tara powerpoint male breast cancer
TRANSCRIPT
12/29/2015 2
The Basics of Male Breast Cancer
Objectives
1. Identify and describe the clinical presentations of male breast cancer
2. Identify the risk factors and symptoms of male breast cancer
3. Diagnosis of male breast cancer
12/29/2015 3
Male and females are born with breast tissue. At puberty, high testosterone levels and low estrogen levels stop the breast development in males. Because males are born with a small amount of breast tissue, they too can develop breast cancer.
A portion of the male’s nonfunctioning breast tissue, (breast tissue that cannot produce milk), concentrated directly behind the nipple on the chest wall, creates a potential for spread of cells. If these cells become abnormal in appearance and behavior they are referred to as “cancer cells.”
Introduction
The Basics of Male Breast Cancer
12/29/2015 4
Clinical Presentation
The Basics of Male Breast Cancer
Though breast cancer is most commonly thought of as a woman's disease, male breast cancer does occur.
Breast cancer may occur in men at any age, but occurrence is most often between 60 and 70 years of age. Male breast cancer accounts for about 1% of breast cancers diagnosed yearly.
12/29/2015 5
The Basics of Male Breast Cancer
Advanced ageFamily history of breast cancerKlinefelter's syndromeLiver diseaseObesityRadiation exposureExposure to estrogen
Risk Factors
12/29/2015 6
SymptomsThere are no routine screening mammograms for men. Male breast cancer is usually discovered when the patient notices a change in his breast.
Male breast cancer presents with the same symptoms as in a woman:
•Lump•Bloody or clear nipple discharge•Dimpling of the skin•Inverted nipple
The Basics of Male Breast Cancer
12/29/2015 7
The Basics of Male Breast Cancer
Men diagnosed with male breast cancer at an early stage have a good chance for a cure. Still, many men delay seeing their doctors if they notice unusual signs or symptoms, such as a breast lump. For this reason, many male breast cancers are diagnosed when the disease is more advanced. *More than 40% of patients have stage III or IV disease at presentation
Most common types of cancer diagnosed in men are:• Infiltrating or invasive ductal carcinoma (also most common among female breast cancers).• Inflammatory breast cancer• Paget’s disease of the nipple
Diagnosis
Paget’s Disease
12/29/2015 8
The Basics of Male Breast Cancer
The most common type of male breast cancer is invasive ductal carcinoma. Ductal carcinoma refers to cancers that develop within origins of the ducts (tubular structures). Infiltrating means the cancer cells have spread beyond the ducts into the surrounding tissue.
Lobular cancers (cancers of the milk glands), are extremely rare in men since male breast tissue does not normally contain lobules.
Diagnosis Cont’d
Invasive Ductal Carcinoma (IDC)
12/29/2015 9
Grading of Breast CancerThe grade of a breast cancer is representative of how “aggressive” the tumor’s potential is.
-For example: A “low-grade” cancer is less aggressive than “high-grade” cancers. Determining the grade is important to healthcare providers as they use this information to guide the patient’s treatment options.-There are different “scoring systems” available for determining the grade. Scoring systems consider three factors:
1. Glandular formation- How well the tumor cells attempt to recreate normal glands2. Nuclear features- “Pleomorphism” or how ugly the tumor cells look3. Mitoses- Rate of cellular division
The Basics of Male Breast Cancer
12/29/2015 10
Grading Scores
The Basics of Male Breast Cancer
Total Feature Score Tumor Grade Cellular Appearance
3-5 Grade 1 Tumor Well-differentiated (appear normal, growing slowly, non-aggressive)
6-7 Grade 2 Tumor Moderately-differentiated (semi-normal, growing moderately fast)
8-9 Grade 3 Tumor Poorly-differentiated (abnormal, growing quickly, aggressive)
12/29/2015 11
BIRADS System
The BIRADS system is a tool that is used to assess a patients risk of developing breast cancer. This is rated from zero to six, zero being incomplete and in need of further imaging and six being a known malignancy. The BIRADS system also takes into account the patient’s breast density and risk factors.
