Breast carcinoma in a 46, XX true hermaphrodite

Synchronous bilateral breast carcinoma in a 50-year-old man with 45,X/46,XY mosaic karyotype: report of a case

We report a case of synchronous bilateral breast cancer in a patient with ambiguous external genitalia attributed to a 45,X/46,XY mosaicism. To our knowledge, this represents the first such case ever to be reported. Mammography, ultrasonography, computed tomography, and magnetic resonance imaging all showed bilateral suspicious breast masses with microcalcifications. There were no radiological findings of muscle invasion or axillary lymphadenopathy. The patient was successfully treated by bilateral radical modified mastectomy followed by external irradiation and adjuvant endocrine therapy. Histological examination revealed a bilateral ductal carcinoma in situ, with a cribriform and papillary pattern and microfoci of infiltrating ductal carcinoma. The hormonal profile revealed high levels of follicle-stimulating hormone and luteinizing hormone, and low levels of testosterone. Testicular sonography revealed small hypoechoic testicles with bilateral microlithiasis. This case shows that 45,X/46,XY men may have an increased risk of breast cancer and must be followed up carefully.

Clinical management of breast cancer in males: a report of four cases

Breast cancer in men is a rare cancer manifestation, accounting for less then 1% of all breast cancers in both genders. The incidence in Germany during the last years has been approximately 1.0 per year/100,000. In the US, only 0.2% of all malignancies in men. Predisposing risk factors seem to include radiation exposure, hereditary factors, estrogen administration, and diseases associated with hyperestrogenism, such as cirrhosis of the liver or genetic syndromes (i.e. Klinefelter disease). The incidence of male breast cancer is increased in families with a number of first degree relatives affected with breast or prostate cancer. An increased risk of male breast cancer has been reported in families with a mutation of the breast cancer susceptibility gene BRCA-2. For a period of decades, prognosis of breast cancer in males was thought to be worse than that of female patients. Data and cases being published demonstrate that prognosis and strategies of treatment in male breast cancer do not differ from those in females. The cases presented clearly demonstrate that diagnostic work-up, staging procedures and treatment options for primary treatment and advanced stages are identical compared to the recommendation for female breast cancer.

Localized male breast carcinoma and family history. An analysis of 142 patients

BACKGROUND

Male breast carcinoma is rare; therefore, the effect of family history on the course of the disease has not been well described. Germ-line mutations in breast carcinoma susceptibility genes, particularly BRCA2, are associated with an increased risk of male breast carcinoma. The authors sought to correlate significant family history with clinical phenotype in males with breast carcinoma.

METHODS

One hundred forty-two men with breast carcinoma were treated at Memorial Sloan-Kettering Cancer Center or the Ochsner Clinic from 1973 to 1994. The authors reviewed the effect imparted by a family history of breast carcinoma on the duration of symptoms, the age at diagnosis, and the survival of men with this disease.

RESULTS

Fifteen percent of male breast carcinoma patients had a first-degree relative with the disease. Fifty-eight years was the mean age at diagnosis for those with a family history, compared with 61 years for those without (P = not significant [NS]). The mean duration of symptoms was 23 months for those with a family history, compared with 22 months for those without. Three of 22 patients (13.6%) with a family history, compared with 11 of 90 patients (12%) without a family history, had Stage III disease (P = NS) at presentation. The overall 5-year and 10-year survival rates were 86% and 64%. Survival was not affected by family history. Lymph node positivity reduced 5-year and 10-year survival rates to 73% and 50% (P = 0.0004).

CONCLUSIONS

For men with breast carcinoma, the presence of a family history did not affect the age at presentation, the duration of symptoms, the stage of disease at presentation, or the overall survival. In multivariate analysis, the most powerful predictor of outcome for these men was the status of the axillary lymph nodes.

