|BREAST MINI SYMPOSIUM
|Year : 2012 | Volume
| Issue : 3 | Page : 272-276
Male breast cancer in Indian patients: Is it the same?
SB Chikaraddi, R Krishnappa, V Deshmane
Department of surgical oncology, Kidwai Memorial Institute of Oncology, Bangalore, India
|Date of Web Publication||12-Dec-2012|
S B Chikaraddi
Department of surgical oncology, Kidwai Memorial Institute of Oncology, Bangalore
Source of Support: None, Conflict of Interest: None
Background: Cancer of the male breast accounts for about 1% of all malignancies in men and 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. This study was done to analyse the demographic data, management and survival of male breast cancers in Indian subset of patients and compare it with that of western literature. Materials and Methods: A 10 year (2001-2010) retrospective study of all male breast cancers was done. Data regarding the incidence, presentation, histopathology, stage and grade of tumor, management and outcome of patients were analysed. Results: 26 cases of male breast cancer were encountered. This comprised 0.4% of all breast cancers seen in our department during the 10 year period. The ages of patients ranged from 45-75 years with a mean age of 57 years. Family history was present in 4 patients. Clinically, symptoms included self-detected lump in 23 (88.5%) patients, nipple retraction in 12 (46.1%) and pain in 12 (46.1%). All cases were unilateral (16 on right, 10 on left). Disease most commonly involved central quadrant (9 patients). Grade 3 disease was found in 13 patients and Stage 3 disease was most commonly encountered (13 patients). None of our patients received neo adjuvant chemotherapy. 20 (76.9%) patients had modified radical mastectomy and 6 (23.1%) had radical mastectomy. Most of our patients were hormone receptor positive (21 patients). Bilateral orchidectomy, Adjuvant chemotherapy, Adjuvant radiotherapy and Tamoxifen were offered in 3 (11.5%), 16 (61.5%), 17 (65.4%) and 15 (57.7%) patients respectively. Follow up ranged from 1-59 months. Conclusion: Male breast cancer is rare in our centre. Late presentation with advanced disease is a common feature in our environment. Further multiinstitutional, prospective studies are needed for better understanding of management of male breast cancers in Indian subset of patients.
Keywords: Male breast cancer, adjuvant therapy in male breast cancer, clinicopathology of male breast cancer
|How to cite this article:|
Chikaraddi S B, Krishnappa R, Deshmane V. Male breast cancer in Indian patients: Is it the same?. Indian J Cancer 2012;49:272-6
| » Introduction|| |
Relative to the disease in women, Male breast carcinoma (MBC) is rare, accounting for 1% of all malignancies in men and around 1% of all cases of breast carcinoma.  In the United States, approximately 1910 new cases of MBC were estimated to be diagnosed and 440 deaths to occur in 2009.  The worldwide variation of MBC resembles that of breast cancer in women,with higher rates in North America and Europe and lower rates in Asia.  The mean age of diagnosis for men with breast cancer is 67 years, which is approximately 5-10 years older than that in women. As in women, the incidence of MBC has increased, approximately about 26% over the past 25 years. 
A number of factors have been considered to be related to increased risk for breast carcinoma in men. A family history of breast carcinoma, clinical conditions causing hypoandrogenism (including Klinefelter's syndrome, testicular trauma, or infertility), liver disease causing hyperestrogenism, and gynecomastia have all been implicated as possible risk factors. Unfortunately, these factors are not consistently reported; therefore, their relation to the disease is unclear. 
Previous reports have drawn similarities between breast carcinoma in men and women with regard to presentation and sites of distant metastases. In addition, there is clinical evidence that, as in females, tumor size and axillary lymph node involvement are important prognostic factors in male breast carcinoma.  Histopathologic subtypes are also similar in men. Lobular carcinoma, previously not thought to occur in men due to lack of lobular differentiation, has now been reported in a few cases. 
Development of optimal treatment strategies specific to male breast carcinoma is limited by a lack of traditional large scale clinical trial data. As a result, current clinical management is generally extrapolated from principles established for the treatment of female breast carcinoma. Data on male breast cancer in indian patients has been a rarity. We present here our series of male breast carcinoma cases over a 10 year period. This study was done to analyse the demographic data, tumor characteristics, management and outcome of male breast cancers in Indian subset of patients and compare it with that of western literature.
