ANZ J. Surg.

2003;

73

: 774–775

CASE REPORT

Case Report

MALE BREAST DUCTAL CARCINOMA

IN SITU

J

ONATHAN

A

RMSTRONG

, C

HRISTOBEL

S

AUNDERS

AND

C

ECILY

M

ETCALF

Breast and Endocrine Surgery, Royal Perth Hospital, Perth, Western Australia, Australia

Key words: ductal carcinoma

in situ

, male breast.

Abbreviation

: DCIS, ductal carcinoma

in situ.

INTRODUCTION

Breast cancer in males is rare, accounting for only 0.5% of allbreast malignancies.

1

Only 5% of male breast cancer is pure ductalcarcinoma

in situ

(DCIS).

2

We report a case of DCIS in a young man with nipple dischargeand a family history of breast cancer. We discuss the pathology andmanagement of the case.

CASE REPORT

A 35-year-old male presented to his local general practitioner withbreast discomfort and nipple discharge. His symptoms had begun5 months prior to his ultimate surgery. He noticed a degree ofswelling in the left breast region and a blood stained dischargefrom one duct. There was no history of trauma or infection in theregion. He had no significant past medical or drug history.

His mother had died at 45 years from breast cancer. A maternalaunt had also been diagnosed with breast cancer aged 56. A mater-nal cousin was diagnosed and undergoing treatment for breastcancer aged 37. There was no history of breast cancer affecting thematernal or paternal grandfather. The patient was unmarried withno children (Fig. 1).

On examination he had a slight diffuse swelling of the breast andhaemoserous nipple discharge from one duct. There was no associ-ated axillary lymphadenopathy or any concerning features in theother breast.

Cytological examination of the discharge showed papillaryaggregates of epithelial cells exhibiting mild disorganization andmoderate anisonucleosis with red cells and macrophages, findingssuggestive of an intraduct papilloma.

A microdochectomy was performed. The pathology revealed anintraduct proliferation of tumour cells filling multiple dilated ducts(Fig. 2). The cells were intermediate in size with mildly pleomor-phic nuclei and scant to moderate amounts of cytoplasm (Fig. 2).The predominant pattern was a solid papillary proliferation withcompressed epithelium and fibrovascular cores. A smaller compo-nent was largely solid with very occasional glands. A few aggre-gates of foam cells occurred within the tumour. In some ducts, anaccumulation of proteinaceous material often associated with bloodwas seen.

J. Armstrong

MB BS, FRACS;

C. Saunders

FRCS;

C. Metcalf

FRCPA,FIAC.

Correspondence: Mr J. Armstrong, c/o Priory Thatch, Priory Green,Dunster, Somerset, TA 246RY, England.Email: zoedog68@hotmail.com

Accepted for publication 17 June 2003.

Fig. 1.

Family tree of patient.

Fig. 2.

Photomicrograph illustrating male breast ductal carcinoma

in situ

.

MALE BREAST DUCTAL CAARCINOMA

IN SITU

775

There was no evidence of invasion. A diagnosis of papillary ductcarcinoma

in situ

was made.

C-erbB2

was not expressed and oestrogen receptors were notpositive.

The intraduct proliferation was noted to extend to one margin.The patient therefore underwent a left simple mastectomy. Thisrevealed no evidence of residual DCIS or invasive carcinoma. Thepatient also had a contralateral mammogram of the right breast toexclude further disease. This revealed no microcalcifications or anyother abnormalities.

He developed a wound haematoma requiring drainage but other-wise made an uneventful recovery.

He has since undergone genetic counselling and has beenoffered genetic mutation analysis but so far has declined until thestatus of his cousin becomes known.

DISCUSSION

There are several reviews of male DCIS in the literature. Thelargest review examined the USA Armed Forces Institute ofPathology data.

2

A total of 280 cases of pure DCIS were identified.Men with pure DCIS presented at a median age of 65 years with

a typically nodular, retro-areolar, partially cystic mass that was fre-quently associated with a nipple discharge.

Histologically, 74% of cases were papillary carcinoma, as in ourpatient, often with a superimposed cribriform pattern.

Most of the pure DCIS was of low or intermediate grade. Highergrades of DCIS tended to be associated with an invasive carci-noma. Invasive carcinoma was associated much more commonlywith non-papillary DCIS patterns.

Several studies have suggested that male breast cancer has a higherincidence of oestrogen receptor positivity.

3

There have been nostudies assessing oestrogen receptor positivity in cases of pure DCIS.

Male breast cancer is often quoted as being more aggressivethan its female counterpart; but in the largest series of cases of pureDCIS the lowest grades of DCIS have actually been most preva-lent.

2

There also appears to be high expression of

c-erbB2

expres-sion in male breast cancer. There are, however, no reviews of theprevalence of c-erbB2 expression in pure DCIS.

Commonly, male breast cancer is associated with germ-line

BRCA2

mutations. In one study 33% of men with breast cancer hadgerm-line.

4

BRCA2

mutations

Unlike many tumours in individuals with a

BRCA1

mutation, the

BRCA2

mutations have a similar phenotype to tumours lacking

mutations. Unfortunately our patient has declined to undergoformal genetic screening at this stage but given his strong familyhistory he is most likely to have a

BRCA2

mutation.Making the diagnosis of DCIS or invasive carcinoma in men is

similar to the diagnosis in women. The ‘triple test’ should be used:history and examination, imaging with mammography and/or ultra-sound scan and pathological analysis such as fine needle aspirationor core biopsy.

Nipple discharge smears only have a sensitivity of 50%, and cantherefore be unreliable, as in our case.

The treatment of male DCIS is also similar to that of femaleDCIS. Excision with a margin of >10 mm in practical termsrequires a mastectomy with removal of the nipple areolar complex.Axillary clearance would be performed if invasive carcinoma isfound. There is no role for adjuvant local or systemic therapy incases of DCIS.

Genetic counselling of all male breast cancer patientsshould be considered because of the high probability of

BRCA2

mutations.

5

Follow up should include initial 6 monthly examinations andyearly contralateral mammography.

In summary, male breast DCIS is an extremely rare entitywith a different incidence of pathological subtypes to those inwomen. DCIS should always be considered in a man whopresents with nipple discharge. As shown in this case, DCIS canoccur in younger men. Treatment of DCIS in men requires com-plete excision of the breast tissue either by subcutaneous or totalmastectomy.

REFERENCES

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Int. J.Cancer

1989;

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: 27–31.2. Hittmair A, Lininger R, Tavossoli F. DCIS in the male breast, a

morphological study of 84 cases of pure DCIS and 30 cases ofDCIS associated with invasive carcinoma – a preliminary report.

Cancer

1998;

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: 2139–49.3. Ravandi–Kashani F, Hayes TG. Male breast cancer: a review of

the literature.

Eur. J. Cancer

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: 1341–7.4. Csokay B, Udvarhelyi N, Sulyok Z

et al.

High frequency ofgerm-line BRCA2 mutations among Hungarian male breastcancer patients without family history.

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5. National (Australian) Breast Cancer Centre.

Advice AboutFamilial Aspects of Breast Cancer and Ovarian Cancer: A guidefor Health Professionals.

Sydney: National (Australian) BreastCancer Centre publication, 2000.