Breast cancer in men and mammography of the male breast.
Breast cancer occurs in men with relative infrequency. One man is diagnosed with breast cancer for every 100 women who have the disease, and breast cancer represents less than 0.17% of all new cancers diagnosed in men.[1,2] Researchers estimate that 1000 new cases are reported and 300 men die from breast cancer every year in the United States, accounting for 0.5% of morbidity and 0.7% of mortality associated with the disease.[3-5]
Because breast cancer's etiology, progression, response to treatment and prognosis are similar regardless of whether the disease occurs in a man or a woman. Some researchers believe that a better understanding of male breast cancer, which occurs in the absence of factors related to menstruation and childbearing, might offer clues to the development of the disease in women.
Although previous studies suggested that men with breast cancer have a less favorable prognosis than women, it now appears that any differences are slight, and the prognosis for similar cases is the same regardless of the patient's gender.
Of course, there are differences in the disease's progression as well. Breast cancer in men occurs much less frequently than breast cancer in women, occurs at an older age, arises more generally underneath the nipple, and is more hormonally sensitive than breast cancer in women.
The incidence rate of breast cancer is higher in black men than white men, and higher rates of breast cancer in both sexes have been reported in the United States in Jews compared with non-Jews.[8-10]
The risk of developing breast cancer increases steadily with age in both sexes.[11,12] In the United States, the difference in the incidence of breast cancer between men and women decreases as the population ages. For example, between the ages of 35 and 39 breast cancer is 572 times more common in women than in men, but by age 85 it is only 34 times more frequent. (See Fig. 1.) In addition, men do not see the decreased risk of developing breast cancer that is reported in postmenopausal women. As men age, their risk of breast cancer increases sharply.[5,13] (See Fig. 2.)
[Figures 1 and 2 ILLUSTRATION OMITTED]
It is interesting to note that despite its rarity in modern times, male breast cancer was recognized clinically as long as 5000 years ago. An excerpt from an ancient Egyptian papyrus (3000-2500 BC) translated by J.H. Breasted and known as the "Edwin Smith Surgical Papyrus" clearly refers to cancer of the male breast:[5,14]
If thou examines" a man having
bulging tumors of his breast (and)
thou findest that (swellings) have
spread over his breast; if thou puttest
thy hand upon his breast upon these
tumors, (and) thou findest them very
cool, there being no fever at all therein
when thy hand touches him; they have
no granulation, they form no fluid,
they do not generate secretions of fluid,
and they are bulging to thy hand.
There is no (treatment).
Breast cancer in men usually presents as a lump or nipple discharge. Because men are not routinely screened for breast cancer, breast cancer in men is rarely found when it is asymptomatic or in the absence of physical findings. It is almost always clinically evident and often does not require additional evaluation with mammography.
Once an abnormality is suspected, men often are slow to seek medical guidance. A review of cases diagnosed since 1900 showed that men waited an average of 18 months before seeking medical advice. By the 1950s, this delay had dropped to an average of 10 months.
At least part of the reason for past delays in diagnosis may have been embarrassment. Some researchers suggest that men may try to ignore a breast abnormality because they believe that breast cancer is indicative of a flaw in their masculinity. Fortunately, however, recent studies indicate that a delay in diagnosis may be less of a problem now than in the past.[19-21] In a retrospective review published in 1994 of 28 male breast cancer patients, 75% of the patients presented with early stage disease, and the mean duration of symptoms was 3.3 months. The most common presenting symptom was a mass (79%), followed by nipple discharge (29%).
Cancer of the male breast typically is in the form of a small, solid mass with well-defined contours, generally located eccentrically in relationship to the nipple. In most cases, a small, painless lump under the nipple is accidentally discovered by the patient. However, a lump is rarely the only symptom. Men with a breast abnormality are more likely than women to experience nipple discharge. It is interesting to note that bloody nipple discharge is associated with cancer in men in 75% of cases, while it is associated with cancer in women only 10% to 15% of the time.[19,24]
In addition, men are also more likely to have indications of local spread such as nipple retraction, fixation to the skin and skin ulceration. (See Fig. 3.) In fact, upon initial diagnosis, nearly 50% of men with breast cancer have palpable axillary lymph nodes. Table 1 lists the common presenting signs and symptoms of male breast cancer.
[Figure 1 ILLUSTRATION OMITTED]
Table 1 Presenting Signs and Symptoms Of Male Breast Cancer (5) Sign or Symtom Prevalence (%) Mass 43-92 Painful mass 2 Nipple involvement 38-39 Nipple retraction 8-31 Nipple discharge 3.7-9 Bloody nipple discharge without mass 2 Bloody nipple discharge 8-15 Itching of the nipple 2 Nippel ulceration 7.9-31.6 Ulceration of the breast 9-10 Breast swelling 4 Edema of the Breast 5.3 Erythema, inflammatory changes 7.9-10.5 Skin reaction 16 Skin nodules 3.4 Local pain 5.1-16 Fixed or ulcerated axillary nodes 16 Enlarged axillary nodes 5.1-22 Axillary mass only 2 Supraclavicular metasteses 7.7 Bone pain 2.2
In general, male breast cartcinomas are not large. One study revealed that 51% of male breast tumors were less than 3 cm in diameter. Researchers have noted a striking resemblance between male breast cancer and scirrhous or hard carcinoma of the female breast.[26,27]
Calcifications also may be present in male breast carcinoma. However, calcifications in the male breast tend to be somewhat larger and rounder than calcifications in the female breast, which usually are punctate and rod-shaped. Calcifications in the male breast also are fewer in number and more scattered than those found in the female breast.
