of Locally Advanced Breast Cancer in a 59-Year-Old Man Requiring a Modified Approach to Management

Patient: Male, 59

Final Diagnosis: Invasive ductal carcinoma

Symptoms: Foul-smelling discharge • painful breast mass

Medication: —

Clinical Procedure: Modified radical mastectomy

Specialty: Surgery

Neoadjuvant concurrent chemoradiation in male breast cancer: Experience from a tertiary cancer center

BACKGROUND

Male breast cancers (MBC) account for 1% of all breast cancers. Neoadjuvant concurrent chemoradiation (CTRT) is not the standard of care for treating breast cancer. However, in our center, it has been routinely used in patients with locally advanced breast cancer to downsize the tumor and make it amenable to surgery.

AIM

This study was conducted to examine the clinical and pathological profile and outcomes of patients with MBC treated at our institute with neoadjuvant CTRT.

SETTINGS AND DESIGN

The study was conducted at a tertiary cancer center and was retrospective in nature.

MATERIALS AND METHODS

All MBC patients treated with neoadjuvant CTRT at our center between 2001 and 2016 were enrolled in the study. Data were retrospectively extracted from the patients' case records.

STATISTICAL ANALYSIS

Kaplan-Meier method was used for survival analysis and the outcome variables were compared using the log-rank test.

RESULTS

Thirty-one MBC patients who received neoadjuvant CTRT were analyzed in this study. The median age of the patients was 53 years. Stage IIB disease was observed in 8/31 (26%) patients, stage III in 20/31 (64%), and stage IV in 3/31 (10%) patients. There was no grade 3 or 4 toxicity due to CTRT. Surgery was performed in 29/31 (94%) patients and none of the patients had a pathological complete response. The median duration of follow-up was 95.3 months. The 8-year event-free survival and overall survival for stage IIB, III, and IV were 75%, 50%, and 0% and 87.5%, 69%, and 0%, respectively.

CONCLUSION

This is the first study to report on the use of neoadjuvant CTRT in MBC. Prospective evidence from phase-3 randomized controlled trials on the safety and efficacy of CTRT in breast cancer is required before its routine use can be recommended.

Nanoparticle-mediated targeted drug delivery for breast cancer treatment

Breast cancer (BC) is the most common malignancy in women worldwide, and one of the deadliest after lung cancer. Currently, standard methods for cancer therapy including BC are surgery followed by chemotherapy or radiotherapy. However, both chemotherapy and radiotherapy often fail to treat BC due to the side effects that these therapies incur in normal tissues and organs. In recent years, various nanoparticles (NPs) have been discovered and synthesized to be able to selectively target tumor cells without causing any harm to the healthy cells or organs. Therefore, NPs-mediated targeted drug delivery systems (DDS) have become a promising technique to treat BC. In addition to their selectivity to target tumor cells and reduce side effects, NPs have other unique properties which make them desirable for cancer treatment such as low toxicity, good compatibility, ease of preparation, high photoluminescence (PL) for bioimaging in vivo, and high loadability of drugs due to their tunable surface functionalities. In this study, we summarize with a critical analysis of the most recent therapeutic studies involving various NPs-mediated DDS as alternatives for the traditional treatment approaches for BC. It will shed light on the significance of NPs-mediated DDS and serve as a guide to seeking for the ideal methodology for future targeted drug delivery for an efficient BC treatment.

Male DCIS diagnosed after use of over-the-counter hormonal supplement

INTRODUCTION

Male breast cancer is a rare disease. Although epidemiologic and genetic factors are associated with male breast cancer, hormonal factors may also play a role.

CASE PRESENTATION

We report the case of a 39-year-old BRCA negative male patient taking a sexual performance enhancement supplement who presented with worsening asymmetric gynecomastia and unilateral spontaneous bloody nipple discharge and was found to have ductal carcinoma in-situ.

DISCUSSION

The altered cellular environment related to the hormone contents of the supplement coincided with the rapid worsening of his gynecomastia and may have played a role in the development of the ductal carcinoma in-situ, or growth of an existing focus.

CONCLUSION

The use of hormonal male enhancement supplements can lead to higher levels of androgens in users. It is possible for this altered hormonal environment to cause the growth of tumor or promote the progression of an existing focus.

Is Breast-Conserving Therapy Appropriate for Male Breast Cancer Patients? A National Cancer Database Analysis

BACKGROUND

Current treatment guidelines for male breast cancer are predominantly guided by female-only clinical trials. With scarce research, it is unclear whether breast-conserving therapy (BCT) is equivalent to mastectomy in men. We sought to compare overall survival (OS) among male breast cancer patients who underwent BCT versus mastectomy.

METHODS

We performed a retrospective analysis of 8445 stage I-II (T1-2 N0-1 M0) male breast cancer patients from the National Cancer Database (2004-2014). Patients were grouped according to surgical and radiation therapy (RT). BCT was defined as partial mastectomy followed by RT. Multivariable and inverse probability of treatment-weighted (IPTW) Cox proportional hazards models were used to compare OS between treatment groups, controlling for demographic and clinicopathologic characteristics.

RESULTS

Most patients underwent total mastectomy (61.2%), whereas 18.2% underwent BCT, 12.4% underwent total mastectomy with RT, and 8.2% underwent partial mastectomy alone. In multivariable and IPTW models, partial mastectomy alone, total mastectomy alone, and total mastectomy with RT were associated with worse OS compared with BCT (p < 0.001 all). Ten-year OS was 73.8% for BCT and 56.3, 58.0 and 56.3% for other treatment approaches. Older age, higher T/N stage, histological grade, and triple-negative receptor status were associated with poorer OS (p < 0.05). Subgroup analysis by stage demonstrated similar results.

CONCLUSIONS

In this national sample of male breast cancer patients, BCT was associated with greater survival. The underlying mechanisms of this association warrant further study, because more routine adoption of BCT in male breast cancer appears to translate into clinically meaningful improvements in survival.

