Ductal carcinoma in situ (DCIS) in the male breast: a morphologic study of 84 cases of pure DCIS and 30 cases of DCIS associated with invasive carcinoma--a preliminary report

Incidental Bilateral Ductal Carcinoma In Situ (DCIS) in Excisional Surgery for Gynecomastia

Male breast cancer is a rare disease, and it is important to have a high index of suspicion in patients presenting with breast symptoms, such as a breast mass or nipple discharge. Most male patients who are diagnosed with breast cancer present with breast complaints and/or a strong family history of cancer. Here, we will present a 47-year-old male patient who was diagnosed with bilateral ductal carcinoma in situ during a routine gynecomastia surgery after massive weight loss. This case demonstrates the importance of sending breast tissue specimens for pathology, especially in a male patient.

Imaging the Male Breast: Gynecomastia, Male Breast Cancer, and Beyond

The number of men undergoing breast imaging has increased in recent years, according to some reports. Most male breast concerns are related to benign causes, most commonly gynecomastia. The range of abnormalities typically encountered in the male breast is less broad than that encountered in women, given that lobule formation rarely occurs in men. Other benign causes of male breast palpable abnormalities with characteristic imaging findings include lipomas, sebaceous or epidermal inclusion cysts, and intramammary lymph nodes. Male breast cancer (MBC) is rare, representing up to 1% of breast cancer cases, but some data indicate that its incidence is increasing. MBC demonstrates some clinical features that overlap with those of gynecomastia, including a propensity for the subareolar breast. Men with breast cancer tend to present at a later stage than do women. MBC typically has similar imaging features to those of female breast cancer, often characterized by an irregular mass that may have associated calcifications. Occasionally, however, MBC has a benign-appearing imaging phenotype, with an oval shape and circumscribed margins, and therefore most solid breast masses in men require tissue diagnosis. Histopathologic evaluation may alternatively reveal other benign breast masses found in men, including papillomas, myofibroblastomas, and hemangiomas. Radiologists must be familiar with the breadth of male breast abnormalities to meet the rising challenge of caring for these patients. ©RSNA, 2024 Supplemental material is available for this article.

Male ductal carcinoma in situ: diagnosis and management of a rare disease in men

Ductal carcinoma in situ is very rare in male patients, accounting for approximately 5%-7% of all male breast cancers. We present a case of a man in his early 70s who presented with bloody nipple discharge and gynaecomastia and was subsequently diagnosed with ductal carcinoma in situ (DCIS). We discuss his management with surgical resection and the consideration of adjuvant treatment. We also review the existing literature on the presentation, diagnosis and management of DCIS in men.

Ductal carcinoma in situ of the male breast: clinical radiological features and management in a cancer referral center

Purpose

To present an overview of the management of male patients with Ductal Carcinoma In Situ of the breast (male DCIS).

Methods

We retrospectively studied all male patients with a diagnosis of pure DCIS from January 1999 to December 2018: 20 patients were identified in our cancer referral center. We collected data regarding clinical presentation, age of onset, radiological features, receptor status of the neoplasm, histological type, and the follow-up of those patients.

Results

The median age was 62 years (range 21–80). All patients underwent surgery, in 15/20 (75%) cases a mastectomy was carried out. Two patients (10%) underwent endocrine treatment and 1/20 (5%) underwent radiotherapy. The receptor status for 15/20 patients was documented: 13/15 patients were ER+/Pr+. In 3 cases the Ki 67% was positive (i.e., > 20%). All cases were negative for Her2. The median follow-up time was 9.0 years (IQR 4.0–13.7). Only one patient had an ipsilateral recurrence with the finding of an infiltrating carcinoma in the same breast after 14 years. The 5-year disease-free survival was 92.9%.

Conclusion

Pure DCIS in men is an extremely rare disease: proper diagnosis and management allow an excellent prognosis.

Male Breast Cancer Review. A Rare Case of Pure DCIS: Imaging Protocol, Radiomics and Management

Ductal carcinoma in situ (DCIS) of male breast is a rare lesion, often associated with invasive carcinoma. When the in situ component is present in pure form, histological grade is usually low or intermediate. Imaging is difficult as gynaecomastia is often present and can mask underlying findings. We report a rare case of pure high-grade DCIS in a young male patient, with associated intraductal papilloma and atypical ductal hyperplasia. Digital breast tomosynthesis (DBT) showed an area of architectural distortion at the union of outer quadrants of the left breast without gynaecomastia. Triple assessment suggested performing a nipple-sparing mastectomy, which revealed the presence of a focal area of high-grade DCIS of 2 mm. DCIS, even of high grade, is difficult to detect with mammography and even more rare, especially when associated with other proliferative lesions. DBT with 2D synthetic reconstruction is useful as the imaging step of a triple assessment and it should be performed in both symptomatic and asymptomatic high-risk men to differentiate between malignant and benign lesions. We propose a diagnostic model to early detect breast cancer in men, optimizing resources according to efficiency, effectiveness and economy, and look forward to radiomics as a powerful tool to help radiologists.

