|Year : 2014 | Volume
| Issue : 2 | Page : 202-205
Male breast carcinoma and review of the literature
Sunder Goyal1, Snigdha Goyal2, Gulshan Kumar Garg1
1 Department of Surgery, Kalpana Chawla Govt. Medical College, Karnal, Haryana, India
2 Department of Pathology, Dr. RML Postgraduate Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||11-Nov-2014|
Department of Surgery, Kalpana Chawla Govt. Medical College, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
Male breast cancer is a rare disease with unclear etiology. Its incidence is about 0.5-1%. Usually, these male patients present in advance stages due to non-specific clinical features and due to lack of awareness. Treatment scheduling is similar to female breast cancer.
Keywords: Advance stage, male breast cancer, non-specific signs and symptoms
|How to cite this article:|
Goyal S, Goyal S, Garg GK. Male breast carcinoma and review of the literature. Arch Med Health Sci 2014;2:202-5
| Introduction|| |
Male breast cancer (MBC) is uncommon disease with peak occurrence at 71 years of age, whereas female breast cancer has two peaks, at 52 and 71 years. No doubt, exact etiology of male breast cancer is unclear; still the factors that influence malignant changes are common in both male as well as in females. Risk factors have been basically attributed to old age, genetic, endocrine factors, or exposure to radiation or hormones. As there is smaller amount of breast tissue in male, it behaves like breast cancer in the post-menopausal women. Diagnostic and treatment protocols are not clear as incidence of MBC is low. ,,, No doubt, mammographic characteristics of male breast cancer are suggestive of disease, yet fine needle aspiration and surgical biopsy confirm the diagnosis and describes the proper treatment modalities. Treatment modalities depend on the stage of the disease at the time of presentation.
| Case Report|| |
A 70-year-old male presented to our outpatient clinic with right breast pain of six month's duration. Examination revealed a 3 × 2.5 cm hard medial sub-areola tender mass with irregular borders almost fixed to underlying structure. This was associated with right nipple retraction [Figure 1]. Clinically, there were no palpable axillary nodes. There was no history of gynecomastia. Liver function tests, prostatic specific antigen, abdominal ultrasound, and chest x-ray were normal. A fine needle aspiration cytology showed findings consistent with invasive carcinoma. The patient underwent modified radical mastectomy with right axillary clearance. Histopathological examination of the tumor revealed infiltrating ductal carcinoma. There were cords and nests of malignant epithelial cells embedded within dense collagenous stroma; some are surrounding normal non-neoplastic ducts [Figure 2]. One lymph node revealed infiltration with ductal carcinoma. Tissue was negative for receptors. Patient was given chemotherapy in the form of CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) regime. CMF treatment consisted of the cyclic administration of cyclophosphamide (100 mg per square meter of body-surface area orally from day 1 to 14), methotrexate (30 mg per square meter intravenously on days 1 and 8), and 5-fluorouracil (400 mg per square meter intravenously on days 1 and 8). Each cycle was followed by a four-week rest period. As patient was older than 60 years of age, the initial dose of methotrexate was reduced to 30 mg per square meter and that of fluorouracil to 400 mg per square meter. Chemotherapy was started two weeks after modified radical mastectomy. Total five cycles were given. The patient did not turn up for the follow-up after last cycle.
Breast cancer in men is a very rare cancer, accounting 1% of all breast cancer with an incidence ratio of 1:100 of men to women and about 1% of all malignancies in men.  It usually occurs in men of advanced age and is mostly noticed at advance stage of disease. Genetics, exposure to radiation, endocrine problems, and history of benign breast lesions are common risk factors in both men and women. Old age, high socio-economic status, exposure to female hormone, and patients with decreased testicular function are risk factors in men only. In few cases of male breast cancer, hyperprolactinemia, and/or gynecomastia have also been linked. Obesity is probably a risk factor for male breast cancer because fat cells in the body convert male hormones (androgens) into female hormones (estrogens). This means that obese men have higher levels of estrogens in their body. Men with severe liver disease such as cirrhosis have relatively low levels of androgens and higher estrogen levels. As incidence of gynecomastia is high, there is increased risk of developing breast cancer. Heavy drinking of alcohol increases the risk of breast cancer in men. This may be because of its effects on the liver. Exposure to higher temperatures for long duration can affect testicles, which in turn would affect hormone levels, so men working in hot environment like steel mills and exposed to gasoline fumes might also have a higher risk for breast carcinoma.
Male breast cancer (MBC) is uncommon disease with peak occurrence at 71 years of age, whereas female breast cancer has two peaks, at 52 and 71 years. It rarely can occur in younger age as early as at 25 years.  Bilateral involvement is reported to occur in fewer than 2% of all the diagnosed cases of MBC, and synchronous tumors are very rare. 
Types of cancer in males
- Ductal carcinoma in situ (DCIS) accounts for about 1 in 10 cases of breast cancer in men. It is almost always curable with surgery.
- Infiltrating ductal carcinoma (IDC) is most frequent, and least 8 out of 10 male breast cancers are IDCs.
