2021, Number 4
Breast cancer in man. Case report
Full text
10.35366/109128
Language: English/Spanish [Versi?n en espa?ol]
References: 10
Page: 248-250
PDF size: 117.83 Kb.
ABSTRACT
Breast cancer in men is a relatively uncommon entity that occurs in a very low proportion, however, the importance of breast cancer in men should not be ignored due to the poor prognosis since its diagnosis in later stages and its high mortality rate; paradoxically more men have died from breast cancer than from testicular cancer. We present a case of a male patient with no significant history who came to the consultation for presenting a retroareolar tumor to the general surgery consultation, being referred to the oncological surgery consultation, an ultrasound was performed, cataloged as a BI-RADS 5 for which he is scheduled for treatment surgical. Due to the infrequency of this pathology, it was decided to carry out a case report.INTRODUCTION
Breast cancer is common in women but relatively rare in men, accounting for approximately less than 1% of all diagnosed cases.1 According to epidemiological figures, between 1975 and 2015, its incidence was 40%, exceeding that of women by 25%.2 It is usually observed in the last decades of life (60-70 years).
The most critical risk factor is a positive family history of breast cancer: the risk doubles if the history is positive for first-degree relatives and quintuples if other first-degree relatives are affected.3 Breast cancer in men occurs more frequently in estrogen receptor (ER)-positive patients.4 Neoadjuvant tamoxifen-based endocrine therapy has now been added as a treatment option for breast cancer in men.5
CLINICAL CASE
A 63-year-old female patient with a history of appendectomy seven years ago, fracture of the proximal humerus due to a gunshot wound, diabetes mellitus of seven years of evolution in treatment with biguanides and sulfonylureas, systemic arterial hypertension of seven years of evolution in treatment with ARA II, with no significant family history, who came to the consultation for an increase in breast volume of seven years of evolution, which was increasing progressively.
Physical examination revealed a painless mass measuring 4 × 5 cm, mobile, thickening and erythema of the skin, and negative axilla and supraclavicular fossa for adenopathy. Ultrasound was performed, which described a retro areolar lesion with an ovoid image antiparallel to the skin, hypoechoic with internal calcifications and lobulated margins; Doppler showed increased vascularity measuring 45.4 × 45.8 × 46.6 mm, with an approximate volume of 50.7 cm3; axillary region level 1 with 15 × 10 mm Doppler lymph node with peripheral vascularity, so it was classified as a BI-RADS 5.
According to the clinical picture and the findings during the ultrasound, it was decided to schedule a modified radical mastectomy of the Madden type; subsequently, a transoperative histopathological study was performed with a report of a fungating lesion suspicious for malignancy.
The histopathologic diagnosis was infiltrating ductal carcinoma without a specific pattern with areas of intraductal carcinoma of the comedocarcinoma type, high-grade central necrosis. The lymph node dissection of the right axilla was positive for ductal carcinoma metastasis in two of the 18 lymph nodes dissected.
DISCUSSION
In most males, cancer presents between 60 and 70 years of age (five to 10 years earlier than in women) with an average age of 62 years and is usually diagnosed in more advanced stages due to a delay in diagnosis.6 Some of the risk factors for the development of breast cancer in men are age, history of breast cancer in first-degree relatives (either male or female), hyperestrogenism, history of mediastinal radiation, history of exogenous estrogen use, genetic predisposition (BRCA1 or BRCA2 mutations, CHEK2, PALB2) and Klinefelter's syndrome.7 Studies have shown that hormone replacement therapy increases the risk of breast cancer, especially in the transgender population, especially in transgender women (male sex at birth and female gender identification), with a mean age of onset of 52 years.8
Infiltrating ductal carcinoma is the most common subtype of breast cancer in men; it usually presents unilaterally, fixed, and as a painless subareolar tumor mass, which may be the only symptomatology presented by the patient. It appears spiculated with irregular borders and, in up to 15% of cases, as a dense nodular mass with defined borders.7
At present, there is no prevention program. However, ultrasound should be considered the first-line imaging study due to its low cost and easy accessibility.9 In the ultrasound study, microcalcifications that are smaller in number, non-linear and thicker, compared to that of women, are present in up to 30% of cases. In the transgender population who have not undergone a mastectomy, they should be protocolized with mastography as preventive studies from the age of 50 if they have used hormone replacement therapy for more than five years.8
It has been observed that men with breast cancer have a survival disadvantage compared to women with breast cancer of up to 5 to 10 years due to their diagnosis in more advanced stages and to the primary site of the tumor, since in men, it occurs in the central area below the nipple, in addition to the fact that the histology of the tumor contributes to a worse prognosis than tumors located in the upper quadrant.
Today, it has been demonstrated that neoadjuvant endocrine therapy with tamoxifen should be the first choice and should be administered for an initial period of five years. Tamoxifen was considered the standard of treatment in premenopausal women with ER+ receptor-positive breast cancer and aromatase inhibitors in postmenopausal women, and given the similarity between breast cancer in men and cancer in postmenopausal women, aromatase inhibitors were used as a treatment for breast cancer in men; However, recent studies have shown a reduction in mortality in those who received tamoxifen compared to aromatase inhibitors, since the production of testicular estrogens is not abolished by the inhibitors, which leaves tamoxifen as the first treatment option. Unfortunately, there are side effects with the use of tamoxifen, which include reduced libido, weight gain, hot flashes, and mood alterations, as well as deep vein thrombosis, leading to a high dropout rate from treatment due to these side effects.
Another aspect to highlight is the scarce data on the psychological consequences of this pathology in the male population. Patients with breast cancer have an increased risk of obesity, comorbidities, reduced physical activity, poor quality of life, and deterioration in health associated with depression or anxiety.5 The recommended study for follow-up and cancer detection in patients already undergoing curative therapy is ipsilateral mastography in patients with lumpectomy and annual contralateral mastography in patients with a history of breast cancer or genetic predisposition; genetic counseling should also be offered.10
REFERENCES
AFFILIATIONS
1 Second-year resident physician of General Surgery. General Hospital of Zone No. 1 "Nueva Frontera". Tapachula, Chiapas.
2 Oncologic Surgeon. Primary physician of Oncologic Surgery. General Hospital of Zone No. 1 "Nueva Frontera". Tapachula, Chiapas.
Ethical considerations and responsibility: the authors declare that they followed the protocols of their work center on the publication of patient data, safeguarding their right to privacy through the confidentiality of their data.
Funding: no financial support was received for this work.
Disclosure: the authors declare no conflict of interest in the work.
CORRESPONDENCE
Tere Ivanova Alipio Núñez. E-mail: novalipio@gmail.comReceived: 10/14/2021. Accepted: 11/19/2022