Cystic Encapsulated Papillary Carcinoma in the Male Breast: An Unusual Feature With a Diagnostic Challenge

Papillary carcinoma in the male breast is uncommon. Here, we report a case of a large encapsulated papillary carcinoma (EPC) in a 62-year-old male. The patient presented with a left breast mass of 1-year duration and bloody nipple discharge for several days. Mammography and breast ultrasonography showed a large left breast mass. The initial biopsy demonstrated fat necrosis with acute and chronic inflammation only. Due to clinical suspicion, a repeat biopsy was performed and revealed scant fragments of papillary carcinoma in a background of inflammation. The patient underwent left total mastectomy. Grossly, the breast contained a 9.0 cm entirely cystic lesion lined by a hemorrhagic thick fibrotic wall. No solid area was identified in the cyst. The entire cyst wall was examined under microscopy; only a few sections with papillary carcinoma were identified. The lesion was confined to the cyst wall; so, a diagnosis of EPC was made. Compared to the previously reported EPC cases of male breast, the lesion of this case was unusually cystic, which making the diagnosis challenging. Therefore, awareness of this unusual feature, repeat biopsy when the pathology result is discordant, and extensive sampling of the lesion are essential for making the correct diagnosis and guiding patient management.

Updates on Lobular Neoplasms, Papillary, Adenomyoepithelial, and Fibroepithelial Lesions of the Breast

CONTEXT.—

This review article is a result of the breast pathology lectures given at the Sixth Chinese American Pathologists Association annual diagnostic pathology course in October 2020 (held virtually due to the coronavirus disease 2019).

OBJECTIVE.—

To update recent developments, in this review article, the authors wrote minireviews in the following 4 areas: lobular neoplasm, adenomyoepithelial lesions, papillary lesions, and fibroepithelial lesions.

DATA SOURCES.—

The sources include extensive literature review, personal research, and experience.

CONCLUSIONS.—

With the wide practice of screening mammography, these lesions are not uncommon in image-guided core biopsies and excisional specimens. Many recent developments have emerged in understanding these lesions. We aim to provide readers with concise updates for each of these lesions with a focus on recent updates in definitions, diagnostic criteria, management, and molecular profiles that are most relevant to the daily practice of pathology and patient management.

Ductal carcinoma in situ (DCIS) presenting as a cystic retroareolar lesion in an African American man

Ductal carcinoma in situ (DCIS) in males is rare, and there are limited data aimed at understanding the adequate workup, imaging, and follow-up for men who present with breast masses. Attention should be given to black men who have a higher cancer risk and worse prognosis than white male counterparts.

Unusual Male Breast Lesions

Most of male breast masses are benign with gynecomastia being the most common entity encountered. Primary male breast cancer accounts for less than 1% of the total number of breast cancer. Male breast can be affected by a variety of conditions affecting the female breast with less frequency due to the lack of hormonal influence and consequent glandular sub-development. Imaging features of male breast masses are quite similar to the female breast. Therefore, using the knowledge of the female breast and applying it may help in the diagnosis and management of male breast abnormalities. In this article, we aim to review a variety of unusual male breast masses. We discuss the demographics of male breast tumors, describe the diagnostic algorithm for evaluating male breast masses, and review the imaging features of rare breast masses and mimickers of male breast cancer.

Papillary Lesions of the Male Breast: A Study of 117 Cases and Brief Review of the Literature Demonstrate a Broad Clinicopathologic Spectrum

Papillary lesions of the male breast (PLMB) are uncommon. To date, PLMB have been reported as individual case reports and in relatively small series. We reviewed cases of PLMB diagnosed at our medical center over a 19-year (2000-2019) period. A total of 117 cases were identified, with an age range of 7 months to 88 years. These cases included 3 of papillary ductal hyperplasia, 5 intraductal papillomas, 1 adenomyoepithelioma, 5 atypical papillomas (ie, papillomas with atypia), 51 papillary ductal carcinoma in situ, 14 encapsulated papillary carcinomas, 38 solid papillary carcinomas, and 8 invasive papillary carcinomas. Malignant papillary neoplasms, including invasive and noninvasive ones, had a mean size of 1.3 cm (range: 0.3 to 4.4 cm), and all were ER and HER2. Fifty-four percent (19/35) of carcinomas were treated with excision alone, 46% (16/35) underwent mastectomy, and 63% (22/35) had axillary lymph node sampling. Only one case had metastatic involvement of axillary lymph nodes. Of the cases with follow-up, no (0/8) invasive carcinoma showed distant metastasis or proved fatal, and no (0/23) noninvasive papillary carcinoma recurred. Two notable cases of PLMB were encountered: one of a 7-month-old boy with NF1 mutation and florid papillary hyperplasia, and another of a 57-year-old man with Klippel-Feil syndrome and bilateral solid papillary carcinoma, invasive and oligometastatic on one side and noninvasive on the other. On the basis of this study of PLMB cases, the largest to date, and review of literature, we conclude that PLMB span a broad clinicopathologic spectrum, and that both invasive and noninvasive papillary carcinomas have relatively good prognosis.

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.