The Basics of Male Breast Cancer
12/29/2015 12
Treatment/Management Options•Sentinel lymph node biopsy (SLNB)•Surgery•Tamoxifen•Adjuvant/Neoadjuvant hormone therapy•Radiotherapy
– Adjuvant chemotherapy: Chemotherapy given to patients who have no evidence of cancer after surgery, is called adjuvant therapy. Although surgery is used to remove all of the cancer that can be seen, adjuvant therapy is used to kill any cancer cells that might be left behind but cannot be seen.
– Neoadjuvant chemotherapy: Chemotherapy given to patients before surgery is called neoadjuvant. Giving these drugs before surgery helps to lower the chance of reoccurrence and improves survival rate as much as treatment post surgery.
The Basics of Male Breast Cancer
12/29/2015 13
The Basics of Male Breast Cancer
Survival RatesSurvival rates when compared to women diagnosed at the same stage are very similar. However, because of the higher incidence of BRCA2 mutations, men diagnosed with breast cancer are recommended to undergo genetic testing so the information can be passed on to female relatives.
BRCA1 and BRCA2 are human genes. These genes produce tumor suppressor proteins. The genes help repair damaged DNA and play a large role in ensuring the cell’s genetic material remains stable.
12/29/2015 14
Reconstruction Options•Decisions should be made prior to surgery•Reconstruction options include
– Surgery in conjunction with the mastectomy– Delayed surgery or day after the mastectomy– As immediately following the mastectomy as possible
Some men will require an implant to make the affected breast size the same as the remaining breast. In this case, immediate reconstruction is recommended. This is due to the combination of radiation treatment and whether any skin stretching is necessary to insert the implant; which can damage the skin and decrease the cosmetic appeal.
The Basics of Male Breast Cancer
12/29/2015 15
The Basics of Male Breast Cancer
Case Study #1History of the case study patient
– A 25-year-old Brazilian male– Referred from primary physician presenting with a right breast lump,
slowly growing over an 8 month period (Initial symptoms reported 2007)
– No family history of breast cancer – No history of drug, alcohol or steroid use – Takes prescription medication to treat seizures – Current smoker (Approx. 10 cigarettes per day)– Normal sex life– No children
Physical examination revealed a nodule located on the right breast; hardened consistency Retraction of the nippleNo presentation of enlarged or suspicious lymph nodes
12/29/2015 16
The Basics of Male Breast Cancer
Mammographic findings showed a noncalcified high density mass
Breast ultrasound revealed a hypoechoic nodule of irregular shape and partially defined limits measuring 1.7 × 1.3 × 1.1 cm of the right breast.
The MRI showed a retroareolar nodule in the right breast. There were also signs of infiltration of the pectoralis muscle.
(BI-RADS) category was 5: highly suggestive of malignancy.
Mammographic image of breast nodule
Imaging
12/29/2015 17
The Basics of Male Breast Cancer
A fine-needle aspiration and a core biopsy of the lesion was performedDiagnosis of invasive ductal carcinomaPatient began neoadjuvant therapy Underwent a modified radical mastectomy in 2008 of right breast
Biopsy and Diagnosis
12/29/2015 18
The Basics of Male Breast Cancer
Glandular (Acinar)/Tubular Differentiation
-Score 2: 10% to 75% of tumor area forming glandular/tubular structures
Nuclear Pleomorphism-Score 2: Cells larger than normal
with open vesicular nuclei, visible nucleoli, and moderate variability in both size and shape
Diagnosis Cont’d
12/29/2015 19
High grade vs low grade cancer (Histology)
The Basics of Male Breast Cancer
12/29/2015 20
The Basics of Male Breast Cancer
Pathology Results
• Final breast surgical margins were free of cancer cells, but the pectoralis muscle fascia and nipple were infiltrated
• Axillary lymph node dissection did not show any signs of cancer
• Staining of the tumor was positive for estrogen and progesterone receptors
12/29/2015 21
The Basics of Male Breast Cancer
The patient received adjuvant therapy; radiation therapy and tamoxifen (20mg/day).One year after the radiation therapy concluded, the patient presented with cervical and dorsal nodules, jaundice and weight loss; evaluation of suspicious recurrent breast cancer was done.Other health complications eventually caused his health to deteriorate and patient passed away in 2009. No biopsy was performed to diagnose a reoccurrence of breast cancer.
