Pure low-grade DCIS in a male patient: a case report

Pure low-grade DCIS in a male patient: a case report Breast cancer in males represents a small proportion of all cancers diagnosed. Pure ductal carcinoma in situ (DCIS), a low- grade form of breast cancer, is even more rare in male patients. We present a case of a 47-year-old male patient with a ten- der breast lump that was noted for 6 months. He was subsequently found to have a low grade, pure micropapillary and cribriform type DCIS with no evidence of invasive disease. Current literature does not provide distinct guidelines regarding management of male breast cancer, and it is currently managed in a similar fashion to female breast cancer. appendectomy and a cholecystectomy as well as several sinus INTRODUCTION procedures. Social history includes being a social drinker, but Male breast cancer is very rare and represents 1% of all cancers he denies ever smoking. Physical exam showed symmetrical diagnosed in the USA [1]. Pure ductal carcinoma in situ (DCIS) breasts with normal nipple–areolar complexes. No masses in a male is even more rare and represents ~0.1% of all breast were palpated in the right breast, but there was a firm, tender, cancers [2]. Proposed risk factors for development of DCIS in thickened area at the areolar border laterally in the left breast men is the same as the risks factors for any male breast cancer extending inferiorly ~2 cm. No nipple discharge or retraction and includes age, family history, exposure to radiation, condi- was noted, and there were no palpable axillary or supraclavicu- tions causing increased estrogen to androgen ratio (Klinefelter, lar nodes bilaterally. obesity), and pathological gene mutations (CHEK2, BRCA2 > Bilateral mammogram demonstrated mild gynecomastia in BRCA1) [3]. Management of male breast cancer stems from both sides with no discrete mass or clusters of microcalcifica- understanding of female breast cancer due to a lack of research tions (Fig. 1). A follow-up ultrasound around the area of palp- in men and includes combinations of surgery, radiation and able concern did show a prominent duct with irregular chemotherapy. contours at the 6:00 position in the left breast (Fig. 2). Excisional biopsy was recommended and a subareolar biopsy of the left breast was performed. CASE REPORT The pathology showed pure micropapillary and cribriform A 47-year-old Caucasian male with no family history of breast type low-grade DCIS with no evidence of invasive disease or ovarian cancer presented with a tender mass in the subareo- (Fig. 3). Breast specific gamma imaging (BSGI) and genetic test- lar, outer left breast region. The patient noted the mass 6 ing for BRCA gene mutations were ordered. BRCA testing was months ago, but it had persisted with no improvement in negative for both BRCA1 and BRCA2 mutations. The BSGI symptoms. His past medical history includes gastric ulcer, gas- revealed minimal parenchymal activity in the bilateral breasts, troesophageal reflux, hypercholesterolemia, sciatica, sleep however, an area with vague radiotracer activity in a 2.5 cm apnea and lumbar canal stenosis. He also previously had an diameter region was seen that was consistent with the biopsy Received: April 5, 2018. Accepted: May 2, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Zaesim et al. Figure 1: Diagnostic mammogram of the left (a) and right (b) breast demon- strates mild bilateral gynecomastia without discrete mass. Figure 3: Excisional biopsy at 10× magnification (a) shows neoplastic cells within ducts; 20× magnification (b) demonstrates cribriform and micropapillary features (samples stained with hematoxylin and eosin). the patient has continued medical follow-up with medical oncology. DISCUSSION DCIS is defined as a group of lesions caused by a proliferation of neoplastic cells within the mammary duct system of the breast [4]. It is differentiated from invasive breast cancer by detection of an intact basement membrane, but it is still asso- ciated with a risk for progression to invasive cancer, and thus, should be treated. Figure 2: Ultrasound of the left breast at the 6:00 region reveals a mildly hypoe- All breast cancer regardless of type is staged the same way choic mass with ductal extension. in men as in women and follows the TNM staging protocol. Receptor expression for the hormones estrogen and progester- one as well as overexpression of the epidermal growth factor location. After discussing the diagnosis and treatment options receptor-2 (HER2) is also regularly analyzed and plays a small with the patient, he strongly desired bilateral mastectomy. role in the staging of breast cancers. For the case presented After further discussions with other breast surgeons