Cytological evaluation in males presenting with bloody nipple discharge, with or without breast mass: Report of two cases depicting two poles of the disease spectrum

Nipple discharge (ND) either in the presence or in the absence of underlying mass is a very uncommon presentation in males and its bloody nature is still rarer. ND cytology in males has not been reported much in the literature. Spontaneous and expressed ND, however, can be very useful in establishing the diagnosis. Two males with bloody ND, one, without any palpable mass and another with underlying mass, were evaluated on ND cytology. The presence of loose papillaroid clusters and cell sheets with mild atypia was seen in ND smears itself in case 1. The discharge was more copious in case 2, but the ND smears were paucicellular. The presence of tall columnar cells in ND smears as well as in the FNA from underlying mass with clear features of malignancy was helpful in reaching the diagnosis of papillary carcinoma in case 2. Histopathology in case 1 was a spectrum of ADH to DCIS, whereas in case 2, was tubulopapillary carcinoma. Following two cases highlight the importance of the cytological evaluation of ND smears.

Magnetic resonance imaging findings of high-grade ductal carcinoma in situ of the male breast: A case report

Ductal carcinoma in situ in men is incredibly rare and detection by conventional mammography and ultrasound is often challenging. We report an unusual case of a 50-year-old male, with no family history of breast cancer, who presented with an 8-year history of left-sided breast pain and recurrent bloody nipple discharge without any significant suspicious imaging features in mammography and targeted high-resolution ultrasound. Breast magnetic resonance imaging was performed as an adjunct modality. Magnetic resonance imaging findings revealed a suspicious retroareolar non-mass abnormality of segmental, linear and dendritic pattern, which was highly suspicious for a ductal carcinoma in situ. Stereotactic guided biopsy and subsequent mastectomy were consistent with pure high-grade ductal carcinoma in situ of the left breast. Overall, this case highlights the challenges in diagnosing ductal carcinoma in situ in men and demonstrates the importance for further investigating clinical suspicions of the male breast.

Efficiency of Imaging Modalities in Male Breast Disease: Can Ultrasound Give Additional Information for Assessment of Gynecomastia Evolution?

Objective

The purpose of this study is to present mammography and ultrasound findings of male breast lesions and to investigate the ability of diagnostic modalities in estimating the evolution of gynecomastia.

Materials and Methods

Sixty-nine male patients who admitted to Taksim and Bakirkoy Education and Research Hospitals and underwent mammography (MG) and ultrasonography (US) imaging were retrospectively evaluated. Duration of symptoms and mammographic types of gynecomastia according to Appelbaum's classifications were evaluated, besides the sonographic findings in mammographic types of gynecomastia.

Results

The distribution of 69 cases were as follows: gynecomastia 47 (68.11%), pseudogynecomastia 6 (8.69%) primary breast carcinoma 7 (10.14%), metastatic carcinoma 1 (1.4%), epidermal inclusion cyst 2 (2.8%), abscess 2 (2.8%), lipoma 2 (2.8%), pyogenic granuloma 1 (1.4%), and granulomatous lobular mastitis 1 (1.4%). Gynecomastia patients who had symptoms less than 1 year had nodular gynecomastia (34.6%) as opposed to dendritic gynecomastia (61.5%) (p<0.01) based on mammography results according to Appelbaum's classifications. In patients having symptoms for 1 to 2 years, diffuse gynecomastia (70%) had a higher rate than the dendritic type (20%). Patients having the symptoms more than 2 years had diffuse gynecomastia (57.1%) while 42.9% had dendritic gynecomastia (p<0.001). With sonographic examination patients who had symptoms less than 1 year had higher rates of dendritic gynecomastia (92.3%) than noduler type (1.9 %). Patients having symptoms for 1 to 2 years had more dentritic gynecomastia (70%) than diffuse type (30%). Patients having symptoms more than 2 years had diffuse gynecomastia (57.1%) comparable to dendritic gynecomastia (42.9 %).

Conclusion

Diagnostic imaging modalities are efficient tools for estimation of gynecomastia evolution as well as the diagnosis of other male breast diseases. There seems to be an incongruity between duration of clinical complaints and diagnostic imaging classification of gynecomastia. The use of these high resolution US findings may demonstrate an early phase fibrosis especially in patients visualized by mammography as with nodular phase.

Male Breast Carcinoma: A Clinical and Pathological Review

Male breast carcinomas (MBCs) are rare neoplasms that account for 0.1% of all male cancers. Still, there are 2000 new cases of MCB diagnosed annually in the United States. Because of its rarity, data regarding the etiology, risk factors, diagnosis, management, and prognosis of MBC are limited. MBC shares some similarities with female breast carcinoma (FBC). This review will address the important clinical, histopathological, immunohistochemical and molecular features, genetics, management, and prognosis of MBC.

Ductal Carcinoma In situ of the Male Breast

BACKGROUND

Ductal carcinoma in situ of the male breast is an unusual lesion and most often associated with invasive carcinoma. On rare occasions when the in situ component is present in pure form, histological grade is almost always low to intermediate. Imaging for these patients is difficult as gynecomastia is often present and can mask underlying calcifications or carcinoma.

CASE REPORT

We report a case of pure high-grade ductal carcinoma in situ of the male breast in a patient with clear nipple discharge. Breast mammography showed bilateral gynecomastia and benign calcifications. Subsequent breast ultrasound showed dilated ducts of the left breast, and a left breast ductogram showed filling defects suggestive of a papilloma. Excisional biopsy and subsequent mastectomy were consistent with high-grade ductal carcinoma in situ.

