A 52-year-old Ashkenazi Jewish man presented to a breast clinic with a seven-week history of a non-tender lump in his left breast. Examination of the left breast revealed a hard retro-areolar mass of 2cm with no overlying skin changes and no palpable axillary lymph nodes. His lab tests’ results are as follows:

Calcium – 11.1 mg/dL

Total bilirubin – 1.5 mg/dL

ALT (alanine aminotransferase) – 46U/L

AST (aspartate aminotransferase) – 46 U/L

ALP (alkaline phosphatase) – 45 U/L.

The rest of the serological tests were normal.

Breast imaging was done with instructions to follow up.

Past history was significant for a viral infection around 20 years back which resulted in the deafness of the left ear. The patient had undergone a vasectomy and his usual medications included antiallergy, fexofenadine, and daily mometasone nasal spray for his rhinitis. Tobacco or alcohol use was not reported. He had a positive family history of breast cancer with his father, maternal grandfather and paternal aunt being the victims of breast carcinoma.

The mammography revealed a spherical but irregular mass with heterogeneous calcifications. Imaging of the right breast showed characteristics of benign nodular gynecomastia. A tissue sample was extracted from the mass of the left breast with a core-biopsy needle under ultrasonographic guidance.

No metastasis was detected neither on the CT scan of the chest, abdomen, and pelvis nor on the technetium-99m bone scan. The patient was referred for genetic counselling and later left modified radical mastectomy was performed. Histopathological results confirmed the diagnosis of invasive ductal carcinoma of the left breast.

If mammography is inconclusive or a suspicious finding is identified, ultrasonography is performed. Because of its high sensitivity and specificity in men, mammography is the test of choice to distinguish breast cancer from benign conditions, such as gynecomastia, in this clinical context.

The first question that crosses the mind of a layman is how come males have breast cancer when they don’t have breasts? Or do they have breasts?

Well everyone has breast tissue! In females, the breast tissue, under the influence of hormones, grows and develops into visible breasts whereas in males the breast tissue remains inactivated, therefore does not fully grow into breasts. Certain diseases and hormonal imbalances due to endogenous processes or exogenous stimuli like certain medicines can enlarge the breasts in males too.

Although breast cancer is rare in men, but males usually around 50 to 70 years of age can also feel a lump in their breast tissue. The following characteristics of a breast lump are essential:

Consistency

Mobility

Adherent to underlying structures or not

Overlying skin changes

Associated nipple discharge

Along with the above features, the armpit should be examined for lymph node enlargement. It is extremely crucial to rule out gynecomastia before proceeding to a diagnosis of tumour growth.

Gynecomastia is an increase in the amount of breast tissue and is the most common breast disorder in males. This happens due to hormonal changes, primarily estrogen, hence mostly in teenagers and in elderly males. Apart from physiological causes, there are some other causes like endocrine tumours, liver diseases, genetic diseases and medicines such as antihypertensives, antipsychotics, etc. For any breast lump, history, physical examination, and mammography are dispensable as their findings determine the management strategy. A tissue sample from the lump drawn by fine-needle aspiration determines the type of breast carcinoma.



Treatment options are similar for both males and females including surgery, hormonal therapy, chemoradiotherapy, and immunotherapy with hormonal therapy being more effective in males than in females.





References

teven J. Isakoff, M. P. (2020, Feb 27). Case 7-2020: A 52-Year-Old Man with a Mass in the Left Breast. Retrieved from New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMcpc1913470

WebMD Medical Reference Reviewed by Laura J. Martin, M. (2019, November 17). Breast Cancer in Men. Retrieved from WebMD: https://www.webmd.com/breast-cancer/breast-cancer-men American Cancer Society. Key Statistics for Breast Cancer in Men. January 2020. Available at https://www.cancer.org/cancer/breast-cancer-in-men/about/key-statistics.html.