MALE BREAST CANCER
Antony Joseph ,
Kefah Mokbel ,
Breast Unit, St. George’s Hospital, London
Male breast cancer (MBC) is a rare condition constituting less than 1 % of all
mammary malignancies. However, the incidence of MBC has been rising over the
last 2 decades1. This increase is partly due to greater recognition of this condition
and improved screening and general awareness. In contrast to female breast
cancer (FBC), the incidence shows a unimodal pattern with the highest incidence
at the age of 71 compared to FBC which showed a bimodal pattern with highest
rates at the age of 52 and 712,3.
The risk factors associated with MBC include undescended testes, congenital
inguinal hernia, orchidectomy, orchitis, testicular injury, infertility, anti-androgen
therapy and Klinefelter’s syndrome1. The data from National Cancer Institute in
their Surveillance, Epidemiology and End Results (SEER) program showed an
increased odds ratio of MBC in those with positive family history4. While genetic
mutations in BRCA1 and BRCA2 are associated with increased risk of breast
cancer in females, only mutations in BRCA 2 have been associated with an
increased risk of developing MBC5. This gene is also associated with prostate
cancer. The cumulative life-time risk of MBC in carriers of BRCA2 muations is
approximately 7%5.
Invasive ductal carcinoma is the commonest type accounting for 90% of cases 6.
Most MBC tumor specimens are positive for estrogen (ER), progesterone (PgR)
and androgen (AR) receptors7. The incidence of Her-2/neu gene positivity is similar
to that of FBC8. Her-2 expression is associated with adverse prognosis in FBC;
however
its
role
in
MBC
is
currently
unclear9.
MBC usually presents as a subareolar breast lump, with the majority of cases
being stage II infiltrative ductal carcinoma. The involvement of axillary lymph node
is seen in approximately 70% of the cases10 and the nipple is involved in 40 -50%
of MBC presentations11. Presentation at the ductal carcinoma in situ (DCIS) stage
is relatively rare due to the absence of screening programs and the limited value of
mammography in the assessment of breast symptoms.
The diagnosis of MBC is usually confirmed by fine needle aspiration cytology
(FNAC) and/or core biopsy12,13. Mammography has a limited value due to the small
size of male breast and the obvious palpable lump at presentation14.
MBC is usually treated by modified radical mastectomy including axillary node
dissection as studies have shown no significant difference in survival rates
compared to radical mastectomy14. The role of sentinel node biopsy (SLNB) in
FBC is well documented and is emerging as a new standard of care in men with
clinically node negative breast cancer15.
The adjuvant therapy available in MBC is based on data from FBC studies, which
include hormonal therapy, chemotherapy and radiotherapy. Since MBC tends to be
ER positive, endocrine therapy with tamoxifen is an important treatment modality
despite the lack of randomized clinical trials. As in FBC, men should ideally receive
5 years of tamoxifen, though most men are treated only for 2 years14. It is also an
ideal treatment option for ER positive metastatic carcinoma, in preference to other
options such as ablative orchidectomy, adrenalectomy and hypophysectomy which
are associated with surgical co-morbidity16.
The data on adjuvant chemotherapy is limited, a study by National Cancer Institute
showed that chemotherapy achieved a superior 5 year survival rate compared with
historical controls17. The current indications for chemotherapy include positive
nodes, large primary tumour and hormone receptor negative metastases14. The
role of adjuvant radiotherapy is not well defined. The current literature advocates
radiation in patients with tumour larger than 1cm and/or presence of >1 metastatic
axillary node18.
In summary men are more likely to present at an advanced age as well as stage
with nodal metastasis. Due to the lower incidence of MBC, the main modalities of
treatment currently used have been based on FBC data. Therefore, there is a
great potential for randomized controlled trials, especially with regard to hormonal
therapy (e.g. third generation aromatase inhibitors) in view of the high ER positivity
in MBC. Untill then, the current management of MBC will continue to be based on
data from FBC studies.
References
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