CONCLUSION

Male breast cancer is uncommon and, although there is increasing awareness, it is less studied compared to female breast cancer. With a clinical history of nipple discharge of any kind, further evaluation with imaging should be considered. In males with gynecomastia, it is important to remember that ductal carcinoma in situ, even of high grade, is difficult to detect on mammography and may not be associated with suspicious calcifications.

The Management and Outcomes of Male Breast Cancer

OBJECTIVE

Due to a lack of sufficient data, the treatment protocols for male breast cancer are usually the same as those used for female breast cancer. The aim of the current study was to present our clinical experience with male breast cancer.

MATERIALS AND METHODS

The records of 37 patients who were treated for male breast cancer in our hospital between 2004 and 2014 were reviewed retrospectively. The data of patients were recorded and analyzed.

RESULTS

The mean age of the patients was 63.03±12.36 years. Thirty-three patients (89.2%) had invasive ductal carcinoma, two (5.4%) had ductal carcinoma in situ, and two had invasive lobular carcinoma (5.4%). The most common molecular subtype was luminal A (17 cases, 45.9%). Twenty-nine patients with male breast cancer underwent mastectomy and two underwent breast conserving surgery. Axillary lymph node dissection was performed in 25 patients. The most common surgical procedure was modified radical mastectomy. Distant metastases were present in 17 (45.9%) patients. Overall, the 5-year survival was 60%. The 5-year survival was 100% for those with stage 0-I disease, 87% for stage II, and 42% for stage III. The 3-year survival was 14% for stage IV.

CONCLUSION

Patients with male breast cancer presented at an older age, a later stage, and with earlier metastasis. Early metastasis and death increases with increasing stage. Poor prognosis correlates with late admission. Data from different centers should be compiled and reviewed in order to determine a specific treatment protocol for male breast cancer; each paper published reveals new data.

Benign and Malignant Male Breast Diseases: Radiologic and Pathologic Correlation

Male breast disease comprises a wide spectrum of benign and malignant processes. We present the spectrum of diseases encountered at our institution over the past 7 years (2007-2013) and correlate their radiological and histopathological appearances. Gynaecomastia is the most frequently encountered disease due to its association with a variety of causes. Male breast malignancies, though rare, must be considered. The most frequently encountered pathological characteristic is invasive and the predominant histologic subtypes are infiltrating ductal carcinomas.

Elucidating encounters of atypical ductal hyperplasia arising in gynaecomastia

AIMS

Atypical ductal hyperplasia (ADH) rarely arises in gynaecomastia. We set out to understand more clearly the clinical, histological and immunohistochemical features of ADH in this setting.

METHODS AND RESULTS

Twenty-five cases of ADH arising in gynaecomastia, nine cases of ductal carcinoma in situ (DCIS) and 36 cases of gynaecomastia with usual ductal hyperplasia (UDH) were studied. Reviews of clinical, morphological and immunohistochemical findings were performed. The extent of cytokeratin 5/6 (CK5/6) luminal epithelial cell staining was assessed (0% = 0, < 10% = 1, 10-50% = 2 and > 50% = 3). Oestrogen receptor (ER) was evaluated using the H-scoring system. The average age of ADH patients was 35 years (range 14-78). ADH was bilateral in 20% and less frequent in active gynaecomastia (24%). ADH often showed a cribriform pattern (72%), with less nuclear variation/size and similar frequency of mitoses than UDH cells. CK5/6 luminal epithelial staining was decreased in ADH (68%) versus UDH (11%). ADH showed high ER expression compared to UDH (H score > 270 in 88% and 14%, respectively).

CONCLUSIONS

ADH in gynaecomastia can be distinguished from UDH by morphological and immunohistochemical features. We also identified a subset of young patients (< 25 years) with extensive bilateral ADH. More studies are needed to characterize this patient subset more clearly.

[Breast cancer in men: about 6 cases]

Le but de ce travail était d'analyser les caractéristiques cliniques, histologiques, thérapeutiques et pronostiques du cancer du sein chez l'homme. Il s'agissait d'une étude rétrospective portant sur six patients colligés au service de gynécologie obstétrique II, CHU Hassan II durant la période 2009-2012. L’âge moyen de nos patients est de 65.3 ans. Il s'agit dans 83.3% des cas, d'une tumeur rétroaréolaire dont la taille moyenne est de 44.16 mm. Nous avons retrouvé 4 (66.7%) T4, 1 (16.7%) T3 et dans un cas, une tumeur inclassable. Le type histologique le plus représenté est le carcinome canalaire infiltrant (66.7%). Le taux d'envahissement ganglionnaire axillaire est de 66.7%. L'hormonodépendance de ces tumeurs est prouvée dans 100% des cas. La survie à cinq ans est en cours d’évaluation. L'envahissement ganglionnaire, l'invasion du derme, le stade clinique TNM sont des facteurs qui influencent significativement la survenue de métastases. Aucun de ces facteurs de risque n'est apparu significatif en termes de survie globale. Le cancer du sein chez l'homme est une maladie rare (environ 1% des cancers du sein) au pronostic sombre. Le diagnostic est le plus souvent tardif et les lésions sont traitées à des stades avancés.

