Male breast carcinoma. I. A study of the total material reported to the Swedish Cancer Registry 1958-1967 with respect to clinical and histopathologic parameters

Male Breast Carcinoma: Review of a Multicenter Series of 150 Cases

The authors report on a consecutive retrospective series of 150 male breast cancers. Clinical, diagnostic and therapeutic features are compared over time and with respect to a large consecutive series of female breast cancers. Both age at diagnosis and tumor stage were more advanced in males than in females. Poor alertness of both men and doctors for this unfrequent disease may account for such a delay in diagnosis. The use of mammography increased over time and sonography or cytology were frequently and successfully employed in the last decade. Unfortunately no improvement of tumor stage at diagnosis was observed over time in the present series. A time trend was also evident for the type of surgical and postoperative treatment. Modified radical mastectomy and adjuvant chemo- or hormone therapy were increasingly adopted, although Halsted operation and postoperative radiotherapy were still common in the last decade due to the relatively high proportion of locally advanced T3-4 cancers. Both disease-free and overall survival were worse in men than in women, even after adjustment by stage at diagnosis. This study suggests that male breast cancer has a worse prognosis with respect to female breast cancer and provides no complete explanation of this finding, except for an intrinsic higher aggressivity. No evidence was found which may justify a different diagnostic or therapeutic approach with respect to female breast cancer.

Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship

BACKGROUND

The causes, optimal treatments, and medical/psychosocial sequelae of breast cancer in men are poorly understood.

DESIGN

A systematic review of the English language literature was conducted to identify studies relevant to male breast cancer between 1987 and 2012 and including at least 20 patients. Searches were carried out on PubMed using the title terms 'male breast cancer' or 'male breast carcinoma'.

RESULTS

Relevant published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation and treatment, and survivorship issues in male breast cancer patients are presented. BRCA2 mutations, age, conditions that alter the estrogen/androgen ratio, and radiation are proven risk factors. Disease biology is distinct in men, but diagnostic approaches and treatments for men are generally extrapolated from those in women due to inadequate research in men. Survivorship issues in men may include sexual and hormonal side-effects of endocrine therapies as well as unique psychosocial impacts of the disease.

CONCLUSION

Further research is needed to address gaps in knowledge pertaining to care of male breast cancer patients and survivors.

Prediction of axillary lymph node status in male breast carcinoma

BACKGROUND

To evaluate whether predictive factors of axillary lymph node metastasis in female breast cancer (BC) are similar in male BC.

PATIENTS AND METHODS

From January 1994 to May 2011, we recorded 80 non-metastatic male BC treated at Institut Curie (IC). We analysed the calibration and discrimination performance of two nomograms [IC, Memorian Sloan-Kettering Cancer Center (MSKCC)] originally designed to predict axillary lymph node metastases in female BC.

RESULTS

About 55% and 24% of the tumours were pT1 and pT4, respectively. Nearly 46% demonstrated axillary lymph node metastasis. About 99% were oestrogen receptor positive and 94% HER2 negative. Lymph node status was the only significant prognostic factor of overall survival (P = 0.012). The area under curve (AUC) of IC and MSKCC nomograms were 0.66 (95% CI 0.54-0.79) and 0.64 (95% CI 0.52-0.76), respectively. The calibration of these two models was inadequate.

CONCLUSIONS

Multi-variate models designed to predict axillary lymph node metastases for female BC were not effective in our male BC series. Our results may be explained by (i) small sample size (ii) different biological determinants influencing axillary metastasis in male BC compared with female BC.

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.

Strategies in treating male breast cancer

Male breast cancer is rare. Median age at diagnosis is approximately 65 years, and > 35% of male breast cancers occur in elderly men. Retroareolar lump is the most frequent symptom, and 25-30% of tumours are T(4) lesions. Infiltrating ductal carcinoma represents almost 90% of the cases, and 10% are ductal carcinoma in situ. Axillary nodal involvement is present in 50-60% of the cases. Estrogen and progesterone receptors are positive in 75-92% and 54-77% of the cases. Mastectomy with axillary dissection remains the standard treatment. Sentinel lymph node biopsy could be proposed in small tumours (< or = 2 cm). Locoregional radiotherapy is very often indicated. Tamoxifen is the standard adjuvant treatment, but chemotherapy is proposed in young men with axillary nodal involvement and/or negative hormone receptors. Tumour size and, more particularly, histopathological axillary involvement are the strongest predictive factors for both locoregional recurrence and metastasis. Globally, the prognosis is similar to that in women (at identical stage), but the intercurrent death rate is higher due to the important impact of comorbidities and second neoplasm.

