A 76-year-old man presented to his primary care
physician with a lump in the left axilla. The primary physician palpated a hard
mass and, due to concern of malignant lymphadenopathy, referred the patient to
the surgeon for excision.
The excision of the lymph node was consistent with
malignancy. PET/CT was recommended for further evaluation.
PET/CT showed post-operative changes at the excision
site and hypermetabolic axillary lymph nodes consistent with additional sites
of metastatic lymphadenopathy. There was evidence of gynecomastia,
asymmetrically larger on the left side, ipsilateral to the excised lymph node.
There also was evidence of asymmetric increased
metabolic activity on PET images, implying that the primary site of malignancy
is left breast cancer.
FIGURE 1. (Clockwise from top left): CT image, PET image, whole
body maximum intensity projection PET image, and CT/PET fusion image. There is
a hypermetabolic lymphadenopathy in the left axilla (arrow). There are
postoperative changes posterior to the left axillary lymph node, consistent
with history of excision of the lymph node that proved to be malignant. FIGURE
2. There is asymmetric left breast tissue with asymmetric increased metabolic
Photos courtesy of Munir Ghesani, MD
Male breast cancer is a rare disease, accounting for
less than 1% of all breast cancer diagnoses worldwide. It is estimated that
1,970 men will be diagnosed with breast cancer in 2010 in the United States as
compared with 207,090 women. Due to its rarity and subsequent paucity of data,
optimal treatment for male breast cancer is not known.
Risk factors for breast cancer in men include age, race,
radiation exposure and familial predisposition. Black men have a higher
incidence than white men at all ages. Black men also tend to have poorer
prognostic features, such as advanced stage disease, larger tumor sizes, more
nodal involvement and higher tumor grade than whites.
About 15% to 20% of men with breast cancer have a family
history of the disease. Among male BRCA2 mutation carriers, the
estimated lifetime risk of breast cancer is 5% to10%. For male BRCA1
mutation carriers, the estimated lifetime risk is 1% to 5%.
The NCCN guidelines recommend that BRCA mutation
testing be offered to men who develop breast cancer with or without a family
history of breast or ovarian cancer. As seen in this patient, gynecomastia is
prevalent, and increased estradiol levels also are associated with male breast
Male breast cancers tend to be more hormonally receptor
positive than their female counterparts. The majority of tumors are invasive
ductal carcinoma followed by ductal carcinoma in situ. Invasive papillary
carcinoma is seen more often in males than females.
Male breast tumors present with a painless, firm mass
usually subareolar in location. They often are palpable and may have associated
nipple retraction, nipple ulceration or palpable axillary lymph nodes.
Mammography usually is abnormal in 80% to 90% of cases, with radiographic
findings of nipple eccentricity, spiculated margins and, less often,
The staging workup and diagnostic procedures are the
same as in women.
The NCCN supports additional staging studies such as
bone scan, abdominal staging and chest imaging for patients with clinical stage
T3N1M0 disease. These tests are not indicated in earlier stage disease without
signs or symptoms of metastatic disease.
In a study by Puglisi and colleagues that evaluated
newly diagnosed male and female breast cancer patients by conventional imaging,
bone scan detected metastases in 5.1% of patients with stage I disease, 5.6% of
patients with stage II disease and 14% of patients with stage III disease. No
evidence of metastasis was seen with liver ultrasound or chest radiograph in
patients with stage I or II disease.
PET/CT increasingly is being used in staging, as it is a
single test that can evaluate the presence of bone, liver and lung metastases.
A NCCN panel recommends against the use of PET or PET/CT, as it is associated
with a high false negative rate in the detection of small- or low-grade
lesions, with a low sensitivity for detection of axillary node metastases and a
high rate of false positive scans.
A 2011 study by Koolen in Breast Cancer Research
and Treatment showed PET/CT may be superior to conventional imaging
techniques in untreated stage II or III breast cancer. This was a prospective
trial of 154 patients with stage II or III breast cancer who received PET/CT
and conventional imaging (bone scan, liver ultrasound and chest radiography)
prior to receiving neoadjuvant chemotherapy.
Results showed that 42 additional lesions were seen in
25 patients with PET/CT and could be confirmed in 20 (13%) of 154 patients.
PET/CT was false positive for 8 additional lesions (19%) and misclassified the
presence of metastatic disease in 5 (3%) of 154 patients. Additional lesions
were seen exclusively with PET/CT in 16 (80%) of 20 patients, resulting to a
change of treatment in 13 (8%) of 154 patients.
This study showed a sensitivity of 100%, specificity of
96%, positive predictive value of 80%, negative predictive value of 100% and
accuracy of PET/CT of 97%. The authors realize the suboptimal specificity and
positive predictive value of PET/CT and suggest verification by microscopic
evaluation of any suspicious lesions prior to any change in treatment.
Groheux also prospectively evaluated the role of PET/CT
in 131 stage II or III breast cancer patients. FDG PET/CT modified staging for
5.6% of stage IIA patients, for 14.6% of stage IIB patients and for 27.6% of
stage IIIA patients. The authors suggested that PET/CT scan outperformed bone
scan, with only 1 misclassification vs. 8 for bone scanning (P=0.036). In our
patient, PET/CT not only reveals additional suspicious lymph nodes in the left
axilla but also it demonstrates the exact location of the suspected primary
malignancy in the left breast. Addionally, lack of distant disease on this very
sensitive examination is reassuring, as the surgeon embarks on definite
resection of the primary malignancy and left axillary dissection.
Munir Ghesani, MD, is an attending radiologist at St.
Luke’s-Roosevelt Hospital Center and Beth Israel Medical Center and a
HemOnc Today section editor. He is an associate clinical professor
of radiology at Columbia University College of Physicians and Surgeons. Irene
Dy, MD, is a fellow in hematology and oncology at St Luke’s-Roosevelt
Hospital Center. Alan Sickles, MD, is a practicing surgeon affiliated with
Lutheran Medical Center in Brooklyn, N.Y. Disclosures: Drs. Ghesani, Dy and
Sickles report no relevant financial disclosures.
Earn CME this spring at the HemOnc Today Breast Cancer Review & Perspective meeting to be held March 23-24, 2012 at the Hilton San Diego Bayfront. See details at HemOncTodayBreastCancer.com.
For more information:
- Groheux D. J Nucl Med. 2011 Oct;52(10):1526-34. Epub
2011 Aug 30.
- Jemal A. Cancer 2010; 60:277-300. CA Cancer J
Clin. 2010 Sep-Oct;60(5):277-300. Epub 2010 Jul 7. Erratum in: CA
Cancer J Clin. 2011 Mar-Apr;61(2):133-4.
- Koolen BB. Breast Cancer Res Treat. 2011. Sep 21.
[Epub ahead of print]
- Korde LA. J Clin Oncol. 2010.28(12):2114-2121.
- Puglisi F. Ann Oncol. 2005;16:263-266.