From the radiologic pathology archives: diseases of the male breast: radiologic-pathologic correlation

Male breast disease includes a variety of benign and malignant conditions, many of which are hormonally influenced. Gynecomastia and skin lesions account for the majority of conditions in symptomatic men with a palpable abnormality, and these conditions should be accurately recognized. Imaging patterns of gynecomastia include nodular, dendritic, and diffuse patterns. Histopathologically, the nodular and dendritic patterns correlate with the florid and quiescent (fibrotic) phases of gynecomastia, respectively. The diffuse pattern may have features of both phases and is associated with exposure to exogenous estrogen. Benign-appearing palpable masses in male patients should be approached cautiously, given the overlapping morphologic features of benign and malignant tumors. In addition to gynecomastia, other benign male breast tumors include lipoma, pseudoangiomatous stromal hyperplasia, granular cell tumor, fibromatosis, myofibroblastoma, schwannoma, and hemangioma. Male breast cancer accounts for 1% of all breast carcinomas. Invasive ductal carcinoma accounts for the majority of cases in adult males and typically appears as a subareolar mass without calcifications that is eccentric to the nipple. Other epithelial and mesenchymal tumors that may occur, albeit not as commonly as in women, include papillary carcinoma, invasive lobular carcinoma, adenoid cystic carcinoma, liposarcoma, dermatofibrosarcoma, pleomorphic hyalinizing angiectatic tumor, basal cell carcinoma of the nipple, hematopoietic malignancies, and secondary tumors. Knowledge of the natural history, clinical characteristics, and imaging features of tumors that occur in the male breast will help narrow the radiologic differential diagnosis and optimize treatment.

Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship

BACKGROUND

The causes, optimal treatments, and medical/psychosocial sequelae of breast cancer in men are poorly understood.

DESIGN

A systematic review of the English language literature was conducted to identify studies relevant to male breast cancer between 1987 and 2012 and including at least 20 patients. Searches were carried out on PubMed using the title terms 'male breast cancer' or 'male breast carcinoma'.

RESULTS

Relevant published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation and treatment, and survivorship issues in male breast cancer patients are presented. BRCA2 mutations, age, conditions that alter the estrogen/androgen ratio, and radiation are proven risk factors. Disease biology is distinct in men, but diagnostic approaches and treatments for men are generally extrapolated from those in women due to inadequate research in men. Survivorship issues in men may include sexual and hormonal side-effects of endocrine therapies as well as unique psychosocial impacts of the disease.

CONCLUSION

Further research is needed to address gaps in knowledge pertaining to care of male breast cancer patients and survivors.

Pathology of invasive breast disease

Invasive breast cancers constitute a heterogeneous group of lesions. Although the most common types are ductal and lobular, this distinction is not meant to indicate the site of origin within the mammary ductal system. The main purpose of the identification of specific types of invasive breast carcinoma is to refine the prediction of likely behavior and response to treatment also offered by the other major prognostic factors, including lymph node stage, histologic grade, tumor size, and lymphovascular invasion.

Case report: ductal carcinoma in situ in the male breast

High-grade ductal carcinoma in situ is incredibly rare in male patients. The prognosis for ductal carcinoma in situ (DCIS) in a male patient is the same as it would be for a female with the same stage disease; therefore, early recognition and diagnosis are of the utmost importance. We present a case of a male with unilateral invasive ductal carcinoma who was diagnosed with DCIS in the contralateral breast. The DCIS presented as microcalcifications on mammography and was found to be biopsy proven grade 3 papillary DCIS. This case also illustrates the importance of family history and risk factors, all of which need to be evaluated in any male presenting with a breast mass or nipple discharge.

The management of preinvasive breast cancer

SUMMARY Ductal carcinoma in situ (DCIS) is a preinvasive breast cancer in which the proliferations of malignant ductal epithelial cells have not breached the ductal basement membrane. Currently there is controversy over the optimum management of DCIS, with suggestions that there may be an element of ‘overdiagnosis’ of some low-risk cases that may never progress to invasive cancer within a patient’s lifetime. This review discusses the biology and natural history of DCIS and current management strategies, addresses the risk factors for recurrence and how these can be minimized, highlights areas of controversy and suggest the possible direction of future research.

Ductal carcinoma in situ: recent advances and future prospects

Introduction. This article reviews current management strategies for DCIS in the context of recent randomised trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment. Methods. Literature review facilitated by Medline, PubMed, Embase and Cochrane databases. Results. DCIS should be managed in the context of a multidisciplinary team. Local control depends upon clear surgical margins (at least 2 mm is generally acceptable). SLNB is not routine, but can be considered in patients undergoing mastectomy (Mx) with risk factors for occult invasion. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions should be treated by Mx and immediate reconstruction should be discussed. Adjuvant hormonal treatment may reduce the risk of LR in selected cases with hormone sensitive disease. Conclusion. Further research is required to determine the role of new RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of tumour biology in DCIS to rationalise treatment. Reliable identification of low-risk lesions could allow treatment to be less radical.

