Male Breast Cancer: A Comparative Analysis from the National Cancer Database

PURPOSE

Breast cancer (BC) in males accounts for <0.5% of all male cancer diagnoses and ~1% of all BCs in the United States. We sought to describe clinicopathologic characteristics among male and female BC patients and differences in overall survival (OS) through the National Cancer Database over 13 years (2004-2016).

MATERIALS AND METHODS

Secondary to the 1:99 ratio of male to female BC cases, we randomly selected female cases for equal comparison to males cases by diagnosis year. Chi-square and t-tests compared demographic and tumor characteristics. OS was examined using Kaplan-Meier survival analysis.

RESULTS

Among the ~2.7 million BC patients, 9 per 1,000 BCs were in males, the rate remained similar over time. The mean (SD) age was 64.9±13.0 years for males and 60.7±13.6 years for females. Most of the male BC cases were white (non-Hispanic) (n=19,015 [80.2%]), clinical stage I (n=7,353 [32.1%]) or stage II disease (n=7,923 [34.6%]), and tumors were moderate or poorly differentiated (84.5%). Males exhibited more comorbidities, presented with a larger proportion of disease, and decreased OS (p<0.005) than females. Male OS was >10% lower at 5-years and nearly 20% lower at 10-years for males. More males had primary BC tumors under the nipple; the 10-year OS rate for this site was 48.8%.

CONCLUSIONS

This study reports clinicopathologic characteristics of a large cohort of male BC. Males present at older age, with a greater comorbidity index, at later stages of disease. Increased education regarding the continued risks of male breast cancer may be warranted.

Clinical and Demographic Factors, Treatment Patterns, and Overall Survival Associated With Rare Triple-Negative Breast Carcinomas in the US

IMPORTANCE

Triple-negative breast cancers are known collectively to demonstrate a more aggressive clinical course and earlier recurrence than cancers of other histological subtypes. However, the literature on rare triple-negative breast cancers and the association of histological type with survival and risk of metastasis is sparse.

OBJECTIVE

To present the clinical and demographic characteristics, treatment patterns, and overall survival (OS) for histologically rare (<10% of breast cancers) triple-negative breast cancer types: medullary carcinoma, adenoid cystic carcinoma, and metaplastic breast carcinoma.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was performed in the US using data reported by the National Cancer Database between 2010 and 2016. Confirmed cases of medullary carcinoma, adenoid cystic carcinoma, and metaplastic breast cancer were analyzed. Univariable analyses and multivariable Cox regression models were performed. Data analysis was performed from April to May 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was 5-year OS. Secondary outcomes included site of metastasis, effect of immunohistochemistry, management, and 2-year mortality.

RESULTS

A total of 8479 patients with breast cancer (mean [SD] age; 62.6 [14.3] years; 8435 women [99.48%]) were analyzed. Metaplastic carcinoma was the most commonly diagnosed histological type in this cohort, with 6867 patients (81%), followed by 1357 (16%) with adenoid cystic carcinoma and only 255 (3%) with medullary carcinoma. Medullary carcinoma presented earlier in life, at a median (interquartile range) age of 53 (45-62) years, compared with 62 (53-72) years for patients with adenoid cystic carcinoma and 63 (52-74) years for patients with metaplastic carcinoma. The proportion of tumors with triple-negative immunohistochemistry varied by histological type for medullary carcinoma (57 patients [22.4%]), adenoid cystic carcinoma (653 patients [48.1%]), and metaplastic carcinoma (3637 patients [53.0%]). Patients with adenoid cystic carcinoma were less likely to receive radiotherapy (711 patients [52.4%]) and chemotherapy (175 patients [12.9%]) compared with patients with medullary carcinoma (radiotherapy, 156 patients [61.2%]; chemotherapy, 190 patients [74.5%]) and metaplastic carcinoma (radiotherapy, 3416 patients [49.7%]; chemotherapy, 4709 patients [68.6%]). The 5-year OS rate was superior for patients with medullary (91.7%) and adenoid cystic carcinoma (88.4%) compared with patients with metaplastic carcinoma (63.1%). The 5-year mortality rate for adenoid cystic carcinoma was 8.33% vs 36.91% for metaplastic carcinoma.