and a above, the tumor stage would be classified as a stage 0, low medical oncologist, simple left and right mastectomy with sen- grade tumor under the latest guidelines by the American Joint tinel node biopsy on the left were offered to the patient. Committee on Cancer [5]. Subsequently, a simple left mastectomy with sentinel Limited data exists regarding the natural history of low- lymph node biopsy and a simple right mastectomy were per- grade DCIS. Low-grade DCIS does not often progress to invasive formed. The sentinel node was negative for metastatic carcin- carcinoma with proper management. Research has shown that oma, and both breasts demonstrated no residual in situ or there is an increased likelihood of local recurrence with pos- invasive carcinoma. The post-op course was uneventful, and sible invasion after excisional biopsy even after 30 years, Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Pure low-grade DCIS in a male patient 3 especially if the margins of excision were not fully negative [6]. REFERENCES In men, the incidence of bilateral invasive breast cancer is also 1. Ferzoco RM, Ruddy KJ. The epidemiology of male breast extremely low. Thus, management for men focuses only on the cancer. Curr Oncol Rep 2016;18:1. breast where the primary lesion was detected. Patients should 2. Brents M, Hancock J. Ductal carcinoma in situ of the male be educated about their risk for further evolution of their breast breast. Breast Care 2016;11:288–90. disease before providing them with options for management. 3. Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, Regardless of the risk, some patients still desire maximal risk diagnosis, treatment, and survivorship. Ann Oncol 2013;24: reduction using techniques such as bilateral mastectomy, as in 1434–43. this case. 4. Dabbs DJ. Breast Pathology. Philadelphia, PA: Elsevier, 2017. There are few studies regarding the management guidelines 5. Giuliano AE, Connolly JL, Edge SB, Mittendorf EA, Rugo HS, of breast cancer in males. This is likely due to the low incidence Solin LJ, et al. Breast cancer—major changes in the of breast cancer in the population. Male breast cancer is currently American Joint Committee on Cancer eighth edition cancer managed in a similar fashion to female breast cancer [7]. Even so, staging manual. CA Cancer J Clin 2017;67:290–303. there are various options for management of such lesions in 6. Sanders ME, Schuyler PA, Simpson JF, Page DL, Dupont WD. females. After confirmed biopsy of such a lesion, all management Continued observation of the natural history of low-grade options revolve around surgery which is the primary method ductal carcinoma in situ reaffirms proclivity for local recur- required to remove the lesion from the breast leaving negative rence even after more than 30 years of follow up. Mod Pathol margins. For a stage 0 low grade-DCIS, mastectomy (with or with- 2015;28:662–9. out reconstruction) is considered equivalent to breast conserving 7. Scott-Conner C, Jochimsen P, Menck H, Winchester D. An surgery (lumpectomy) with radiation [8, 9]. All options are offered analysis of male and female breast cancer treatment and to patients with discussions about risks and benefits as medical survival among demographically identical pairs of patients. management involves patient satisfaction and cost. Surgery 1999;126:775–81. Due to the rarity of male breast cancer, strong genetic pre- 8. Hwang ES, Lichtensztajn DY, Gomez SL, Fowble B, Clarke disposition is suspected whenever a case occurs. It is recom- CA. Survival after lumpectomy and mastectomy for early mended that all male breast cancer patients should be tested stage invasive breast cancer. Cancer 2013;119:1402–11. for genetic mutations, especially BRCA1 and BRCA2 [10]. Men 9. Christiansen P, Carstensen SL, Ejlertsen B, Kroman N, with BRCA2 mutations may have higher risk of developing Offersen B, Bodilsen A, et al. Breast conserving surgery ver- breast cancer than men with BRCA1 mutations. Other gene sus mastectomy: overall and relative survival—a population mutations could also be considered in a workup and data based study by the Danish Breast Cancer Cooperative Group shows that a multi gene panel test checking for alternative (DBCG). Acta Oncol (Madr) 2017;57:19–25. gene mutations could be offered. 10. Fostira F, Saloustros E, Apostolou P, Vagena A, Kalfakakou D, Mauri D, et al. Germline deleterious mutations in genes CONFLICT OF INTEREST STATEMENT other than BRCA2 are infrequent in male breast cancer. Breast Cancer Res Treat 2018;169:105–13. None declared. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Pure low-grade DCIS in a male patient: a case report