Male breast cancer: a review of clinical management

AIMS

Male breast cancer incidence is 1% of all breast cancers and is increasing. We aim to present an overview of male breast cancer with particular emphasis on clinical management.

METHODS

Studies were identified by an online search of literature in the MEDLINE database till June 2006 followed by an extensive review of bibliographies.

RESULTS

Increased risk factors include genetic predisposition as in BRCA2 families; testicular dysfunction due to chromosomal abnormality such as Klinefelter's syndrome or environmental factors such as chronic heat exposure and radiation. Clinical assessment with biopsy is the hallmark of diagnosis. Earlier presentations are becoming commoner but there are wide geographical differences. Surgical treatment involves simple or modified radical mastectomy along with surgical assessment of the axilla, either via sentinel node biopsy in clinically node-negative disease or axillary sampling/clearance in node-positive disease. Reconstructions for restoring body image have been recently reported. Indications for adjuvant therapies are similar to that in women. For metastatic disease, tamoxifen is still the mainstay for oestrogen receptor positive disease. For oestrogen receptor negative disease, doxorubicin based chemotherapy regimens are used. In addition, the oft neglected psychological aspects of men having a "cancer of women" are increasingly being recognised.

CONCLUSIONS

There is, thus, need for further increasing awareness among men to reduce stigma associated with presentation of symptoms related to breast. This should be in addition to stressing to clinicians the ways of earlier detection and tailor-made "gender oriented" treatment of breast cancer in men.

Prognostic Variables in Male Breast Cancer

The prognostic role of ploidy status, S phase fraction, estrogen and progesterone receptor status, and the expression of p53 and erbB-2 protein in male breast carcinoma (MBC) remains controversial. The primary objective of this study was to determine which of the common prognostic factors for female breast cancer predict prognosis in MBC. A secondary objective was to assess the impact of comorbid illnesses on survival. A retrospective review of demographic data, surgical treatment, pathological staging, adjuvant treatment and follow-up was completed for 16 patients with MBC (1 intraductal and 15 invasive). Formalin-fixed, paraffin-embedded tissue was processed for ploidy, S phase fraction, and immunohistochemical detection of estrogen and progesterone receptors plus expression of p53 and erbB-2 protein. Six of 15 patients with infiltrating ductal carcinoma are currently alive without evidence of disease and a median survival of 61 months. Nine patients died after a median survival of 52 months, with 6 patients having no evidence of recurrent breast cancer. Two of 3 deaths secondary to advanced breast cancer occurred in patients who initially presented with T4 lesions and were staged IIIB. Two of 15 tumors were erbB-2 positive, whereas only 1 tested weakly positive for p53 protein. We observed that MBCs express erbB-2 and p53 proteins infrequently. Neither ploidy status, S phase fraction, nor erbB-2/ p53 status provided any apparent improvement in establishing prognosis beyond routine pathological staging. Advanced TNM stage was associated with diminished survival. The majority of MBCs express estrogen and progesterone receptors. Survivals in MBC were reduced in association with comorbid medical conditions.

Male breast cancer: a review of the literature

Although breast cancer is uncommon in men, it can cause significant morbidity and mortality. The current review was undertaken to determine whether strategies applied for the evaluation and treatment of breast cancer in females are appropriate in male breast cancer. Male breast cancer has biological differences compared with female breast cancer, including a high prevalence in certain parts of Africa, a higher incidence of oestrogen receptor positivity and more aggressive clinical behaviour. It responds to hormonal manipulation and chemotherapy, but optimal treatment regimens in males are unknown. Male breast cancer remains an uncommon disease. Most of our current knowledge regarding its biology, natural history and treatment strategies has been extrapolated from its female counterpart. Much research is needed to further characterise the molecular biological properties of male breast tumours and their prognostic significance, and to devise treatment strategies, including optimal chemotherapy regimens.

Lobular carcinoma of the male breast associated with the use of cimetidine

A case of carcinoma in the breast of a male patient with a chronic gastric ulcer is described. The patient had received cimetidine for 17 years. Histological examination of an excisional biopsy showed lobular in situ and infiltrating carcinoma. In our review of the English literature, this is the 18th case of lobular carcinoma of the male breast to be reported; it is also the first report of lobular carcinoma associated with the use of cimetidine, and the second in a man with documentation of genotype.