Anatomy of the Male Breast
The male breast is a vestigial organ, very similar in anatomy to the breast of a pre-adolescent girl. The male breast consists of a small rudimentary nipple, fatty and fibrous tissues and a few duct-like structures in the subareolar region. In women, these ducts develop in response to hormones secreted during puberty. In men, breast tissue also can respond to hormonal stimulation.
Enlargement of the male breast due to the growth of surrounding ducts and supporting tissues is known as gynecomastia. Nearly 40% of all adolescent boys experience temporary enlargement of the breast, probably related to the secretion of hormones by the testes. This adolescent form of gynecomastia typically disappears within 12 to 24 months.
In adult men, enlargement of the breast can occur as the result of a disease process or the use of several commonly available drugs.5 For example, gynecomastia can be caused by the administration of estrogen to treat cancer of the prostate. It also can be caused by nonhormonal drugs used to treat cardiovascular diseases (digitalis), high blood pressure (reserpine, spironolactone), migraines (ergotamine) and seizures (phenytoin). Gynecomastia also may occur in conjunction with cancer of the testes or adrenal glands, cirrhosis of the liver, chronic renal dialysis or a chromosomal disorder known as Klinefelter's syndrome. Enlargement of the breast in obese patients is primarily due to the accumulation of fatty tissue and is not considered true gynecomastia.
Risk Factors for Male Breast Cancer
The cause of male breast cancer is unknown. However, several potential risk factors have been identified in the development of male breast cancer, including a positive family history, increasing age, gynecomastia, Klinefelter's syndrome, obesity, prior radiation therapy to the chest, liver dysfunction, testicular injury, estrogen therapy, certain occupational exposures and racial predisposition.[19,21,32-35] Data supporting these risk factors is limited because scant information exists due to the infrequency of male breast cancer. It is important to note that most individuals who develop breast cancer have no apparent risk factors, and the majority of men who are diagnosed with breast cancer do not have any hormonal imbalances.[36,37]
The risk of male breast cancer increases steadily with age. After age 35, a man's risk of breast cancer increases sharply and does not show the mid-life decline demonstrated in women. This trend confirms the notion that the mid-life decrease in the incidence in breast cancer reported in women is clearly a function of menopause. In the United States, the median age at diagnosis is 67.4 years for men and 60.3 years for women.[10,38]
Higher rates of breast cancer have been observed in Jews of both sexes when compared with non-Jews.[7-9] In the United States, reported incidence rates of breast cancer are lower in immigrants and their descendants of both sexes from Japan, China, Korea and Latin America than in American men and women of other ethnic groups. Accordingly, many of the differences in the incidence of breast cancer in different ethnic groups cannot be explained by factors related to gender. Interestingly, however, in 11 areas of the world with the highest incidence of breast cancer in white women, there was a greater variability in female rates6 than male rates, suggesting perhaps that the higher variability seen in women may be due in fact to factors associated with being female.
Family History of Breast Cancer
A family history of breast cancer places both men and women at higher risk for the disease.[40-43] In fact, men with breast cancer often report that a male or female family member has had breast cancer.[5,44] In addition, the relative risks associated with a family history of breast cancer are similar for men and women. A history of breast cancer in a first-degree relative is associated with two times the risk of breast cancer in both sexes. In the largest case-control study of breast cancer in men, the relative risks of breast cancer for men with an affected mother or sister were 2.33 and 2.23, respectively, compared with relative risk estimates for women of 1.97 and 2.35.
Transmission of breast cancer through the male line has been demonstrated in rodents, and several researchers have reported the occurrence of two or more cases of male breast cancer within a single family. Of these reports, several involved two brothers, one involved three brothers, and another described breast cancer in a father, a son and the father's brother. Even with this information, the small number of cases makes it difficult to determine the potential risk of developing breast cancer in men with relatives who have breast cancer.
The relationship between gynecomastia and male breast cancer is unclear. Gynecomastia typically occurs in two groups of males: adolescent boys and men older than 50. Gynecomastia's age-specific frequency parallels that of male breast cancer, although the two conditions are not always associated clinically.
Gynecomastia has been documented histologically in 1% to 40% of male breast cancer patients.[45,46] However, this rate may be no higher than that expected, since gynecomastia is clinically detectable in 57% of the male population older than 44.47 Although epithelial proliferation and atypia are found in gynecomastia, pathologists have not identified any clear transition from these cells to cells characteristic of cancer. Several factors may be implicated in the development of gynecomastia. They fall into four categories: hormonal, systemic, drug-induced and various neoplasms.
* Hormonal. Hormonally influenced gynecomastia is the primary cause of breast enlargement in boys during puberty and men older than 50.[46,47] In boys, gynecomastia usually develops between the ages of 11 and 15 and disappears in 1 to 2 years. High serum levels of estradiol are found in relation to circulating levels of testosterone. This hormonal imbalance reverts to normal as puberty continues, and gynecomastia disappears. Gynecomastia in older men is attributed to the gradual decline in serum testosterone while serum levels of estradiol remain constant, resulting in an estradiol/testosterone imbalance.