Nomogram Predicting Cause-Specific Mortality in Nonmetastatic Male Breast Cancer: A Competing Risk Analysis

Introduction: Male breast cancer (MBC) is a rare tumor with few cases for research. Using the Surveillance, Epidemiology, and End Results program database, we carried out a competing risk analysis in patients with primary nonmetastatic MBC and built a predictive nomogram. Materials and Methods: We extracted primary nonmetastatic MBC patients according to the inclusion and exclusion criteria. Cumulative incidence function (CIF) and proportional subdistribution hazard model were adopted to explore risk factors for breast cancer-specific death (BCSD) and other cause-specific death (OCSD). Then we built a nomogram to predict the 3-year, 5-year and 8-year probabilities of BCSD and OCSD. C-indexes, Brier scores and calibration curves were chosen for validation. Results: We identified 1,978 nonmetastatic MBC patients finally. CIF analysis showed that the 3-year, 5-year and 8-year mortalities were 5.2%, 10.6% and 16.5% for BCSD, and 6.1%, 9.6% and 14.4% for OCSD. After adjustment of Fine and Gray models, black race, PR (-), advanced T/N/grade and no surgery were independently associated with BCSD. Meanwhile, elderly, unmarried status, advanced AJCC stage and no chemotherapy resulted in OCSD more possibly. A graphic nomogram was developed according to the coefficients from the Fine and Gray models. The calibration curves displayed exceptionally, with C-indexes nearly larger than 0.700 and Brier scores nearly smaller than 0.100. Conclusion: The competing risk nomogram showed good accuracy for predictive prognosis in nonmetastatic MBC patients. It was a useful implement to evaluate crude mortalities of BCSD and OCSD, and help clinicians to choose appropriate therapeutic plans.

Diagnostic and prognostic value of 18F-FDG PET/CT imaging in suspected recurrence of male breast cancer

Purpose

Male breast cancer (MBC) is a rare malignancy, with recurrence being one of the main adverse predictors for prognosis. The aim of the study was to evaluate the diagnostic and predictive value of fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) PET/CT in the setting of suspected recurrence of MBC.

Patients and methods

Retrospective analysis of PET/CT findings was performed in 23 previously treated, histologically proven patients with MBC (mean age: 59.3±10.9 years; range: 36–79 years) with suspected recurrence. Kaplan–Meier disease-specific survival analysis was made with respect to histological, hormonal profile as well as PET/CT findings.

Results

Of the 23 patients, 19 (82.6%) showed recurrence. Recurrence at primary site with/without regional/distant site recurrence was seen in 12 (52.2%) patients. Only metastatic recurrence without primary site was seen in seven (30.4%) patients. Bone was the most common site of distant metastasis (14/23) followed by lungs (9/23), liver (4/23), brain (2/23), and adrenal (1/23). No recurrence (regional/distant) was noted in 4/23 (17.3%) patients; however, three of them had ¹⁸F-FDG-avid soft tissue lesions in esophagus, rectum and tongue, correspondingly, confirmed as second primaries with histopathology. Disease-specific survival analysis yielded nodal (P=0.01) as well as distant metastases (P=0.02) as the main survival predictors on PET/CT. Lung (P=0.001), followed by liver (P=0.009), and skeletal (P=0.01) metastases were the most adverse survival predictive factors.

Conclusion

¹⁸F-FDG PET/CT showed good diagnostic and prognostic utility in recurrent MBC. It was better than bone scan in evaluation of skeletal metastases. Most importantly, ¹⁸F-FDG PET/CT helped in early detection of second malignancy and their clinical management in studied patients.

Surgical options for male breast cancer

BACKGROUND

Male breast cancer (MBC) is a rare disease for which no randomised controlled trials (RCT) have been conducted to determine optimal surgical management. The available data have been reviewed to identify reasonable options and reveal areas in need of investigation.

METHODS

All published series on the surgical management of MBC have been reviewed to determine approaches to treatment of the primary, the breast and the axilla together with the psychological sequelae of surgery.

FINDINGS

Mastectomy is still the major surgical offer but a convincing case can be made for the use of neoadjuvant endocrine treatment in order to facilitate breast conserving surgery. Sentinel node biopsy has been successfully used for staging MBC although nomograms for prediction of nodal status are inadequately calibrated. There are psychological sequelae of mastectomy in males and as yet no evidence that the needs of those with MBC are being met.

CONCLUSIONS

Collaborative studies are required so that men can participate in meaningful RCTs to provide an evidence-based rational foundation for the surgery of MBC.

Combination Technique Is Superior to Dye Alone in Identification of the Sentinel Lymph Node in Male Breast Cancer

Sentinel lymph node (SLN) biopsy is the main method in staging the axilla. There are insufficient data available regarding the accuracy of an SLN biopsy in male breast cancer. The aim of this study is to evaluate whether the combination of dye and radiotracer would improve the detection rate of SLNs versus dye alone in male breast cancer patients. From February 2009 to January 2012, our SLN biopsy database was retrospectively reviewed to identify male breast cancer cases. Of the 890 SLN procedures contained in the database, 10 male breast cancer patients were identified. Patient age, body mass index, SLN biopsy technique, SLN identification, number of SLN excised, and pathology reports were reviewed. Mean age was 57.2 (34–85) years with a mean tumor size was 2.2 (1.0–4.0) cm. SLN detection ratios were two in four with blue dye and six in six with the combination technique. Overall, SLNs were identified in 8 of the 10 patients. SLN biopsy is applicable in male breast cancer cases. The addition of a radiotracer to the dye in SLN biopsy increases the detection rate of sentinel nodes in male breast cancer patients.

Video Education on Hereditary Breast and Ovarian Cancer (HBOC) for Physicians: an Interventional Study

The National Comprehensive Cancer Network (NCCN) guidelines are the gold standard in hereditary cancer risk assessment, screening, and treatment. A minority of physicians follow NCCN guidelines for BRCA1 or BRCA2 mutations. This study assesses the impact of an interventional educational program on HBOC in terms of knowledge. Physicians were sent an invite to join either an intervention survey (web-training offered prior to the knowledge survey) or control survey (web-training offered after the knowledge survey). Sixty-nine physicians in the intervention arm and 67 physicians in the control arm completed the survey. The interventional group regularly answered items correctly at a higher frequency than the control group. For example, 64.71% (n = 44) of physicians in the intervention group knew that multi-gene testing does not have to include only highly penetrant genes compared to 32.84% (n = 22) of the control group (p < 0.01). Similar results were seen with other specific survey items. The current study is important in that it shows web-based education to be a feasible and effective modality for training on hereditary breast cancer. This type of education may be incorporated into CME programs and can be used as a foundation for further studies as well.

