Diagnostic Value of Fine-Needle Aspiration in Male Breast Lesions

Male Breast Cancer: Three Case Reports and a Literature Review

INTRODUCTION

Male breast cancer (MBC) accounts for 0.5%-1% of all breast cancers diagnosed worldwide. However, its biological characteristics can be distinguished from that of female breast cancer (FBC).

CASE REPRESENTATION

The diagnostic and treatment approaches for MBC are mainly similar to that of FBC due to the lack of male breast cancer-related studies, clinical trials, and literature. An increasing number of retrospective and prospective studies have been conducted to clarify the individualized care for MBC. Herein, we report three cases of advanced MBC to describe the diagnostic approaches, treatment process, and survival prognosis.

CONCLUSION

MBC patients had older age, later stage at first diagnosis, higher expression of hormone receptors, and poor prognosis. A literature review was conducted to determine the incidence, risk factors, disease features, diagnosis, treatment, survival, and management of MBC.

An Update on the General Features of Breast Cancer in Male Patients-A Literature Review

Male breast cancers are uncommon, as men account for less than 1 percent of all breast carcinomas. Among the predisposing risk factors for male breast cancer, the following appear to be significant: (a) breast/chest radiation exposure, (b) estrogen use, diseases associated with hyper-estrogenism, such as cirrhosis or Klinefelter syndrome, and (c) family health history. Furthermore, there are clear familial tendencies, with a higher incidence among men who have a large number of female relatives with breast cancer and (d) major inheritance susceptibility. Moreover, in families with BRCA mutations, there is an increased risk of male breast cancer, although the risk appears to be greater with inherited BRCA2 mutations than with inherited BRCA1 mutations. Due to diagnostic delays, male breast cancer is more likely to present at an advanced stage. A core biopsy or a fine needle aspiration must be performed to confirm suspicious findings. Infiltrating ductal cancer is the most prevalent form of male breast cancer, while invasive lobular carcinoma is extremely uncommon. Male breast cancer is almost always positive for hormone receptors. A worse prognosis is associated with a more advanced stage at diagnosis for men with breast cancer. Randomized controlled trials which recruit both female and male patients should be developed in order to gain more consistent data on the optimal clinical approach.

Performance of Rapid On-Site Evaluation in Breast Fine-Needle Aspiration Biopsies: Identifying Areas of Diagnostic Challenge

INTRODUCTION

Fine-needle aspiration (FNA) is a well-established method for sampling breast lesions with high accuracy and positive predictive value. Despite its decline in recent years relative to the use of core needle biopsies, there are several advantages to FNA which include cost-effectiveness, low complication rate, and the ability to perform rapid on-site evaluation (ROSE). The aim of this study was to evaluate breast FNAs with ROSE to identify diagnostic challenges during ROSE.

MATERIALS AND METHODS

We identified all breast FNAs with ROSE performed at Massachusetts General Hospital from January 2014 to December 2019. From the electronic medical record, clinical, radiological, and follow-up pathology results were recorded. Comparison between the rapid and final cytological diagnosis was made. All discrepancies were documented with major discrepancy defined as a malignant rapid interpretation not confirmed on final diagnosis or a negative rapid interpretation upgraded to suspicious or positive on final diagnosis.

RESULTS

The study cohort consisted of 483 breast FNAs with ROSE. The rapid and final cytological interpretations showed good correlation, with only 6 (1.2%) major discrepancies. Problematic areas included low-grade, lobular, and fibroepithelial lesions with low cellularity being a contributory factor to misclassification.

CONCLUSIONS

FNA remains a highly accurate method for the evaluation of breast lesions with ROSE.

Cytological Evaluation of Pathological Male Breast Lesions

Objective

This study aimed to determine the cytodiagnostic spectrum of various male breast lesions, which were corroborated on histopathology as appropriate, to describe the process of the cytomorphology of some uncommon pathological lesions, and to discuss the reasons of their misdiagnoses.