Several disorders also can disturb the estradiol/testosterone imbalance and cause gynecomastia, including hypogonadism (retardation of sexual function), Klinefelter's syndrome and various testicular neoplasms.[50,51] In addition, tumors and disorders of other endocrine glands, such as cancer of the adrenal glands or hyperthyroidism and, in rare cases, pituitary adenomas, are known to cause gynecomastia.[52-54] In most patients, the gynecomastia is resolved once the primary source has been eliminated. It is important to note that hormonally induced gynecomastia is generally bilateral. (See Fig. 4.)
[Figure 4 ILLUSTRATION OMITTED]
* Systemic disorders. Gynecomastia has been noted in patients with cirrhosis, patients in chronic renal failure who are undergoing long-term hemodialysis, and patients with chronic pulmonary conditions such as emphysema or tuberculosis.[56-58] The condition also has been seen in cases of malnutrition.
* Drug-induced gynecomastia. Gynecomastia is very common in men receiving estrogen for the treatment of prostate cancer. In addition, several nonhormonal drugs are known to cause gynecomastia, including digitalis, cimetidine, spironolactone, reserpine, thiazide, isoniazid and ergotamine. Tricyclic antidepressants, phenethiazines and amphetamines also are known to cause gynecomastia. Even the use of marijuana has been implicated in the development of gynecomastia. Drug-induced gynecomastia tends to be unilateral in nature.
* Various neoplasms. Hepatomas are known to cause gynecomastia, and gynecomastia also has been reported in patients with lung cancer.
The strongest risk factor for male breast cancer is Klinefelter's syndrome, a rare genetic disorder characterized by the presence of an extra X chromosome in men (XXY). This syndrome is characterized by poorly developed sexual organs, hormonal abnormalities and gynecomastia. Men with Klinefelter's syndrome are 20 times more likely to develop breast cancer than men with a single X chromosome.[63-65] They also are more likely to develop cancer in both breasts or unusual types of secondary cancers.
It appears that the higher risk of breast cancer associated with Klinefelter's syndrome is the result of abnormal hormonal stimulation of cell growth in the mammary duct epithelium. It also has been speculated that increased risk of breast cancer in men with Klinefelter's syndrome may be due to treatment with exogenous testosterone that is converted to estrogens in peripheral adipose tissue.
Abnormal hormonal function has been linked to the development of female breast cancer, and it is believed to play a role in the development of male breast cancer as well. Several disorders associated with hormonal imbalances are associated with an increased risk of male breast cancer.
For example, testicular pathology and dysfunction have been associated with an increased risk of breast cancer in men. A higher risk is associated with undescended testes,[9,41] congenital inguinal hernia,[9,40] orchiectomy, testicular injury,[8,9,40] mumps as an adult (mumps infection in the adult male often is associated with testicular involvement),[8,9] and other testicular infections.[9,68] Occupational exposure of the testes to high temperatures also has been associated with breast cancer in some studies.[8,42]
In addition, risk is associated with a history of infertility, and it is inversely associated with the number of children a man fathers. There also may be an increased risk for men with delayed puberty.
Some researchers suggest that androgen deficiency may cause an increased risk of male breast cancer, whereas excess levels of androgen may be associated with a decreased risk of breast cancer. However, other researchers hypothesize that exposure to high levels of androgens is associated with an increased risk of male breast cancer. These researchers note that production of estrogens from androgens is increased in obese individuals. Rapid weight gain in men also is associated with the development of gynecomastia due to elevated estrogen production. Not surprisingly, small increases in the risk of developing male breast cancer have been noted with obesity in the third and fourth decades of life,[8,41] along with an increase in weight of more than 30 pounds during a 6-month period, a history of high blood cholesterol and a history of gallstones. There also seems to be an increased risk over time for men with non-insulin-dependent diabetes.
Individuals with chronic liver disease have a decreased ability to metabolize estrogens, and in men this often results in gynecomastia. Although several studies[8,9,41] have shown that the risk of male breast cancer is not correlated with the amount of alcohol an individual consumes, an increased risk is associated with chronic alcoholism, cirrhosis of the liver and a history of liver disease.
The use of exogenous estrogens in men is relatively uncommon, and therefore the relative risk for men taking estrogens has not been clearly established. One fascinating cohort study in Sweden reported that an eight-fold increase in risk was observed in men who worked in the soap and perfume industry at a time when cosmetic creams containing estrogens were manufactured. In addition, three case reports[74,75] of transsexual males who developed breast cancer after castration and treatment with high doses of estrogen seem to offer evidence in support of the hypothesis that exogenous estrogens in the presence of reduced androgen levels can induce breast cancer.
Several older studies indicated a link between a history of trauma to the breast and the development of breast cancer in nearly 30% of cases. However, other evidence suggests that this finding may be coincidental, with trauma possibly resulting in the discovery of a preexisting tumor.
Exposure to ionizing radiation is known to increase the risk of breast cancer for both sexes. Exposure to ionizing radiation increases the risk of breast cancer in men by approximately the same degree as women who were exposed during puberty. Similar to the trend seen in prepubertal girls, men tend to develop breast cancer after a longer latent period than women irradiated after puberty.
