Hormonal therapy for male breast cancer: A different approach for a different disease

Male Breast: A Review of the Literature and Current State of the Art of Diagnostic Imaging Work-Up

Pathological conditions affecting the male breast (MB) share some similarities with those found in women, while others are specific to men. The first part of this review provides an overview of MB disorders, exploring the most common types of MB diseases. The second part then emphasizes the state-of-the-art approaches proposed in the literature for screening and follow-up with MB cancer patients, which highlights the importance of tailored strategies for diagnosis, follow-up, and identifying high-risk populations. Considering the increasing attention in recent years on the topic, transgender individuals are also included in this review. Together with the MB, it is an understudied category thus far. This review aims to raise awareness among radiologists that MBs should be approached differently from female breasts, contributing to the advancement of medical knowledge, improving patient outcomes, and promoting early detection of MB disorders. The review also provides an update on breast cancer and screening in the transgender population.

Proximal shift of colorectal cancer with increasing age in different ethnicities

Background

Studies have indicated a variation in colon cancer pathology with increased age. More findings have also suggested differences in genetics, biology, and demography in terms of ethnicity. Large-scale studies closely examining tumor location shift with aging and ethnicity are scarce.

Objective

We compared the tumor location shift with aging and the difference in survival based on tumor location by age group among the African-American, White, and Asian/Pacific Islander patients with colorectal cancer.

Materials and methods

We collected 270,390 cases from the Surveillance, Epidemiology, and End Results database between 2004 and 2014. Ethnicity distribution between younger (age <70 years) and older (age ≥70 years) patients was analyzed using univariate and multivariate logistic regression. The Kaplan–Meier method was used to compare the tumor location survival difference in the African-American, White, and Asian/Pacific Islander patients.

Results

Larger tumors, female sex, M0, advanced N stage, no treatment, moderate to poor differentiation, total number of lymph nodes evaluated >12, and right-sided colon cancer were more common in patients aged ≥70 years. More adverse prognosis was found in younger patients compared to older patients. Tumor location frequency differed based on age; the most pronounced differences were found in White patients. The right-sided colon cancer survival inferiority was present only in White patients.

Conclusion

Our findings support the premise of etiological and carcinogenic differences based on tumor location and between younger and older patients.

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.

CT-guided percutaneous laser ablation of metastatic lung cancer: three cases report and literature review

Objective

To report the efficacy and safety of CT-guided percutaneous laser ablation (PLA) for metastatic lung tumors.

Methods

Three cases of metastatic lung cancer underwent CT-guided PLA, and we searched for previously published articles on the minimally invasive CT-guided RFA or MWA for lung tumors in recent five years.

Results

With the guidance of CT, all lesions had good prognosis under laser ablation. Case 1 suffering from severe pulmonary dysfunction and diffuse pulmonary bullae, had small pneumothorax. CT scan obtained four months following the ablation showed two lesions had complete responses and one partial response. Case 2 had successful complete response with absent lung mass, and also had a good postoperative condition without any discomfort in the two-month follow-up. Case 3 showed partial response and improved greatly after five months. 962 cases (mean age of 45.7 years, 62.2% male) of 1297 lung tumors with detailed information were identified from 27 articles. Of these cases, the minority manifested complications such as pneumothorax, hemoptysis, hemothorax, pneumonia, pain and fever.

Conclusions

Percutaneous CT-guided PLA could be a safe and promising minimally invasive treatment for patients with primary lung cancer or unresectable pulmonary metastases, especially multineedle PLA in large tumors, which still needs more large-scale prospective studies to convince this method in the future.