Clinical features of patients with male breast cancer in Shanxi province of China from 2007 to 2016

This study aims to understand the clinical features, treatment, and prognosis of patients with male breast cancer (MBC) in Shanxi province of China from 2007 to 2016. Data for 77 patients with MBC were collected for analysis. Immunohistochemistry, pathological results, and other data such as demographic characteristics (age, marital status, smoking history, drinking history, and family history of cancer) as well as clinical data were investigated by retrieving information from the patients' medical records. A total of 12,404 patients were diagnosed with breast cancer between 2007 and 2016, and 77 were patients with MBC among them. The median diagnosis age of patients with MBC was 62 years (range, 24-84 years). The most common complaint was a painless lump in the breast, accounting for 68.8% of the patients, and the main pathological type in MBC was infiltrating ductal carcinoma (66.2%). In terms of hormone receptors, 80.5% (62/77) of patients with MBC were estrogen receptor positive, 75.3% (58/77) of patients were progesterone receptor positive, and only 6.5% (5/77) of patients were HER2 overexpressing. The multivariant Cox proportional hazards regression analysis showed that M stage is an independent prognostic factor (p=0.018, HR=18.791, 95% CI 1.663 to 212.6). The epidemiological and clinical features of Chinese MBC are similar to that of other countries. As the Chinese public have limited knowledge of MBC, it is necessary to increase awareness among them about it. Further research with a large sample size is required for better understanding of the risks associated with MBC.

Male breast cancer: a disease distinct from female breast cancer

PURPOSE

Male breast cancer (BC) is rare, representing approximately 1% of cancers that occur in men and approximately 1% of all BCs worldwide. Because male BC is rare, not much is known about the disease, and treatment recommendations are typically extrapolated from data available from clinical trials enrolling female BC patients.

METHODS

We review the epidemiology, risk factors, prognosis, and the varied molecular and clinicopathologic features that characterize male BC. In addition, we summarize the available data for the use of systemic therapy in the treatment of male BC and explore the ongoing development of targeted therapeutic agents for the treatment of this subgroup of BCs.

RESULTS

There are important biological differences between male and female BC. Male BC is almost exclusively hormone receptor positive (+), including the androgen receptor (AR), and is associated with an increased prevalence of BRCA2 germline mutations, especially in men with increased risk for developing high-risk BC. Additional research is warranted to better characterize male BC. To accomplish this, a multi-national consortium approach, such as the International Male Breast Cancer Program, is needed in response to the scarcity of patients. This approach allows the pooling of information from a large number of men with BC and the creation of registries for future therapeutic-focused clinical trials.

CONCLUSIONS

Given the unique biology of BC in men, promising new therapeutic targets are currently under investigation, including the use of poly-ADP-ribose polymerase inhibitors or AR-targeted agents either as monotherapy or in combination with other agents.

5-alpha Reductase Inhibitors and risk of male breast cancer: a systematic review and meta-analysis

OBJECTIVE

To assess the relationship between 5α-reductase inhibitors (5ARIs) and the risk of male breast cancer (MBC).

MATERIAL AND METHODS

We systematically searched Medline via PubMed, Embase and the Cochrane Library Central Register up to May 2017 to identify published articles related to 5ARIs and the risk of MBC.

RESULTS

Summary effect estimates were calculated by a random-effect model, and tests for multivariable-unadjusted pooled risk ratios (RR) and heterogeneity, as well as the sensitivity analyses were conducted to assess publication bias. All four studies were conducted in a quality assessment according to the Newcastle Ottawa Scale system. The strength of association between 5ARIs and the prevalence of MBC was evaluated by using summarized unadjusted pooled RR with a 95% confidence interval [CI]. Four studies involving 595.776 participants, mean age range from 60 to 73.2 years old, were included in a meta-analysis, which produced a summary unadjusted RR of the risk of MBC for the treatment of 5ARIs of 1.16 (95% CI 0.85-1.58, P=0.36) and the multivariable-adjusted RR is 1.03, (95% CI 0.75-1.41, p=0.86). There was no heterogeneity among included studies (I2=0%, P=0.49). Estimates of total effects were generally consistent with the sensitivity.

CONCLUSION

We did not observe a positive association between the use of 5ARIs and MBC. The small number of breast cancer cases exposed to 5ARIs and the lack of na association in our study suggest that the development of breast cancer should not influence the prescribing of 5ARIs therapy.

Favorable Long-Term Outcome in Male Breast Cancer

Objective

Male breast cancer (MBC) is a rare type of cancer in the breast cancer series and in the male population. Data is usually extrapolated from female breast cancer (FBC) studies. We aim to study the clinicopathological characteristics and outcome of MBC patients at our institution and we aim to emphasize the differences compared with FBC.

Materials and Methods

Between January 1993 and April 2016, 56 male patients who were diagnosed as breast cancer and underwent surgical operation were retrospectively analyzed. Patients were evaluated for demographical characteristics, surgery type, clinicopathological characteristics, adjuvant and neoadjuvant treatments, follow-up time, overall survival (OS), disease free survival (DFS), and disease specific survival (DSS).

Results

The ratio of MBC among all breast cancers at our institution is 1%. The median age was 64 (34-85). Surgical procedures were modified radical mastectomy (MRM) in 41 patients (77%), simple mastectomy in 11 patients (21%), and lumpectomy in 1 patient (2%). Two patients were Stage 0 (4%), 7 were Stage 1 (13%), 12 were Stage 2 (22.6%), and 32 were Stage 3 (60.4%). Molecular subtypes of the invasive tumors were luminal A in 40 (80%), luminal B in 6 (12%), HER-2 type in 1 (2%), and basal-like in 3 (6%). Median follow-up time was 77 (3-287) months. 5-year and 10-year OS, DFS, and DSS rates were 80.7%, 96%, 95.6% and 71.6%, 81.9%, 91.7% respectively.

