Male breast cancer

Section: Breast Curriculum: Curriculum, page 14

Incidence

• <1% of Breast Ca
• 0.8/100 000 per year
• Mean age 65 (10 yrs older than women

Risk Factors

• Personal Hx (Increased oestrogen: testosterone exposure)
  • Klinefelter’s – 50 x fold increased risk
  • Undescended testes/ congenital inguinal hernia, Orchidectomy, Testicular injury/orchitis
• Cirrhosis
• Rx of Prostate & Testicular Ca
• Obesity
• FHx:
  • 1° Relative
  • BRCA2 + BRCA1
    • Male BRCA-2 > 5% risk
    • Accounts for ~ 4-5% of male Breast Ca
  • [Cowden’s syndrome]
  • CHEK2
• Environmental - Radiation exposure, oestrogens, alcoholism

Clinical

• Present 10 yrs later than women
• Breast mass: Asymmetrical (gynaecomastia: symmetrical involvement of entire breast plate)
• Nipple retraction / discharge – 50%
• Fixity, ulceration, pain
• Lymphadenopathy - 30%
• Bilateral (synchronous or metachronous) in 5%

Pathology

• Invasive Ductal Ca = Commonest (70-90%)
• DCIS 7%
• LCIS not been reported + Lobular Ca rare due to low no. of lobular units in men
• Secretory Breast Ca (rare) observed at younger ages
• Higher rate of hormone +ve = 85% ER +ve, 70% PR +ve (Cf 75% and 65% female breast ca)

Investigations

• Triple Assessment
• Mammography diagnostic in 90%
• Core biopsy (FNA accurate in ~ 85%)

Management

• Surgery
  • Surgery for Proven Ca = Mastectomy
  • SLNB for clinically/radiologically negative
  • ALND for clinical/radiological +ve nodes confirmed on FNA/core
• Radiotherapy
  • Same guidelines as for women following mastectomy
  • Indications: Poor Prognostic Features, e.g.
    • Large tumour

    • 3 Axillary LN positive

    • High Grade
• Adjuvant treatment:
  • Chemotherapy – same indications as female
  • Endocrine
    • Hormonal if ER+ve recommended for 5 yrs.
      • Tamoxifen preferred
      • AI and GnRHa an option
        • 80% oestrogen produced by adipose tissue and 20% produced by testes
        • If you block adipose production hypothalamus will stimulate testes to produce more reducing effect of AI
        • Can’t use AI unless orchidectomy/chemical castration
• Management of Distant Mets:
  • As per women and as above for endocrine treatment

Prognosis / Natural Hx:

• Stage for stage same prognosis but usually present later
• Same predictive factors
  • Nodal burden
  • Size
  • Grade
  • Hormonal status
• 5Y Survival:
  • 90% for node -ve patients
  • 65% for node +ve patients
• Up to 40% will develop local recurrence
• 18-54% distant mets
• Median survival from time of presentation with mets is approx. 2 years

Follow-up

• 1° relatives of male Breast Ca pts at high risk