Metastatic Breast Carcinoma to the Superior Oblique in a Male

We describe a case of breast cancer metastatic to the superior oblique, in a male. The patient was a 66-year-old Caucasian male with a history of stage IIIB rectal adenocarcinoma and stage IIA left breast carcinoma diagnosed 12 years and 5 years prior, respectively, who presented with headaches and intermittent diplopia. He underwent left total mastectomy with sentinel lymph node biopsy 6 years prior, which showed ER/PR+, HER2/neu-, moderately-differentiated, infiltrating ductal carcinoma with 3/14 positive nodes. He completed adjuvant doxorubicin/cyclophosphamide and oral tamoxifen, and prior routine surveillance imaging had found no evidence of recurrent disease. MRI of the orbit revealed a 0.7 × 1.4 × 1.9 cm mass in the superomedial right orbit in the region of the superior oblique. Transcaruncular orbitotomy with biopsy of the superior oblique revealed metastatic breast carcinoma. Unfortunately, he developed new metastases. Post-operatively, he continues to have good vision with minimal diplopia.

Male Breast Cancer

Male breast cancer (MBC) is a rare disease, accounting for less than 1% of all breast cancer diagnoses worldwide. Although breast carcinomas share certain characteristics in both genders, there are notable differences. Most studies on men with breast cancer are very small. Thus, most data on male breast cancer are derived from studies on females. However, when a number of these small studies are grouped together, we can learn more from them. This review emphasizes the incidence, etiology, clinical features, diagnosis, treatment, pathology, survival, and prognostic factors related to MBC.

Male breast carcinoma: radiotherapy contributed to favorable local control in two cases and related literature review

Male breast carcinoma (MBC) is rarely encountered in clinical practice. Due to its paucity, our knowledge of MBC only rely on small or single-institutional studies and sporadic cases. The current guidelines for MBC are extrapolated from its female counterparts Rudlowski (Breast Care (Basel) 3(3):183–189, 2008). Nowadays, MBC is actively studied and viewed as a potentially different entity on the aspects of etiology, biological behavior and prognosis. Thus, special treatment strategy guidelines should be established for MBC. Additionally, advance in the systemic chemotherapy and hormonal therapy also contribute to the local control. The indication of radiotherapy need to be clarified and over-treatment should be avoided. Here we present two cases of MBC in which radiotherapy help to sustain a satisfactory disease free survival. Our cases will provide valuable experience for identifying the role of radiotherapy in MBC.

Protein tyrosine phosphatase SHP-1 sensitizes EGFR/HER-2 positive breast cancer cells to trastuzumab through modulating phosphorylation of EGFR and HER-2

Background

Trastuzumab resistance in HER-2 positive breast cancer cells is closely related to overexpression of both epidermal growth factor receptor (EGFR) and human epidermal receptor (HER-2). SHP-1 has been demonstrated to downregulate tyrosine kinase activity including EGFR via its phosphatase function, but its effect on HER-2 activity is still unknown. Here, we examined the hypothesis that SHP-1 enhances the anticancer efficacy of trastuzumab in EGFR/HER-2 positive breast cancer cells through combining dual inhibition of EGFR and HER-2.

Methods

Trastuzumab-resistant breast cancer SKBr-3 cells were generated by long-term in vitro culture of SKBr-3cells in the presence of trastuzumab. The SHP-1 was ectopically expressed by stable transfection. The activity and expression of EGFR, HER-2, and downstream signaling pathways were tested by Western blot. Cell viability was examined by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, and apoptosis was examined by flow cytometry. The binding between SHP-1 and EGFR/HER-2 was evaluated by immunoprecipitation assay and bimolecular fluorescence complementation. The effects of SHP-1 on tumorigenicity and trastuzumab sensitivity were confirmed via in vivo xenograft model.

Results

Trastuzumab-resistant SKBr-3 cells showed aberrant co-expression of EGFR and HER-2. Introduction of wild-type SHP-1 inhibited cell proliferation, clone formation, and promoted the apoptosis induced by trastuzumab. Meanwhile, SHP-1 overexpression reduced phosphorylation levels of EGFR and HER-2 both in parental and trastuzumab-resistant SKBr-3 cells. In vivo study showed an increased antitumor effect of trastuzumab in SHP-1 overexpressed xenografts. At last, we discovered that SHP-1 can make complexes with both EGFR and HER-2, and both phospho-EGFR and phosphor-HER-2 levels in wild-type SHP-1 immunoprecipitates were less than those in phosphatase-inactive SHP-1 (C453S) immunoprecipitates, indicating that EGFR and HER-2 are potential substrates of SHP-1.