Breast cancer in men

Aside from its much lower frequency, breast cancer in men is remarkably similar to the disease in women. The cause remains equally obscure; the clinical presentation, pathology, and natural history are similar; and men are probably as curable in similar circumstances. Men are generally older and in more advanced stages than women when diagnosed, the tumors are located more often beneath the nipple and are more often responsive to hormonal therapy, but otherwise differences are negligible. Stage and axillary node status are strong prognostic indicators. Modified radical mastectomy has replaced radical mastectomy for surgical treatment of early states, and systemic adjuvant therapy appears to improve the prognosis for cases with involvement of lymph nodes.

Male breast cancer in Iceland

All malignant tumours of the male breast diagnosed in Iceland during the 40-year period 1955-1994 were studied with regard to histological classification, tumour grading and flow cytometric analysis. Of 31 malignant tumours diagnosed, 29 were primary breast carcinomas. Male breast carcinoma constitutes 1% of all breast malignancies in Iceland and 0.25% of all malignant tumours in males. About 80% of the male breast carcinomas were diagnosed during the latter half of the study period. The mean age of the patients was 66.3 years and the left-to-right ratio was 1.9:1.0. Right-sided tumours appeared to be more aggressive. The mean tumour size was 2.6 cm. The vast majority of the carcinomas (79%) were of the infiltrating ductal type. Of these 21.7% were grade I, 43.5% were grade II and 34.8% grade III. Papillary carcinomas made up 17% of the total. These occurred in slightly older patients than the infiltrating ductal carcinomas and were diploid tumours. In this study 57% of the tumours were found to be aneuploid, but nearly 70% of the invasive ductal carcinomas NOS were aneuploid. In general, the aneuploid tumours were larger, of higher average histological grade and had a higher mean S-phase value. The overall mean S-phase fraction was 7.2% which is similar to that found in female breast tumours in Iceland. It is concluded that male-to-female ratio of breast carcinoma in Iceland is similar to that found in other Western countries. The age-standardised incidence has increased considerably in the last 20 years, in contrast to the rates reported from most other countries. Papillary tumours are unusually common in Icelandic males.

Male breast carcinoma: an evaluation of prognostic factors contributing to a poorer outcome

BACKGROUND

Although breast cancer in men is far less common than breast cancer in women, it is associated with a less favorable prognosis. Conventional histopathologic features and new prognostic markers were evaluated to explain the less favorable survival outcome.

METHODS

Forty-six consecutive male breast carcinomas were studied for size, histologic and nuclear grade, histologic subtype, presence of carcinoma in situ, nipple involvement, lymphovascular invasion, hormone receptor status, c-erbB-2 protein overexpression, and p53 protein accumulation. These findings were correlated with survival.

RESULTS

Of the 46 carcinomas, 4 were noninvasive and 42 were invasive. In the invasive carcinomas, the median patient age was 64 years, and the median tumor size was 2 cm. The predominant histologic patterns were invasive ductal (45%) and mixed invasive ductal and cribriform (28%). Most tumors were of low histologic and nuclear grades (histologic grades: I, 17%; II, 50%; III, 33%; nuclear grade: I, 12%; II, 44%; III, 44%). Of those surgically staged, 22 patients (60%) were lymph node positive and 15 patients (40%) were node negative. Stage at presentation was higher than in women (0, 10%; 1, 17%; 2, 50%; 3, 13%; 4, 10%). The estrogen and progesterone receptor status was positive in 76% and 83% of tumors, respectively. Lymphatic vessel invasion (63%) and nipple involvement (48%) were also more common than in women. True Paget's disease of the nipple was not seen; all cases with nipple ulceration were the result of direct tumor extension to the epidermis. Of the 17 tumors tested, 41% were c-erbB-2 positive and 29% were p53 positive. Survival analysis was limited by the relatively small cohort size. Five- and 10-year adjusted overall survival rates for invasive tumors were 76 +/- 7% and 42 +/- 9%, respectively. Skin and nipple involvement (P = 0.03) and c-erbB-2-positivity (P = 0.03) were significant predictors of adverse survival.

CONCLUSIONS

Male breast carcinoma presents in an advanced stage with less favorable survival, despite low histologic grade, high estrogen receptor content, and small size. Anatomic factors may have been responsible for the poor survival outcome (i.e., paucity of breast tissue and close tumor proximity to skin and nipple, facilitating dermal lymphatic spread and early regional and distant metastasis).