Several studies have shown that the relative risk of breast cancer is increased in men exposed to ionizing radiation.[77,78] In two of these studies,[41,79] the relative risk of breast cancer was elevated in men who had undergone multiple fluoroscopic examinations or upper body radiation therapy. In the largest of these studies, a trend in risk with the number of chest radiographs also was observed. Risk in relation to exposure was elevated from 20 to 35 years after initial exposure, suggesting a latency period of up to 2 decades or more.
Research shows that men occupationally exposed to electromagnetic field (EMF) radiation may be at increased risk of developing breast cancer. In one case-control study, the highest relative risk was observed in men who worked in the electrical field and related occupations. The highest risk was reported in men who had worked in an electrical trade for more than 30 years, although the increased risk was observed only in men who had been exposed to EMF for the first time when they were younger than 30.
In a Swedish cohort study, an increased risk of breast cancer was observed in men who worked in government, the newspaper industry, retail hardware and health care industries. Other studies[8,61] did not find an increased risk of breast cancer in men who had been occupationally exposed to chemical carcinogens such as pesticides, herbicides, dry cleaning materials, solvents, gasoline, coal and carbon monoxide.
Mammographic Evaluation And Diagnosis of Male Breast Cancer
Because breast cancer in men is almost always clinically apparent, mammography usually is performed to evaluate gynecomastia rather than to diagnose or screen for breast cancer.[15,81,82] However, mammography is occasionally used to view a male breast abnormality prior to biopsy.
When mammography is used to image the male breast, the procedure and positioning are basically the same as for a female breast. The breast is compressed between the film holder and a compression paddle. Two views are obtained, a craniocaudal and a mediolateral oblique. Additional views, magnification or spot films also may be required.
Usually, it is no more difficult to position a male breast than it is to position a small female breast. In fact, some male patients may have more breast tissue than a small woman. With proper positioning, maximal breast tissue can be visualized.
The craniocaudal view is the most challenging to perform with a male mammography patient. If the patient's breast slips out from under the compression plate on the craniocaudal view, the mammographer should reduce the amount of compression or use a reverse craniocaudal view (a caudal-cranial view). The caudal-cranial projection will help fully compress the inferior portion of the breast. To perform the caudal-cranial projection, the x-ray tube assembly should be rotated 1800 (upside down). The image receptor should be against the chest wall and superior to the breast.
If the caudal-cranial projection is not possible because the mammography equipment in use is not designed to rotate, the mammographer should position the patient for the standard craniocaudal projection and ask him to relax his shoulder, knee and hip. Doing so should make the breast tissue easier to manipulate onto the receptor. If the breast is too small to cover the automatic exposure control (AEC) chamber, the mammographer must use manual exposure.
Men undergoing mammography may be embarrassed or hesitant because they consider the procedure to be a "woman's examination." The mammographer should make the patient as comfortable as possible during the procedure and encourage him to relax. A cooperative patient will help improve the diagnostic value of the films.
In an attempt to objectively evaluate the mammographic findings of breast cancer in men, Dershaw and colleagues retrospectively reviewed the mammograms of 23 men with proven breast cancer. The men in the study ranged in age from 44 to 86 years, with a mean age of 63. The most common signs were a mass in 13 cases, bloody nipple discharge in 8 and nipple inversion in 1. All but one patient were symptomatic. The asymptomatic patient had previously undergone a mastectomy of the right breast for breast cancer and had been followed up since with annual screening mammography. Their medical histories included gynecomastia in five cases, prior cancer in three and prior radiation exposure to the breast in two. There were no cases of Klinefelter's syndrome, but three men had a previous history of different forms of cancer.
In this retrospective review, carcinoma was evident mammographically as an uncalcified mass in 17 patients (24%) and as a mass with microcalcifications in two patients (9%). Three tumors were not visible on mammograms, including one that was obscured by gynecomastia. Tumors were primarily subareolar (14/17, 82%), and all were ductal cancers, including six pure intraductal carcinomas.
Mammographically, gynecomastia appears as increased ductal tissue while breast cancer usually appears as an uncalcified subareolar mass that may mimic or be obscured by gynecomastia. (See Fig. 5.) Calcifications are rare in cases of male breast cancer. When present, they tend to be larger, rounder and more scattered than calcifications found in women's breasts. (See Fig. 6.) Calcifications interpreted as benign in women may indicate malignancy in men.
[Figures 5-6 ILLUSTRATION OMITTED]
Lobules are extremely rare in the male breast, so breast cancer in men is almost always ductal. In addition, breast cancer in men is usually subareolar. Studies have demonstrated that as many as 88% of male breast cancer cases are subareolar with nipple involvement. A unilateral, firm, painless mass usually is connected to the nipple. Changes in the nipple are common, such as nipple retraction, itching of the nipple and bloody nipple discharge. Detection of clinically occult cancer had been reported in two men who had undergone previous mastectomy because of breast cancer.[15,82]
Controversy exists whether cancer can be easily distinguished from gynecomastia upon radiographic examination.[85,86] Several researchers have noted that the presence of gynecomastia can obscure underlying carcinoma on a mammogram. In the study by Dershaw and colleagues, three cancers were not apparent with mammography. In one patient, the tumor was obscured by gynecomastia and in the other two cases there were no mammographic findings that could be correlated with the presence of breast cancer. However, it is interesting to note that a clinically occult cancer was detected during screening mammography in a man who had undergone previous mastectomy for breast cancer in the contralateral breast.
