Clinical management of breast cancer in males: a report of four cases

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Abstract

Breast cancer in men is a rare cancer manifestation, accounting for less then 1% of all breast cancers in both genders. The incidence in Germany during the last years has been approximately 1.0 per year/100,000. In the US, only 0.2% of all malignancies in men. Predisposing risk factors seem to include radiation exposure, hereditary factors, estrogen administration, and diseases associated with hyperestrogenism, such as cirrhosis of the liver or genetic syndromes (i.e. Klinefelter disease). The incidence of male breast cancer is increased in families with a number of first degree relatives affected with breast or prostate cancer. An increased risk of male breast cancer has been reported in families with a mutation of the breast cancer susceptibility gene BRCA-2. For a period of decades, prognosis of breast cancer in males was thought to be worse than that of female patients. Data and cases being published demonstrate that prognosis and strategies of treatment in male breast cancer do not differ from those in females. The cases presented clearly demonstrate that diagnostic work-up, staging procedures and treatment options for primary treatment and advanced stages are identical compared to the recommendation for female breast cancer.

Introduction

Breast cancer is a rare event in men, accounting for less then 1% of all breast cancers in both genders [1]. The incidence in Germany is documented at about 1.0 per year/100,000 (cancer registry of the county Saarland). In the US, only 0.2% of all malignancies in men account for this disease [8]. The first case of male breast cancer was reported by a British physician, John of Arderne, in the early 14th century [9].

The mean age at diagnosis is approximately 65 years. Although men of all ages can be affected by the disease, it is rare in young men. Radiation exposure, estrogen administration, and diseases associated with hyperestrogenism, such as liver cirrhosis or Klinefelter syndrome appear to be predisposing risk factors [2], [3], [4], [5]. There is an increased incidence of male breast cancer among men who have a number of female relatives with breast cancer. Furthermore, occurrence of male breast cancer increases the risk for breast cancer in predominantly first degree female relatives [35]. An increased risk of male breast cancer has been reported in families with a mutation in the breast cancer susceptibility gene BRCA-2, located on chromosome 13q [6], [7]. Male carriers of BRCA-mutations may act as conductors; they may not have an elevated risk for developing breast cancer, but they have a three-fold increased risk of suffering from colon or prostate cancer [10].

For a long time, it was generally been accepted that the prognosis of male breast cancer was worse than that of women suffering from breast cancer [9], [11], [13].

In the majority of patients, the first clinical symptom is a painless tumor in the breast, mostly detected by the patient himself. Discharge from the nipple as an early symptom of disease is reported in approximately 15% of all cases [9], [11]. Furthermore, some cases of inflammatory breast cancer in men have been reported [11]. As in women, the most important predictor of survival is the status of axillary lymphnodes involved. In 56% of invasive cancer a positive nodal status was found with significant correlation to primary tumor size [30]. Hereditary male breast cancer seems to have no different prognosis when compared at individual stages to their sporadic counterparts [12].

Section snippets

Patients and clinical management

From 1996 to 1999 four male patients with invasive breast cancer presented to our department and to the Department of Oncology at the Paracelsus Clinic of Osnabrueck. Patients’ characteristics including stage of disease at presentation, surgical management, lymph node involvement, histology and hormone receptor status, are listed in Table 1. Estrogen and progesterone receptor levels were evaluated by immunohistological staining using the Remmele score [36].

Case 1: A 57-year-old patient

Discussion

The first clinical sign of male breast cancer is often noted by the patient himself. In comparison to female breast cancer, the delay from onset of first clinical signs to diagnosis is approximately 22 months. This delay of diagnosis has severe impact on survival. Hill et al. demonstrated that patients with a delay of 6 months or less had a 5 and 10 years survival rate of 90 and 70%, respectively. On the other hand, patients with a duration of symptoms of more than 6 months had 5 and 10 years

Conclusions

To reduce the portion of advanced stages of the disease at diagnosis, measures should be taken to remind general practitioners and other healthcare providers of the entity of male breast cancer and to inform the public about the disease. In families with female breast cancer, breast examination in men should be performed and vice versa. In case of a male breast cancer, family members should be offered a genetic counseling for breast cancer risk evaluation and screening.

Currently, no clear data

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    Both authors contributed equally to the manuscript.

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