| » Materials and Methods|| |
Men presenting to our institute with breast carcinoma were ascertained from patient registration records from Jan 2001-Dec 2010. Data regarding patient history, presenting signs and symptoms, risk factors, primary tumor pathology, treatment strategy (surgery, chemotherapy, and radiation), details of recurrence, treatment for recurrence, and follow up were obtained by retrospective analyses of patient case records. Obesity was estimated by calculating body mass index (BMI > 30) from height and weight recorded by attending surgeon. As high alcohol intake was regarded the statement of that by surgeon in the patient record. Diagnosis of the disease was done in all cases by fine needle aspiration cytology(FNAC) of tumor. Mammography was not used in our study. Preoperative metastatic work up included chest Xray, ultrasound abdomen and bone scan in all cases. TNM staging was based on 6 th American joint committee on cancer (AJCC) classification system. Receptor positivity was assessed with immunohistochemistry. The patients were followed up by clinic visits every six months in first 3 years and every year thereafter till death or till Dec 2010. All patients underwent physical examination, ultrasound abdomen, chest Xray and bone scan during follow up. Genetic study (BRCA 1, BRCA 2, PTEN) was not done in any of our patients.
| » Results|| |
Twenty six male breast carcinoma patients were treated over the 10-year period. The median age at diagnosis was 57 years (range 45-75). A positive family history of carcinoma breast was reported in only 15.4% of cases overall. There were no patients with clinical Klinefelter's syndrome or a history of unusual exposure to radiation. History of gynaecomastia was present in 1 patient. Most common mode of presentation was a self-detected lump (88.5%) followed by pain (46.1%). Mean delay from first appearance of symptoms to first surgeon contact was 8 months (range 1-48 m). The most common sign at first examination was a palpable breast mass. Risk factors and other patient characteristics at presentation are summarized in [Table 1].
Right breast was most commonly involved (61.5%). Tumors occurred most frequently in the central retroareolar region (34.6%). The second most common site was the lower outer quadrant (26.9%). Most of the tumors belonged to clinical stage 3 (46.1%). Tumor characteristics at presentation are summarized in [Table 2].
Primary treatment consisted of surgery. The majority of patients underwent modified radical mastectomy (76.9%). Radical mastectomy was done in 6 (23.1%) patients. Breast conservation surgery was not done in any of our patients. Orchidectomy was done in 3 (11.5%). Most common histologic subtype was pure ductal carcinoma (96.2%). Tumors most commonly belonged to grade 3 (50%) and pathologic stage 3 (50%). Lymph nodal harvest was most commonly found to be between 1-3 nodes (38.5%). ER/PR hormone receptor positivity was found in 76.9% and triple negativity in 19.2% of our patients. Histopathologic features are summarized in [Table 3].
None of the patients received neoadjuvant chemotherapy. Adjuvant chemotherapy (Epirubicin and Cyclophosphamide × 6 cycles), Radiotherapy (50 gy in 25 fractions) and Hormone therapy (Tamoxifen) were offered in 16 (61.5%), 17 (65.4%) and 15 (57.7%) patients respectively. Surgery alone was received as a treatment modality by 5 (19.2%) patients. Adjuvant treatment is summarized in [Table 4].
Median follow-up was 17 months and ranged from 1-59 months. At last follow-up, 4 patients had recurrence. The site of recurrence was locoregional in 1 patient and distant in 3. Duration of occurrence of recurrence ranged from 3-31 months. The one case of locoregional recurrence was in supraclavicular area and was treated with second line chemotherapy (Docetaxel and Capecitabine). Two of distant recurrences occurred as pleural effusion, one of which was treated with second line chemotherapy (Docetaxel and Capecitabine) and the other symptomatically. The third distant recurrence occurred as bone metastasis and was treated with radiotherapy and biphosphonate therapy. Thus most common site of recurrence was distant.
| » Discussion|| |
The median age at diagnosis in our series was similar to that in previous studies, further supporting the theory that breast carcinoma generally presents 5-10 years later in men than in women. Unlike in women, for whom familial breast carcinoma is often associated with an earlier age of onset, the median age at diagnosis was similar for patients with and without a family history of cancer. 
A family history of breast cancer confers a relative risk of 2.5. About 20% of men with breast cancer have a positive family history.  This was found to be present in 15.4% of our patients. Inherited mutations in BRCA increase the risk of MBC, more so with BRCA 2 (5- 15%) than BRCA 1 (0-4%).  Because of the prevalence of these mutations, the national comprehensive cancer network (NCCN) recommend that BRCA mutation testing be offered to men who develop breast cancer.  Genetic study was not done in any of our patients.
Male breast carcinoma and gynecomastia may be unrelated except that both may be caused by abnormal hormonal environments.  A longitudinal, prospective histologic or mammographic study of men with gynecomastia may be the only way to resolve this question.
Consistent with previous reports, the central retroareolar region is the most common tumor site in our series. In women the most frequent location is the upper outer quadrant of the breast. These gender differences in tumor location are likely related to the relatively rudimentary nature of the male breast.  As shown in previous studies nipple involvement is a fairly early event, with retraction in 9%, discharge in 6% and ulceration in 6% of patients.  Nipple retraction was found in 46.1% of our patients.