Conclusion

MBC presents different clinicopathological and prognostic factors when compared to FBC. Our survival rates are higher than the average presented in available literature. Because of the high rate of hormone receptor positivity, hormonal therapy is the mainstay for the treatment of estrogen receptor (ER)+ male breast cancer.

Male Breast Cancer in the Age of Genetic Testing: An Opportunity for Early Detection, Tailored Therapy, and Surveillance

In detection, treatment, and follow-up, male breast cancer has historically lagged behind female breast cancer. On the whole, breast cancer is less common among men than among women, limiting utility of screening, yet the incidence of male breast cancer is rising, and there are men at high risk for breast cancer. While women at high risk for breast cancer are well characterized, with clearly established guidelines for screening, supplemental screening, risk prevention, counseling, and advocacy, men at high risk for breast cancer are poorly identified and represent a blind spot in public health. Today, more standardized genetic counseling and wider availability of genetic testing are allowing identification of high-risk male relatives of women with breast cancer, as well as men with genetic mutations predisposing to breast cancer. This could provide a new opportunity to update our approach to male breast cancer. This article reviews male breast cancer demographics, risk factors, tumor biology, and oncogenetics; recognizes how male breast cancer differs from its female counterpart; highlights its diagnostic challenges; discusses the implications of the widening clinical use of multigene panel testing; outlines current National Comprehensive Cancer Network guidelines (version 1, 2018) for high-risk men; and explores the possible utility of targeted screening and surveillance. Understanding the current state of male breast cancer management and its challenges is important to shape future considerations for care. Shifting the paradigm of male breast cancer detection toward targeted precision medicine may be the answer to improving clinical outcomes of this uncommon disease. ^©RSNA, 2018.

Pattern of care of adjuvant radiotherapy in male breast cancer patients in clinical practice: an observational study

BACKGROUND AND PURPOSE

Due to the rarity of male breast cancer (male BC), no consensus has been reached regarding the most appropriate curative treatment strategy. The objective of the present observational study was to identify patient and tumor characteristics and assess the role of radiotherapy (RT) in clinical practice.

METHODS

Between 1998 and 2014, data of male BC patients treated at two breast centers were consecutively collected and retrospectively analyzed. Patients were stratified based on the addition of adjuvant RT. Data on overall survival (OS) and local recurrence-free survival (LRFS) were estimated with the Kaplan-Meier method and compared by the log-rank test.

RESULTS

A consecutive cohort of 58 male BC patients was evaluated. Median follow-up was 56 months. Twenty-one patients (36.2%) received adjuvant RT. Overall, patients undergoing postoperative RT were characterized by more high-risk features. Patients receiving postoperative RT had significantly more frequently a high UICC stage (50 vs. 9.7% UICC III, p = 0.018) and positive lymph nodes as compared to patients undergoing surgery alone (65 vs. 34.4% pN+, p = 0.046). Accordingly, there was a higher proportion of patients receiving axillary lymph node dissection in the RT group (71.4 vs. 35.6%). Mastectomy was performed in 31/37 (86.1%) in the surgery group as compared to 14/21 (66.7%) in patients receiving postoperative RT. In addition, RT patients were more likely to receive endocrine therapy (78.9 vs. 39.3%, p = 0.016). Outcome was not significantly different between the groups (5-year LRFS: 89.8 vs. 80.0%, p = 0.471 and 5‑year OS 88.4 vs. 88.9%, p = 0.819).

CONCLUSION

The present observational study evaluated the pattern of care in male BC patients treated in clinical practice. Due to its rarity, randomized clinical trials are unlikely and male BC remains an entity with a poor evidence base. Nevertheless, RT remains a crucial component of the multidisciplinary treatment strategy in male BC.

Male Breast Cancer: An Updated Surveillance, Epidemiology, and End Results Data Analysis

BACKGROUND

Male breast cancer is rare and understudied compared with female breast cancer. A current comparison with female breast cancer could assist in bridging this gap. Although conflicting data have been reported on male and female survival outcomes, data from 1973 through 2005 in the Surveillance, Epidemiology, and End Results (SEER) program have demonstrated that the improvement in breast cancer survival in men has fallen behind that of women. As treatment for breast cancer has improved significantly, an updated analysis using a contemporary population is necessary.

MATERIALS AND METHODS

An analysis of SEER data from patients with a diagnosis of primary breast cancer from 2005 to 2010 were included. A Cox regression model was used to examine the association between sex and breast cancer mortality after controlling for prognostic factors, including age, race, marital status, disease stage, estrogen and progesterone receptor status, lymph node involvement, tumor grade, surgery, and geography. Subgroup analyses were performed by race and stage.

RESULTS

We included a total of 289,673 breast cancer cases (2054 men) with a diagnosis from 2005 to 2010. The 5-year survival rate for male patients was lower than that for female patients (82.8% vs. 88.5%). After controlling for other factors, the risk of death in men was 43% greater than that in women during the follow-up period (hazard ratio, 1.43; 95% confidence interval, 1.26-1.61). Similar results were noted in the race and stage subgroup analyses.

CONCLUSION

In recent years, male breast cancer patients have had worse survival outcomes compared with those of female patients.

Oral and maxillofacial metastasis of male breast cancer: Report of a rare case and literature review

Oral and maxillofacial metastatic tumors are uncommon, with the breast, prostate, lung, and kidney representing the most common primary sites. Less than 1% of all breast cancers occur in male patients, and to date, only 8 cases of metastatic breast adenocarcinoma to the oral and maxillofacial region in a male patient have been reported in the literature. An 88-year-old male with previous history of a successfully treated primary breast adenocarcinoma 12 years earlier was referred for evaluation of an oral swelling lasting 6 months. Intraoral examination revealed a 2-cm reddish, pedunculated nodule with a smooth surface located in the left retromolar region. Imaging revealed maxillary sinus involvement. The patient underwent incisional biopsy, and microscopic evaluation revealed invasive tumor islands compounded by malignant epithelial cells, sometimes exhibiting ductal arrangement, which were positive for the estrogen receptor and gross cystic disease fluid protein 15. The final diagnosis was metastatic breast adenocarcinoma. Breast metastases are exceedingly rare in the oral and maxillofacial region of male patients; however, clinicians should consider breast metastasis when evaluating reddish oral nodules in older patients, including men, especially those with a history of malignancy.

