Case Report
High-grade Ductal Carcinoma In Situ (DCIS) of the Male Breast Treated with Breast Conserving Therapy
Rebekah Young2*, Kimberly Gergelis3, Shalom Kalnicki1 and Jana L. Fox1
1Department of Radiation Oncology, Einstein/Montefiore Center for Cancer Care, USA
2The Ohio State University, The James Cancer Center/Stefanie Spielman Comprehensive Breast Center, USA
3Albert Einstein College of Medicine, USA
*Corresponding author: Rebekah Young, Ohio State University, James Cancer Center/Stefanie Spielman Comprehensive Breast Center, 1145 Olentangy River Road, Columbus, OH 43212, USA
Published: 22 Jun, 2017
Cite this article as: Young R, Gergelis K, Kalnicki S, Fox
JL. High-grade Ductal Carcinoma In
Situ (DCIS) of the Male Breast Treated
with Breast Conserving Therapy. Ann
Clin Case Rep. 2017; 2: 1383.
Abstract
Ductal carcinoma in situ (DCIS) is a rare diagnosis in a man, and rarer still is the detection of a high grade in situ lesion. The surgical management of both invasive breast cancer and DCIS in men is typically mastectomy. We report the case of a 61 year-old man who presented with a right-sided breast mass. The abnormality was appreciated by his primary physician, and she also palpated a left-sided nodule. Subsequent bilateral diagnostic mammogram and ultrasound showed no abnormalities on the right, but did reveal a suspicious sub-centimeter lesion in the upper inner quadrant of the left breast. Biopsy showed high grade DCIS. He underwent lumpectomy followed by adjuvant radiotherapy (RT) to the whole left breast. He tolerated surgery and RT well and has no evidence of disease and good cosmesis at 20 months follow-up. Much is known about both invasive and in situ breast disease in women, including risk factors, distribution of sub-types, and treatment options. The same cannot be said for male DCIS. In this case, we discuss the differences in male and female DCIS, as well as disparities in surgical management.
Keywords: Male breast cancer; Male DCIS; Ductal carcinoma in situ; Breast conserving therapy
Introduction
Male breast cancer (MBC) accounts for less than 1% of breast carcinomas in the US [1]. Among MBCs, pure DCIS is rare, comprising approximately 5% of cases [2,3], and high-grade DCIS is seldom detected. An extensive literature search revealed only two such reported cases [4,5]. The histopathology and risk factors of MBC differ in part from those of women [6]. Many female breast cancers, particularly those that are early stage, are treated with breast conserving therapy (BCT), which includes lumpectomy, +/- adjuvant chemotherapy, and RT; and the majority of women with DCIS undergo lumpectomy. The standard surgical approach for men with in situ and invasive disease, however, is mastectomy, with very few undergoing BCT.
Case Presentation
A 61 year-old African-American man with a past medical history of prostate cancer treated
with radical prostatectomy alone in 2006, hypertension, and morbid obesity (BMI: 46 kg/m2) and a
family history of breast cancer in his sister, presented to his primary physician with a palpable right
breast nodule. She conducted a bilateral breast exam and in addition to palpating the initial area of
concern, she palpated an approximate 1cm lesion in his left breast.
The right breast appeared normal on diagnostic mammogram and ultrasound with no
abnormality detected corresponding to the self-palpated area. Imaging with subsequent spot
compressions of the contralateral (left) breast, however, revealed a9mm lesion in the upper inner
quadrant. Acore needle biopsy of the left-sided lesion revealed DCIS. (Figure 1) shows the diagnostic
mammography and ultrasound images of the left breast and lesion.
The case was presented at multi-disciplinary tumor board. At initial consultation, the
surgeon appreciated the palpable mass in the 10-11 o’clock position of the left breast, noted to
be approximately 2 cm from the nipple areolar complex (NAC). She noted the patient’s bilateral
gynecomastia (described as “C-cup sized” breasts) and remarked that he had adequate tissue to
undergo a lumpectomy, thus obviating the more involved surgical mastectomy. Final pathology
from lumpectomy revealed high-grade DCIS that was 0.5 cm in largest dimension, cribriform
subtype with focal necrosis, estrogen receptor (ER) and progesterone receptor (PR) positive, and negative surgical margins. The specimen weighed 7.0 g and measured
3 cm x 2.7 cm x 1.2 cm. As is customary in cases of DCIS without
suspicion of micro-invasion, no sentinel lymph nodes were sampled.
Approximately 4 weeks following surgery, we saw the patient for
initial radiation oncology consultation. He was healing well with an
approximate 3 cm surgical incision about 1.5 cm superior to the nipple
with some associated nipple retraction likely due to the proximity of
the incision to the NAC. We appreciated bilateral gynecomastia, and
questioned the patient regarding this finding. He reported that he
had this condition for 10 to 15 years, during a time when he gained
considerable weight. He added that he had significant gynecomastia
when he was young and undergoing puberty. Blood levels of
testosterone and estrogen were checked prior to commencing RT,
with the former being below normal (not surprising as he underwent
prostatectomy) and the latter within normal range. A comprehensive
chemistry panel and thyroid and liver function tests were checked to
rule out other causes of gynecomastia, and were within normal limits.