CONCLUSIONS AND RELEVANCE

Nationally, over the course of 7 years, medullary carcinoma was most common and metaplastic carcinoma had the worst 5-year OS among the rare histological breast cancer subtypes analyzed. Factors associated with a poor prognosis for metaplastic carcinoma included advanced stage, lung metastasis, older age, and not receiving chemotherapy or radiation therapy. Future research focusing on rare subtypes of breast cancer is desirable and could inform the optimal management of these relatively understudied carcinomas.

Histologic Transformation in an Untreated Waldenstrom's Macroglobulinemia After 14 Years: Case Report and Review of the Literature

Waldenstrom's macroglobulinemia (WM) is an indolent B-cell non-Hodgkin lymphoma characterized by lymphoplasmacytic histology in the bone marrow with monoclonal IgM. Median survival can be in excess of 10 years. The 5-year cumulative incidence of death is low at about 10%. One-third of all-cause specific mortality is due to the lymphoma for which histologic transformation (HT) is rare. Here we present a case of a 60-year-old man with longstanding untreated WM, presenting with minimally symptomatic transformation to diffuse large B-cell lymphoma (DLBCL), with an accompanying review of the literature. Transformed WM, diagnosed greater than 5 years, has a reported survival period of 8 - 9 months. This case highlights that after a decade of continued stability in WM, not requiring treatment, an acute change in laboratory data with minimally progressive IgM levels, in the absence of B symptoms and clinical findings, may be the harbinger of transformation and at the time of diagnosis can have a rapidly deteriorating clinical course. In this case, the tripling of the lactate dehydrogenase (LDH) as the primary drastic change demonstrates the importance of the rapid increase in LDH as a singly reliable marker for HT. Late transformation has been borne out as a negative variable as the generally indolent course of WM is curtailed with the poor outcome in HT. Although MYD88 wildtype is a possible predictive factor for transformation, it is unclear if late transformation is clonally or non-clonally related and further molecular investigation is needed.

A pilot study of improved psychological distress with art therapy in patients with cancer undergoing chemotherapy

Background

Art therapy may improve the physical, mental, and emotional wellbeing of individuals for a variety of purposes. It remains understudied and underutilized in cancer care. We sought to determine the ability of a pilot art therapy program to improve the physical, mental, and emotional well-being of cancer patients.

Methods

Chemotherapy-recipients, age 18 years and older, diagnosed with any type or stage of cancer, were considered eligible to participate in this single arm, pilot study, using four visual analog scales (VAS) with visually-similar, 0–10 scale (10 being worst) thermometers assessing: 1) pain, 2) emotional distress, 3) depression, and 4) anxiety. Participants were asked to complete all 4 metrics, pre-treatment, post-treatment, and at 48–72 h follow-up, after an hour-long art therapy session. Primary endpoints included post-intervention changes from baseline in the 4 VAS metrics.

Results

Through a reasonable pilot sample (n = 50), 44% had breast cancer, 22% gastrointestinal cancers, 18% hematological malignancies, and 20% had other malignancies. A decrease in all VAS measures was noted immediately post-treatment but remained low only for pain and depression, not for emotional distress and anxiety upon follow up. There was a significant difference between the depression VAS scores of Hispanics (32%) compared to non-Hispanics (56%) (p = 0.009) at baseline. However, compared to non-Hispanics, Hispanics exhibited higher levels of depression after art therapy (P = 0.03) and during the follow-up intervals (p = 0.047).

Conclusion

Art therapy improved the emotional distress, depression, anxiety and pain among all cancer patients, at all time points. While depression scores were higher pre-intervention for Hispanic patients, Hispanic patients were noted to derive a greater improvement in depression scores from art therapy over time, compared to non-Hispanics patients. Discovering simple, effective, therapeutic interventions, to aid in distress relief in cancer patients, is important for ensuring clinical efficacy of treatment and improved quality of life.