Distribution of 21-Gene Recurrence Scores in Male Breast Cancer in the United States

BACKGROUND

The 21-gene recurrence score (RS) is a RT-PCR assay estimating risk of distant recurrence in estrogen receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2) breast cancer (BC). Studies validating RS are limited to women. Our objective was to assess RS distribution and factors associated with high-risk RS in male BC.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified men and women with ER+/HER2- BC from 2010 to 2013. Patients were categorized into risk groups using the traditional and the Trial Assigning Individualized Options for Treatment (TAILORx) cutoffs. Multivariable logistic regression determined factors associated with testing and high-risk TAILORx RS.

RESULTS

We identified 1388 men and 154,196 women with ER+/HER2- BC. Twenty-five percent of men and 30% of women had RS testing. Mean age of tested men was 63; most were white (81%), had grade I or II tumors (67%), and had stage I or II (95%) BC. Factors associated with increased RS testing were younger age, recent year of diagnosis, lymph node negativity, and lower-stage tumors (p ≤ 0.05). By TAILORx, 21% of men had high-risk RS compared with 14% of tested women. Men with grade III and PR negative tumors were more likely to have a high-risk RS (p ≤ 0.05). Chemotherapy utilization was correlated with RS.

CONCLUSIONS

Using a large population-based dataset, we found that compared with women, men were significantly more likely to have high-risk RS. Grade III and PR-negative BC were significantly associated with high-risk RS. Higher RS in men correlated with increased chemotherapy utilization.

Survival Comparisons Between Early Male and Female Breast Cancer Patients

We aimed to compare the overall survival (OS) and standardized mortality rate (SMR) of the male breast cancer (MBC) with female breast cancer (FBC) after propensity score matching. Based on the Surveillance, Epidemiology, and End Results (SEER), the early breast cancer patients (T1-2N0-2M0) were extracted from 1998-2007. This study included 1,111 and 2,151 patients with early MBC and FBC, respectively, whose clinicopathological characteristics were well balanced. At a mean follow-up time of 97 months, 10-year OS rate was 58.3% in the MBC group and 68.7% in the FBC (log-rank test, P < 0.001; hazard ratio (HR) = 1.45, 95% confidence interval (CI) = 1.29 to 1.64). Adjusted HR for OS between MBC and FBC were revealed from propensity score matched-multivariable Cox proportional hazards models (HR = 1.53, 95% CI = 1.35 to 1.73). Similar adjusted SMRs between MBC and FBC ((SMR = 1.98, 95% CI = 1.83,2.14) for FBC and (SMR = 2.07, 95% CI = 1.88-2.28) for MBC) were observed. The nomogram was constructed for FBC, and predicted probabilities were generally good (C-index = 0.71), whose area under curve is higher than TNM stage classification (0.74 vs 0.62). OS was significantly decreased among early MBC patients compared with FBC, but similar SMRs and its trends by age groups were observed between MBC and FBC except for young patients.

The endocrinology of male breast cancer

Male breast cancer (MBC) is a rare disease but, as a result of epidemiological collaborations, there is now greater clarity concerning endocrine risk factors. The significant rise in global age-standardised mean BMI in men is likely to lead to increases in incidence of maturity-onset diabetes and MBC. The metabolic changes accompanying obesity decrease androgens and sex hormone-binding globulin (SHBG), thereby increasing available oestrogens. The higher rates of MBC in North and Equatorial Africa are largely due to liver damage from endemic bilharziasis and hepatitis B causing elevated oestradiol (E₂) levels from hepatic conversion of androgen. Klinefelter's syndrome (XXY) is associated with a 50-fold increase in incidence of MBC compared with XY males, and this is the most pronounced evidence for testicular malfunction amplifying risk. Delay in presentation means that up to 40% of cases have stage III or stage IV disease at diagnosis. No randomised controlled trials have been reported on endocrine treatment of advanced disease or adjuvant/neoadjuvant therapy following or preceding surgery. Tamoxifen is the most effective endocrine therapy, but side effects can lead to non-compliance in a substantial number of men. Aromatase inhibitors are less effective because they do not inhibit testicular oestrogen production. There is an urgent need for collaborative trials to provide an evidence base for the most effective endocrine and least toxic therapies for men with breast cancer.

The challenges of modeling hormone receptor-positive breast cancer in mice

Estrogen receptor-positive (ER+) tumors account for 70-80% of all breast cancer (BC) cases and are characterized by estrogen dependency for their growth. Endocrine therapies using estrogen receptor antagonists or aromatase inhibitors represent a key component of the standard of care for these tumors. The occurrence of de novo or acquired resistance to estrogen withdrawal represents an important clinical problem, impacting on patient survival. In addition, despite an initially favorable outcome, a part of ER+ BC patients present with disease recurrence locally or at distant sites years or even decades after apparent remission. In vivo models that closely mimic human disease are urgently needed to study the biology of these tumors, investigate the molecular mechanisms underlying endocrine resistance and identify patients at risk of recurrence. Despite the similarities in the overall hormonal regulation of mammary gland development between mice and humans, the majority of the mammary carcinomas occurring in genetically engineered mouse models (GEMMs) are ER negative and most xenograft models are based on few ER+ cancer cell lines. We recently showed that the microenvironment is critical for ER+ cancer cells and discuss in this review the potential of intraductal xenograft model for basic and preclinical research.

ACR Appropriateness Criteria® Evaluation of Nipple Discharge

Appropriate imaging evaluation of nipple discharge depends the nature of the discharge. Imaging is not indicated for women with physiologic nipple discharge. For evaluation of pathologic nipple discharge, multiple breast imaging modalities are rated for evidence-based appropriateness under various scenarios. For women age 40 or older, mammography or digital breast tomosynthesis (DBT) should be the initial examination. Ultrasound is usually added as a complementary examination, with some exceptions. For women age 30 to 39, either mammogram or ultrasound may be used as the initial examination on the basis of institutional preference. For women age 30 or younger, ultrasound should be the initial examination, with mammography/DBT added when ultrasound shows suspicious findings or if the patient is predisposed to developing breast cancer. For men age 25 or older, mammography/DBT should be performed initially, with ultrasound added as indicated, given the high incidence of breast cancer in men with pathologic nipple discharge. Although MRI and ductography are not usually appropriate as initial examinations, each may be useful when the initial standard imaging evaluation is negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The 21-Gene Recurrence Score in Male Breast Cancer

BACKGROUND

Given the limited data, systemic treatment of male breast cancer has been extrapolated from female patients. The 21-gene recurrence score (RS) assay estimates the risk of distant recurrence and chemotherapy benefit in early-stage, ER+/HER2- female breast cancer. We assessed the association between RS and type of treatment in male breast cancer.