Ductal carcinoma in situ of the male breast presenting as adolescent unilateral gynaecomastia

A 17 year old male patient was referred to the breast surgery service with a unilateral swelling of the left breast. Subsequent evaluation led to discharge with a diagnosis of adolescent gynaecomastia. Four years later the same patient was referred back to the breast surgery service and the referral was turned down without a consultation as the surgical treatment of gynaecomastia was not funded by the local Primary Care Trust (PCT). Three years following, this now 24 year old gentleman was referred to the Plastic surgery service at the Hospital Trust where he had been initially referred as a 17 year old. He underwent a nipple sparing mastectomy through a peri-areolar incision. The histology amounted to a diagnosis of ductal carcinoma in situ (DCIS). A literature review revealed the rarity of pure DCIS in the adolescent male. The variation in availability of treatments across the National Health Service in England has lead to a "postcode lottery" due to "rationing" decisions being made by individual Primary Care Trusts. "Action on Plastic Surgery", an NHS Modernisation Agency document, was designed as an aid to PCT's making funding decisions on Plastic Surgery patients in 2005. The case described in this report illustrates the difficulty in clinical diagnosis of a male breast lump. This persistent lesion was sampled on 2 separate occasions with fine needle aspiration, neither aspirate raising the possibility of DCIS. In conclusion this case describes a rare pre-malignant condition of the male breast. Complete histology of such a lump is the only conclusive investigation necessary and the limitations put upon the surgeon by the "rationing" of such treatment must be overcome on clinical grounds.

Male breast cancer

Male breast cancer (MBC) is a rare disease. However, as global populace ages, there is a trend to MBC increasing. Although aetiology is still unclear, constitutional, environmental, hormonal (abnormalities in estrogen/androgen balance) and genetic (positive family history, Klinefelter syndrome, mutations in BRCA1 and specially BRCA2) risk factors are already known. Clinic manifestation is painless hard and fixed nodule in the subareolar region in 75% of cases, with nipple commitment earlier than in women. Breast cancer has similar prognostic factors in males and females, among which axillary adenopathy (present in 40-55% cases) is the most important one. Although mammography, ultrasonography and scintigraphy can be useful tools in diagnosis; clinical assessment, along with a confirmatory biopsy, remains the main step in the evaluation of men with breast lesions. Infiltrating ductal carcinoma is the most frequent histological type. The established standard of care is modified radical mastectomy followed by tamoxifen for endocrine-responsive positive disease, although other options are being explored. While similarities between breast cancer in males and females exist, it is not appropriate to extrapolate data from female disease to the treatment of male. There is a need for specific multi-institutional trials to better understanding of clinicopathologic features and establishment of optimal therapy for this disease.

Ductal carcinoma in-situ: an update for clinical practice

INTRODUCTION

Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment.

METHODS

Literature review facilitated by Medline, PubMed, Embase and Cochrane databases.

RESULTS

DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease.

CONCLUSION

Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.

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.

The Diagnostic Accuracy of Mammography and Ultrasound in the Evaluation of Male Breast Disease: A New Algorithm

SUMMARY: BACKGROUND: The purpose of this study was to define the diagnostic accuracy of mammography and ultrasound in the evaluation of male breast disease, and to suggest a diagnostic protocol for male breast disease. MATERIAL AND METHODS: We retrospectively reviewed clinical, radiographic, and pathologic records of 75 patients. Breast Imaging Reporting and Data System (BI-RADS) category 4-5 mammograms and ultrasonograms were suggested as suspicious for malignancy. RESULTS: Of the 75 patients, 23 (31%) were considered to have suspicious lesions by mammography and/or ultrasonography. 13 of the patients were shown to have breast cancer. The remaining 52 (69%) were referred for biopsy by clinicians; all of the biopsy specimens were benign (gynecomastia). The accuracy data of mammography and ultrasonography are: sensitivity, 69 and 100%; specificity, 87 and 97%; positive predictive value, 53 and 87%; negative predictive value, 93 and 100%; and accuracy, 84 and 97%, respectively. CONCLUSION: We suggest a new diagnostic algorithm for the evaluation of male breast disease in which ultrasonography may be used to evaluate palpable abnormalities as the first diagnostic tool of choice. To use and to trust imaging would decrease the number of false-positive biopsies that would be generated by physical examination alone.

A 16-year-old male with gynecomastia and ductal carcinoma in situ

While gynecomastia is common in adolescents, male breast cancer in the pediatric population is exceedingly rare. Occasional reports describe malignant and pre-malignant lesions in mastectomy specimens for gynecomastia in young adults. We present a 16-year-old male with unilateral gynecomastia discovered to have ductal carcinoma in situ (DCIS), treated by mastectomy with 4 year follow-up.

Ductal carcinoma in situ in a 15-year-old boy with gynaecomastia: a case report

Carcinoma in situ of the male breast is rare, especially when associated with bilateral gynaecomastia and during puberty. Only two cases in adults and one during puberty have been described in the literature. We present the case of a 15-year-old boy whom we have been observing for about 2 years for puberal bilateral gynaecomastia, treated with bilateral exeresis of the mammary gland and subsequently re-operated with total bilateral mastectomy because the tissue removed presented atypical features upon histological examination. The authors believe, after a careful review of relevant literature, that this is the second case of intraductal carcinoma in the presence of gynaecomastia described during adolescence.

