Carcinoma of the male breast: a review and recommendations for management

Clinical and ultrasonographic features of male breast tumors: A retrospective analysis

Objective

The purpose of this study was to determine clinical and ultrasonographic characteristics of male breast tumors.

Methods

The medical records of male patients with breast lesions were retrieved from an electronic medical record database and a pathology database and retrospectively reviewed. A total of 112 men (125 breast masses) with preoperative breast ultrasonography (US) were included (median age, 59.50 years; age range, 15–96 years). Data extracted included patient age, if the lesions were bilateral, palpable, and tender, and the presence of nipple discharge. Breast lesion features on static US images were reviewed by three experienced radiologists without knowledge of physical examination or pathology results, original breast US image interpretations, or surgical outcomes. The US features were documented according to the BI-RADS (Breast Imaging-Reporting and Data System) US lexicons. A forth radiologist compiled the data for analysis.

Results

Of the 125 breast masses, palpable tender lumps and bilateral synchronous masses were more likely to be benign than malignant (both, 100% vs 0%, P < 0.05). Advanced age and bloody discharge from nipples were common in malignant lesions (P <0.05). A mass eccentric to a nipple, irregular shape, the presence of an echogenic halo, predominantly internal vascularity, and rich color flow signal on color Doppler ultrasound were significantly related to malignancy (all, P < 0.05). An echogenic halo and the presence of rich color flow signal were independent predictors of malignancy.

Conclusion

Specific clinical and US characteristics of male breast tumors may help guide treatment, and determine if surgery or conservative treatment is preferable.

Pharmacologic treatment of male breast cancer

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

Male breast cancer: is the scenario changing

Background

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

Methods

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

Conclusion

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

Systemic chemotherapy and tamoxifen induced regression of choroidal metastasis from a breast carcinoma in a male

We report a case of a 55-year-old male patient with breast carcinoma, who developed choroidal metastasis. The patient had undergone mastectomy for carcinoma of right breast, five years ago. The patient was advised close follow-up for the left eye, as he was already on tamoxifen therapy (started a month ago) for spinal metastasis. On last follow-up, a year later, the choroidal lesion had completely scarred, with no recurrences. Systemic hormonal therapy like tamoxifen given for the breast primary and other systemic metastases may cause regression of the choroidal metastasis, thereby avoiding ocular radiotherapy. Medline search revealed only one published case of regression of choroidal metastasis from a male breast primary, on tamoxifen therapy.

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.

Comparative epidemiology of breast cancer among men and women in the US, 1996 to 2000

OBJECTIVE

Few investigations of breast cancer among men have been conducted because of the relative rarity of this malignancy. The objective of this analysis was to compare the demographic, pathological, and clinical features of breast cancer among men and women.

METHODS

Breast cancer among 6379 men and 744,275 women was identified through 34 US population-based registries in the US during the period 1996 to 2000. These registries were estimated to represent 69% of the US population. Age-adjusted incidence rates (AAIR) were calculated per million population using counts derived from the 2000 US census.

RESULTS

The AAIR of breast cancer among men (16.6) was substantially lower than the incidence among women (1557.7). Rates of breast cancer among black men were higher than among white and Asian-Pacific Island men, in contrast to women among whom rates in whites exceeded those among other ethnic groups. Similar to women, breast cancer rates among non-Hispanic men were 50% greater than among Hispanic men. Ductal cancer was the most common histologic type diagnosed in both sexes. The incidence of lobular cancer was rare in men, but Paget's disease and papillary carcinoma occurred with lower relative frequency in women than in men. Lobular breast cancers were less common among black men and women than among other ethnic groups. In situ breast cancer was diagnosed in 10.8% of men and 16.2% of women. Localized breast cancer was the most common stage at diagnosis in both sexes and all ethnic groups, although women were more likely than men to be diagnosed at a localized stage. Cancer was 10% more likely to be diagnosed in the left breast than the right breast among men compared to 4% in women.

CONCLUSIONS

In spite of the rare incidence of breast cancer in men, the descriptive epidemiology of this malignancy is surprisingly similar to that in women. An explanation for the greater relative incidence of breast cancer in black men is a research challenge.

Pharmacotherapy for male breast cancer

Breast cancer in males is uncommon, occurring at approxiamtely 1% of the rate of female breast cancer. Male breast carcinomas tend to be highly positive for hormone receptors, including oestrogen, progesterone and androgen receptors. Owing to this, hormone therapy is recommended as the primary treatment modality. Adjuvant therapy is recommended for male breast cancers with large size or positive axillary nodes. For metastatic disease, options for therapy include tamoxifen, orchiectomy, anti-androgens with or without luteinising hormone releasing hormone analogues or combination chemotherapy. The newer hormonal treatments, such as the selective aromatase inhibitors or novel antioestrogens, have not yet been well studied in male breast cancer but have potential for efficacy in this disease.