The sensitivity and specificity of mammography for the diagnosis of MBC is 92% and 90% respectively.  The nonusage of mammography in our patient population, likely reflects both the large proportion of palpable tumors at presentation and the absence of routine breast carcinoma screening in men. The relative ease of diagnosis by physical exam and the rarity of the disease does not support widespread mammographic screening. However, mammography is useful for differentiating between gynecomastia and malignancy in the male patient. 
The diagnostic evaluation and staging system used for MBC are the same as for female breast cancer. Only 48% of MBC are diagnosed at stage 1 or stage 2, so that, in comparison with women, men tend to be diagnosed with later stage disease.  The same was reflected in our study where most of the patients belonged to stage 3.
The transition in primary surgical procedure from the radical mastectomy to the modified radical mastectomy mirrors the elimination of the radical mastectomy from standard treatment of female breast carcinoma in the 1970s. Retrospective studies suggest the equivalence of these two surgical procedures in terms of local recurrence and survival. The only exception is cases that have extensive chest wall muscle involvement may benefit from a radical mastectomy.  Breast conserving surgery was not performed in our series. The paucity of breast tissue in men may often render adequate tumor excision by breast conservation impossible.  It is not likely that breast conserving surgery will be performed as often on men as on women.
Consistent with previous reports, ductal carcinoma was the most common histologic subtype. Lobular carcinoma was not found in our study. The earlier assumption that lobular carcinoma could not occur in men due to the absence of lobules in normal male breast tissue has been dispelled. It is now known that true acinii and lobules can develop in the male breast during exposure to increased estrogen. 
Lymph node involvement has often been cited as a significant prognostic indicator in men. Men who have nodal dissection omitted tend to have a worse outcome. Lymph nodal harvest was most commonly found to be between 1-3 nodes in our study. Sentinal lymph node biopsy (SLNB) has been evaluated in MBC. Large studies have not been performed. However, several case series have been published that have established the feasibility of SLNB in MBC. ,,
Recommendations for adjuvant chemotherapy are based on benefits that have been observed in clinical trials performed in women. Retrospective comparisons have supported a reduced risk for recurrence and a survival benefit after adjuvant chemotherapy in MBC. Adjuvant chemotherapy should be considered in men similarly as in female breast cancer and is mandatory in hormone receptor negative tumors. ,
There is limited data regarding usefulness of adjuvant radiotherapy in MBC. Men are more likely to have nipple and skin involvement. Hence a review suggested that adjuvant radiotherapy should be used on similar guidelines as of female breast cancer. ,,
MBCs have high rate of hormone receptor expression. Approximately 90% are ER positive and 81% PR positive. In contrast, 60-70% of female breast cancers are ER or PR positive. Recent studies have shown lower rate of Her 2-neu overexpression in men (2- 15%) in contrast to females(18-20%). ,, ER/PR hormone receptor positivity was found in 76.9% and triple negativity in 19.2% of our patients. Tamoxifen is accepted as the standard of care for adjuvant hormonal therapy in MBC. No randomised clinical trials have assessed the their use in men, but several retrospective studies have shown a reduced risk of recurrence and death with adjuvant tamoxifen in MBC. The role of aromatase inhibitors in the adjuvant setting is limited when compared with female breast cancer. As of now, five years of adjuvant tamoxifen is recommended for hormone receptor positive men following mastectomy and there is insufficient data to support the use of aromatase inhibitors in MBC. , Though there is no data for their usage in MBC, in view of the benefit seen in females, adjuvant trastuzumab should be considered in Her2-positive men. 
In the past, MBC was considered to have a worser prognosis than female counterpart. Overall survival rates were lower, which was probably thought to be due to older age of diagnosis and advanced disease at presentation. Contemporary reports of both MBC and female breast cancer that were carefully matched for age, stage and grade do not substantiate a worse survival in men. ,,
The limitations of this study included the small sample, single institute experience and retrospective data. To better detect possible other differences between female and male breast cancer, more systematic characterization of tumors, identifying tumor subtypes and genetic mutations as well as gathering of clinical data prospectively are warranted.
| » Conclusion|| |
Carcinoma of the male breast has many similarities to breast cancer in women, but there are distinct features that should be appreciated. Male breast cancer is a rare disease at our centre. Late presentation with advanced disease is a common feature in our environment. The data presented in this retrospective study is not appropriate for accurately assessing the efficacy of any given treatment. Though the rarity of the disease limits the feasibility of clinical trials, a comprehensive, multiinstitutional, prospective data collection would augment our understanding of risk factors and prognostic factors as well as improve management of male breast cancers in Indian subset of patients.
| » Acknowledgment|| |
- Department of Surgical oncology, Kidwai Memorial Institute of Oncology, Bangalore.
- Department of Pathology, Kidwai Memorial Institute of Oncology, Bangalore.
- Department of Anaesthesia, Kidwai Memorial Institute of Oncology, Bangalore.
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[Table 1], [Table 2], [Table 3], [Table 4]