Shortly after our meeting he underwent adjuvant RT to 42.4 Gy to
the whole left breast in 16 fractions (hypofractionated regimen). The
patient tolerated RT well, experiencing mild skin hyperpigmentation,
well within normal range (see Figure 2: patient’s chest on his last day
of treatment). Of note, medical oncology was consulted regarding
placing this patient on hormonal therapy given his positive hormone
receptor status, but it was felt there was not enough evidence to
support its use in a man with DCIS. Now in follow-up, he is monitored
with clinical breast exams and annual bilateral mammograms.
Figure 1
Figure 1
Diagnostic mammographic views of the patient’s left breast: far left:
CC view, center: MLO view, right: ultrasound.
Figure 2
Figure 2
The patient on his last day of his radiotherapy treatment. Note mild
hyperpigmentation of his left breast.
Discussion
The most commonly reported male DCIS patterns are papillary
and cribriform, whereas women’s histological patterns are more
evenly distributed among the five subtypes. One of the larger published series addressing male DCIS is from Hittmair in which 84 men with
pure DCIS were retrospectively reviewed. Nearly 90% of cases were
papillary, cribriform, or a mix of the two [7]. A smaller series reports
31 pure DCIS cases retrospectively reviewed from a group of French
regional cancer centers. Papillary and cribiform patterns accounted
for the majority of cases [8]. An important prognostic factor in DCIS
is grade, with high grade lesions conferring an increased risk of in situ
and invasive recurrence. Approximately 45-50% of female DCIS is
high grade, but is an exceptionally rare finding in men [9]. Hittmair
reported no grade 3 lesions among his patients and noted that “high
grade pure DCIS [is] a rare lesion in the male breast,” particularly
when compared with invasive ductal carcinoma (IDC) cases in men
[7].
Review of the literature yielded two case reports detailing highgrade
male DCIS [4,5], both of which were surgically managed with
mastectomy.
Although roughly 15% of MBC patients have a genetic mutation
(most commonly BRCA2), the etiology for many cancers remains
unknown. Some reports do not cite patient race [10], although
the vast majority present Caucasian patients. Unlike the slightly
higher incidence rates among white (versus black) women, African
American men have a higher incidence of MBC, with age-adjusted
rates of 1.65 per 100,000 in blacks and1.31 in whites [1]. Factors
known to increase risk in women also increase MBC risk, including
obesity, prior chest radiation, and family history. Specific to men,
however, are conditions that perturb the physiological estrogen-toandrogen
balance. Klinefelter syndrome (inheritance of an additional
X chromosome) confers the highest risk for MBC with a 20- to 50-
fold increase compared to normal 46XY karyotype men [11]. Other
conditions causing increased estrogen include obesity and liver
disease, both cited as risk factors for MBC [1]. Gynecomastia is the
pathophysiological enlargement of glandular male breast tissue,
and is a common condition among pubertal boys and aging men
[9]. Although gynecomastia is listed as a MBC risk factor in several
sources [4,10,11], causality has not been established. Acohort study
reported by Olsson and Bladstrom [10] followed 446 men with a
clinical and histopathological diagnosis of gynecomastia who were
matched to Swedish population registries and followed for over 20
years. There was no significantly increased risk of MBC among these
men.
The surgical approach for MBC has historically been a simple
or modified radical mastectomy. Lumpectomy, as part of BCT, is
rarely performed in MBC patients. All single published case reports
of male DCIS reviewed for this article – with one exception –
involved surgical management with mastectomy. The Hittmair series
focuses on morphological features and does not address surgical
management [7]. Cutili's account reported six of the 31 men with
DCIS undergoing lumpectomy, with the rest undergoing mastectomy
[8]. It should be noted that no men in the lumpectomy group received
adjuvant RT. With a median of 83 months follow-up, local relapse
is reported in four (13%), three of whom were in the lumpectomy
alone group. Cutuli concludes that the “cosmetic aspect is of minor
importance [in men], and therefore the optimal treatment for DCIS
is simple mastectomy.” Deutsch and Rosenstein describe the case of
a 53 year-old obese man diagnosed with left-sided DCIS treated with
lumpectomy and adjuvant RT [12,13]. The patient did not wish to
undergo mastectomy because he feared poor cosmesis given the likely
subsequent size discrepancy between his breasts. Following resection he underwent adjuvant RT to the whole left breast. Deutsch and
Rosenstein reported very favorable cosmesis at 3.5 years of follow-up
with no evidence of recurrence.
Conclusion
The rarity of male DCIS has led to a paucity of data regarding its management and outcomes. Whereas major national trials provide clear guidance for the management of DCIS in women, no such studies exist for men. Although there are some differences between male and female breast disease, including DCIS, data suggests that men have similar responses to treatment and recurrence patterns. BCS and BCT should be routinely considered for eligible men, as it has for women, thus eliminating unnecessarily extensive surgeries.
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