Bilateral synchronous ductal carcinoma in situ in a young man: case report and review of the literature

We report a rare case of synchronous bilateral ductal carcinoma in situ (DCIS) developing in a man with long-standing gynecomastia. He underwent bilateral staged subcutaneous mastectomies with the right side being performed first at age 26 years. Histology confirmed bilateral pure DCIS. There was no identifiable causative factor for the development of bilateral DCIS, and there was no familial history of the disease. He ultimately experienced progression to total bilateral mastectomies. This case highlights the importance of remaining vigilant about the presence of malignancy in normally benign conditions.

Current management of DCIS: a review

Ductal carcinoma in-situ (DCIS) is a heterogeneous disease, in terms of its radiological characteristics, histological morphology and molecular attributes. This diversity is reflected in its natural history and influences optimal treatment strategy. A significant proportion of DCIS lesions behave in a clinically benign fashion and do not progress to invasive disease. Reliable identification of these patients could allow treatment to be less radical or safely omitted. Management should be tailored to the individual within the context of a multidisciplinary team. Approaches such as biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. This article reviews the management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy, adjuvant radiotherapy and tamoxifen.

Synchronous Bilateral Breast Cancer in Men: A Case Report and Review of the Literature

Breast carcinoma is a rare disease in men, and bilateral cases are extremely uncommon. The rarity of male breast carcinoma and the small number of large studies on this topic have made it necessary to extrapolate treatment standards and outcomes from those established for women. Between 1997 and 2007, 75 men with breast cancer were referred to our institute, and the bilateral case we present here was the only one we have observed since 1994. The goal of our work was to contribute to the available literature with this extremely unusual presentation of the disease.

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.

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.

Cytokeratin profiles of male breast cancers

AIMS

The prognostic factors and expression of molecular markers in male breast carcinomas are similar to those in female breast cancers. The identification of distinct cytokeratin (CK) profiles (basal as opposed to luminal cells) helps to identify subsets of tumours with different clinical behaviour. The aim of this study was to investigate CK expression in male breast cancer.

METHODS AND RESULTS

Thirty-two cases of male breast cancer were studied. The panel of CKs studied by immunohistochemistry included: 5/6, 14, 17, 18 and 19. Pathological findings and CK expression were analysed in all cases. Histological patterns included ductal carcinoma in situ, invasive ductal carcinoma and mixed patterns. Four cases were positive for CK5/6 and CK14, identifying a basal-like phenotype. CK17 was negative in all but two cases. All cases expressing either CK5/6 or CK14 were invasive carcinomas of high nuclear and histological grade and were also larger compared with the tumours not expressing CK5/6 and CK14. All tumours except three (also negative for CK5/6) expressed CK18 and CK19. The four basal-like tumours were negative for Her-2 expression.

CONCLUSIONS

Male breast carcinomas have a basal-like phenotype that is similar in frequency to that of female breast carcinomas. The expression of CK5/6 and CK14 identifies a subset of pathologically aggressive male breast cancers.

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.

Male breast cancer: a review of clinical management

AIMS

Male breast cancer incidence is 1% of all breast cancers and is increasing. We aim to present an overview of male breast cancer with particular emphasis on clinical management.

METHODS

Studies were identified by an online search of literature in the MEDLINE database till June 2006 followed by an extensive review of bibliographies.

RESULTS

Increased risk factors include genetic predisposition as in BRCA2 families; testicular dysfunction due to chromosomal abnormality such as Klinefelter's syndrome or environmental factors such as chronic heat exposure and radiation. Clinical assessment with biopsy is the hallmark of diagnosis. Earlier presentations are becoming commoner but there are wide geographical differences. Surgical treatment involves simple or modified radical mastectomy along with surgical assessment of the axilla, either via sentinel node biopsy in clinically node-negative disease or axillary sampling/clearance in node-positive disease. Reconstructions for restoring body image have been recently reported. Indications for adjuvant therapies are similar to that in women. For metastatic disease, tamoxifen is still the mainstay for oestrogen receptor positive disease. For oestrogen receptor negative disease, doxorubicin based chemotherapy regimens are used. In addition, the oft neglected psychological aspects of men having a "cancer of women" are increasingly being recognised.

CONCLUSIONS

There is, thus, need for further increasing awareness among men to reduce stigma associated with presentation of symptoms related to breast. This should be in addition to stressing to clinicians the ways of earlier detection and tailor-made "gender oriented" treatment of breast cancer in men.

Cytomorphologic features of papillary lesions of the male breast: a study of 11 cases

BACKGROUND

Breast masses occur in men far less commonly than women and are infrequently subjected to fine-needle aspiration (FNA) biopsy. Papillary lesions of the male breast are rare and are comprised of a spectrum of lesions ranging from papillary hyperplasia in gynecomastia to invasive papillary carcinoma. The following study describes the cytomorphology of papillary breast lesions in 11 men. The patients ranged in age from 23 to 78 years old and each presented with an unilateral subareolar or periareolar breast mass that varied in size from 0.5 to 3 cm. Two patients presented with bloody nipple discharge.

