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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 98-102

Male breast cancer: An overview


1 Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi, India
2 Department of Radiation Oncology, Safdarjung Hospital, New Delhi, India

Date of Web Publication14-Jun-2017

Correspondence Address:
Deepti Sharma
Department of Radiation Oncology, VMMC and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jrcr.jrcr_21_17

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  Abstract 


Male breast cancer (MBC) is extremely rare, with an incidence of about 1% but the incidence has increased over the past 25 years. Most data on MBC come from small single-institution studies, and because of the paucity of data, the optimal treatment for MBC is not known. In the present article, we reviewed MBC and its risk factors, recommendations for screening and diagnosis, and management of patients with MBC.

Keywords: Female breast cancer, gynecomastia, male breast cancer, rare


How to cite this article:
Sharma D, Singh G. Male breast cancer: An overview. J Radiat Cancer Res 2017;8:98-102

How to cite this URL:
Sharma D, Singh G. Male breast cancer: An overview. J Radiat Cancer Res [serial online] 2017 [cited 2017 Jun 28];8:98-102. Available from: http://www.journalrcr.org/text.asp?2017/8/2/98/208026


  Introduction Top


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.[1],[2] It accounts for <0.2% of all cancer-related deaths among men.[3] Because this disease is rare, no randomized trials have been possible. Most information on male breast cancer (MBC) has been collected from retrospective studies spanning several decades, and treatment recommendations have been extrapolated from results of trials in female patients. Because the incidence of MBC is rising, there has been an increasing interest in this disease.[4] Because this disease is rare, no randomized trials have been possible, most information on breast cancer in men has been collected from retrospective studies spanning several decades, and treatment recommendations have been extrapolated from results of trials in female patients. However, this enormous volume of data on female breast cancer may not be completely relevant to men, particularly with regard to differences concerning the hormonal environment, gender differences, medical and/or psychosocial side effects, and survival priorities. The purpose of this review is to examine systematically all recently published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation, and treatment in MBC patients.

A database search was conducted on Google Scholar, PubMed, and MEDLINE using phrase words, male breast carcinoma, risk factors, in combination with terms such as “treatment,” “features,” “diagnosis,” and “prognosis.” References of all publication were also searched. All relevant publications were collected, reviewed, and were analyzed in detail to summarized in this paper.


  Epidemiology Top


Although MBC accounts for <1% of all cancers in men. Its incidence is variable in different regions. Incidence of MBC in Northwest Europe and North America is approximately 1/100,000 as compared to <0.5/100,000 in Japan.[5],[6] MBC patients are usually a disease of sixties, but in the Middle East, China, and South Asia and also in Africa, they are more often in their 50s; symptom duration before diagnosis has decreased.[7] However, there are large geographical differences, i.e., <8 months in Western countries.[8] and at least 1 year in Asia and in Africa.[9] Disease frequency is higher among Jewish men at 2.3/100,000 and in countries with a high incidence of parasitic liver disease such as Egypt and Zambia.[10],[11]


  Risk Factors Top


The etiology of MBC is unclear, but hormonal levels may play a role in the development of this disease. Testicular abnormalities such as undescended testes, congenital inguinal hernia, orchiectomy, orchitis, and infertility have been consistently associated with elevations in breast cancer risk.[12] Klinefelter's syndrome, in which patients carry XXY chromosomes, may be present in 3%–7% of men with breast cancer, giving males with Klinefelter's syndrome a 50-fold greater risk over the general male population.[13] Men with a family history of breast cancer in a female relative have 2.5 times the odds of developing breast cancer.[14] Prior radiation as in case of mantle field for Hodgkin lymphoma also increases the risk of a subsequent breast cancer.[12] Alcohol use, liver disease, obesity, electromagnetic field radiation, and diet have all been proposed as risk factors, but findings have been inconsistent across studies.[15],[16],[17],[18]