Conclusion

Taken together, we have demonstrated that the SHP-1 is a negative regulatory factor of the tyrosine kinase activity of HER-2 and EGFR through inhibiting phosphorylation. Dual targeting of EGFR and HER-2, by combining trastuzumab with SHP-1 overexpression, may improve response in HER-2 overexpressing breast cancer cells that also express high levels of EGFR.

Modeling prolactin actions in breast cancer in vivo: insights from the NRL-PRL mouse

Elevated exposure to prolactin (PRL) is epidemiologically associated with an increased risk of aggressive ER+ breast cancer. To understand the underlying mechanisms and crosstalk with other oncogenic factors, we developed the NRL-PRL mouse. In this model, mammary expression of a rat prolactin transgene raises local exposure to PRL without altering estrous cycling. Nulliparous females develop metastatic, histotypically diverse mammary carcinomas independent from ovarian steroids, and most are ER+. These characteristics resemble the human clinical disease, facilitating study of tumorigenesis, and identification of novel preventive and therapeutic approaches.

[Breast cancer update in primary care: (V/V)]

Breast cancer is a prevalent disease affecting all areas of patients' lives. Therefore, family physicians ought to know thoroughly this pathology to optimize the health care services for these patients making the best use of available resources. A series of five articles on breast cancer is presented below. It is based on a review of the scientific literature over the last ten years. In this final section, the social, psychological, occupational and family issues related to the disease will be reviewed, as well as presenting some special situations of breast cancer, including breast cancer in men, during pregnancy and last stages of life. This summary report aims to provide a current and practical review about this disease, providing answers to family doctors and helping them to be by the patients for their benefit throughout their illness.

Poorer survival of male breast cancer compared with female breast cancer patients may be due to biological differences

OBJECTIVE

The objective of the study was to compare disease-free survival and overall survival in a group of matched males and females with breast cancer, and to analyze possible treatment- and gender-related differences.

METHODS

We retrospectively analyzed the data of 150 operable male breast cancer patients treated in our hospital from December 1980 to June 2012. Each male breast cancer patient recorded in the database was matched with two female breast cancer patients of equal stage. Prognosis in terms of disease-free survival and overall survival was evaluated.

RESULTS

The mean age at diagnosis was 58.6 ± 9.7 years for males and 57.2 ± 10.3 years for females. The median follow-up was 69 months for males and 81 months for females. Significant differences were identified for tumor location, hormone receptor status, molecular subtypes and hormone therapy between the two groups. Monofactorial analysis demonstrated that tumor size, lymph node state, American Joint Committee on Cancer stage, molecular subtypes and adjuvant chemotherapy treatment were prognostic factors in male breast cancer patients. The 5- and 10-year disease-free survival rates were 65.6 and 40.1% for males, and 74.9 and 51.5% for females, respectively. The 5- and 10-year overall survival rates were 72.9 and 53.9% for males, and 83.2 and 68.5% for females, respectively. There was significantly difference in disease-free survival and overall survival between the two matched groups (P = 0.002).

CONCLUSIONS

Male breast cancer patients had inferior outcome despite of equal stage in comparison with matched female breast cancer patients, which demonstrates that biological differences may contribute to the worse prognosis.

New approaches in the management of male breast cancer

Male breast cancer (MBC) is a rare condition that accounts for 0.1% of all male cancers. Our current evidence base for treatment is derived from female breast cancer (FBC) patients. Risk factors for MBC include age, genetic predisposition, race, sex hormone exposure, and environmental factors. Most patients present later and with more advanced disease than comparable FBC patients. Tumors are likely to be estrogen receptor and progesterone receptor positive, with the most common histologic type being invasive ductal carcinoma. Triple assessment remains the criterion standard for diagnosis. Primary MBC is mostly managed initially by simple mastectomy, with the option of breast conserving surgery, which carries an increased risk of recurrence. Sentinel node biopsy is recommended as the initial procedure for staging the axilla. Reconstructive surgery focuses on achieving primary skin closure, and radiotherapy largely follows treatment protocols validated in FBC. We recommend chemotherapy for men with more advanced disease, in particular, those with estrogen receptor negative histology. MBC responds well to endocrine therapy, although it is associated with significant adverse effects. Third-generation aromatase inhibitors are promising but raise concerns due to their failure to prevent estrogen synthesis in the testes. Fulvestrant remains unproven as a therapy, and data on trastuzumab is equivocal with HER2 receptor expression and functionality unclear in MBC. In metastatic disease, drug-based hormonal manipulation remains a first-line therapy, followed by systemic chemotherapy for hormone-refractory disease. Prognosis for MBC has improved over the past 30 years, with survival affected by disease staging, histologic classification, and comorbidity.

