GENDER MEDICINE/VOL. 7, NO. 2, 2010

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Accepted for publication November 4, 2009. doi:10.1016/j.genm.2010.04.003© 2010 Excerpta Medica Inc. All rights reserved. 1550-8579/$ - see front matter

Case Report

A Male Patient From the West Indies With Invasive Ductal Carcinoma in the Right Breast: A Case Report and Literature ReviewRizwan Ahmad, MBBS; Sharlon Lewis, MBBS; and Dale Maharaj, MBBS, FRCSFaculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad, West Indies

ABSTRACTBackground: Men with breast carcinoma have a poor prognosis, especially in the younger age group

(30–40 years of age), because most breast enlargements in young men are dismissed as gynecomastia, resulting in an unnecessary delay in treatment.

Objective: We describe the case of a young male patient with invasive ductal breast carcinoma.Case summary: In November 2005, a 30-year-old Afro-Caribbean man presented at St. Clair Medical

Centre in Port of Spain, Trinidad, with a painless lump in the right breast. Diagnostic findings revealed that the patient had stage II invasive ductal carcinoma, for which he underwent a mastectomy with total axillary clearance.

Conclusion: Surgeons investigating unilateral breast swellings in young males should not dismiss them simply as gynecomastia, and should be wary of cancer. (Gend Med. 2010;7:179–183) © 2010 Excerpta Medica Inc.

Key words: male breast cancer, invasive ductal carcinoma.

INTRODUCTIONBreast cancer has long been a deadly condition associated with women. Men succumb to the disease as well, albeit at a far lower incidence (male:female ratio of 1:100).1 The tragic reality for men with breast carcinoma, especially in the younger age group (30–40 years of age), is that very often the outcome is grim. This can be attributed to the fact that surgeons dismiss most breast enlargements in young males as gynecomastia, resulting in an unnecessary delay in treatment and further translating into a poorer prognosis.2,3

It is imperative, at a time when the incidence of breast cancer for both males and females is increasing,4 that a destructive and fatal disease not be confused clinically with a benign condition simply because of its low incidence.

We present the case of a 30-year-old male patient with invasive ductal breast carcinoma. This case is unique not only because of the patient’s sex but also his age of presentation. To our knowledge, he is the youngest male ever reported to have breast cancer in the Caribbean.

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tiated invasive ductal carcinomas. Only after diag-nosis did the patient consent to imaging. A com- puted tomography (CT) scan of the chest and abdomen showed no metastasis. Subsequently, a simple mastectomy with total axillary clearance was performed, with 8 of 13 nodes found to be positive for metastasis. Based on these findings, the patient’s tumor was staged as TNM (tumor/nodes/metastasis) IIB. Given his node-positive status, he was offered adjuvant radiotherapy to the chest wall, supraclavicular fossa, and internal mammary nodes, which was refused. The tumor was found to be estrogen-receptor positive, and tamoxifen along with adjuvant cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemothera- py was prescribed for 3 months’ duration.

As of March 2010, and in consideration of the patient’s refusal to continue chemotherapy after the initial 3 months, there has been no evidence of clinical recurrence confirmed by bone, ultra-sound, and CT scans.

CASE SUMMARYA 30-year-old Afro-Caribbean male (weight, 60 kg; body mass index, ~23 kg/m2) presented at St. Clair Medical Centre in Port of Spain, Trinidad, in Novem- ber 2005 with a painless lump in the right breast. There were no complaints of nipple discharge, and no evidence of any of the associated signs or symp-toms of Klinefelter’s syndrome. There was no perti-nent medical history or occupational exposure.

Physical exam revealed a 3- × 3-cm mobile lump that was located in the subareolar region extend-ing to the upper outer quadrant of the right breast (Figure). Although it was nodular, the lump felt harder than a typical gynecomastia. Preoperative ultrasonography was offered to the patient but was refused. The issue was not pressed by the surgi-cal team, as the patient and his family vehemently declined any form of preoperative imaging.

An excisional biopsy was performed, revealing 2 distinct tumors that were 1.0 and 1.5 cm in diame- ter. Histology showed them to be poorly differen-

Figure. A lump in the right breast was located in the upper outer quadrant in this 30-year-old male patient.

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an increased risk of male breast cancer was associat-ed with employment in blast furnaces, steel works, rolling mills (odds ratio [OR] = 3.4; 95% CI, 1.1–10.1, based on 6 cases), and motor vehicle manufacturing (OR = 3.1; 95% CI, 1.2–8.2, based on 7 cases).

When considering the pathologic characteris-tics of male breast carcinoma, ~90% are invasive carcinomas.1 Of those that are invasive, the pre-dominant histologic subtypes are infiltrating duc-tal carcinomas, which account for >80% of all tumors, and papillary carcinomas, which com-prise ~5% of all tumors. Lobular carcinoma is much less common in men than in women and represents only 1% of all cases. The rarer sub- types, such as medullary, tubular, mucinous, and squamous carcinomas, have all been reported in men, although these tumors may be slightly more uncommon in men than in women. Inflammatory carcinoma and Paget’s disease are seen with simi-lar frequency in men and women. Another impor-tant pathologic characteristic of breast cancer in males is that there is a higher rate of hormone receptor expression compared with their female counterparts. Approximately 90% of male breast cancers express estrogen-receptor positivity, and ~80% express progesterone-receptor positivity.

