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Encapsulated Papillary Carcinoma in A Man with Gynecomastia: Ultrasonography, Mammography and Magnetic Resonance Imaging Features with Pathologic Correlation.

Introduction

Male breast cancer accounts for 1% of all breast cancers and 0.17% of all male cancers (1). The papillary variant of breast cancer represents 3 to 5% of cases in men, which is more common than women representing 1 to 2% of cases (2). Based on recent immunohistochemical studies, intracystic papillary carcinoma is called encapsulated papillary carcinoma (EPC) (3). Imaging findings of EPC in women have been reported in the literature many times (4-7). Mammography (MG) and ultrasonography (US) findings of male EPC was reported in a few case reports (8-10). However, to our knowledge, magnetic resonance (MR) imaging features of EPC in a male patient has been described in only one case which was an incomplete assessment (11). We report MG, US and MR imaging findings of a 63-year-old male patient with bilateral gynecomastia and a right subareolar palpable mass. This is the second case report of male breast encapsulated papillary cancer that included MR imaging features.

Case Presentation

A 63-year-old male who had a 1.5-year history of a mass located just below his right areolar region. He was admitted to our clinic because the mass has recently grown painless. There were no risk factors of breast cancer in his history. He did not have any systemic illness or drug usage history; routine blood and urine tests were normal. His BMI was 24. On physical examination, a 2 cm mobile mass was palpated in the right subareolar region. No skin abnormality was noted on inspection. Axillary examination was unremarkable. Bilateral craniocaudal and mediolateral oblique MG demonstrated an ellipsoidal nodular density under bilateral areolas considered as gynecomastia. These nodular appearances were evaluated as nodular gynecomastia. The right MG also showed an oval-shaped dens mass with circumscribed margins adjacent to gynecomastia (Figure 1). On US, we found a 23x19 mm well-circumscribed, predominantly cystic mas with solid components that evaluated as complex lesion. Increased blood flow was present within the solid components on Doppler US (Figure 2). Hypoechoic area compared to regional fat tissue that represented fibroglandular enlargement compatible with gynecomastia was seen on US in both breasts. MR images revealed a cir cumscribed hypointense mass and bilateral hypointense parenchyma on pre-contrast T1-weighted sequences. Axial T2-weighted images revealed complex mass containing hypointense solid components and hyperintense cystic component. Axial T1-weighted contrast-enhanced subtraction images revealed enhancement of the cystic mass wall and solid components. Sagittal post-contrast images showed a circumscribed complex mass with a cystic component (star) and markedly enhancing wall and solid nodules (Type III kinetic curve/suggestive of malignancy-not illustrated) (Figure 3). The lesion was reported as intracystic mass with a preliminary diagnosis of papillary carcinoma. Core needle biopsy was performed under US guidance. Histopathologically, the lesion had few papillary folds and was filled with uniform tumoral cells. Immunohistochemical analysis also confirmed no myoepithelial cells were stained with p40 in the lesion. So the final pathological diagnosis was EPC (Figure 4). Simple mastectomy was performed with axillary sentinel lymph node sampling. The size of the specimen was 15 cm and the tumor size was 2.5 cm. All 4 sentinel lymph nodes were negative. Receptor status was ER: 90% and PR:90%. The tumor cells were moderately differentiated (grade 2) and tumor stage was reported as T2N0. Written informed consent was obtained from the patient.

Discussion and Conclusion

Encapsulated papillary carcinoma is a localized, encysted kind of papillary ductal cancer that surrounded by a fibrous capsule found within a dilated duct. EPC may be asymptomatic or present with a bloody nipple discharge or palpable mass. Many cases were also described in the male population in the literature, (12). The average age of EPC is higher than the other types of breast cancer, being 65-year old (13). Gynecomastia is quite common in male breast. In our patient, cancer and gynecomastia was diagnosed at the same time. Gynecomastia is not an independent risk factor for male breast cancer; most of the time, it presents concurrently with relative estrogen excess associated clinical conditions. Usually, this tumor can Show benign MG findings as a well-circumscribed, round or oval mass. However, true diagnosis of EPC can be made by adding US. US was absolutely necessary to evaluate internal structure of this mass which typically reveals complex appearance that includes a cystic area with solid components originating from the wall of the cyst.

Magnetic resonance imaging can give additional information about the morphological features and the local extension of the mass for preoperative mapping (14, 15). At MR imaging, round or oval mass with circumscribed margins has typical heterogeneous internal composition with solid nodules of intermediate signal intensity and also depends on the cystic component. EPC shows strongly enhancing cyst wall and solid nodules on post-contrast images. Differentiating EPC from intracystic papilloma is difficult, however MR imaging can guide us by showing the types of the kinetic curves of the solid nodules that demonstrate the presence of cancer (15). Even pathologically, EPC can be misdiagnosed as intraductal papilloma especially in small biopsies. Showing presence of myoepithelial layer is enough to give a diagnosis of intraductal papilloma. The recommended treatment is surgical excision with negative margins. Sentinel lymph node biopsy is recommended when tumor shows clinical N0 as usual breast cancer.

In conclusion, EPC in male breast is an extremely rare entity; however, cystic lesions in men should be worked up as potentially malignant lesions. MG and US together provide valuable information to direct us to the correct diagnosis. MR imaging of EPC in male breast has similar features as in female breast. Round or oval shape with predominantly circumscribed margins and the complex appearance of solid and cystic components are the specific features of EPC on US and MR imaging. Absence of myoepithelial cell layer by immunohistochemical study is significant for pathologic diagnosis.

Informed Consent: Written informed consent was obtained from patient who participated in this study.

Peer-review: Externally peer-reviewed

Author Contributions: Concept - R.Y., Y.T.; Design - R.Y., R.G.C.; Supervision - R.Y., V.O.; Resources - R.Y., S.A.; Materials - R.Y., S.E.; Data Collection and/or Processing - R.Y., R.C.G.; Analysis and/or Interpretation - R.Y., S.O.; Literature Search - R.Y., R.C.G.; Writing Manuscript - R.Y., S.A.; Critical Review - R.Y., V.O.

Acknowledgements: Authors would like to thank patients who participated this study.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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Ravza Yilmaz (1) [iD], Rana GunOz COmert (1) [iD], Samil Aliyev (1) [iD], Yucel Toktas (1) [iD], Semen Onder (2) [iD], Selman EmirikCi (3) [iD], Vahit Ozmen 3 [iD]

(1) Department of Radiology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey

(2) Department of Pathology, Istanbul University, Istanbul School culty of Medicine, Istanbul, Turkey

(3) Department of Surgery, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey

Address for Correspondence:

Ravza Yilmaz, e-mail: ravzaylmz@gmail.com

Received: 17.08.2017

Accepted: 28.11.2017

DOI: 10.5152/ejbh.2018.3761

Cite this article as: Yilmaz R, GunOz COmert R, Aliyev S, Toktas Y, Onder S, Onder S, EmirikCi S, Ozmen V. Encapsulated Papillary Carcinoma in A Man with Gynecomastia: Ultrasonography, Mammography and Magnetic Resonance Imaging Features with Pathologic Correlation. Eur J Breast Health 2018; 14: 127-131.
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Article Details
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Title Annotation:Case Report
Author:Yilmaz, Ravza; COmert, Rana GunOz; Aliyev, Samil; Toktas, Yucel; Onder, Semen; EmirikCi, Selman; Ozm
Publication:European Journal of Breast Health
Article Type:Clinical report
Date:Apr 1, 2018
Words:1601
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