Materials and Methods

In this 8-year study, a total of 114 patients underwent fine needle aspiration cytology (FNAC). In a representative case, nipple discharge from an 8-month-old child was examined. Confirmatory histopathology was obtained in 38 cases only.

Results

Gynecomastia was the most common (63.5%) male breast pathology. Invasive breast carcinoma of no special type was the most common variant of male breast malignancy. Half of the "gray zone" of cytological lesions was confirmed as cancer, but the rest were diagnosed as fibrocystic disease and intraductal papilloma. All cases with malignant cytology matched their corresponding histopathology. However, a tumor from an intraductal papillary carcinoma was miscued as ductal carcinoma on previous FNAC.

Conclusion

Cytological evaluation of male breast lesions provides highly sensitive and specific results with excellent histologic reproducibility. Thus, it should be the ideal pretherapeutic diagnostic procedure for male breasts. However, some benign pathological conditions, which are particularly associated with epithelial hyperplasia, perplex the cytomorphologic scenario into the "gray zone."

Classification of Male Breast Lesions According to the IAC Yokohama System for Reporting Breast Cytopathology

OBJECTIVE

This study aims to determine the diagnostic utility of the International Academy of Cytology (IAC) Yokohama System for reporting breast cytopathology in lesions of the male breast.

STUDY DESIGN

Fine-needle aspiration biopsy (FNAB) reports between 2015 and 2019 were retrospectively recategorized according to the 5-tiered IAC Yokohama Reporting System. Our database yielded a total of 1,532 FNAB reports from breast lesions, obtained from 1,350 male patients. The risk of malignancy (ROM) and diagnostic performance of FNAB were determined using follow-up histopathological diagnosis and/or clinical follow-up, where available, for each category.

RESULTS

The category distribution were as follows: inadequate, 40%; benign, 57%; atypical, 0.6%; suspicious for malignancy, 0.7%; and malignant, 1.6%. The ROM in each category was nondiagnostic, 11%; benign, 3%; atypical, 28%; suspicious for malignancy, 56%; and malignant, 100%. The sensitivity, specificity, positive predictive value, and negative predictive value were recorded as 63, 100, 100, and 84.6% respectively, when only malignant cases were considered as positive tests.

CONCLUSION

This study validates the IAC Yokohama System for reporting male breast cytopathology. In accordance with the aim of the Yokohama System to establish best practice guidelines for reporting breast cytopathology, this comprehensive scheme facilitates comparisons between local and international institutions. The ROM acts as an internal audit for quality assurance within one's own laboratory and provides guidance for clinical management. It highlights inefficiencies such as high inadequacy rates for category 1 and also features strengths with impressive specificity for categories 4 and 5.

Is core needle biopsy effective at diagnosing male breast lesions?

PURPOSE

The objective of this study was to examine the diagnostic accuracy of sonographically guided core needle biopsy (CNB) of breast lesions in men.

METHODS

This was a retrospective study where we analyzed consecutive sonographically guided 14-gauge CNB results on 234 male breast lesions. The CNB accuracy is determined by the comparison between the CNB and its corresponding excisional biopsy or to long-term follow-up imaging.

RESULTS

Sonographically guided CNB was effective to collect satisfactory samples from all 234 lesions. Out of those, 58.55% (137/234) were benign, 38.0% (89/234) were malignant, 1.71% (4/234) were papilloma with atypia and 1.71% (4/234) were atypical ductal hyperplasia lesions. Underestimation occurred in 3.4% (8/234) of the lesions. As for the detection of breast malignancy, the sensitivity of the CNB is 98.9%, specificity is 100%, negative predictive value is 99.3%, positive predictive value is 100%, false positive is 0% and false negative is 1.1%. The overall accuracy of sonographically guided CNB as a diagnostic tool is 99.6%.

CONCLUSION

Sonographically guided 14-gauge CNB is an accurate, reliable and low invasive procedure for assessing breast lesions in men. Triple tests and follow-up checks of benign cases are essential for a successful breast biopsy program in men.