Bilateral breast tumors, malignant phyllodes tumor and invasive lobular carcinoma in a 46,XX/46,XY mosaic female with family history of breast cancer

Bilateral breast tumors, a malignant phyllodes tumor in the right breast and an invasive lobular carcinoma in the left breast, occurred in a 47-year-old woman with 46XX/46XY mosaic karyotype in her peripheral blood lymphocytes and intersex external genitalia. Postmortem examination revealed bilateral ovotestis. Three of the patient's sisters also had breast cancer. In situ hybridization with a Y-specific probe revealed Y-chromosome-specific signal in both tumors, suggesting that the clonal origin of tumors in this patient was Y-containing cells. Androgen-receptor polymorphism also revealed a monoallelic X chromosome pattern in the recurrent phyllodes tumor tissue taken at autopsy, in addition to loss of heterozygosity demonstrated at locus TP53. The slippage of the CA repeats in the tumor was also shown at the loci of D5S82 and D11S527. The mechanistic basis for the occurrence of bilateral malignant tumors of the breast, XX/XY mosaicism, and familial clustering of breast cancer is still unknown. The present study, however, suggests that the sex chromosome abnormality may have modified the cancer phenotype in a manner similar to breast cancer in Klinefelter's syndrome (though phenotypically male) and the Y chromosome may have promoted cell growth.

True hermaphroditism: geographical distribution, clinical findings, chromosomes and gonadal histology

We reviewed 283 cases of human true hermaphroditism published from 1980 to 1992. Of the 96 cases described in Africa 96.9% showed a 46,XX karyotype. In Europe 40.5% of 74 cases and 21.0% of the patients in North America had chromosomal mosaicism. The 46,XY karyotype is extremely rare (7%) and equally distributed through Asia, Europe and North America. Of 283 cases 87 were of black or black mixed origin with a 46,XX chromosomal constellation. The most common gonad in patients with true hermaphroditism, an ovotestis, was found in 44.4% of 568 gonads. Gonads with testicular tissue were more frequent on the right side of the body, while pure ovarian tissue was more common on the left. Histologically the testicular tissue was described to be immature and only twice was spermatogenesis reported while the ovarian portion often appeared normal. This coincides with 21 pregnancies reported in ten true hermaphrodites while only one true hermaphrodite apparently has fathered a child. Of the patients 4.6% were reported to have gonadal tumours. Position and type of the genital ducts, frequency of clinical findings such as genital abnormalities and gynaecomastia, correlations between assigned sex and karyotype as well as the age at diagnosis are reported.

Current management of male breast cancer. A review of 104 cases

Between 1975 and 1990, 104 male patients with a total of 106 breast cancers were treated at Memorial Hospital or the Ochsner Clinic and their records reviewed. The patients were followed for a median of 67 months (range, 0.5 to 14.4 years). Analysis of the frequency distribution by stage showed that 16 (17%) patients were stage 0 and 26 (27%) patients were stage I. The median duration of symptoms before diagnosis was 18 weeks (mean, 5 weeks; range, 1 to 156 weeks). Modified radical mastectomy was undertaken in 71 (67%) patients. The actuarial 5-year relapse-free survival for the entire group was 68% and the actuarial 5-year overall survival was 85%. Relapse-free survival at 5 years for axillary node-negative patients was 87% and for node-positive patients was 30% (p less than 0.001). Overall survival figures for the same subsets showed a 5-year survival of 100% for the node-negative subset and 60% for the node-positive subset. On multivariate analysis, the most powerful predictor of outcome in men was the status of the axillary lymph nodes, and the only prognostic factor that added significantly to this predictive power was the duration of symptoms. Patients who sought treatment less than 6 months after the onset of symptoms experienced a significant survival advantage when compared with patients whose symptoms were present for more than 6 months (p = 0.03). The profile of the stages at diagnosis, the treatment approach, and the survival rates approximate those reported in series of female breast cancers, and overall, the two diseases are remarkably similar.

Male breast cancer

Breast cancer in the male is an uncommon disease, occurring less than 1% as often as in females. Because of its rarity, this disease has not been as extensively studied as its female counterpart. Male breast cancer is evaluated and managed in a fashion very similar to that for female breast cancer. Primary management in early stage disease is usually a modified radical mastectomy. First line hormonal therapy for metastatic disease, in our institution, is tamoxifen for patients with positive estrogen receptors. Second line therapy consists of progestins or antiandrogens/LHRH analogs. No firm recommendations can be made concerning adjuvant systemic therapy. However, it is likely that studies from female patients are adaptable. Unfortunately, carcinoma of the male breast is such an infrequently encountered tumor that unfamiliarity with the disease can lead to delays in diagnosis and treatment. An increased awareness of the disease may be expected to result in earlier detection and institution of therapy at a stage when cure may be possible.