Treatment
12/29/2015 22
The Basics of Male Breast Cancer
History of the case study patient -40 year old male-Presents with a right breast lump-Physical examination revealed a fixed subareolar nodule-Second nodule also felt in right axillary region-Retraction of right nipple-Patient has no family history of breast cancer-Patient has three children
Mammographic findings-CC and MLO views demonstrated a right nodule
measuring 3 x 3 cm with irregular borders. Bilateral similar appearing axillary lymph nodes are present
Ultrasound findings -Demonstrates a 3 cm mass within retroareolar position of
the right breast -Irregular margins-Heterogeneously hypoechoic
Case Study #2
12/29/2015 23
The Basics of Male Breast Cancer
12/29/2015 24
The Basics of Male Breast Cancer
DiagnosisUltrasound-guided biopsy revealed findings consistent with poorly-differentiated invasive ductal carcinoma (grade III). Minor component of high nuclear-grade ductal carcinoma in situER-7 positivePR-6 positive4/4 lymph nodes biopsied; negative for metastatic carcinoma
TreatmentThe patient underwent modified right radical mastectomy
12/29/2015 25
The Basics of Male Breast Cancer
History of the case study patient -70 year old man presents with a
right breast lump-1.3 cm soft tissue nodule is
present in the subareolar area-Mammographic findings show a
mildly spiculated mass with poorly circumscribed borders
-Ultrasound demonstrates a 1 x 1.5 cm hypoechoic lesion with poorly defined margins and mild shadowing
Case Study #3
12/29/2015 26
The Basics of Male Breast Cancer
12/29/2015 27
The Basics of Male Breast Cancer
12/29/2015 28
The Basics of Male Breast Cancer
Ultrasound-guided core biopsy of right breast lumpDiagnostic findings consistent with those for invasive ductal carcinomaInvasive moderately-differentiated (grade II) ductal carcinomaMaximum tumor size 1.6 cmInvasive carcinoma present at excisional marginsMicrocalcifications presentInvasive carcinoma does not invade into the epidermis, right nipple, skeletal or muscleThe decision and assessment of invasive ductal carcinoma was made based on the diagnostic findings and pathologyBIRADS 4, suspicious abnormality
Biopsy and Diagnosis
12/29/2015 29
The Basics of Male Breast Cancer
Pathology and Treatment• Sections show invasive ductal carcinoma with
moderate pleomorphism and a low rate of mitoses
• Glandular differentiation: Score of 2
• Nuclear pleomorphism: Score of 3
• Sentinel node injection performed on right axilla; one lymph node with metastatic deposit
• Mastectomy performed, no residual tumor identified
12/29/2015 30
The Basics of Male Breast Cancer
History of the case study patient -66 year old male-Presents with a left breast lump x 2-3
months-Physical examination of the left breast
revealed a fixed nodule at the 12:00 position-Bilateral diagnostic mammogram was
performed-Bilateral ultrasound was performed-Left nipple retraction-No nipple discharge -Patient’s father had a history of breast
cancer; underwent bilateral mastectomy in his 60’s
Case Study #4
12/29/2015 31
The Basics of Male Breast Cancer
12/29/2015 32
The Basics of Male Breast Cancer
12/29/2015 33
The Basics of Male Breast Cancer
12/29/2015 34
The Basics of Male Breast Cancer
• Ultrasound findings of the left breast demonstrate a micro-lobulated hypoechoic vascular mass with internal calcifications
• Nodule at 12:00 position measures 2.1 x 2.1 x 2.1 cm• There is a small tail of extension of hypoechoic material into the subareolar
region
• Located in the left axilla there is an adjacent spherical abnormal appearing lymph node measuring 1.2 x 0.8 x 0.9 cm.