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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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Abstract

Breast cancer in males represents a small proportion of all cancers diagnosed. Pure ductal carcinoma in situ (DCIS), a low- grade form of breast cancer, is even more rare in male patients. We present a case of a 47-year-old male patient with a ten- der breast lump that was noted for 6 months. He was subsequently found to have a low grade, pure micropapillary and cribriform type DCIS with no evidence of invasive disease. Current literature does not provide distinct guidelines regarding management of male breast cancer, and it is currently managed in a similar fashion to female breast cancer. appendectomy and a cholecystectomy as well as several sinus INTRODUCTION procedures. Social history includes being a social drinker, but Male breast cancer is very rare and represents 1% of all cancers he denies ever smoking. Physical exam showed symmetrical diagnosed in the USA [1]. Pure ductal carcinoma in situ (DCIS) breasts with normal nipple–areolar complexes. No masses in a male is even more rare and represents ~0.1% of all breast were palpated in the right breast, but there was a firm, tender, cancers [2]. Proposed risk factors for development of DCIS in thickened area at the areolar border laterally in the left breast men is the same as the risks factors for any male breast cancer extending inferiorly ~2 cm. No nipple discharge or retraction and includes age, family history, exposure to radiation, condi- was noted, and there were no palpable axillary or supraclavicu- tions causing increased estrogen to androgen ratio (Klinefelter, lar nodes bilaterally. obesity), and pathological gene mutations (CHEK2, BRCA2 > Bilateral mammogram demonstrated mild gynecomastia in BRCA1) [3]. Management of male breast cancer stems from both sides with no discrete mass or clusters of microcalcifica- understanding of female breast cancer due to a lack of research tions (Fig. 1). A follow-up ultrasound around the area of palp- in men and includes combinations of surgery, radiation and able concern did show a prominent duct with irregular chemotherapy. contours at the 6:00 position in the left breast (Fig. 2). Excisional biopsy was recommended and a subareolar biopsy of the left breast was performed. CASE REPORT The pathology showed pure micropapillary and cribriform A 47-year-old Caucasian male with no family history of breast type low-grade DCIS with no evidence of invasive disease or ovarian cancer presented with a tender mass in the subareo- (Fig. 3). Breast specific gamma imaging (BSGI) and genetic test- lar, outer left breast region. The patient noted the mass 6 ing for BRCA gene mutations were ordered. BRCA testing was months ago, but it had persisted with no improvement in negative for both BRCA1 and BRCA2 mutations. The BSGI symptoms. His past medical history includes gastric ulcer, gas- revealed minimal parenchymal activity in the bilateral breasts, troesophageal reflux, hypercholesterolemia, sciatica, sleep however, an area with vague radiotracer activity in a 2.5 cm apnea and lumbar canal stenosis. He also previously had an diameter region was seen that was consistent with the biopsy Received: April 5, 2018. Accepted: May 2, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Zaesim et al. Figure 1: Diagnostic mammogram of the left (a) and right (b) breast demon- strates mild bilateral gynecomastia without discrete mass. Figure 3: Excisional biopsy at 10× magnification (a) shows neoplastic cells within ducts; 20× magnification (b) demonstrates cribriform and micropapillary features (samples stained with hematoxylin and eosin). the patient has continued medical follow-up with medical oncology. DISCUSSION DCIS is defined as a group of lesions caused by a proliferation of neoplastic cells within the mammary duct system of the breast [4]. It is differentiated from invasive breast cancer by detection of an intact basement membrane, but it is still asso- ciated with a risk for progression to invasive cancer, and thus, should be treated. Figure 2: Ultrasound of the left breast at the 6:00 region reveals a mildly hypoe- All breast cancer regardless of type is staged the same way choic mass with ductal extension. in men as in women and follows the TNM staging protocol. Receptor expression for the hormones estrogen and progester- one as well as overexpression of the epidermal growth factor location. After discussing the diagnosis and treatment options receptor-2 (HER2) is also regularly analyzed and plays a small with the patient, he strongly desired bilateral mastectomy. role in the staging of breast cancers. For the case presented After further discussions with other breast surgeons and a