METHODS

We identified male patients with ER+/HER2- breast cancer and available RS results treated at our institution in 2006-2016. We collected data on clinicopathologic features, treatment, and outcome. The Institutional Review Board approved the study.

RESULTS

The study cohort consists of 38 male breast cancer patients with a median age of 70 years. Median tumor size was 1.6 cm, and 81.6% (31) were node-negative. RS was low (≤ 17) in 26 (68.4%) cases, intermediate (18-30) in 9 (23.7%) cases, and high (≥ 31) in 3 (7.9%) cases, comparable to that in female patients at our institution. All patients underwent total mastectomy, and one received radiotherapy. Thirty-four (89.5%) patients received adjuvant endocrine therapy, mostly tamoxifen (81.6%; 31). Five (13.2%) patients with intermediate or high RS were treated with adjuvant chemotherapy. No locoregional recurrence was observed, and one patient developed distant recurrence (median follow-up 34 months).

CONCLUSIONS

The RS distribution in male breast cancers was similar to that in females treated at our institution. With limited follow-up, patients with low RS were spared chemotherapy and did not develop recurrence. Our results suggest that the RS may have a clinical utility in male breast cancer patients.

Treatment Outcomes in Male Breast Cancer: A Retrospective Analysis of 161 Patients

AIMS

Male breast cancer is a rare disease with limited evidence-based guidelines for treatment. This study aimed to identify demographic, pathological and clinical factors associated with its prognosis.

MATERIALS AND METHODS

A retrospective review of 161 male breast cancer patients diagnosed at a single institution from 1987 to June 2017 was conducted. Patient demographics, disease characteristics, treatment and outcome were extracted and included in competing-risk analysis and the univariate Cox proportional hazard model for univariate analysis. Factors with P < 0.10 were included in multivariable analysis.

RESULTS

The mean age at diagnosis was 67 years (standard deviation = 11.2) and the median follow-up duration was 5.3 years (range 0-25 years). There were 48 deaths, including 23 cancer-specific deaths. The actuarial median survival was 19.9 years. In multivariable analysis, factors associated with overall survival were size of tumours (hazard ratio 2.0; 95% confidence interval 1.4-2.7, P < 0.0001) and diagnosis of metastatic disease (hazard ratio 8.7; 95% confidence interval 1.9-40.6; P = 0.006). Of 138 patients without metastases at diagnoses, 11 had local-regional recurrence and 26 had distant metastases. In the multivariable model for local-regional recurrence, a more recent year of diagnosis was associated with reduced risk (hazard ratio 0.9, 95% confidence interval 0.8-1.0, P = 0.008), whereas more positive lymph nodes was associated with higher risk (hazard ratio 2.2, 95% confidence interval 1.2-4.0, P = 0.01). A higher risk of metastases was associated with more positive lymph nodes (hazard ratio 1.9; 95% confidence interval 1.1-3.3; P = 0.03) and tumour size (hazard ratio 1.8; 95% confidence interval 1.1-2.9; P = 0.01). A higher risk of any recurrence or metastases was associated with the number of positive nodes (hazard ratio 1.9; 95% confidence interval 1.2-3.0; P = 0.005) and tumour size (hazard ratio 1.6; 95% confidence interval 1.1-2.2; P = 0.01).

CONCLUSION

In general, tumour size and more positive lymph nodes were associated with worse prognosis. Larger powered studies are needed to identify prognostic factors with smaller effect sizes.

Poorer breast cancer survival outcomes in males than females might be attributable to tumor subtype

BACKGROUND & AIMS

Substantial controversy exists regarding the differences in tumor subtypes between male breast cancer (MBC) and female breast cancer (FBC). This is the largest population-based study to compare MBC and FBC patients.

METHODS

Using data obtained by the Surveillance, Epidemiology, and End Results (SEER) program from 2010-2012, a retrospective, population-based cohort study was conducted to investigate tumor subtype-specific differences in various characteristics, overall survival (OS) and breast cancer-specific mortality (BCSM) between males and females.

RESULTS

In all, 181,814 BC patients (1,516 male and 180,298 female) were eligible for this study. The male patients were more likely to be black, older, and have lower histological grades, more advanced stages, larger tumors, more lymph node and distant metastases and human epidermal growth factor receptor 2 (HER2)-negative tumors (each p<0.05). A matched analysis showed that the 2-year OS was 91.2% and 93.7% and that the BCSM was 2.2% and 2.5% for male and female patients, respectively. The univariate analysis showed that male triple-negative (TN), hormone receptor (HoR)-positive/HER2-positive and HoR-positive/HER2-negative patients had poorer OS (p <0.01). Meanwhile, the HoR-positive/HER2-positive and TN subtypes were associated with a higher BCSM in MBC patients (p<0.01). The multivariate analysis revealed that TN MBC patients had poorer OS and BCSM (p<0.05). Simultaneously, the results showed that male patients in the HoR-positive/HER2-negative subgroup were less likely to die of BC when adjusting for other factors (p<0.05).

CONCLUSIONS

The analysis of 2-year OS and BCSM among the BC subtypes showed clear differences between MBC and FBC patients with the TN subtype; these differences warrant further investigation.

Preferential expression of NY-BR-1 and GATA-3 in male breast cancer

BACKGROUND

Male breast cancer is an uncommon disease often discovered in advanced stage; thus, in the setting of metastatic adenocarcinoma, breast origin must be taken to account. Breast markers as NY-BR-1, GATA-3, mammaglobin, and BRST-2 are established tools for labelling primary and metastatic female breast cancer; however, none of them has been sufficiently studied in male breast cancer. The aim of this study was to analyze the expression of these markers in male breast cancer.

