CASE 14463 Published on 28.02.2017

Teaching Case

Section

Breast imaging

Case Type

Clinical Cases

Authors

Mavromati Areti, Ege Jon, Drabløs Ole, Nes Harald, Radiology Department, Igor Plotnikov Pathology Department, General Public Hospital of Haugesund, Norway.

General Public Hospital of Haugesund, Norway

Patient

59 years, male

Categories

Area of Interest Breast, Lymph nodes ; Imaging Technique Mammography, Image manipulation / Reconstruction, Ultrasound ;

Procedure Imaging sequences, Biopsy, Diagnostic procedure ; Special Focus Neoplasia, Metastases ;

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Clinical History

A 59-year-old man presented to our hospital with a palpable mass in the right side of his breast.The physical examination revealed a non-mobile, painless lump in the right breast and a second similar mass in the contralateral breast. There was no history of familial breast cancer, solid organ tumour or hormonal treatment.

Differential Diagnosis List

Male breast cancer, synchronous neoplasm, bilateral.

gynecomastia

abscess

sarcoma

metastasis

Imaging Findings

Digital mammography was performed revealing a discrete, dense mass with spiculated margins eccentric to the nipple-areolar complex on both breasts (fig.1, 2a-b, 3, 4a-b). There were no associated axillary adenopathy, pathological calcifications, nipple discharge or retraction phenomena. A further work-up included a US examination of the breast. The imaging features included an irregular hypoechoic mass with angular margins, without any posterior enhancement/shadowing or internal vascularity on both breasts (fig.5a-c, 6a). The patient underwent ultrasonography-guided core needle biopsy of both breast masses (fig.5c, 6b).The histologic report confirmed the diagnosis of invasive ductal carcinoma bilaterally(fig7a-d).
On the CT thorax/abdomen/pelvis with iv contrast and bone-scanning there were no signs of metastatic spread.
Mastectomy bilaterally and sentinel lymphnode biopsy were subsequently performed, one lymphnode with mikrometastasis with no extranodal growth was found on the right axilla(fig8a-b)[9, 10]. The patient was commenced on adjuvant hormone therapy with tamoxifen and radiotherapy on the right axilla.

Discussion

Male breast cancer (MBC) is a rare neoplasm which accounts for 1.2–2% of all cancers in men [1-4]. Bilateral breast cancer accounts for only 0.5 – 1% of MBC and synchronous cancers, as in our case, are extremely rare [7]. The median age of MBC onset is 62-69 years, and is much later than that reported for female breast cancer (< 50 years) [1, 4, 5, 7]. The most important risk factors are family history and mutations of BRCA (primarly BRCA2)[2, 3]. Other important risk factors are: Klinefelter syndrome, oestrogen or testosterone use, orchitis/epididymitis, obesity, lack of exercise, and exposure to radiation [2, 5, 6]. The majority of male breast tumours are invasive ductal carcinoma (85% to 95%), followed by ductal carcinoma in situ (5% to 10%) [9]. Among invasive carcinomas, 93.7% are ductal or unclassified carcinomas, 2.6% are papillary tumours, 1.8% are mucinous tumours and only 1.5% are lobular tumours [7, 9]. The most common type of male breast cancer is hormone receptor positive – 82%, 15% are human epidermal growth factor receptor 2 (HER2)-positive (young patients more likely), and 3% are triple negative [2, 3, 6].
The most common presentation of male breast cancer is a painless, firm subareolar mass. Other symptoms may include nipple retraction and/or ulceration and/or bleeding, axillary lymphadenopathy and gynecomastia [5, 7].
Imaging findings of MBC most often include a unilateral discrete mass with spiculated, angulated or microlobulated margins and increased vascularity at an eccentric location with respect to the nipple-areolar complex. Microcalcifications are rare but if present are usually fewer in number, coarser and less frequently rod-shaped compaired to those seen in FBC. The additional presence of nipple retraction, skin thickening and axillary lymphadenopathy are also important secondary features of MBC [8].
Surgery is the keystone in the treatment of MBC (including modified radical mastectomy or total mastectomy [1-3]) with sentinel lymph node biopsy gaining wider acceptance among breast surgeons [3]. Radiotherapy, hormone therapy and chemotherapy constitute an essential part of the adjuvant therapy depending on the extent of tumour (T- & N-stage), hormone receptor status, age, performance status of the patients, and associated co-morbidities [2, 3, 5]. MBC has a less favourable prognosis compared with FBC [4, 5]. This might be due to poor level of awareness, delayed diagnosis, increased age of onset, increased co-morbidity and a more progressive stage of disease at initial presentation [2, 5, 7]. In conclusion, MBC remains a rare disease, and synchronous, bilateral male breast cancer, as it was noted in our case, an exceptional finding.

