SBI Case of the Month

Content on this page requires a newer version of Adobe Flash Player.

History
The patient is an 80-year-old male with a known BRCA2 gene mutation and a history of prostate cancer, status post external beam radiation with androgen deprivation treatment. He presented with a palpable left breast lump, just superior to the left nipple and left nipple retraction. The patient's daughter had breast cancer.

Diagnosis
Infiltrating lobular carcinoma in a male

Description of Findings
A diagnostic mammogram of the left breast (figure 1: Panel A is the MLO view and Panel B is the CC view) demonstrates irregular focal asymmetry in the retroareolar region measuring up to 2.5 cm in diameter without associated microcalcifications. However, there is associated left nipple retraction. Ultrasonography of the left breast (figure 2) shows a corresponding irregular hypoechoic mass measuring without significant posterior enhancement or shadowing. These findings were interpreted as BI-RADS Category 4 and biopsy was recommended. Ultrasound-guided core needle biopsy was subsequently performed, which revealed an infiltrating mammary carcinoma with lobular features, nuclear grade 2. The neoplastic cells were positive for estrogen and progesterone receptors.

Discussion
Breast cancer in males is uncommon, comprising 0.7% of all breast cancers. Infiltrating ductal carcinoma is the most common histologic type of breast cancer in males, comprising about 85% of cases. In contrast, invasive lobular breast carcinoma is particularly uncommon in males due to underdevelopment of the lobules. Indeed, these represent only 1.5% of male breast cancer cases. The presence of BRCA1 and BRCA2 gene mutations are risk factors. Other potential risk factors include Kleinfelter's syndrome, history of breast cancer in a first degree relative, and conditions related to hyperestrogenism and androgen deficiency.

Males with breast cancer most commonly present with a palpable mass. Mammography and ultrasound are appropriate diagnostic modalities. On mammography, male breast cancers have similar features as their female counterparts, including spiculated or indistinct margins, although microcalcifications are less common in males. Similarly, on ultrasound male breast cancers are typically appear as spiculated or microlobulated, solid, hypoechoic masses. However, cystic lesions are frequently malignant in male patients as well. Most tumors are subareolar. Up to 40% of males with breast cancer have underlying gynecomastia and 50% have axillary lymphadenopathy.

Routine mamographic screeing in males is not performed and is controversial in those with risk factors. Nevertheless, males that present with a suspicious finding should undergo biopsy. Although invasive lobular carcinoma is not well characterized in male patients, staging and treatment for male breast cancers in general are comparable to those for the female counterparts.

References

Brenner RJ, Weitzel JN, Hansen N, Boasberg P. Screening-detected breast cancer in a man with BRCA2 mutation: case report. Radiology. 2004 Feb;230(2):553-5.

Brem RF, Ioffe M, Rapelyea JA, Yost KG, Weigert JM, Bertrand ML, Stern LH. Invasive Lobular Carcinoma: Detection with Mammography, Sonography, MRI, and Breast Specific Gamma Imaging. AJR 2009; 192:379-383.

Chen L, Chantra PK, Larsen LH, Barton P, Rohitopakarn M, Zhu EQ, Bassett LW. Imaging characteristics of malignant lesions of the male breast. Radiographics. 2006 Jul-Aug;26(4):993-1006.

Case Contributed By
Daniel Ginat, M.D. and Radha Iyer, M.D.
University of Rochester Medical Center