The most common presenting feature in men with breast cancer is a painless subareolar lump.1,2,7 Other associated symptoms in the nipple include local pain, retraction, ulceration, bleeding, and discharge. Similar to that in females, involvement of the left breast appears to be more common than that of the right breast; however, bilateral breast involvement is rare in males.1,2 One major differ-ence in the presentation of breast cancer in men compared with women is that men tend to have a delay between the onset of symptoms and a diag-nosis of breast cancer, owing to the rarity and resultant limited public awareness of the condi-tion.7 This delay in diagnosis contributes to men presenting with more advanced disease.

The diagnosis and staging of breast cancer are identical in men and women.1,2 When a man pre- sents with a breast mass, the primary differential diagnosis is gynecomastia versus carcinoma.7 Mammography can be useful in distinguishing the benign versus the malignant condition.1,2,7

DISCUSSIONIn Western countries, where breast cancer is the leading malignancy among women, male breast carcinoma accounts for <1% of all cancers in men and 0.7% of all breast cancer cases.2,3 Breast cancer usually affects older men, with a mean age at diag-nosis of 67 years.3 However, isolated cases of its appearance in young males (aged 20–30 years) have been documented worldwide.2 Facts about its incidence rate are conflicting. The largest study ever conducted on male breast carcinoma found disease incidence to have increased by as much as 26% over the past 25 years.4 This was an impor-tant finding, owing to the fact that, up until July of 2004, studies had reported that the incidence of male breast cancer remained stable.5,6 A possible reason for this increase could be attributed to the epidemiologic risk factors for male breast carcino-ma. Hormonal imbalances such as excess exposure to estrogen have been well documented as a caus-ative factor in the development of male breast cancer.3,7,8 With the incidence of obesity increas-ing, and the association it shares with male breast cancer in the United States,8 excess production of estrogen by adipocytes could play a factor in cer-tain individuals. This was not the case with our patient, as he was not obese. According to the available literature (PubMed cases of male breast cancer in the West Indies from 1980–2005), our patient was the youngest documented case of male breast carcinoma in the West Indies. So the ques-tion that must be asked is: “If the incidence of male breast cancer is rising, is it striking younger patients?” With the incidence of obesity increasing among the younger population, this trend may become more evident.

The etiology of male breast cancer is not as well understood as that of female breast carcinoma. Several factors, both genetic and congenital, have been implicated.3 Of all known etiologic factors, the greatest risk factor is concomitant Klinefelter’s syndrome. Patients with this condition carry an XXY chromosome and may have up to a 50-fold increased risk for developing breast cancer.8 Cocco et al9 examined a possible relationship between occupational exposure and male breast cancer in a case–control study of 178 subjects, and found that

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tamoxifen compared with those who did not.14 With respect to adjuvant chemotherapy, in a pro-spective study of 24 male patients with stage II node-positive breast cancer who received treat-ment with adjuvant CMF at the National Cancer Institute, the 5-year survival rate was >80%.15

CONCLUSIONSThe age of presentation for our patient is remark-able. Males presenting with bilateral subareolar swelling likely have gynecomastia secondary to a systemic cause. While rare in young males, the incidence of male breast cancer appears to be on the rise. This strongly supports our position that unilateral breast swelling should not be dismissed simply as gynecomastia. It is also apparent that more studies are needed to investigate how best to treat the disease and to establish separate proto-cols for men, rather than extrapolating protocols from studies of women with breast carcinoma. This will lead to a greater understanding of male breast cancer and provide a better outlook for the men affected by it.

ACKNOWLEDGMENTThe authors have indicated that they have no conflicts of interest regarding the content of this article.

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Screening mammography, however, is of little use in men because of the rarity of the disease and the small size of the male breast, which allows easy palpation of most masses.1 As in women, a biopsy of any suspicious mass should be performed.1,2 Fine-needle aspiration has been evaluated in male patients and has been found to be very sensitive and specific. When malignancy is diagnosed, the tumor should be staged according to the TNM system. Also, tissue evaluation should include the assessment of hormone-receptor status, because of its prognostic significance.

The major prognostic factors in male breast can-cer are the same as those found in women, with lymph node involvement being the most signifi-cant negative prognostic factor for both sexes.4 Clinical outcome for men with breast carcinoma is similar to that for women, with the stage of the disease predicting the survival of the patient. It must be understood, however, that although stud-ies have reported a similar clinical outcome for men and women with the same stage of disease, men present at a later and more advanced stage, which results in a bleaker outlook for them.

For men who present with nonmetastatic dis-ease, the current recommendation for surgical therapy is a modified radical mastectomy with axillary lymph node dissection.3 Surgeons also agree that radiation to the internal mammary nodes should be conducted in all patients, and that chest wall radiation also be considered for patients with locally advanced disease.

Because 90% of tumors are estrogen-receptor positive, tamoxifen is standard adjuvant therapy.10

Many studies have retrospectively compared men who were treated with tamoxifen in an adjuvant setting with men who received no hormonal therapy and found improved survival rates in patients treated with tamoxifen.11–13 A study of 229 patients by Goss et al12 revealed significant improvement in 57 patients who were treated with adjuvant tamoxifen therapy (P < 0.037). Half of these patients did not need to continue hor-monal therapy after 2 years. Another study of 39 males with breast carcinoma conducted in Manchester, England, found a 61% survival rate in those individuals who received treatment with

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the breast. Am J Clin Oncol. 1987;10:55–60.

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cancer mortality in Europe, 1955–1989: III, Breast

and genital sites. Eur J Cancer. 1992;28A:927–998.

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systemic therapy for male breast carcinoma.

Cancer. 2005;104:2359–2364.

11. Spence RA, MacKenzie G, Anderson JR, et al.

Long-term survival following cancer of the male

Address correspondence to: Dr. Dale Maharaj, 12 Park View, Trincity, Trinidad, West Indies. E-mail: dalemaharaj@

hotmail.com