MATERIALS AND METHODS

Thirty consecutive cases of male breast cancer and eight loco-regional metastases were re-revaluated, assembled in tissue micro array (TMA), and stained with immunohistochemistry (IHC) for NY-BR-1, GATA-3, mammaglobin, and BRST-2. The IHC stains were scored either positive or negative. In addition, concordant expression patterns of primary tumors and matched metastasis were noted.

RESULTS

30 of 30 (100%) primary tumors and 8 of 8 (100%) metastases were positive for NY-BR-1. 30 of 30 (100%) primary tumors and 6 of 8 (75%) metastases were positive for GATA-3. 22 of 30 (73.3%) primary tumors and 6 of 8 (75%) metastases were positive for Mammaglobin. 18 of 30 (60%) primary tumors and 5 of 8 (62.5%) metastases were positive for BRST-2. Differences in staining percentage were not significant with Fisher's exact test.

CONCLUSION

We found a high sensitivity for all the markers analyzed. Moreover, the expression of NY-BR-1 and GATA-3 seemed the most effective for labelling male breast cancer in primary and metastatic setting.

Ultrasonographic assessment of male breast diseases

Although rare and accounting for less than 1% of all breast cancers, the incidence of breast cancer in men has increased by 26% over the past few decades. Very little has been reported on the sonographic appearance of benign and malignant male breast conditions. The aim of this study was to describe the ultrasonographic features of male breast disease and the value of ultrasound in the evaluation of male breast disease. Between December 2006 and October 2014, ultrasound examinations were performed in 560 male patients presenting with enlargement of, pain in, and/or a lump in the breast. One hundred and thirty-six patients (24.3%) underwent surgical excision, and 424 patients (75.7%) were diagnosed by ultrasound. Their ultrasonographic features were retrospectively evaluated. The final diagnoses were gynecomastia (n = 537), primary breast cancer (n = 9), lipoma (n = 7), chronic mastitis (n = 6), and fibroadenoma (n = 1). Of the 560 lesions, 356 (63.6%) were classified as Breast Imaging Reporting and Data System (BI-RADS) category 2, 191 (34.1%) were classified as BI-RADS category 3, and 13 (2.3%) were classified as BI-RADS 4 or 5. The sensitivity, specificity, PPV, NPV, and accuracy of the detection of malignant breast masses according to ultrasound were 100%, 99.3%, 69.2%, 100%, and 97.7% respectively. The sonographic patterns of gynecomastia were nodular (n = 131, 24.4%), dendritic (n = 50, 9.3%), and diffuse glandular (n = 356, 66.3%). Color Doppler flow imaging revealed hypervascularity in five of these malignant masses, moderate vascularity in two of the masses, and mild vascularity in the remaining two masses. Other diseases included in the study are also described. Ultrasonography (US) is useful in the diagnosis of male breast diseases, especially in differentiating cancer from benign lesions.

Mammary Myofibroblastoma in a Transgender Patient on Feminizing Hormones: Literature Review and Case Report

Purpose: Defining the risk of neoplasia associated with gender-affirming hormone therapy (GAHT) is a priority for transgender medical research. The purposes of this article are to present a unique case of breast neoplasia in a transgender individual and to review the existing evidence base on GAHT as a potential risk for breast pathology. Methods: We present the case of a 76-year-old transgender patient who developed an estrogen receptor-positive mammary myofibroblastoma (MFB) after 13 months of treatment on feminizing hormones. To our knowledge, this is the first reported case of MFB occurring in a transgender individual. A literature review was conducted to identify all reported cases of breast neoplasia among transgender individuals receiving feminizing GAHT. Information was abstracted from each of the included cases to describe the existing body of literature and to compare published cases to the case reported in this study. Results: We identified a total of 19 malignant and 3 benign cases of breast neoplasia among transgender women. Ours is the first reported case of MFB in a transgender individual receiving feminizing hormones and the first reported case of breast neoplasia associated with GAHT administered via the estradiol patch. Conclusion: This case reinforces the need for additional reporting of breast neoplasia presenting in transgender individuals treated with feminizing hormones. The relationship between estrogen exposure and breast neoplasia in the transgender population remains poorly defined, and additional research is needed to define risks and inform clinical practice.

Determining factors influencing survival of breast cancer by fuzzy logistic regression model

Background

Fuzzy logistic regression model can be used for determining influential factors of disease. This study explores the important factors of actual predictive survival factors of breast cancer's patients.

Materials and Methods

We used breast cancer data which collected by cancer registry of Kerman University of Medical Sciences during the period of 2000-2007. The variables such as morphology, grade, age, and treatments (surgery, radiotherapy, and chemotherapy) were applied in the fuzzy logistic regression model. Performance of model was determined in terms of mean degree of membership (MDM).

Results

The study results showed that almost 41% of patients were in neoplasm and malignant group and more than two-third of them were still alive after 5-year follow-up. Based on the fuzzy logistic model, the most important factors influencing survival were chemotherapy, morphology, and radiotherapy, respectively. Furthermore, the MDM criteria show that the fuzzy logistic regression have a good fit on the data (MDM = 0.86).

Conclusion

Fuzzy logistic regression model showed that chemotherapy is more important than radiotherapy in survival of patients with breast cancer. In addition, another ability of this model is calculating possibilistic odds of survival in cancer patients. The results of this study can be applied in clinical research. Furthermore, there are few studies which applied the fuzzy logistic models. Furthermore, we recommend using this model in various research areas.

