CASE 14463 Published on 28.02.2017
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Male breast cancer: a rare case of synchronous bilateral invasive ductal carcinoma.

Section

Breast imaging

Case Type

Clinical Cases

Authors

Mavromati Areti, Ege Jon, Drabløs Ole, Nes Harald, Radiology Department, Igor Plotnikov Pathology Department, General Public Hospital of Haugesund, Norway.

General Public Hospital of Haugesund, Norway
Connected authors
Patient

59 years, male

Categories
Area of Interest Breast, Lymph nodes ; Imaging Technique Mammography, Image manipulation / Reconstruction, Ultrasound
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Clinical History
A 59-year-old man presented to our hospital with a palpable mass in the right side of his breast.The physical examination revealed a non-mobile, painless lump in the right breast and a second similar mass in the contralateral breast. There was no history of familial breast cancer, solid organ tumour or hormonal treatment.
Imaging Findings
Digital mammography was performed revealing a discrete, dense mass with spiculated margins eccentric to the nipple-areolar complex on both breasts (fig.1, 2a-b, 3, 4a-b). There were no associated axillary adenopathy, pathological calcifications, nipple discharge or retraction phenomena. A further work-up included a US examination of the breast. The imaging features included an irregular hypoechoic mass with angular margins, without any posterior enhancement/shadowing or internal vascularity on both breasts (fig.5a-c, 6a). The patient underwent ultrasonography-guided core needle biopsy of both breast masses (fig.5c, 6b).The histologic report confirmed the diagnosis of invasive ductal carcinoma bilaterally(fig7a-d).
On the CT thorax/abdomen/pelvis with iv contrast and bone-scanning there were no signs of metastatic spread.
Mastectomy bilaterally and sentinel lymphnode biopsy were subsequently performed, one lymphnode with mikrometastasis with no extranodal growth was found on the right axilla(fig8a-b)[9, 10]. The patient was commenced on adjuvant hormone therapy with tamoxifen and radiotherapy on the right axilla.
Discussion
Male breast cancer (MBC) is a rare neoplasm which accounts for 1.2–2% of all cancers in men [1-4]. Bilateral breast cancer accounts for only 0.5 – 1% of MBC and synchronous cancers, as in our case, are extremely rare [7]. The median age of MBC onset is 62-69 years, and is much later than that reported for female breast cancer (< 50 years) [1, 4, 5, 7]. The most important risk factors are family history and mutations of BRCA (primarly BRCA2)[2, 3]. Other important risk factors are: Klinefelter syndrome, oestrogen or testosterone use, orchitis/epididymitis, obesity, lack of exercise, and exposure to radiation [2, 5, 6]. The majority of male breast tumours are invasive ductal carcinoma (85% to 95%), followed by ductal carcinoma in situ (5% to 10%) [9]. Among invasive carcinomas, 93.7% are ductal or unclassified carcinomas, 2.6% are papillary tumours, 1.8% are mucinous tumours and only 1.5% are lobular tumours [7, 9]. The most common type of male breast cancer is hormone receptor positive – 82%, 15% are human epidermal growth factor receptor 2 (HER2)-positive (young patients more likely), and 3% are triple negative [2, 3, 6].
The most common presentation of male breast cancer is a painless, firm subareolar mass. Other symptoms may include nipple retraction and/or ulceration and/or bleeding, axillary lymphadenopathy and gynecomastia [5, 7].
Imaging findings of MBC most often include a unilateral discrete mass with spiculated, angulated or microlobulated margins and increased vascularity at an eccentric location with respect to the nipple-areolar complex. Microcalcifications are rare but if present are usually fewer in number, coarser and less frequently rod-shaped compaired to those seen in FBC. The additional presence of nipple retraction, skin thickening and axillary lymphadenopathy are also important secondary features of MBC [8].
Surgery is the keystone in the treatment of MBC (including modified radical mastectomy or total mastectomy [1-3]) with sentinel lymph node biopsy gaining wider acceptance among breast surgeons [3]. Radiotherapy, hormone therapy and chemotherapy constitute an essential part of the adjuvant therapy depending on the extent of tumour (T- & N-stage), hormone receptor status, age, performance status of the patients, and associated co-morbidities [2, 3, 5]. MBC has a less favourable prognosis compared with FBC [4, 5]. This might be due to poor level of awareness, delayed diagnosis, increased age of onset, increased co-morbidity and a more progressive stage of disease at initial presentation [2, 5, 7]. In conclusion, MBC remains a rare disease, and synchronous, bilateral male breast cancer, as it was noted in our case, an exceptional finding.
Differential Diagnosis List
Male breast cancer, synchronous neoplasm, bilateral.
gynecomastia
abscess
sarcoma
metastasis
Final Diagnosis
Male breast cancer, synchronous neoplasm, bilateral.
Case information
URL: https://www.eurorad.org/case/14463
DOI: 10.1594/EURORAD/CASE.14463
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Mammography of the right breast, MLO view