above, the tumor stage would be classified as a stage 0, low medical oncologist, simple left and right mastectomy with sen- grade tumor under the latest guidelines by the American Joint tinel node biopsy on the left were offered to the patient. Committee on Cancer [5]. Subsequently, a simple left mastectomy with sentinel Limited data exists regarding the natural history of low- lymph node biopsy and a simple right mastectomy were per- grade DCIS. Low-grade DCIS does not often progress to invasive formed. The sentinel node was negative for metastatic carcin- carcinoma with proper management. Research has shown that oma, and both breasts demonstrated no residual in situ or there is an increased likelihood of local recurrence with pos- invasive carcinoma. The post-op course was uneventful, and sible invasion after excisional biopsy even after 30 years, Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Pure low-grade DCIS in a male patient 3 especially if the margins of excision were not fully negative [6]. REFERENCES In men, the incidence of bilateral invasive breast cancer is also 1. Ferzoco RM, Ruddy KJ. The epidemiology of male breast extremely low. Thus, management for men focuses only on the cancer. Curr Oncol Rep 2016;18:1. breast where the primary lesion was detected. Patients should 2. Brents M, Hancock J. Ductal carcinoma in situ of the male be educated about their risk for further evolution of their breast breast. Breast Care 2016;11:288–90. disease before providing them with options for management. 3. Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, Regardless of the risk, some patients still desire maximal risk diagnosis, treatment, and survivorship. Ann Oncol 2013;24: reduction using techniques such as bilateral mastectomy, as in 1434–43. this case. 4. Dabbs DJ. Breast Pathology. Philadelphia, PA: Elsevier, 2017. There are few studies regarding the management guidelines 5. Giuliano AE, Connolly JL, Edge SB, Mittendorf EA, Rugo HS, of breast cancer in males. This is likely due to the low incidence Solin LJ, et al. Breast cancer—major changes in the of breast cancer in the population. Male breast cancer is currently American Joint Committee on Cancer eighth edition cancer managed in a similar fashion to female breast cancer [7]. Even so, staging manual. CA Cancer J Clin 2017;67:290–303. there are various options for management of such lesions in 6. Sanders ME, Schuyler PA, Simpson JF, Page DL, Dupont WD. females. After confirmed biopsy of such a lesion, all management Continued observation of the natural history of low-grade options revolve around surgery which is the primary method ductal carcinoma in situ reaffirms proclivity for local recur- required to remove the lesion from the breast leaving negative rence even after more than 30 years of follow up. Mod Pathol margins. For a stage 0 low grade-DCIS, mastectomy (with or with- 2015;28:662–9. out reconstruction) is considered equivalent to breast conserving 7. Scott-Conner C, Jochimsen P, Menck H, Winchester D. An surgery (lumpectomy) with radiation [8, 9]. All options are offered analysis of male and female breast cancer treatment and to patients with discussions about risks and benefits as medical survival among demographically identical pairs of patients. management involves patient satisfaction and cost. Surgery 1999;126:775–81. Due to the rarity of male breast cancer, strong genetic pre- 8. Hwang ES, Lichtensztajn DY, Gomez SL, Fowble B, Clarke disposition is suspected whenever a case occurs. It is recom- CA. Survival after lumpectomy and mastectomy for early mended that all male breast cancer patients should be tested stage invasive breast cancer. Cancer 2013;119:1402–11. for genetic mutations, especially BRCA1 and BRCA2 [10]. Men 9. Christiansen P, Carstensen SL, Ejlertsen B, Kroman N, with BRCA2 mutations may have higher risk of developing Offersen B, Bodilsen A, et al. Breast conserving surgery ver- breast cancer than men with BRCA1 mutations. Other gene sus mastectomy: overall and relative survival—a population mutations could also be considered in a workup and data based study by the Danish Breast Cancer Cooperative Group shows that a multi gene panel test checking for alternative (DBCG). Acta Oncol (Madr) 2017;57:19–25. gene mutations could be offered. 10. Fostira F, Saloustros E, Apostolou P, Vagena A, Kalfakakou D, Mauri D, et al. Germline deleterious mutations in genes CONFLICT OF INTEREST STATEMENT other than BRCA2 are infrequent in male breast cancer. Breast Cancer Res Treat 2018;169:105–13. None declared. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy109/4999773 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 19, 2018

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