Approximately 15%–20% of men with breast cancer report a family history of breast or ovarian cancer. It is estimated that approximately 10% of men with breast cancer have a genetic predisposition, and BRCA2 is the most clearly associated gene mutation.[19],[20] BRCA1 mutation is also associated with PTEN, P53, and CHEK2.[21],[22],[23],[24] Among male BRCA2 mutation carriers, the estimated lifetime risk of breast cancer is 5%–10% compared with a general population risk of 0.1%.[25] The lifetime risk of MBC with BRCA1 mutations is approximately 1%–5%.[26] CHEK2 1100 del C increases the risk of both male and female breast cancer, particularly among individuals with a family history and a CHEK2 mutation.[27] At all ages, black men have a higher incidence than white men. Black men also tend to have poorer prognostic features such as advanced-stage disease, larger tumor sizes, more nodal involvement, and higher tumor grade, compared with their white counterparts.[28]


  Clinical Presentation Top


The most common presenting symptoms in MBC patients are a painless subareolar lump, nipple retraction, and bleeding from the nipple.[10],[29],[30],[31] Nipple is involved in about 50% of cases at presentation.[32] Due to lack of awareness, >40% of men present with stage III or IV disease.[9],[33],[34]


  Diagnosis Top


Mammographic characteristics of MBC are subareola and eccentric to the nipple.[35],[36] Margins of the lesions are usually well defined; calcifications are rarer and coarser than those occurring in female breast cancer.[37],[38],[39] In one study, the sensitivity and specificity of mammography was 92% and 90%, respectively; i.e., mammography detected malignancy in 92% of known malignant cases and ruled out malignancy in 90% of known benign cases.[40]

On ultrasound, it appears as a hypoechoic area whose edges are angled or with microchannels and points on the surface.[41],[42] The appearance of a complex cystic mass in a male breast with ultrasound suggests possible malignancy, and biopsy is required. Ultrasound is important for demonstrating axillary lymphadenopathy.[43]


  Histopathology Top


Biopsy is required for definitive diagnosis in most breast cancer cases in men.[37],[44] Fine-needle aspiration (FNA) biopsy of the male breast has high sensitivity and high specificity, and with almost 100% positive predictive value for the diagnosis of malignancy.[45],[46],[47],[48] FNA biopsy allows accurate diagnosis in many medical changes that occur in the male breast. However, this technique is less helpful with ductal carcinoma in situ(DCIS), especially in lesions that are cystic, such as papillary DCIS, which has been described as having a strong cystic component.[43] Core needle biopsy or FNA biopsy should be used more often because these procedures can help to avoid unnecessary surgery and may help in the planning of any surgeries for cancer cases.[48]

Histopathologically, the majority of tumors are invasive ductal carcinoma (85%–95%), followed by DCIS (5%–10%). Invasive papillary carcinoma is more common in males than in females, accounting for approximately 2%–4% of breast cancers in men compared with up to 1% in women.[34]

Estrogen receptors are expressed in 90% of MBCs, a higher proportion than in women and up to 96% are progesterone receptor positive.[49],[50] Human epidermal growth factor receptor 2 overexpression has been reported in 16%, on average slightly lower than in females but its effects on prognosis are unclear.[30],[50],[51]


  Treatment Top


Management options for MBC patients are based mainly on information from the treatment of full blood count.[7],[31],[34] Surgery as a form of therapy is generally a key part of the treatment of breast cancer and is a “gold standard” for MBC treatment.[1],[31],[52] Modified radical mastectomy with subcutaneous reconstruction is commonly done surgical procedure, whereas 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.[4],[31] Axillary node dissection may be performed even though it is associated with other complications such as lymphedema and paresthesia (9).[53] Sentinel node biopsy is now accepted as a reliable method to establish axillary node status for invasive MBC, avoiding complications associated with axillary node dissection.[31],[32],[54]