Mammography of the right breast, MLO view
Mediolateral oblique view of the right breast shows a subareolar eccentric irregular mass with spiculated margins.
Figure 2

Mammography of the right breast, CC view

Mammography of the right breast, CC view
Craniocaudal projection: the suspicious mass is in the retroareolar region
Mammography of the right breast, CC view
CC projection, zoom in image: the spiculated margins of the mass are clearly seen.
Figure 3

Mammography of the left breast, MLO view

Mammography of the left breast, MLO view
An eccentric irregular opacity is depicted in the subareolar area
Figure 4

Mammography of the left breast, CC view

Mammography of the left breast, CC view
CC view: a suspicious nodule with irregular margins is better seen on this projection
Mammography of the left breast, CC view
CC view, zoom in image: the mass is approx. 7mm in diameter and is located laterally to the areola
Figure 5

Ultrasound of the right breast

Ultrasound of the right breast
A mass with angulated margins corresponds to the clinically palpable lump
Ultrasound of the right breast
The size of the mass is 1,1 x 1,0cm
Ultrasound of the right breast
An ultrasound guided core needle biopsy was performed
Figure 6

Ultrasound of the left breast

Ultrasound of the left breast
A 1,0cm irregular mass is seen eccentric to the nipple-areolar complex
Ultrasound of the left breast
A core needle biopsy was performed
Figure 7

Histopathology and Immunohistochemistry

Histopathology and Immunohistochemistry
LEFT BREAST(IDC grad 1) Magnification x 4: Breast tissue with malignant infiltrating tumor (up is the malignant tumor, down is fibrous breast tissue and some dilated ductuli
Histopathology and Immunohistochemistry
LEFT BREAST P120: an immunohistochemistry marker that helps to differentiate between ductal and lobular carcinoma: Ductal carcinoma shows membranous reaction, lobular carcinoma cytoplasmic reaction (in our case was membranous in both breasts).
Histopathology and Immunohistochemistry
RIGHT BREAST (IDC grad 1) estrogen receptor: 3+ intranuclear in 100% of the cells (the same outcome to both breasts)
Histopathology and Immunohistochemistry
RIGHT BREAST Progesterone receptor: 3+ intranuclear in 95% of the cells (3+ intranuclear in 80% of the cells to the left breast)
Figure 8

Sentinel lymphnode biopsy from the right axilla

Sentinel lymphnode biopsy from the right axilla
1 out of 3 lymphnodes with metastatic tumor was found (1/3, 2,0mm with no extranodal growth - pN1a). (lymphocytes as dark small cells on the right - metastatic carcinoma on the left).
Sentinel lymphnode biopsy from the right axilla
CKAE1-AE3 (a special marker): Cytokeratin verified that there is metastasis (with brown colour), this type of antibody reacts with epithelial cells but does not react with lipid and lymphoid tissue