The effect of antineoplastic drugs in a male spontaneous mammary tumor model

Male breast cancer is a rare disease. The limited number of clinical cases has led to the primary treatments for men being derived from female breast cancer studies. Here the transgenic strain FVB/N-Tg(MMTV-PyVT)634Mul/J (also known as PyVT) was used as a model system for measuring tumor burden and drug sensitivity of the antineoplastic drugs tamoxifen, cisplatin, and paclitaxel on tumorigenesis at an early stage of mammary carcinoma development in a male mouse model. Cisplatin treatment significantly reduced tumor volume, while paclitaxel and tamoxifen did not attenuate tumor growth. Cisplatin treatment was shown to induce apoptosis, grossly observed by reduced tumor formation, through reduced Bcl-2 and survivin protein expression levels with an increase in caspase 3 expression compared to control tumors. Tamoxifen treatment significantly altered the hormone receptor expression levels of the tumor, while additionally upregulating Bcl-2 and Cyclin D1. This suggests an importance in hormonal signaling in male breast cancer pathogenesis. The results of this study provide valuable information toward the better understanding of male breast cancer and may help guide treatment decisions.

Are there biologic differences between male and female breast cancer explaining inferior outcome of men despite equal stage and treatment?!

BACKGROUND

Reasons for inferior outcome of male compared to female breast cancer are still under debate. Therefore, we retrospectively analyzed male breast cancer cases to figure out possible treatment- and gender-related differences.

PATIENTS AND METHODS

A total of 40 men (median age 62 years) were curatively treated with mastectomy and postoperative radiotherapy from 1982-2007. They presented predominantly in stages II and IIIb. Postoperative radiotherapy was applied with doses of 1.8-2.5 Gy to a median of 50 Gy including regional lymphatics in 22 patients. Adjuvant systemic treatment consisted of chemotherapy (22.5%) and antihormonal treatment (55%). For reasons of comparison, we estimated outcome of a virtual female matched cohort for no/equal to men/optimal adjuvant treatment with the Adjuvant!Online(®) 8.0 algorithm.

RESULTS

After a median follow-up of 47 months, the estimated 5-year local control rate was 97%, disease-free and distant metastasis-free survival rates reached 79% and 82%, respectively. With update of survival data by tumor registry, mean overall survival reached 120 months with 5- and 10-year overall survival rates of 66% and 43%, respectively. Predominant prognostic factor was T-stage for overall survival (T1/2 vs. T4: > 80% vs. 30%). The generated virtual matched cohorts of women with equal characteristics reached superior 10-year-overall survival for no/equal to men/optimal adjuvant treatment with 55/59/68%.

CONCLUSION

Compared to historical and virtual matched cohorts of women, male breast cancer patients had inferior outcome despite of equal stage and treatment which indicates that biological differences (of tumor or population) may contribute to worse prognosis.

Similarities and differences in the characteristics and primary treatment of breast cancer in men and women - a population based study (Sweden)

PURPOSE

Male breast cancer (MBC) is an uncommon disease. In the absence of randomized studies, current guidelines are mainly based on data on the management of female breast cancer (FBC). In light of concerns regarding the quality and extent of management in men, the aim of the present study was to investigate whether there are differences in tumor characteristics, treatment and outcome in male compared with FBC patients.