Postoperative 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.[31],[55] Postoperative radiotherapy reduces the incidence of local recurrence in males as well as in female cancer patients.[56],[57] In 55 Turkish patients, controlling for other disease and treatment factors, receipt of radiotherapy was found to prolong disease-free survival.[58] A case series of 75 men treated with curative intent in Ontario found significantly improved local recurrence-free survival in 46 patients who received postmastectomy radiation, but their overall survival was not different.[59]

Most cases of MBC respond favorably to hormonal manipulation since the majority are estrogen receptor positive. Although no clinical trials have assessed the use of tamoxifen in MBC, men who have been treated with it show improved disease-free and overall survival rates, with the 5-year disease-free rate improving from 28% to 56%, and the 5-year overall survival rate improving from 44% to 61%.[32],[34],[60] In a Chinese retrospective single-institution study of 72 male patients over 40 years, multivariate regression found that receipt of endocrine therapy was associated with better survival.[61] For this reason, tamoxifen has an important role in the treatment of most MBC cases. Studies have demonstrated that male patients experience more side effects from tamoxifen, such as weight gain, sexual dysfunction, nausea, depression, and hot flushes, which may affect their compliance with the prescribed treatment.[62],[63],[64],[65] There are insufficient data on the use of aromatase inhibitors to treat MBC.[60] Orchidectomy, adrenalectomy, and hypophysectomy, once used for hormonal manipulation, are no longer used due to the associated severe side effects.[66]

Chemotherapy appears to benefit survival and prevent recurrence although data are most established for node positive men.[31],[34],[67],[68] It has been suggested that chemotherapy is used in patients with stage II or greater disease.[60],[68] A 2004 retrospective study showed that additional adjuvant therapy in the form of radiation, hormones, and chemotherapy, either alone or in combination, have doubled the survival rate in men with breast cancer.[69] The retrospective study by Giordano et al. showed that 51 patients, including 66% with positive lymph node status, were treated with tamoxifen, chemotherapy, or both.[67] Patients who received adjuvant systemic treatment had 43% lower risk of death, compared with patients who received no form of adjuvant therapy. During tumor progression in male breasts, a combined hormonal and cytostatic treatment can be used with considerably good results.[70]


  Screening Guidelines Top


Due to low incidence of MBC in the general population, there are no guidelines or formal recommendations for screening mammography, nor are there recommendations for clinical breast examination or breast self-examination in asymptomatic men with no other risk factors.

For individuals at increased risk for developing breast cancer, that is individuals with a strong family history of breast cancer, a genetic predisposition (mutations identified that are known to increase risk of breast cancer such as BRCA1 and BRCA2), and prior personal history of breast cancer (particularly MBC), there are clear surveillance and screening guidelines.[71],[72]

For men in the increased risk category, monthly breast self-examinations, semi-annual clinical breast examinations, and baseline mammography followed by annual mammography if gynecomastia and/or breast density are seen on baseline are recommended.[73],[74] Guidelines also recommend that both men and women in the increased risk category are tested for genetic mutations (if mutation status is unknown), are advised of the risk to other relatives, and consider genetic testing for at-risk relatives.[71],[75],[76]


  Prognosis Top


Hill et al. reported an overall 5-year and 10-year survival rate in patients with localized disease to 86% and 64%, respectively. With positive lymph nodes, the 5 and 10-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, comorbidity at presentation, and shorter life expectancy in men also affect prognosis.[77]


  Conclusion Top


MBC, 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, MBC can be cured or controlled if diagnosed and treated properly at its early stages. We need a greater awareness of MBC to guide evidence-based treatment and to encourage enrollment in future studies aiming at optimizing management of this rare disease. The role of adjuvant hormonal treatment and chemotherapy deserves more researches, especially to determine which subgroup of men will benefit.

Financial support and sponsorship

Nil.

Conflicts off interest

There are no conflicts of interest.

 
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Introduction
Epidemiology
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Clinical Present...
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