Endocrine Therapy Plus Anti-HER2 Therapy as Adjuvant Systemic Therapy for Luminal HER2-Positive Breast Cancer: An Analysis of the National Cancer Database

Background:

Guidelines regarding the usage of adjuvant systemic therapy in patients with small human epidermal growth factor receptor 2 (HER2)-positive and estrogen receptor/progesterone receptor–positive (luminal HER2 positive) tumors are nonspecific. Outcomes of chemotherapy followed by endocrine therapy (ET), with or without anti-HER2 therapy, vs ET alone (no chemotherapy) have not been widely studied in this disease subtype. We sought to examine the usage and outcomes of adjuvant systemic therapy (ET vs chemotherapy with or without trastuzumab) in stage I luminal HER2-positive breast cancer (BC), based on the large National Cancer Database.

Methods:

We conducted a retrospective analysis of patients with luminal HER2-positive stage I BC, diagnosed between 2010 and 2015, in the United States, using univariable and multivariable logistic regression analyses. The Kaplan-Meier method estimated overall survival (OS).

Results:

A total of 37 777 patients were included in the analysis; of these, n = 32 594 (86%) received adjuvant ET and n = 5183 (14%) received chemotherapy. Around 40% of all patients received anti-HER2 therapy (trastuzumab). Patients who received trastuzumab had a better 5-year OS (93.4% vs 92.0%, P = .0002) compared with those who did not. Patients who received anti-HER2 therapy plus ET had the best OS rate at 5 years (93.5%, confidence interval [CI]: 89.2%-98%, P < .0001) compared with those receiving anti-HER2 therapy plus chemotherapy (92.7%, CI: 89.4%-96.1%, P < .0001).

Conclusions:

Most patients in the United States, with stage I luminal HER2 positive BC, received ET, not chemotherapy but most of them do not receive anti-HER2 therapy resulting in inferior outcome. Future trials exploring the de-escalation of systemic adjuvant therapy for early-stage luminal HER2-positive BC to ET plus anti-HER2 therapy would be desirable.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF CONGENITAL SIMPLE HAMARTOMA OF THE RETINAL PIGMENT EPITHELIUM

PURPOSE

To describe the optical coherence tomography angiography features of congenital simple hamartoma of the retinal pigment epithelium.

METHODS

Case report.

RESULTS

A 14-year-old boy was referred for an asymptomatic fundus tumor in the left eye. Visual acuity was 20/20 in the right eye and 20/40 in the left eye. The right fundus was normal. The left fundus disclosed a gray-white nodular retinal mass of 2-mm diameter in the juxtafoveal region, protruding into the vitreous cavity and causing radial retinal folds. The mass demonstrated echodensity without calcification on ultrasonography, hypoautofluorescence on short-wavelength autofluorescence, and mixed hyporeflective and hyperreflective areas on near-infrared reflectance imaging. By fluorescein angiography, the mass showed absolute hypofluorescence through the arteriovenous phase and diffuse late hyperfluorescence and staining. Optical coherence tomography revealed an optically dense lesion with abrupt posterior shadowing, whereas optical coherence tomography angiography showed an extensive haphazard intratumoral vascular network with fairly large-caliber (100-200 microns) vessels occupying full-thickness tumor, demonstrating more vascular details than visualized on fluorescein angiography. Serial segmental evaluation of the optical coherence tomography angiography en face images confirmed an intratumoral vascular network for full tumor depth down to retinal pigment epithelium, not related to projection artifact. Final diagnosis was congenital simple hamartoma of the retinal pigment epithelium. Considering the benign tumor, observation was recommended.

CONCLUSION

Optical coherence tomography angiography of congenital simple hamartoma of the retinal pigment epithelium revealed an extensive intratumoral, haphazard, large-caliber vascular network, more evident than seen on fluorescein angiography. Optical coherence tomography angiography has added new insight into this rare tumor.

Asteroid Hyalosis Simulating Vitreous Seeds in a Patient With Retinoblastoma

A patient treated for retinoblastoma developed vitreous floaters 15 years later and was referred for recurrence with vitreous seeding. Clinical examination demonstrated a regressed scar and numerous calcified vitreous opacities with a "clear zone" on ultrasonography. The final diagnosis was asteroid hyalosis in an eye with regressed retinoblastoma. [J Pediatr Ophthalmol Strabismus. 2019;56:e41-e44.].