METHODS

Cohorts of male and female breast cancer were retrospectively analyzed. All male patients diagnosed with invasive breast cancer between 1993 and 2007 were identified from the Regional Breast Cancer Register of the Uppsala-Örebro Region in Sweden. To increase the power of the study and obtain comparable cohorts we sampled four FBC patients (n = 396) for each MBC patient (n = 99) with similar age at diagnosis and time of diagnosis.

RESULTS

No differences were seen in stage at diagnosis between MBC and FBC. Men underwent mastectomy more often than women (92% vs. 44%, p < 0.001). Radiotherapy was delivered less often to MBC than FBC (44% vs. 56%, p = 0.034), but radiotherapy given after mastectomy (44% vs. 39%, p = 0.47) did not differ between the groups. No differences were found regarding adjuvant chemotherapy (16% vs. 21%; p = 0.31) or adjuvant endocrine therapy (59% vs. 52%, p = 0.24). Both overall survival (41% vs. 55%, p = 0.001) and relative survival (74% vs. 88%, p = 0.015) were inferior in MBC compared to FBC.

CONCLUSION

Concerns regarding less extensive treatment in MBC patients were not supported by this study. Although no differences in the stage of the disease or treatment intensity could be demonstrated, outcome was inferior in the male group.

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.

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

Introduction

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

Patients et méthodes

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

Résultats

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

Conclusion

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

High-resolution genomic profiling of male breast cancer reveals differences hidden behind the similarities with female breast cancer

Male breast cancer (MBC) is extremely rare and poorly characterized on the molecular level. Using high-resolution genomic data, we aimed to characterize MBC by genomic imbalances and to compare it with female breast cancer (FBC), and further to investigate whether the genomic profiles hold any prognostic information. Fifty-six fresh frozen MBC tumors were analyzed using high-resolution tiling BAC arrays. Significant regions in common between cases were assessed using Genomic Identification of Significant Targets in Cancer (GISTIC) analysis. A publicly available genomic data set of 359 FBC tumors was used for reference purposes. The data revealed a broad pattern of aberrations, confirming that MBC is a heterogeneous tumor type. Genomic gains were more common in MBC than in FBC and often involved whole chromosome arms, while losses of genomic material were less frequent. The most common aberrations were similar between the genders, but high-level amplifications were more common in FBC. We identified two genomic subgroups among MBCs; male-complex and male-simple. The male-complex subgroup displayed striking similarities with the previously reported luminal-complex FBC subgroup, while the male-simple subgroup seems to represent a new subgroup of breast cancer occurring only in men. There are many similarities between FBC and MBC with respect to genomic imbalances, but there are also distinct differences as revealed by high-resolution genomic profiling. MBC can be divided into two comprehensive genomic subgroups, which may be of prognostic value. The male-simple subgroup appears notably different from any genomic subgroup so far defined in FBC.

Male breast cancer

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

Pharmacologic treatment of male breast cancer

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

Prolactin receptor expression in gynaecomastia and male breast carcinoma

AIMS

Despite the well-established function of prolactin (PRL) in normal breast development, its role in breast cancer pathogenesis is still controversial. PRL activity is dependent on the activation of a transmembrane protein, the PRL receptor (PRLR). The aim was to evaluate and compare PRLR expression in gynaecomastia and male breast carcinoma (MBC).

METHODS AND RESULTS

PRLR expression was detected immunohistochemically in 30 cases of gynaecomastia and 30 cases of MBC. The whole series was also assessed for oestrogen receptors (ER), progesterone receptors (PR) and androgen receptors (AR). A cut-off of 10% was used as the criterion for positivity. Histological type and tumour differentiation were evaluated. Pathological stage was assessed [Tumour Node Metastasis (TNM)-International Union Against Cancer system]. Statistical analysis was performed with Fisher's exact test. PRLR positivity was seen in 20% of gynaecomastia cases and in 60% of MBC cases (P = 0.003). In gynaecomastia immunoreactivity was predominantly observed in luminal cell borders, whereas in MBC the reactivity was heterogeneous and mainly cytoplasmic. There was no statistically significant correlation between PRLR expression and ER, PR, AR, pTNM, or histological grade.