As stated earlier, mammography does not play a key role in the detection of male breast cancer because diagnosis is rarely made in the absence of physical findings. Instead, diagnostic techniques such as fine needle aspiration biopsy, cutting needle biopsy of large masses and excisional biopsy of smaller masses are standard methods of detection. Tissue samples are screened for the presence of estrogen and progesterone receptors. Estrogen receptors are found in more than 80% of male breast cancers, possibly because binding sites in men are not occupied with high levels of circulating estrogens. Chest x-rays and blood tests for hepatic functions are routine in men with proven breast cancer, as is a bone scan for patients with axillary adenopathy, skin involvement or symptoms suggestive of bony metastases. The presence of Klinefelter's syndrome can be confirmed with karyotyping of cells.
Prognosis and Staging
Histologically speaking, male and female breast cancers are virtually indistinguishable. Most are infiltrating ductal carcinomas. Ductal carcinoma in situ is found in combination with invasive carcinomas in 47% of cases and tends to be present more often with less advanced tumors. Other types, including medullary, tubular, papillary and mucinous carcinoma, represent less than 10% of cases.
Breast cancer in men is staged identically to that in women. The tumor-nodes-metastases (TNM) system identifies tumor size, skin changes, axillary node involvement and the presence of distant metastases. Because male breasts generally are small, a tumor of nearly any size can be expected to occur with skin fixation and ulceration more often than would a tumor of similar size in a woman. Tumors in the male breast are associated with nodal metastases in 50% of cases. A direct correlation has been found between the size of the tumor and the presence of axillary node metastases in men. Survival in men is obviously related to the stage at which the cancer is detected. (See Table 2.)
Table 2 Survival of Men with Breast Cancer Survival Survival TNM Stage 5 Year (%) 10 Year (%) Stage 0 (TIS) 88-100 Stage I 75-100 57-89 Stage II 63-83 12 Stage III 25-70 Stage IV 0 Axillary metastases absent 77-100 79-80 Axillary metastases present 38-60 11-36 Overall 42-85 2-60
Recent studies report the following distribution of cases of male breast cancer according to stage: Stage 0 (TIS), 3% to 7%; Stage I, 15% to 30%; Stage II, 15% to 54%; Stage III, 0% to 35%; and Stage IV, 6% to 61%. The wide variation in numbers is indicative of the small number of cases, a combination of the clinical and pathological staging employed and the population observed.[57,87-90]
Previously, male breast cancer was believed to have a worse prognosis for men than women. It is now known that this perception arose as the result of delayed diagnosis in men, presentation of cancer in more advanced stages, the older age of men upon presentation and the higher mortality of elderly men. One investigator found that the cause of death in 28% of men with breast cancer was from other causes. Once confounding factors have been eliminated, the overall survival rate for men and women is nearly identical.[88,92-94]
The primary treatment for male breast cancer is removal of the tumor or breast. Radical mastectomy is rarely performed today, having been replaced by a modified radical mastectomy (removal of only the breast and the axillary nodes) in the majority of cases in both sexes.[30,95] Researchers have recently shown that breast-conserving techniques such as wide local tumor excision, axillary dissection and breast irradiation are the equivalent of modified radical mastectomy in terms of survival and local tumor control.[96,97] However, the cosmetic appeal of this operation is less significant for men, because the subareolar location of most tumors means the nipple must be removed to obtain a tumor-free margin.[5,88]
The addition of irradiation to the chest wall and lymphatics after mastectomy does not increase patient survival, but it can help to curb the frequency of local or regional recurrence. Radiation therapy is most useful when there is evidence of extensive tumor spread or when surgical resection is limited to simple mastectomy, local tumor excision or needle biopsy alone.
Evidence regarding adjuvant chemotherapy in men is limited due to the small number of cases, and its usefulness can only be inferred from studies with women. Anti-estrogen therapy has been successful in postmenopausal women, a situation that is analogous to men because of low estrogen levels and the frequency of estrogen-receptor-positive tumors. Although firm evidence regarding the role of chemotherapy in the treatment of advanced cases of male breast cancer is scanty, results in women have been sufficiently promising to justify the risk of providing treatment, particularly when the chances for reoccurrence after local treatment are high.
Although male breast cancer is infrequent, it is not rare. Biologically, breast cancer in men is similar to breast cancer in women. Earlier reports of a worse prognosis for males with breast cancer when compared with females may be related to a delay in diagnosis or treatment. Recent reports, however, contradict these earlier findings, suggesting that there is in fact little difference in prognosis between men and women with similar stages of the disease.[19,84,93,94,99]
It is hoped that insights from this disease in men will provide clues to the natural history of breast cancer in women. An increased awareness about the disease generated through public health efforts and professional activities directed at health care workers will help increase the potential for early diagnosis and treatment. By initiating treatment in the early stages of the disease, prognosis can be improved and lives saved.
[1.] Boring CC, Squires TS, Tony T. Cancer statistics, 1991. CA Cancer J Clin. 1991;41:19-36.
