Elsevier

The Lancet

Volume 367, Issue 9510, 18–24 February 2006, Pages 595-604
The Lancet

Seminar
Male breast cancer

https://doi.org/10.1016/S0140-6736(06)68226-3Get rights and content

Summary

Occurrence of male breast cancer, a rare disease, peaks at age 71 years. Familial cases usually have BRCA2 rather than BRCA1 mutations. Occupational risks include high temperature environments and exhaust fumes, but electromagnetic fields have not been implicated. Hyperoestrogenisation resulting from Klinefelter's, gonadal dysfunction, obesity, or excess alcohol, all increase risk as does exposure to radiation, whereas gynaecomastia does not. Presentation is usually a lump or nipple inversion, but is often late, with more than 40% of individuals having stage III or IV disease. Most tumours are ductal and 10% are ductal carcinoma in situ. Surgery is usually mastectomy with axillary clearance or sentinel node biopsy. Indications for radiotherapy, by stage, are similar to female breast cancer. Because 90% of tumours are oestrogen-receptor-positive, tamoxifen is standard adjuvant therapy, but some individuals could also benefit from chemotherapy. Hormonal therapy is the main treatment for metastatic disease, but chemotherapy can also provide palliation. National initiatives are increasingly needed to improve information and support for male breast cancer patients.

Section snippets

Epidemiology

The annual prevalence of male breast cancer in Europe is 1 in 100 000, and less than 1% of all breast cancer patients are male.3 Rates of male breast cancer vary widely between countries: in Uganda and Zambia the annual incidence rates are 5% and 15%, respectively.4, 5 These relatively high rates have been attributed to endemic infectious diseases causing liver damage, leading to hyperoestrogenism. By contrast, the annual incidence of male breast cancer in Japan is less than five per million,

Risk Factors

Risk factors for male breast cancer are summarised in the panel.

Clinical features

As with women, the most common symptom of breast cancer is a painless lump, which alone or with other problems arises in 75% of cases.74, 75, 76, 77, 78 Pain is associated with a lump in only 5%.79 Nipple involvement is a fairly early event, with retraction in 9%, discharge in 6%, and ulceration in 6%, although ulceration was separate from the nipple in half the cases. Paget's disease is rare, being the presenting feature in only 1%, with a mean age of 60 years, similar to that of other men

Histopathology

Since male breast tissue is rudimentary, it does not usually differentiate and undergo lobule formation unless exposed to increased concentrations of endogenous or exogenous oestrogen. Thus the predominant histological type of disease is invasive ductal, which forms more than 90% of all male breast tumours (table 4).75, 76, 84, 85, 86, 87 Much rarer tumour types include invasive papillomas and medullary lesions. In large series reporting tumour grade, 12–20% were grade I, 54–58% grade II, and

Diagnosis

In most cases diagnosis is made by triple assessment: clinical assessment, mammography or ultrasonography, and fine-needle aspiration cytology or core biopsy. Core biopsy is preferred because it enables a definitive diagnosis of invasive breast cancer to be made. The presence of malignant cells on a cytology specimen may be the result of ductal carcinoma in situ rather than invasive disease, and the treatment of the two diseases is different.

Mammography in men with breast lesions is an

Surgery

As with female breast cancer, for most of the 20th century the standard treatment for localised breast cancer in men was radical mastectomy, which has now been superseded by less invasive procedures such as modified radical or simple mastectomy, with no detectable decline in survival.76 Wide excision in male breast cancer will almost always include resection of the nipple due to the small amount of breast tissue, and there is some evidence that this is not the most effective method of local

Treatment of advanced disease

For the past five decades hormonal therapy has been, and continues to be, the mainstay of treatment for metastatic carcinoma of the male breast.76, 130, 131 Initial hormonal therapies were ablative: orchidectomy, adrenalectomy, and hypophysectomy. After Farrow and Adair132 first described a response to orchidectomy in 1942, orchidectomy became the standard of care for treatment of advanced disease. A review of 447 patients indicated response rates of 55% to orchidectomy, 80% to adrenalectomy,

Prognosis

The most important prognostic indicators are stage at diagnosis and lymph node status. Estimates for overall 5-year survival are around 40–65%,76, 78, 83, 124 but when grouped by stage at presentation, 5-year survival is 75–100% for stage I disease, 50–80% for stage II disease, and falling to 30–60% for stage III disease.76 Some studies suggested that breast cancer has a worse prognosis in men than in women, but if age- matched and stage-matched breast cancer is compared, there is no difference

Conclusions

Despite evidence that testicular or hepatic failure will increase the risk of male breast cancer, most patients have no identifiable risk factors. Men with breast lumps need assessment in the same way as women and most will prove to have benign gynaecomastia. Carcinoma of the male breast has many similarities to breast cancer in women, but the rarity of the disease precludes large clinical trials necessary to define optimum treatment. Local treatment has to be tailored to stage at presentation

Search strategy and selection criteria

We searched PubMed with the term male breast cancer in combination with the terms “epidemiology”, “risk factors”, “genetic”, “endocrine”, “pathology”, “diagnosis”, “prognostic factors”, “tamoxifen”, “aromatase inhibitors”, “surgery”, “reconstruction”, “radiotherapy”, “hormonotherapy”, and “chemotherapy”. We selected up to date reviews and highly regarded older papers. Search was not restricted by language.

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