Teaching Case

The majority of breast tumours are primary carcinomas and the breast being the site of metastasis is only rarely seen. In this case the breast mass in a male was the result of an unusual metastatic pattern.

A man, who had been a heavy smoker for 65 years, attended the breast surgery department with a 5 x 5 x 3 cm palpable tumour of the right breast. It was located 5 cm. lateral of the right mammarian papilla. The tumour was adherent to the fascia but not to the thorax wall. Because of age restrictions neither mammography nor ultrasonography (< 75 years) was performed. Instead a palpatory, histological biopsy was collected. The mass contained adenocarcinoma as well as small cell carcinoma. No glandular configurations were seen, why breast carcinoma in origin could be excluded. Lung or thyroid cancer was suggested. Ultrasonography of the thyroid gland revealed no tumour. Conventional X-ray of the thorax (single picture, frontal projection), revealed a tumour at the level of the lower part of the right lung. Still, without the lateral projection it was impossible to determine, if the tumour was located in the lung or in the breast. No other tumours were suspected from the picture. Next a CT-examination of the upper abdomen was performed, on which the breast mass was clearly seen. Furthermore the images revealed a 2.8 x 2.7 x 2.3 cm lobulated tumour of the anterior, lower part of the right lung, as well as a focal thickening of the pleura in the space between costa 7/8 on the right side. Based on the advanced disease and the general condition of the patient, he was scheduled to receive palliative radiation therapy solely. He died two months later.

Malignant tumours of the male breast only accounts for 1-2 % of the primary breast carcinomas. Furthermore, the breast is an unusual site for metastasis. According to the WHO classification of tumours, only 0.5-6% of breast malignancies are metastases from other organs. Lymphomas, malignant melanomas, gastrointestinal tumours (GIST) and bronchial carcinomas account for most of the metastases to the breast, but metastases are occasionally seen from carcinomas of the cervix, ovary, endometrium, plasma cell myeloma and from the kidney. In this case the breast/chest wall mass derived from a mixed lung tumour containing adenocarcinoma and small cell carcinoma. Cancer of the lung most often disseminates to the bones, liver, brain, contralateral lung or to the suprarenal glands. Unusual sites of metastasis involve iris, placenta, vagina and breast. Most primary chest wall tumours are benign – the majority being lipomas. Metastases as well as primary malignancies of the chest wall are rare. The typical CT-appearance of a metastatic deposit in the soft tissue of the chest wall is a round or lobulated, often homogeneous, lesion, intensely enhancing after administration of iv. contrast. In contrast to primary chest wall tumours which can be large, diffusely infiltrating and rapidly growing, the metastases tends to be smaller with more well-defined borders. Still, in the male patient or in a female with limited glandular tissue, a metastasis to the breast from a distant tumour can be problematic to distinguish from a breast/chest wall metastasis, since the musculature can be infiltrated in either case. To distinguish between primary malignancies of the breast and metastatic deposits, a histological biopsy of the breast mass is mandatory in every case to secure the correct treatment of the patient. If the patient is male, the importance of this is emphasised, since the incidence of primary cancer of the male breast in general is low. In case a metastatic deposit in the breast or in the chest wall is suspected, a CT scan is needed to determine the origin and eventual spread of the disease.