[2.] Crichlow RW, Galt SW. Male breast cancer. Surg Clin North Am. 1990;70:1165-1177.
[3.] Cancer Facts and Figures--1994. Atlanta, Ga: American Cancer Society; 1994.
[4.] Cutler SJ, Young JL Jr, eds. Third National Cancer Survey: Incidence Data. National Cancer Institute Monograph 41. Bethesda, Md: National Cancer Institute; 1975. U.S. Department of Health and Human Services publication NIH 75-787.
[5.] Donegan WL. Cancer of the male breast. In: Donegan WL, Spratt JS, eds. Cancer of the Breast. 4th ed. Philadelphia, Pa: WB Saunders Co; 1995:765-777.
[6.] Thomas DB. Breast cancer in men. Epidemiol Rev. 1993;15:220-231.
[7.] Muir C, Waterhouse J, Mack T, et al, eds. Cancer Incidence in Five Continents, Vol. 5. Lyon, France: International Agency for Research on Cancer; 1987:882. IARC Scientific publication 88.
[8.] Schottenfeld D, Lilienfeld AM. Some epidemiological features of breast cancer among males. J Chronic Dis. 1963;16:71-81.
[9.] Mabuchi K, Bross DS, Kessler LRS II. Risk factors for male breast cancer. J Natl Cancer Inst. 1985;74:371-375.
[10.] Thomas DB, Jimenez LM, McTiernan A, et al. Breast cancer in men: risk factors with hormonal implications. Am J Epidemiol. 1992;135:734-748.
[11.] Kapdi CC, Parekh NJ. The male breast. Radiol Clin NA. 1983;21:137-148.
[12.] Crichlow RW. Breast cancer in males. Breast. 1976;2:12.
[13.] Ewertz M, Homnberg L, Kajjalainen S, et al. Incidence of male breast cancer in Scandinavia 1943-1982. Int J Cancer. 1989;43:27-31.
[14.] Breasted JH. The Edwin Smith Surgical Papyrus. Chicago, Ill: The University of Chicago Press; 1930;403-406.
[15.] Dershaw DD, Borgen PI, Deutch BM, Liberman L. Mammographic findings in men with breast cancer. AJR. 1993;160:267-270.
[16.] Panettiere FJ. Cancer in the male breast. Cancer. 1974;34:1342.
[17.] Crichlow RW. Carcinoma of the male breast. Surg Gynecol Obstet. 1972;134:1011.
[18.] Everson RB, Lippman ME. Male breast cancer. In: McGuire WL, ed. Breast Cancer. New York, NY: Plenum Publishing Co; 1979.
[19.] Salvadori S, Saccozzi A, Manzari S, et al. Prognosis of breast cancer in males: an analysis of 170 cases. Eur J Cancer. 1994;30:930-935.
[20.] Demeter JG, Waterman NG, Verdi GD. Familial male breast carcinoma. Cancer. 1990;65:2342-2343.
[21.] Harmsen HJ, Porsius AJ. Endocrine therapy of breast cancer. Eur J Cancer Clin Oncol. 1988;24:1099-1116.
[22.] Sandler B, Carman C, Perry RR. Cancer of the male breast. Amer Surg. 1994;60:816-820.
[23.] Wainwright JN. Carcinoma of the male breast: clinical and pathologic study. Arch Surg. 1927;14:836-859.
[24.] Crichlow RW, Kaplan EL, Kearney WH. Male mammary cancer: an analysis of 32 cases. Ann Surg. 1972:175:489.
[25.] Dershaw DD. Male mammography. AJR. 1986;146:127-131.
[26.] Carlson HE. Current concepts: gynecomastia. N Engl J Med. 1980;303:795-799.
[27.] Ouimet-Oliva D, Herbert G, Ladouceur J. Radiographic characteristics of male breast cancer. Radiology. 1978;129:3740.
[28.] Newman J. The Evolution of Mammography and its Impact on the Detection of Microcalcifications. Albuquerque, NM: American Society of Radiologic Technologists; 1996:16-25. ASRT Homestudy Series.
[29.] Roswit B, Edlis H. Carcinoma of the male breast: a thirty year experience and literature review. Current Concepts in Cancer. Radiation Oncology Biology Physics. 1978;4:711-716.
[30.] Prechtel K, Prechtel V. Breast carcinoma in the man. Current results from the viewpoint of clinic and pathology. Pathologe. 1997;18(1):45-52.
[31.] Salyer WR, Salyer DC. Metastases of prostatic carcinoma of the breast. J Urol. 1973;109:671-675.
[32.] Lin RS, Kessler LRS II. Epidemiologic findings in male breast cancer. Proc Am Assoc Cancer Res. 1980;21:72.
[33.] Rosenbaum PF, Vena JE, Zielezny MA, et al. Occupational exposures associated with male breast cancer. Am J Epidemiol. 1994;139:30-36.
[34.] Nance KVA, Reddick RL. In situ and infiltrating lobular carcinoma of the male breast. Hum Pathol. 1989;20:1220-1222.
[35.] Davidson AT. A review of the treatment of cancer of the male breast with a case follow-up. J Natl Med Assoc. 1987;79:879-880.
[36.] Cassagrande JT, Hanisch R, Pike MC, et al. A case-control study of male breast cancer. Cancer Res. 1988;48:1326-1330.
