Looking for C.U.R.E.

  • Increase font size
  • Default font size
  • Decrease font size

Male Breast Cancer

E-mail Print
Attachments:
File
Download this file (Male breast cancer.pdf)PDF

 

Overview

Breast cancer is less common in men than in women, approximately less than 1% of all breast cancers. There are about 1970 new cases of male breast cancer diagnosed each year and 390 cases of deaths in the United States. Men tend to develop breast cancer 5 to 10 years older than women. Most male breast cancers are diagnosed between the ages of 60 and 70. Like female breast cancer, the incidence of male breast cancer has been increasing over the past 25 years. Although male breast cancer is rare, the disease is very similar to women.

 

Causes and Risk factors

The causes of the male breast cancer are not fully understood. Both environmental and genetic factors could play a role in the development of breast cancer. Several risk factors have been identified and many of them are related to hormone levels.

Klinefelter syndrome

The strongest risk factor for developing male breast cancer is Klinefelter syndrome, which is a rare disease of abnormal extra sex chromosome. Patient genotype is 47, XXY instead of 46, XY. Klinefelter patients produce high levels of estrogen and have a high ratio of estrogen-to-testosterone. Patients have enlarged breasts, small testes, and low sperm counts. Klinefelter patients have an increased risk (20 to 50 folds) in developing male breast cancer.

Hormonal imbalance -- relative high estrogen with low androgen

Men can produce little estrogen, but in certain situations, such as some liver disease, there are abnormal high levels of estrogen in men, therefore male breasts can be enlarged. This is called gynecomastia, which can increase the risk of male breast cancer. About 85% of male breast cancers have estrogen receptors on the cancer cell membranes, which allow estrogen to promote cell growth and proliferation. On the other hand, androgen may function protectively on breast tissue by inhibiting cell growth.

Familial predisposition

Men can have an increased risk in developing breast cancer if several female family members have breast cancer. There are two breast cancer genes, BRCA1 and BRCA2. Inherited or acquired mutations in BRCA genes, especially BRCA2 can increase the risk of male breast cancer. Men who inherit germ line mutations in BRCA2 have 5-10% risk of breast cancer in their life time. This is 100-fold risk increase comparing with the general male population. Because of this, all men diagnosed with breast cancer are advised to genetic counseling and BRCA testing.

Other risk factors include: previous benign breast disease, gynecomastia, history of testicular or liver pathology and ionizing radiation to chest area.

 

Types of male breast cancer

Most common type of male breast cancer is infiltrating ductal carcinoma (IDC). IDC origins from the breast ducts and has spread into the surrounding tissue. Less common is ductal carcinoma in situ (DCIS), in which cancer cell does not grow through the walls of the ducts. Lobular cancers are very uncommon in men since male breast tissue does not normally contain lobules.

 

Clinical presentation

Male breast cancer typically presents as a firm, painless mass located just under the nipple. Other findings include nipple retraction, nipple or skin ulceration, nipple redness, local tenderness, and palpable lymph nodes. Nipple discharge either bloody or opaque may also occur. Advanced breast cancer can produce nonspecific symptoms including fatigues, malaise and weight loss.

 

Diagnostic evaluation

Breast cancer in men is detected in the same way as in women: include mammography, Fine needle aspiration (FNA) and open biopsy.

Mammography: The first step of evaluation is mammography. The mammogram is abnormal in 80 to 90 percent of male breast cancers, and can be helpful in distinguish between malignancy and gynecomastia.

Fine needle aspiration (FNA): A needle is inserted into the mass and tissues are removed from the suspicious area. Diagnosis can be made by cytology study. If nipple discharge is present, examination of the discharge can sometimes diagnosis the disease.

Open Biopsy: Open biopsy can be used to confirm the diagnosis. Tissues collected from biopsy can also be used for estrogen or progesterone hormone receptors assay and HER2 expression assays, which will guide the selection for treatment regimen.

Imaging studies such as X-ray, CT scans, magnetic resonance imaging and bone scans are helpful to evaluate the presence of metastatic cancer.

 

Staging

Staging of male breast cancer is identical to that of women. TNM system takes into account the tumor size (T), lymph node involvement (N), and presence of distant metastasis (M). According to American cancer society, the following are breast cancer stages, more details can be found at www.cancer.org.

Stage 0: Ductal Carcinoma In Situ (DCIS), in which cancer cells are within the duct.

Stage I:  Tumor is 2 cm or less and has not spread to the lymph nodes or to other sites in the body.

Stage II:  Stage IIA cancer is either less than 2 cm in diameter with spread to the axillary lymph nodes, or the tumor is between 2 cm-5 cm in diameter but has not spread to the axillary lymph nodes. Stage IIB tumors are either larger than 5 cm without spread to the axillary lymph nodes or are between 2 cm-5 cm in diameter and have spread to the axillary lymph nodes.

Stage III is local advanced cancer. Stage IIIA tumor is smaller than 5 cm in diameter but has spread to the axillary lymph nodes (>3 nodes); or tumor is greater than 5 cm in diameter with spread to the axillary lymph nodes. Stage IIIB tumors have spread to surrounding tissues such as chest wall, skin, or the lymph nodes inside the chest wall.

Stage IV:  Metastatic cancer, tumor has spread to other parts of the body. Most common metastatic sites are the bones, lungs, liver, or brain.

 

Treatment

Treatment of male breast cancer follows the same principles as female breast cancer, and treatment selection depends on the stage of the cancer and the overall condition of the patient. For early stage cancer which is localized, surgery is the first choice for primary tumor, followed by systemic therapy including irradiation therapy, chemotherapy, tamoxifen for hormone receptor-positive disease, and trastuzumab for HER2 positive cancers. For local advanced breast cancer, induction chemotherapy is selected initially. If tumor is shrunken to operable size, surgery may be chosen. Systemic therapy including irradiation therapy, tamoxifen and trastuzumab are also recommended.

 

Prognosis

Tumor size and stage are the most important prognostic factors for male breast cancer. Overall survival rates for each stage are similar for men and women. Since men have less breast tissue than women, upon diagnosis, male breast cancers often have spread beyond the breasts, resulting in an advanced tumor stage. According to American cancer society, five-year survival rates for breast cancer by stage are as follows:

Stage 0 - 100%

Stage I - 96%

Stage II - 84%

Stage III - 52%

Stage IV – 24%

 

 

REFERENCES

1.Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin 2010; 60:277.

2. Giordano SH, Cohen DS, Buzdar AU, et al. Breast carcinoma in men: a population-based study. Cancer 2004; 101:51.

3. Thomas DB. Breast cancer in men. Epidemiol Rev 1993; 15:220.

4. Tai YC, Domchek S, Parmigiani G, Chen S. Breast cancer risk among male BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst 2007; 99:1811.

5. Brinton LA, Richesson DA, Gierach GL, et al. Prospective evaluation of risk factors for male breast cancer. J Natl Cancer Inst 2008; 100:1477.

6. Giordano SH, Buzdar AU, Hortobagyi GN. Breast cancer in men. Ann Intern Med 2002; 137:678.

7. Giordano SH, Cohen DS, Buzdar AU, et al. Breast carcinoma in men: a population-based study. Cancer 2004; 101:51.

8. http://www.uptodate.com

9. The American Cancer Society http://www.cancer.org/

10. "Breast Cancer." National Cancer Institute http://www.cancer.gov/cancertopics/types/breast

11. "Surveillance Epidemiology and End Results." National Cancer Institute http://www.seer.cancer.gov

 

 

 

Hui Gao M.D. Ph.D.

Harbin Medical University

Visiting Medical Resident