-@@

Appi-oximately one case of cancer ofthe male breast is seen for evei-y one

hundi-ed cases of cancei- of the femalebreast. Although cancel- of the malehi-east occurs most frequently in thefifth decade, the age range may extendfrom the early twenties into the lateeighties. As in the case of cancer of thefemale hi-east, the left breast is morefrequently affected.

At one time it was believed that theadministi-ation of estrogen therapyfor advanced piostatic cancer was acausative factor in the development ofcancer of the male breast. Subsequentstudies disclosed that the breast lesions were actually metastatic piostatic cai-cinoma rather than true pm-i-mary cancel-s of the male breast.

A i-eview of the litei-ature indicatesthat thei'e is no definite correlation between trauma and the development ofmale breast cancer. The trauma, inmost cases, merely calls attention to apre-existing lesion. In addition, therewas no anamnestic evidence of a preexisting gynecomastia which could becorrelated with the development ofcancer of the male hi-east.

SymptomsMost male patients with cancer of

the breast have the following majorsymptoms, either alone or in combina

Pu-. Holleb is .1ssociate .1!eo'ico/ Duu'ectm', ciuudA 5sust(Iuuf -i t!euuili uu(/ Suuu'Oeuuui, @!euuuOu'i(I/Hospitalfor (Jauucer aiud Al/icc! Diseases, Sew York City.

25

Cancer of the

Male Breast

Arthur I. Holleb, M.D.

tion: a hi-east mass or swelling;serous or bloody discharge from thenipple; nipple reti-action (Fig. 1),encrusti-ation or ulceration ; axillaiyswelling, and local om-distant pain. Themore advanced the disease, the largerthe symptom complex. In most cases,the first symptom noticed by the patient is the presence of a mass. Pain isa very infrequent finding, even whenthere ai'e nipple abnormalities. Whe:ithere is nipple dischaige, it is mo:@toften bloody, although at times it maybe seious. It has become apparent thatnipple discharge in the adult male frequently indicates an undeilying canceland calls for an immediate and thorough investigation.

The median duration of symptomsis about nine months before the fiistmedical consultation is sought. Onlyabout one quaiter of the patients willseek treatment within three months ofthe onset of symptoms. In a number ofinstances, the patient is observed fora long period of time by a physicianwho may not be aware of the possibility of cancer occui-iing in a malebreast.

A wide range of physical findingsare found in inoperable hi-east cancelin the male. The clinical pictui-e variesfrom massive local disease to widespread dissemination or a combinationof both. In the early group—the operable cases—the most common findingis the presence of a mass in the sub

Fig. 1. Four cases of male breast cancer showing nipple retraction and deformity.

areolar region of the involved breast.The mass may be fixed to the ovet-lyingskin and may even demonstrate ulceration. Ulceration, when present, is almost always within the confines of the

areolar margin and often presents itself as nipple destruction (Fig. 2). Theskin overlying the mass may be encrusted and present an eczematoidappearance. In the early cases, the skinmay not be involved, but true nippledischarge might be present. About75% of the patients will show nippleabnormalities of one type or another.

If a mass in the adult male breast warrants suspicion of cancer, then certainly the disclosure of a mass asso

ciated with a nipple abnormality should

confirm that suspicion, especially whenthere is evidence of nipple reti'action

(see Fig. 1). The importance of nippledischarge as a symptom or a phy@icalsign has been underrated in the diagnosis of male breast cancer and shouldbe considei'ed as a possible early manifestation of this disease. When the disease has extended beyond the breast,enlarged homolateral axillary lymph

26

If_il, /1;'

-.,,, - ‘¿�

/

Fig. 2. Cancer of the male breast showingextensive destruction of the nipple.

Fig. 3. A 61-year old man, nipple replacedby a 4 cm, mass: infiltrating duct carcinoma, with axillary node metastases.

nodes ai-e usually palpable (Fig. 3).The ovem--all size of the bi-east mass

may be misleading when considered interms of eam-ly diagnosis since some patients with a 3 cm. mass have completedestruction of the nipple and other patients show clinical evidence of axillaiyinvolvement.

Almost every histological type of cancei found in the female breast is alsoencountered in the male breast—papillary carcinoma, infilti-ating duct carcinoma (Fig. 4), niedullaiy cai-cinoma,etc. It might be noted that a true caseof fibioadenoma has never been recorded in the male breast in a reviewof the i-ecords of Memorial Hospital,and, accordingly, there is no confirmedieport of a cystosaiconia phyllodes inthe male. Paget's disease (Fig. 5) andinflammatory care inoma have also beeni-eported as occurring iii the malebreast, although there diagnoses areuncommon. On raie occasions, simultaneous bilateial cancel- of the malehi-east will be found. In addition, nonsimultaneous bilatei-al carcinoma ofthe male hi-east may occui, but this,too, is rather uncommon.

TreatmentThe best known method of treating

pi-imai-y opeiable cai-cinoma of themale breast is radical mastectomy. Because of the small size of the malebi-east it is often necessai-y to close thewound by means of a skin graft.

If the pathological repoit of the radical mastectomy specimen demonstratesthe presence of involved i-egional axillary lymph nodes, the patient is subjected to a course of radiation therapyto the supraclavicular amid internalmammary lymph nodes.

PrognosisThe prognosis following appropriate

surgical therapy is essentially no diffem-ent than that encountered in cancer of the female breast. When theaxilla is not involved, about 75% ofthe patients will be fiee of disease atthe end of five years. When the diseasehas extended to the axillary lymphnodes, the sui-vival will he i-educed toabout 30%. This emphasizes onceagain the importance of eam-ly diagnosis of hi-east cancer.

Thei'e appears to be a better sum-vival

27

yr.

@g.4. A 57-year t. ,,,n, 10 cm. mass:infiltrating duct carcinoma, associatedwith a separate primary carcinoma of theprostate.

@rota man, induratea utand a 3 cm. mass: Paget's disease of thenipple and infiltrating duct carcinoma, withnormal axillary nodes.

rate in patients who have papillarycarcinoma of the breast as comparedwith the other malignant histologictypes. Age seems to be a relatively unimportant factor in evaluating prognosis. Prognostication appeal-s to bedependent more on the histological typeof cancer and the absence or presenceof involved axillary lymph nodes.

Patients who have disease beyondthe scope of surgical removal should besubjected to bilateral oichiectomy as aprimary therapeutic measure. However, castration is not advocated as asubstitute for the conventional radicalmastectomy in cases of primal'y opel'-able male breast cancer. Regression oftumor following orchiectomy can beexpected in about 50% of patients but,in some instances, the duration of response may be extremely short. When

i-eci'udescence of activity occurs, additional palliation may be achieved bythe administration of estrogens orprednisone. Due to the infrequency ofthe disease, it is still somewhat uncei-tain which of the two hormonalprepal'ations is the most advisable.

Summary

In summary, although cancei' of themale bi-east accounts fol' about 1 ¶@ofall bi-east cancei-, early diagnosis andprompt surgical thel-apy will give respectable cure rates. The presence of amass in the male breast in a patientover the age of 20 should alei-t thephysician to the possibility of cancer.When there is any suspicion that thehl'east mass may not be a simple caseof gynecomastia, a biopsy should bel)erfol'med without delay.

28