Prognosis of breast cancer in males: an analysis of 170 cases

A statistical analysis was performed on a series of 170 consecutive cases of operable (M0) breast cancer in males. All the patients underwent surgery. The end-points considered were: (i) overall mortality, (ii) all neoplastic events and deaths without evidence of breast disease (first event). Five- and ten-year overall mortalities were 26.9 and 54.3%, respectively. A multiple regression analysis showed that tumour size and nodal status (pT and pN) were statistically significant as prognostic factors. With regard to first events, 12 local recurrences (thoracic wall), one nodal relapse in the axilla and one contralateral tumour were observed. Primary tumours, other than breast cancer, occurred in 11 patients. The observed probability of surviving at 10 years from the treatment was definitely lower than that of the general population. For the follow-up periods of 0-5 and 6-10 years, the excess death rate per 100 man-years was 9.98 and 13.43, respectively. It appears from the analysis that prognosis of breast cancer is worse in men than in women.

Male breast carcinoma: a single centre report of clinical parameters

A total of 68 men (mean age 66.2 years) were treated for a primary carcinoma of the breast at Mount Vernon Hospital between January 1968 and June 1988. The mean duration of the symptoms before diagnosis was 13.3 months. The most common sign of presentation (60% of the patients) was a mass in the breast (mean size 3.9 cm). Thirty-three tumours (48.5%) were fixed to the skin and in nine the skin was ulcerated. Sixty-nine per cent of the patients had a T4 tumour and 51.5% had a palpable axillary node. Thirteen patients (19%) were treated by radiotherapy alone, 46 (67%) by surgery and postoperative radiotherapy, and nine (13.3%) by surgery alone. Sixty patients (88%) were in complete remission after the initial treatment and seven of these (12%) developed a local recurrence. The median follow-up was 54 months. The overall survival was 23% at 10 years and the corrected survival 42% at 10 years. Patients with no nodal disease at presentation had a better survival than those with N1 or N2 disease (55% versus 22% 10 years corrected survival, P < 0.002). The risk of nodal disease was strongly correlated by univariate analysis with the size of the tumour (P = 0.002) and the skin fixation (P = 0.005). The risk of metastatic dissemination was correlated with the nodal clinical involvement (P = 0.02) and the existence of a local recurrence (P = 0.003). In multivariate analysis, T and N stages were significantly associated with an increasing risk of treatment failure (P = 0.01). Forty-seven per cent of the patients with T4 tumours developed metastatic disease. This emphasizes the need for adjuvant systemic treatment for these patients.

DNA content and S-phase fraction in male breast carcinomas

Eighty-five male breast carcinomas limited to the breast, diagnosed between 1958 and 1967 in Sweden, were investigated by flow cytometry using paraffin-embedded tissue. DNA ploidy and S-phase fraction (SPF) were studied in relation to lymph node status, tumour size and malignancy grade, and with respect to clinical outcome. Median age at diagnosis was 65.5 years. Median survival time related to breast cancer was 78.7 months, and 37 patients died from the disease. Forty-nine (57.6%) carcinomas were aneuploid or had multiple stemlines. Median SPF was 8.9% for all tumours, for diploid and tetraploid (euploid) together 6.6%, and for aneuploid tumours 14.3% (p < 0.001). Ploidy was significantly related to the tumour size (p = 0.03), but no significant correlations with node status or malignancy grade were observed. In univariate survival analysis, node status, tumour size and malignancy grade predicted breast cancer mortality significantly. In a multivariate Cox's model, only node status and tumour size were independent prognostic factors. In contrast to females with breast cancer, ploidy and SPF had no significant relation to prognosis in males. This lack of predictive value of DNA analysis needs further evaluation. Studies based on extended materials are necessary to further investigated the role of DNA analysis as a predictor of outcome in male breast cancer patients.

Cancer of the male breast presenting as an axillary mass

The authors describe a 55-year-old man with an axillary mass. Physical examination of the breast was normal, and the patient had not risk factors for cancer of the male breast. A workup for other possible cancers was normal. Excisional biopsy of the mass revealed metastatic adenocarcinoma. The histology favored a primary breast cancer. The patient had a right modified radical mastectomy. The pathologic examination showed infiltrating ductal adenocarcinoma of the breast. Adjuvant therapy included combination chemotherapy followed by tamoxifen. Physicians must be aware of the differential diagnosis of an unknown primary cancer when it presents as an axillary mass.

The prognosis of breast cancer in males. A report of 335 cases

BACKGROUND

Because of the relative rarity of breast cancer in males, data have not been sufficient to support a definitive analysis of pertinent prognostic factors. Remarkably, no studies of male patients with breast cancer have presented survival information based on the number of histologically positive axillary nodes, the most sensitive single indicator of prognosis in women with breast cancer.