CONCLUSIONS

PRLR is significantly more expressed in MBC than in gynaecomastia, and with different patterns of reactivity, suggesting a role for PRL in male breast carcinogenesis.

Changes in Male Breast Cancer over a 30-Year Period

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

Male Breast Cancer

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

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

Introduction

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

Case presentation

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

Conclusion

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

Bilateral Nonsynchronous Male Breast Cancer: Two Case Reports

SUMMARY: BACKGROUND: Bilateral male breast cancer (MBC) is relatively rare. CASE REPORTS: We report 2 bilateral nonsynchronous MBC cases. Second cancers developed during endocrine therapy with selective estrogen receptor modulators (SERM) after the initial surgeries. Since their second surgeries, both patients continued treatment with another SERM, because their second cancers were also hormone receptor-positive. We discuss the endocrine therapy in men based on a review of the literature. CONCLUSIONS: Adequate treatments for early MBC are still controversial. Aromatase inhibitors (AI) are not as effective in men as in women. We consider the higher androgen levels in men to be a major reason for AI not being as effective as expected, i.e. the hormonal environment is very different from that in women. Thus, different approaches are needed for MBC. With further investigation, it is hoped that methods of achieving maximal AI efficacy for MBC will be established.

How to treat male breast cancer

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

Prolactin drives estrogen receptor-alpha-dependent ductal expansion and synergizes with transforming growth factor-alpha to induce mammary tumors in males

Male breast cancer is rare and has been the focus of limited research. Although the etiology is unclear, conditions increasing circulating prolactin (PRL), as well as estrogen, increase the risk of tumorigenesis. We modeled exposure to elevated PRL in transgenic mice, using the mammary-selective, estrogen-insensitive promoter neu-related lipocalin (NRL), to drive PRL expression. Male NRL-PRL mice did not develop mammary tumors. However, in cooperation with the well-characterized oncogene transforming growth factor-alpha (TGF-alpha), PRL induced mammary tumors in 100% of male bitransgenic mice. Similar to disease in human males, these tumors expressed variable levels of estrogen receptor-alpha (ER-alpha) and androgen receptors. However, carcinogenesis was not responsive to testicular steroids because castration did not alter latency to tumor development or tumor ER-alpha expression. Interestingly, both NRL-TGF-alpha/PRL and NRL-PRL males demonstrated increased ductal development, which occurred during puberty, similar to female mice. This outgrowth was diminished in NRL-PRL males treated with ICI 182,780, suggesting that PRL enhances ER-mediated growth. Treatment of MCF-7-derived cells with PRL increased phosphorylation of ER-alpha at residues implicated in unliganded ER-alpha activity. Together, these studies suggest that PRL expands the pool of cells susceptible to tumorigenesis, which is then facilitated by PRL and TGF-alpha cross talk. Activation of ER-alpha is one mechanism by which PRL may contribute to breast cancer and points to other therapeutic strategies for male patients.

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

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

Bilateral male breast cancer with male potential hypogonadism

Background

Male breast cancer is a comparatively rare disease, and simultaneous bilateral male breast cancer is considered to be an extremely rare event. Risk factors are said to be genetic factors and hormonal abnormalities due to obesity or testicular diseases.

Case presentation

The patient was a 47-year-old Japanese male. His family had no history of female breast cancer. This patient also had hypospadias and hormonal examination indicated the presence of primary testicular potential hypogonadism, and these hormonal abnormalities seemed to be present since childhood or the fetal period. The bilateral breast cancer developed in this man at a comparatively young age, and histopathological studies of multiple sections showed that there was almost no normal epithelial cell in the ducts, while the ducts were almost completely filled with breast cancer cells.

Conclusion

It is thought that male breast cancer is caused by an imbalance between estrogen and testosterone. We cannot rule out the possibility that the breast cancer developed due to the effect of the slight elevation of estrogen over a long period of time, but the actual causative factors in this patient were unable to be definitively identified. In the future, we hope to further elucidate the causes of male breast cancer.

Male breast cancer in the veterans affairs population

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Strategies in treating male breast cancer

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

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

BACKGROUND

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.