METHODS

Archival material (8-year period) from FNA biopsies of papillary lesions of the male breast was reviewed. The reviewed cases were correlated with appropriate clinicopathologic follow-up.

RESULTS

The smears had variable cellularity but all showed papillary clusters of mammary epithelial cells with and without fibrovascular cores. Single epithelial cells with a high nuclear-to-cytoplasmic ratio and eccentric nuclei were seen in all smears; however, these were more numerous in cases of adenocarcinoma. Hemosiderin-laden macrophages were present in all cases. Nipple discharge was seen only in the 2 benign lesions. All adenocarcinomas occurred in older men.

CONCLUSIONS

The only cytologic criteria that differentiated benign from malignant papillary lesions were marked cellularity and the presence of abundant 3-dimensional clusters. To the best of the authors' knowledge, the current series is the largest in the English literature to date that examines the cytomorphologic features of papillary breast lesions in men.

Outcome of Men Presenting with Clinical Breast Problems: The Role of Mammography and Ultrasound

The purpose of this study was to determine the outcome of men presenting with clinical breast problems for breast imaging and to evaluate the role of mammography and ultrasound in the diagnosis of benign and malignant breast problems. We retrospectively reviewed clinical, radiographic, and pathologic records of 165 consecutive symptomatic men presenting to Breast Imaging over a 4 year period. We assessed the clinical indication for referral, mammographic findings, sonographic findings, histologic results, and clinical outcomes. Patients ranged in age from 22 to 96 years. Breast Imaging Reporting and Data System (BI-RADS) category 4 and 5 mammograms and solid sonographic masses were considered suspicious for malignancy. Six of 165 men (4%) had primary breast carcinoma, which were mammographically suspicious in all 6 (100%). Five were invasive ductal carcinoma and one was ductal carcinoma in situ (DCIS). Of 164 mammograms, 20 (12%) were suspicious. Six were cancer and 14 were benign. Clinical follow-up for 2 years or biopsy results were available for 138 of the 165 men (84%). Twelve with benign mammographic findings had benign biopsies. All men with benign mammography not undergoing biopsy were cancer free. Sensitivity for cancer detection (mammography) was 100% and specificity was 90%. Positive predictive value (mammography) was 32% (6 of 19) and the negative predictive value was 100%. Sonography was performed in 68 of the 165 men (41%). Three of three cancers (100%) were solid sonographic masses. There were 9 of 68 false-positive examinations (13%). Sensitivity and negative predictive value for cancer detection (ultrasound) was 100% and specificity was 74%. The most common clinical indication for referral was mass/thickening (56%). Mammography had excellent sensitivity and specificity for breast cancer detection and should be included as the initial imaging examination of men with clinical breast problems. The negative predictive value of 100% for mammography suggests that mammograms read as normal or negative need no further examination if the clinical findings are not suspicious. A normal ultrasound in these men confirms the negative predictive value of a normal mammogram.

Heterogeneity of ductal carcinoma in situ and its effects on management

Data derived from histopathological analysis, natural history, radiological characteristics, molecular markers, and clinical outcome indicate that ductal carcinoma in situ (DCIS) is a heterogeneous disease, meaning that no one treatment strategy is best, but rather that treatment should be personalised and entail a systematic and rigorous multidisciplinary approach. Many women with DCIS will develop actual invasive carcinoma over time, whereas others-especially those with low-grade cancers-will not. At the moment, identification of patients at low risk of recurrence risk is very difficult (that is, such people for whom further treatment beyond lumpectomy is not needed). In this context, molecular profiling analysis is a promising method to guide management decisions. In this Review, various treatment strategies for DCIS will be reviewed, highlighting the limitations of randomised trials. Furthermore, discussions about the role of sentinel-node biopsy and tamoxifen in disease management; locoregional recurrence; and special clinical scenarios such as recurrent disease, DCIS after thoracic radiotherapy, ductal carcinoma with concurrent lobular carcinoma in situ, and DCIS in elderly people and in men will be presented.

Imaging Characteristics of Malignant Lesions of the Male Breast

Most men referred for breast imaging have palpable lumps, breast enlargement, or tenderness. Most of the evaluated lesions are benign. Male breast cancer accounts for less than 1% of total male breast lesions. Differentiation between benign and malignant masses is critical because it alleviates patient anxiety and allows unnecessary procedures to be avoided. Clinically suspicious lesions referred for imaging should first be evaluated with mammography. In patients with questionable findings at mammography and for lesions that are difficult to image with mammography, ultrasonography (US) is often useful for further characterization. A discrete mass at mammography or US is suspicious for malignancy. The relationship of the mass to the nipple should be carefully assessed; an eccentric location is highly suspicious for cancer. Secondary signs occur earlier in male patients because of smaller breast size. Such signs include nipple retraction, skin ulceration or thickening, increased breast trabeculation, and axillary adenopathy. US of the axillary region is helpful for staging. At pathologic analysis, cystic lesions commonly demonstrate malignant findings; therefore, all cysts and complex masses should be worked up as potentially malignant lesions. Benign conditions that may mimic male breast cancer include gynecomastia, lipoma, epidermal inclusion cyst, pseudoangiomatous stromal hyperplasia, and intraductal papilloma.