METHODS

In this study, the clinical course of breast cancer was documented for 335 male patients registered from 1965 through 1986. For patients to be eligible, diagnoses had to be made within 3 months of registration and the patients had to have histologic confirmation and receive part or all of their initial treatment at 1 of 11 cancer centers participating in the International Patient Data Exchange System.

RESULTS

The survival rate at 10 years was 84% for patients with histologically negative nodes, 44% for those with one to three positive nodes, and 14% for the group with four or more histologically positive nodes. The survival rates at 5 years were 90%, 73%, and 55%, respectively. In a multivariable analysis, the risk of death due to breast cancer for a patient with four or more histologically positive nodes was 6.75 times that of a patient with negative nodes.

CONCLUSIONS

The findings of the authors indicate the following: (1) The number of histologically positive axillary nodes and, to a lesser degree, tumor diameter are significant prognostic factors for breast cancer in male patients. (2) The prognosis of breast cancer is the same in male and female patients when compared on the basis of the number of histologically positive nodes.

Current management of male breast cancer. A review of 104 cases

Between 1975 and 1990, 104 male patients with a total of 106 breast cancers were treated at Memorial Hospital or the Ochsner Clinic and their records reviewed. The patients were followed for a median of 67 months (range, 0.5 to 14.4 years). Analysis of the frequency distribution by stage showed that 16 (17%) patients were stage 0 and 26 (27%) patients were stage I. The median duration of symptoms before diagnosis was 18 weeks (mean, 5 weeks; range, 1 to 156 weeks). Modified radical mastectomy was undertaken in 71 (67%) patients. The actuarial 5-year relapse-free survival for the entire group was 68% and the actuarial 5-year overall survival was 85%. Relapse-free survival at 5 years for axillary node-negative patients was 87% and for node-positive patients was 30% (p less than 0.001). Overall survival figures for the same subsets showed a 5-year survival of 100% for the node-negative subset and 60% for the node-positive subset. On multivariate analysis, the most powerful predictor of outcome in men was the status of the axillary lymph nodes, and the only prognostic factor that added significantly to this predictive power was the duration of symptoms. Patients who sought treatment less than 6 months after the onset of symptoms experienced a significant survival advantage when compared with patients whose symptoms were present for more than 6 months (p = 0.03). The profile of the stages at diagnosis, the treatment approach, and the survival rates approximate those reported in series of female breast cancers, and overall, the two diseases are remarkably similar.

Male breast cancer

Breast cancer in the male is an uncommon disease, occurring less than 1% as often as in females. Because of its rarity, this disease has not been as extensively studied as its female counterpart. Male breast cancer is evaluated and managed in a fashion very similar to that for female breast cancer. Primary management in early stage disease is usually a modified radical mastectomy. First line hormonal therapy for metastatic disease, in our institution, is tamoxifen for patients with positive estrogen receptors. Second line therapy consists of progestins or antiandrogens/LHRH analogs. No firm recommendations can be made concerning adjuvant systemic therapy. However, it is likely that studies from female patients are adaptable. Unfortunately, carcinoma of the male breast is such an infrequently encountered tumor that unfamiliarity with the disease can lead to delays in diagnosis and treatment. An increased awareness of the disease may be expected to result in earlier detection and institution of therapy at a stage when cure may be possible.

Male breast cancer

Male breast cancer is uncommon but important. The diagnosis is easily made by breast biopsy, and patients are presenting earlier in the course of the disease than in the past. Despite this, patients are often first seen with tumors that have metastasized to the axillary nodes, which markedly decreases the survival rate. Therapy of localized disease includes simple excision, modified radical mastectomy, and radical mastectomy, but there is no consensus for which operation is appropriate. Radiation therapy should be strongly considered in patients with metastases to the axillary nodes, but the role of adjuvant hormonal therapy or chemotherapy is unclear. For treatment of disseminated disease, tamoxifen seems to be replacing orchiectomy. The favorable response rate, especially in patients with estrogen-receptor-positive tumors, the lack of side effects, and the high level of patient acceptability make it an attractive therapeutic choice.

In situ and infiltrating lobular carcinoma of the male breast

An 82-year-old man presented with a right breast mass. Histologic examination of an excisional biopsy showed lobular in situ and infiltrating carcinoma. The patient was phenotypically male and had fathered children. There was no history of predisposing factors to breast lesions, such as drug use or gynecomastia. In our review, this is the first case of lobular in situ and infiltrating carcinoma of the male breast in a phenotypic and apparently genotypic male.