- Infiltrating lobular carcinoma is very rare in men, accounting for only about 2% of male breast cancers. This is because men do not usually have much lobular tissue.
- Paget disease may be associated with DCIS or with infiltrating ductal carcinoma. It accounts for about 1% of female breast cancers and a higher percentage of male breast cancers.
- Inflammatory breast cancer is very rare in males.
Mostly, male breast cancer patients present with a painless lump beneath the areola. MBC size is usually less than 3 cm in diameter and usually associated with nipple retraction, discharge, and fixation to skin and muscles. Because the male breast is much smaller than the female breast, all male breast cancers start relatively close to the nipple, so they are more likely to spread to the nipple and has ulceration or discharge more often than in women.  Breast pain occurs less frequently, and approximately 50% of men with breast cancer have palpable axillary lymph nodes. 
Breast cancer in males is also a high-risk cancer and behaves similar to female breast cancer. The reported incidence of estrogen and progesterone receptor-positive patients is about 75-92% and 54-77%, respectively.  Genetic testing should be done in patient with breast cancer, particularly if there is strong family history. Inherited mutations in BRCA1 and BRCA2 increase the risk of MBC, although not to the same absolute level of risk as in women. BRCA2 mutations are a more important predisposing factor for male breast cancer than are BRCA1 mutations. Other genes (PTEN tumor suppressor gene) mutation may also predispose to MBC. 
Mammography detects 80-90% of patients with breast cancer who present with suspicious masses. Mammographic characteristics of male breast cancer are sub-areola and eccentric to the nipple. Margins of the lesions are usually well defined; calcifications are rarer and coarser than those occurring in female breast cancer. Fine needle aspiration and surgical biopsy in high-risk patients will confirm the diagnosis and provides an indication about potential response to hormonal treatment. Though male breast cancer represents only 1% of all breast cancers, 80-90% of cancers are infiltrating (invasive) ductal carcinoma. Paget's disease of the nipple, lobular carcinoma, and sarcoma are far less common in male breast. Distant metastases include bone, lung, lymph node, liver, and brain involvement.
Surgical, radiotherapy, and chemotherapy treatment protocols of male breast carcinoma are almost similar to post-menopausal female breast cancer. Surgery is gold standard in male breast cancer patient. Modified radical mastectomy with subcutaneous reconstruction is commonly done surgical procedure, while simple mastectomy is done in those patients who are inoperable and are with very poor prognosis and/or are at high risk for wide surgery. Incidence of positive sentinel nodes is higher in males (37%) than to females (22.3%).  Rarely, male breast-conserving surgery with radiotherapy can also be employed.  In locally advanced male breast cancer, neoadjuvant therapies such as endocrine and/or chemotherapy can also be employed.
Post-operative radiotherapy should be given if there is involvement of the skin and/or pectoral muscle and areola along with metastatic involvement of the axillary lymph nodes. , Post-operative radiotherapy reduces the incidence of local recurrence in males as well as in female cancer patients. Ideally, post-operative radiotherapy should be given if tumor is bigger than 1 cm and/or there is more than one positive axillary node.
In inoperable MBC patients, the treatment option is the pre-operative radiation therapy. This approach has been studied in females, and the survival rates are similar to adjuvant therapy. Males have been treated with different types of adjuvant regimens such as CMF (cyclophosphamide, methotrexate and 5-fluorouracil), with anthracycline- and also taxane-containing combinations. 
Mostly, the use of anthracycline- and tamoxifen-based on adjuvant therapies improved disease-free and overall survival. The same procedure is applied in men with relapsed breast cancer as in women. In the past, male breast cancer has been treated by different ablative surgical procedures such as adrenalectomy, hypophysectomy, and orchiectomy. These radical surgical procedures resulted in a 55-80% objective response rate. ,
Tamoxifen has remained the main anti-endocrine treatment modality for males with receptor-positive breast cancer so far. Aromatase inhibitors, androgens, anti-androgens, corticosteroids, high-dose estrogens and progestagenes have also been used. , These agents should be used according to the response or the recurrence of the disease. Their replacement will lead to better response rate. , In males who are affected by biologically aggressive disease and with a negative receptor should be submitted to a systemic chemotherapy.
Hill et al. reported an overall five-year and ten-year survival rate in patients with localized disease to 86% and 64%, respectively. With positive lymph nodes, the five and ten-year survival rate decreased to 73% and 50%, respectively. The prognosis is worse if four or more lymph nodes are involved (10-year survival drops to 14%). The old age, co-morbidity at presentation, and shorter life expectancy in men also effect prognosis. 
| Conclusion|| |
Male breast cancer, though very rare, does exist. Efforts to increase awareness among patients and physicians will lead to earlier presentation and, therefore, diagnosis before spreading to the axilla and other organs. Like the majority of cancers, male breast cancer can be cured or controlled if diagnosed and treated properly at its early stages. Clinical presentation of our male patient resembled those reported in literature. However, conclusions regarding therapeutic modalities and related prognosis need further larger studies.
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[Figure 1], [Figure 2]