Abnormal sexual differentiation and neoplasia

The prevalence of neoplasia is increased in individuals with certain disorders of sexual differentiation. Etiology and frequency of neoplasia vary with the particular disorder. In uncomplicated cryptorchidism, the testis is at least 10 times more likely to undergo neoplastic transformation than a normal scrotal testis. Neoplasia probably is a function of both testicular location (intraabdominal) and underlying dysgenetic structure. If cryptorchidism is unilateral, and if orchiopexy has not been performed prior to age 6-10 years, orchiectomy should be encouraged. In those forms of gonadal dysgenesis not associated with a Y chromosome (e.g., 45,X; 45,X/46,XX; 46,XX) there is no definite increase in neoplasia, suggesting that elevated gonadotropin levels per se are not carcinogenic. Gonadal tumors are found in at least 30% of individuals with XY gonadal dysgenesis and are particularly frequent (55%) in H-Y antigen-positive patients. These tumors are almost always gonadoblastomas or dysgerminomas. Similar tumors are found in 15%-20% of 45,X/46,XY individuals. In either situation the neoplastic transformation could be a) secondary to the existence of XY gonadal tissue in an inhospitable environment, or b) integrally related to that process--genetic or cytogenetic--producing the dysgenetic gonads. The risk of neoplasia is sufficiently high that most of these patients should be offered early gonadal extirpation. The prevalence of gonadal tumors is not increased in Klinefelter's syndrome, further indicating that gonadotropins are not carcinogenic per se. However, Klinefelter patients are 20 times more likely to develop a carcinoma of the breast than are 46,XY males. Extragonadal germ cell tumors also are more common. In female pseudohermaphrodites there is probably no increased risk of neoplasia, whereas, in true hermaphrodites neoplasia is unusual but does occur. Neoplasia occurs in patients with complete testicular feminization (complete androgen insensitivity) but rarely in those with incomplete testicular feminization/Reifenstein's syndrome, 5 alpha-reductase deficiency, anorchia, agonadia, or testosterone biosynthetic defects. In complete testicular feminization the risk of malignant tumors is small prior to age 25. After age 25, it is about 2%-5%. Orchiectomy is recommended after pubertal feminization.

Male breast carcinoma. I. A study of the total material reported to the Swedish Cancer Registry 1958-1967 with respect to clinical and histopathologic parameters

During the time period 1958-1967 190 cases of male breast cancer were reported to the Swedish Cancer Registry. The reported cases were thoroughly re-evaluated from the evidence of the clinical records and histopathologic specimens. The material contained 166 cases of histologically verified invasive breast carcinoma which were analyzed with respect to different clinical and histopathologic parameters. In contrast to the rate in females, the breast cancer incidence rate in males did not increase significantly during the period under review, and the age-specific incidence rate did not show a Clemmesen's hook but increased relatively more rapidly at high ages than for female breast carcinoma. The mean age at diagnosis was 4 to 5 years higher in male breast cancer patients than in females. Larger tumours were more frequent among older patients and there was a 5-year shift between the age-distribution curves for small (less than 2 cm) and larger (2-5 cm) tumours. A similar difference was found between pN0 and pN1 tumours. This difference might reflect the progression rate of male breast cancer. The histopathology pattern and distribution of histologic malignancy grades were similar to those in female breast carcinoma with the exception that lobular carcinoma and medullary carcinoma with lymphoid infiltration were lacking in the male material.

Lobular carcinoma of the breast in a patient with Klinefelter's syndrome. A case with bilateral, synchronous, histologically different breast tumors

A case of bilateral breast cancer in a patient with a Klinefelter mosaic syndrome is presented. The tumor in the left breast was an infiltrating lobular carcinoma with characteristic in situ component. To the knowledge of the authors, this is the first case in the English literature of lobular carcinoma of the breast in a phenotypic man. In fact, it was the pathologic diagnosis which led to the study of the chromosomal abnormality.