Imaging Analysis

A 76-year-old man with primary breast malignancy, axillary lymphadenopathy

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 1Figure 2
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 activity (arrow).

Photos courtesy of Munir Ghesani, MD

Case Discussion

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 cancer.

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, microcalcifications.

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.

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 1Figure 2
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 activity (arrow).

Photos courtesy of Munir Ghesani, MD

Case Discussion

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 cancer.

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, microcalcifications.

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.