[37.] Kessler LRS II. Selected aspects of breast cancer ecology and epidemiology [abstract]. Proc Am Assoc Cancer Res. 1980;21:72.
[38.] Young JL Jr, Percy CL, Asire AJ, eds. Surveillance, Epidemiology and End Results: Incidence and Mortality Data 1973-77. National Cancer Institute Monograph No. 57. Bethesda, Md: National Cancer Institute; 1981:6870. U.S. Department of Health and Human Services publication NIH 81-2330.
[39.] Steinitz R, Katz L, Ben-Hur M. Male breast cancer in Israel: selected epidemiologic aspects. Isr J Med Sci. 1981;17:816-821.
[40.] Olsson H, Ranstam J. Head trauma and exposure to prolactin-elevating drugs as risk factors for male breast cancer. JNatl Cancer Inst. 1988;80:679-683.
[41.] Robison R, Montague ED. Treatment results in males with breast cancer. Cancer. 1982;49:403.
[42.] L'enfant-Pejovic M-H, Mlika-Cabanne N, Bouchardy C, et al. Risk factors for male breast cancer: a Franco-Swiss case-control study. Int J Cancer. 1990;45:661-665.
[43.] Lee PA. The relationship of concentrations of serum hormones to pubertal gynecomastia. Z Kinderheik. 1973;115:89
[44.] Sirtori C, Veronesi U. Gynecomastia: a review of 218 cases. Cancer. 1957;10:645454.
[45.] Braunstein GD. Gynecomasha. N Engl J Med. 1993;328:490-495.
[46.] Heller KS, Rosen PP, Schottenfeld D, et al. Male breast cancer: a clinicopathologic study of 97 cases. Ann Surg. 1978; 188:60.
[47.] Nutall FQ. Gynecomasha as a physical finding in normal man. J Clin Endocrinol Metab. 1979;48:338.
[48.] Nydick M, Bustos J, Dale JH, et al. Gynecomasha in adolescent boys. JAMA. 1961;178:449454.
[49.] Rubens R, Dhont M, Vermoulen A. Further studies on Leydig cell function in old age. J Clin Enocrinol Metabol. 1974;39:4045.
[50.] Vermoulen A, Stoica T, Verdonck I., The apparent free testosterone concentration: an index of androgenicity. J Clin Enocrinol Metabol. 1971;33:759.
[51.] Treves N, Robbins GF, Amoroso WL. Serous and serosanguineous discharge from the male nipple. Arch Surg. 1956;73:319-329.
[52.] Michels LG, Gold RH, Arndt RD. Radiography of gynecomastia and other disorders of the male breast. Radiology. 1977;117-122.
[53.] Rodstein M. Gynecomastia: unusual manifestation of digitalis toxicity. GP. 1962;26:95-97.
[54.] Greenwood SM, Goodman JR, Schneider G, et al. Choriocarcinoma in man: relationship of gynecomasia to chronic somatomammotropin and estrogens. Am J Med. 1971;51:416-422.
[55.] Bannayan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351 cases. Am J Clin Pathol. 1972;57:431-437.
[56.] Friesen H, Wilber JF, Metzger BE. Gynecomastia, prolactin, and other peptide hormones in patients undergoing chronic hemodialysis. J Clin Endocrinol Metabol. 1973;36:428-432.
[57.] Lloyd CW, Williams RH. Endocrine changes associated with Laennec's cirrhosis of liver. Am J Med. 1948;4:315-319.
[58.] Molina C, Aberkane B. Les gynecasties des tuberculeux pulmonaires. Sem Hop (Paris). 1960;36:834-836.
[59.] Jacobs EC. Gynecomastia following severe starvation. Ann Intern Med. 1948;28:792-797.
[60.] Harmon J, Aliapoulios MA. Gynecomasba in marihuana users. N Engl J Med. 1972;287:936.
[61.] Summerskill WH, Adson MA. Gynecomastia as sign of hepatoma. Am J Dig Dis. 1962;7:250-254.
[62.] Hardy JD. Gynecomastia associated with lung cancer. JAMA. 1960;173:1462-1465.
[63.] Harnden DG, MacLean N, Langlands AO. Carcinoma of the breast and Klinefelter's syndrome. J Med Genet. 1971;8:460-461.
[64.] Scheike O, Visfeldt J, Petersen B. Male breast cancer III: Breast carcinoma in association with Klinefelter syndrome. Acta Pathol Microbiol Scand. 1973;81(A):352-358.
[65.] Griesemer DA. Clinical conferences at The Johns Hopkins Hospital: Klinefelter syndrome and breast cancer. Johns Hopkins Med J. 1976;138:102-108.
[66.] Scheike O. Factors provoking male breast cancer. In: Stoll BA, ed. Risk Factors in Breast Cancer. Chicago, Ill: Yearbook Medical Publishers; 1976.
[67.] Mies R, Fischer H, Pfeiff B, et al. Klinefelter's syndrome and breast cancer. Andrologia. 1982;14:317-321.
[68.] Schottenfeld D, Lilienfeld AM, Diamond H. Some Observations on the epidemiology of breast cancer among mares. Am J Public Health. 1963;53:890-897.