• Ultrasound findings of the right breast demonstrate several linear hypoechoic foci which conform to the abnormal appearance demonstrated by the mammographic findings. There is no abnormal color flow or mass.
• BIRADS 5- Highly suggestive of malignancy
12/29/2015 35
The Basics of Male Breast Cancer
Biopsy and Diagnosis• A bilateral ultrasound-guided biopsy was recommended
• This recommendation was discussed with the patient upon the exam and scheduled for the following day
• Pathology showed invasive ductal carcinoma (IDC) of the left breast
• Pathology showed ductal carcinoma in situ (DCIS) of the right breast with micro calcifications present
12/29/2015 36
The Basics of Male Breast Cancer
DCIS incidence in males:
High-grade ductal carcinoma in situ is incredibly rare in male patients and has been investigated to date only in small numbers. The prognosis for ductal carcinoma in situ (DCIS) in a male patient is the same as it would be for a female with the same stage disease; therefore, early recognition and diagnosis are important.
12/29/2015 37
The Basics of Male Breast Cancer
Patient underwent a bilateral mastectomyMastectomy bilateralBiopsy/excise node lymph sentinelDissect axillaDx: Infiltrating ductal carcinoma left breast w metastatic axillary lymph nodes DCIS right breast
Assessment
12/29/2015 38
Treatment and Results-Bilateral mastectomy-Patient had positive nodes; sentinel node injection
-Left 3/3 positive sentinel nodes -Left 7/10 positive axillary node dissection -Right 0/1 positive axillary node- No residual DCIS identified
-Patient will receive adjuvant therapy in the form of chemo and radiation
The Basics of Male Breast Cancer
12/29/2015 39
The Basics of Male Breast Cancer
SummaryAlthough male breast cancer is rare, the incidence appears to be increasing. Education is important. Male breast cancer accounts for less than 1% of all breast cancers, but they too are at risk. Awareness and self breast exams is the starting point to identifying male breast cancer at earlier stages and potentially saving lives.
12/29/2015 40
ReferencesAmerican Cancer Society. Breast cancer: early detection. The importance of findingbreast cancer early. Retrieved March 12, 2014 from www.cancer.org/breast-cancer-early-detection-pdf; 2013. Accessed on February 2, 2013.
American Cancer Society (2013). What are the risk factors for breast cancer? Retrieved February 26, 2014 from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors.
Chern, J. (2012). Case Report: Ductal Carcinoma In Situ in the Male Breast retrieved April 16, 2014 from http://www.hindawi.com/journals/crira/2012/.
Johansen, T., Morisy, L.R., & Osbahr, A.J. (2010). Male breast cancer: risk factors, diagnosis, and management (Review). Retrieved March 16, 2014.
Madeira, M. (2011). A case report of male breast cancer in a very young patient: what is changing?Retrieved March 09, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039618/ .
National Cancer Institute (2013). General information about male breast cancer. Retrieved March 12, 2014 from www.cancer.gov/cancertopics/pdq/treatment/malebreast/Patient/page.
Omigie, A.A., & Hill, C. (2013). The Internet Journal of Advanced Nursing Practice; Volume 12. Retrieved March 8, 2014 from http://ispub.com/IJANP/12/1/2947#.
Saru, E.A., & Mudarris, F. & Amr., S.S. (2004). Male Breast Cancer- Case Report and Brief Review. East Journal of Family Medicine, Vol. 6. Retrieved March 13, 2014 from http://www.mejfm.com/Newarchives2013/Malebreastcancer.pdf.
The Basics of Male Breast Cancer