References

[1] Ji Hyung Hong, MD, PhD, Kyung Sun Ha, MD, Yun Hwa Jung, MD, Hye Sung Won, MD, PhD, Ho Jung An, MD, PhD, Guk Jin Lee, MD, Donghoon Kang, MD, Ji Chan Park, MD, Sarah Park, MD, PhD, Jae Ho Byun, MD, PhD, Young Jin Suh, MD, PhD, Jeong Soo Kim, MD (2016) Clinical Features of Male Breast Cancer: Experiences from Seven Institutions Over 20 Years. Cancer Research and treatment 2016 Oct; 48(4): 1389–1398. (PMID: 27121722)

[2] Maher Soliman and Marcin Hetna (2016) Male breast cancer: a clinicopathological study of an Egyptian population (Alexandria experience). Conteporary Oncology (Pozn.) 2016; 20(4): 335–340. (PMID: 27688732)

[3] Branislav Bystricky, Filip Kohutek, and Andrej Rosik (2016) Male breast cancer - a single center experience. Oncology Letters 2016 Aug; 12(2): 1615–1619. (PMID: 27446481)

[4] Staruch RM, Rouhani MJ, Ellabban M. (2016) The surgical management of male breast cancer: Time for an easy access national reporting database?. Annals of Medicine and Surgery 2016 Aug; 9: 41–49. (PMID: 27408713)

[5] Sanguinetti A, Polistena A, Lucchini R, Monacelli M, Galasse S, Avenia S, Triola R, Bugiantella W, Cirocchi R, Rondelli F, Avenia N. (2016) Male breast cancer, clinical presentation, diagnosis and treatment: Twenty years of experience in our Breast Unit. Int J Surg Case Rep 2016; 20(Suppl): 8–11. (PMID: 26994487)

[6] Raina M Ferzoco and Kathryn J Ruddy (2015) Optimal delivery of male breast cancer follow-up care: improving outcomes. Breast Cancer: Targets and Therapy 2015; 7: 371–379. (PMID: 26648754)

[7] Sunil Vitthalrao Jagtap,corresponding author P. G. Chougule, Wasim Khatib, Dhirajkumar B. Shukla, and Swati Sunil Jagtap (2014) Male Breast Cancer: Presenting as Synchronous, Large, Bilateral Masses. Journal of Clinical and Diagnostic Research 2014 Apr; 8(4): FD07–FD08. (PMID: 24959456)

[8] Tan TJ, Leong LC, Sim LS. (2013) Clinics in diagnostic imaging (147). Male breast carcinoma. Singapore Med J 2013 Jun;54(6):347-52. (PMID: 23820547)

[9] Giordano SH (2005) A review of the diagnosis and management of male breast cancer. Oncologist 2005 Aug;10(7):471-9. (PMID: 16079314)

[10] M Gherghe,C Bordea, A Blidaru (2015) Sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND) in the current surgical treatment of early stage breast cancer. Journal of medicine and life 2015 Apr-Jun; 8(2): 176–180. (PMID: 25866575)

[11] G. ZANGHÌ, G. DI STEFANO, A. CAPONNETTO, R. VECCHIO, A. LANAIA, A. LA TERRA, V. LEANZA, and F. BASILE (2014) Breast cancer and sentinel lymph node micrometastases: indications for lymphadenectomy and literature review. Journal of surgery 2014 Nov-Dec; 35(11-12): 260–265. (PMID: 25644726)

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