[69.] Kirschner MA, Schneider G, Ertel HH, et al. Obesity, androgens, estrogens, and cancer risk. Cancer Res. 1982;42 (suppl) :3281S-3285S.
[70.] Rose DP. Endocrine epidemiology of male breast cancer (review). Anticancer Res. 1988;8:845-850.
[71.] Scheike O, Visfeldt J, Peterson B. Breast carcinoma in association with the Kinefelter's syndrome. In: Bandmann H-J, Breit R, eds. Klinefelter's Syndrome. Berlin, Germany: Springer-Verlag; 1984;118-126.
[72.] Guechot J, Peigney N, Ballet F, et al. Sex hormone imbalance in male alcoholic cirrhotic patients with and without hepatocellular carcinoma. Cancer. 1988;62:760-762.
[73.] McLaughlin JK Malker HSR, Blott WJ, et al. Occupational risks for male breast cancer in Sweden. Br J Ind Med. 1988;45:275-276.
[74.] Symmers WS. Carcinoma of breast in trans-sexual individuals after surgical and hormonal interference with the primary and secondary sex characteristics. Br Med J. 1968;2:82-85.
[75.] Pritchard TJ, Pankowsky DA, Crowe JP, et al. Breast cancer in a male to female transsexual. JAMA. 1988;259:2278-2280.
[76.] Donegan WL, Perez-Mesa CM. Carcinoma of the male breast: a 30-year review of 28 cases. Arch Surg. 1973;106:273.
[77.] Curtin CT, McHeffy B, Kolarsick AJ. Thyroid and breast cancer following childhood radiation. Cancer. 1977;40:2911-2913.
[78.] Cohen R, Schauer PK Male breast cancer following repeated fluoroscopy. Am J Med. 1984;76:929-930.
[79.] Thomas DB, Rosenblatt K, Jimenez LM, et al. Ionizing radiation and breast cancer in men. Cancer Causes Control. 1994;5:9-14.
[80.] Demers PA, Thomas DB, Rosenblatt KA, et al. Occupational exposure to electromagnetic fields and breast cancer in men. Am J Epidemiol. 1991;134:340-347.
[81.] Kalisher L, Peyster RG. Xerographic manifestations of male breast disease. AJR 1975;125:656-661.
[82.] Borgen PL, Wong GY, Vlamis V, et al. Current management of male breast cancer: a review of 104 cases. Ann Surg. 1992;215:451-459.
[83.] Wentz G. Mammography for Radiologic Technologists. New York, NY: McGraw Hill Inc; 1992:53-78.
[84.] Digenis AG, Ross CB, Morrison JG, et al. Carcinoma of the male breast: a review of 41 cases. South Med J. 1990;83:1162-1167.
[85.] Gough DB, Donohue JH, Evans MM, et al. A 50-year experience of male breast cancer. Is outcome changing? Surg Oncol. 1993;2:325-333.
[86.] Spence RAJ, Mackenzie G, Anderson JR, et al. Long-term survival following cancer of the male breast in Northern Ireland. Cancer. 1985;55:648-652.
[87.] Siddiqui T, Weiner R, Moreb J, et al. Cancer of the male breast with prolonged survival. Cancer. 1988;62:1632-1636.
[88.] Beahrs OH, Henson DE, Huter RVP, Myers MH, eds. Manual for Staging of Cancer. 3rd ed. Philadelphia, Pa: JB Lippincott Co; 1988:145-150.
[89.] Lefor AT, Numann PJ. Carcinoma of the breast in men. NY State J Med. 1988;88:293-296.
[90.] Axelsson J, Andersson A. Cancer of the male breast. World J Surg. 1983;7:281.
[91.] Hodson GR, Urdaneta LF, Al-Jurf AS, et al. Male breast carcinoma. Am Surg. 1985:51:47.
[92.] Vercoutere AL, O'Connell TX. Carcinoma of the male breast: an update. Arch Surg.
[93.] Yap HY, Tashima, CK Blumenschein, GR, et al. Male breast cancer: a natural history study. Cancer. 1979;44:748.
[94.] Langer SW, Krasnik M, Hirsch FR, Dombernowsky P. Male breast cancer. A review. Ugeshr Laeger. 1996:158(1): 3740.
[95.] Patel HZ II, Buzdar AU, Hortobagyi G. Role of adjuvant chemotherapy in male breast cancer. Cancer. 1989;64:1583-1585.
[96.] Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1989;822-828.
[97.] Veronesi U, Banfi A, Del Vecchio M, et al. Comparison of Halsted mastectomy with quadrantectomy, axillary dissection, and radiotherapy in early breast cancer: long-term results. Eur J Cancer Clin Oncol. 1986;22:1085-1089.
[98.] Erlichman C, Murphy KC, Elhakim T. Male breast cancer: a 13-year review of 89 patients. J Clin Oncol. 1984;2:903.
[99.] Ouriel K, Lotze MT, Hinshaw JR. Prognostic factors of carcinoma of the male breast. Surg Gynecol Obstet. 1984;159:373.
Julliana Newman, B.A., ELS, is a certified editor of the life sciences. She resides in Albuquerque, N.M.
Reprint requests may be sent to the American Society of Radiologic Technologists, Publications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3917.
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|Title Annotation:||continuing education directed reading, includes test and answer sheet|
|Date:||Sep 1, 1997|
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