Finasteride treatment and male breast cancer: a register-based cohort study in four Nordic countries

A potential link has been suggested between dispensed finasteride and increased risk of male breast cancer (MBC). Due to the rare occurrence of MBC, it remains to be established if such a relationship exists. The purpose of this study was to combine nationwide registers in four countries to assess the potential association between dispensed finasteride and MBC. A cohort of all males with dispensed finasteride in Denmark, Finland, Norway, and Sweden (1,365,088 person years) was followed up for up to 15 years for breast cancer, and compared to a cohort of males unexposed to finasteride. Individual‐level register data included country, dates of dispensed finasteride, MBC diagnosis, and death. Incidence rate ratios (IRRs) were estimated using a generalized linear model with a Poisson distribution. An increased risk of MBC was found among finasteride users (IRR = 1.44, 95% confidence interval [95% CI] = 1.11–1.88) compared to nonusers. The IRR increased to 1.60 (95% CI = 1.20–2.13) when users in Norway and Sweden with short follow‐up time were excluded. The highest IRR was seen among men with medium duration of dispensed finasteride, medium accumulated consumption of finasteride, and among men with first dispensed finasteride prescription 1–3 years prior to diagnosis. The analyses suggested possible ascertainment bias and did not support a clear relationship between dispensed finasteride and MBC. In conclusion, a significant association between dispensed finasteride and MBC was identified. However, due to limited data for adjustment of potential confounding and surveillance bias in the present study, further research is needed to confirm these results.

Male occult breast cancer with axillary lymph node metastasis as the first manifestation: A case report and literature review

RATIONALE

Occult breast cancer (OBC) is extremely rare in males with neither symptoms in the breast nor abnormalities upon imaging examination.

PATIENT CONCERNS

This current case report presents a young male patient who was diagnosed with male OBC first manifesting as axillary lymph node metastasis. The physical and imaging examination showed no primary lesions in either breasts or in other organs.

DIAGNOSES

The pathological results revealed infiltrating ductal carcinoma in the axillary lymph nodes. Immunohistochemical (IHC) staining was negative for estrogen receptor (ER), progesterone receptor (PR), cytokeratin (CK)20 and thyroid transcription factor-1 (TTF-1), positive for CK7, gross cystic disease fluid protein-15 (GCDFP-15), epithelial membrane antigen (EMA) and carcinoembryonic antigen (CEA), and suspicious positive for human epidermal receptor-2 (Her-2). On basis of IHC markers, particularly such as CK7, CK20 and GCDFP-15, and eliminating other malignancies, male OBC was identified in spite of negativity for hormone receptors.

INTERVENTIONS

The patient underwent left axillary lymph node dissection (ALND) but not mastectomy. After the surgery, the patient subsequently underwent chemotherapy and radiotherapy.

OUTCOMES

The patient is currently being followed up without any signs of recurrence.

LESSONS

Carefully imaging examination and pathological analysis were particularly essential in the diagnosis of male OBC. The guidelines for managing male OBC default to those of female OBC and male breast cancer.

Breast disease in men in metropolitan São Paulo - Brazil

Although rare, breast cancer in males represents 1% of all cancer in men, and has shown increasing incidence in 25 years. To analyze age, gender, type of procedure performed and diagnosis of all cases of breast diseases in a public hospital in Sao Paulo, Brazil, with special focus on men. Cross-sectional study of breast surgery in 2010-2014 at Hospital Municipal Universitario de Sao Bernardo do Campo, Brazil. In the period 999 breast surgery were carried out. Patients with benign diseases were about 30 years old and patients with malignant diseases were over 50. Most surgical procedures performed on men were on the benign condition of gynaecomastia (n=21). The prevalence of breast cancer in the male population attending the public health system in Sao Bernardo was 0.27 (per 100,000). There was a single record of malignant disease in men, a 65 years old man, with histological diagnosis of ductal carcinoma. Surgical pathology of the breast in men is a rare event, and accounts for about 2.4% of mammary surgery in the municipality of São Bernardo do Campo. Awareness is necessary for health professionals and the media, regarding breast pathologies in the male population, to reduce the prejudice in the search for an early diagnosis of a condition so strongly linked to the female for the majority of people.

Radiotherapy and Male Breast Cancer: A Population-based Registry Analysis

BACKGROUND

The local-regional management of female breast cancer has been extensively investigated worldwide. The optimal approach for males diagnosed with breast cancer is less clear. We have analyzed the treatment of male breast cancer using a population-based national registry to determine the impact of surgery and radiation therapy on survival.

MATERIALS AND METHODS

The Surveillance Epidemiology and End Results (SEER) database was queried to identify males with invasive ductal carcinoma of the breast who underwent primary surgical resection (radical mastectomy, modified radical mastectomy, total mastectomy, or segmental) for the years 1983 to 2002. Demographic, clinical, and pathologic data were culled and analyzed to determine the impact of radiation therapy (RT) following resection. Survival rates were estimated using the Kaplan-Meier method and significance was determined using the log-rank test (P<0.05). Multivariate analysis with the Cox proportional hazards model was performed to determine factors significant for overall (OS) and cause-specific survival (CSS).

RESULTS

A total of 1337 patients met the eligibility criteria and were analyzed. Median follow-up was 7.3 years (range, 1 mo to 25 y). Most men underwent modified radical mastectomy (n=1062) with a minority undergoing segmental (n=113). About 329 men received postoperative external beam RT. The median rates of OS and CSS for all men were 10.5 years and not yet reached, respectively. The surgical procedure did not significantly associate with OS or CSS. By stage, RT was associated with improved OS for stage I (P=0.03). There was a trend for improved survival with stage II (P=0.21) and III (P=0.15). RT was not associated with improved CSS by stage. RT improved rates of OS and CSS in N2 patients without reaching statistical significance (P=0.10 and 0.22). On multivariate analysis, advancing age, stage and grade, and no postoperative RT predicted for worse OS. However, when controlled for those with known hormone receptor status (n=978), only the factors of advancing age, stage, grade, and hormone receptor negativity predicted for worse OS. Advancing age, stage, and grade were the only predictors of CSS irrespective of the cohort analyzed.

CONCLUSIONS

The primary surgical procedure did not ultimately influence OS or CSS in this population-based registry of males with breast cancer. A statistically nonsignificant improvement with postoperative RT was observed in men with lymph node involvement, larger tumor size, or higher stage. When controlled for age, stage, and grade in multivariate analysis, postoperative RT predicted for improved OS but not CSS. These data suggest a beneficial effect of RT in the postoperative setting. A prospective study is necessary to further elucidate appropriate treatment strategies for men with breast cancer.

Surgical management of gynecomastia: experience of a general surgery center

AIM

Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia.

PATIENTS AND METHODS

Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study.

RESULTS

Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar.

CONCLUSIONS

Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.