Male breast cancer with distant metastases

Case contributed by Dr Ralph Nelson

Presentation

Left breast palpable mass.

Patient Data

Age: 70 years
Gender: Male

Innumerable metastatic liver lesions.

Multiple implants surrounding the stomach fundus and body. 

Indeterminate left adrenal nodule.

Multiple enlarged lower paraesophageal lymph nodes. Moderate abdominal pelvic ascites.

Nonspecific diffuse circumferential wall thickening of the cecum ascending colon and hepatic flexure. 

Small hiatal hernia with mild circumferential wall thickening of the lower esophagus from adjacent right periesophageal lymph nodes node, likely related to the subserosal implant. 

Diffuse upper peritoneal thickening, and fat stranding, suspicious for peritoneal carcinomatosis.

Omental implant, inseparable from the inferior border of the stomach with multiple subserosal along the gastric body wall.

Multiple subcutaneous and intramuscular implants. 

Multiple bilateral lower lung nodules. 

Revisualization of breast masses consistent with the known primary tumor. 

Small right pleural effusion.

A bone scan performed a few days later (not shown) demonstrates no aggressive osseous lesions.

Very dense breast.

Left breast 1.3 cm mass with irregular contour at the lower outer quadrant.  

Gynecomastia.

Heterogenous lobulated mass with posterior acoustic enhancement at the lower outer quadrant. No intrinsic flow on Doppler.

Abnormal left axillary nodes.

A large biopsied mass at 5:00 corresponding to invasive ductal carcinoma is identified.

This mass is extending under the skin and adjacent skin invasion cannot be excluded. It is hypointense on T1 and hyperintense on T2. Post-contrast, the mass is demonstrating peripheral washout, plateau enhancement and central necrosis. Presence of at least moderate adjacent hypervascularity. The biopsy marker is seen in the central/lateral aspect of the mass.

There is a mass seen at 5:00 in the same breast, containing a biopsy marker and also corresponding to biopsy-proven cancer with postcontrast images demonstrating an area of washout.

Distal mass at 2:00, hypointense on T1 and hyperintense on T2, likely corresponding to the mass at 2:00, not biopsied. This mass is measured in the largest dimensions up to 5 mm.

No suspicious axillary or internal mammary lymph node.

Case Discussion

This is a case biopsy-proven invasive ductal carcinoma grade 3 HER2 positive, ER/PR negative in a male born patient. As it has been reported, men tend to present with more advanced disease than women. Our patient, recently diagnosed with breast cancer, presented two months later to the emergency with anorexia, generalized weakness, diarrhea and worsening abdominal distention. A CT scan revealed distant metastatic lesions in his liver, lung, chest wall and peritoneal carcinomatosis. A head CT was negative for metastatic disease. 

Studies revealed that male breast cancer( MBC) patients tend to have a slightly higher rate of distant metastasis compared to female breast cancer patients (7% vs. 4%). 

Xie et al. found that the metastasis rates of bone, lung, liver and brain metastasis in metastatic male breast cancer patients were 82%, 47%, 16%, and 11%, respectively. Under the same conditions, the metastasis rates of various organs in women were 75%, 35%, 28%, and 8%, respectively 3.

Our case confirmed the relatively high rate for lung and liver and low rate for the brain (absent brain metastasis while the presence of metastasis in the abdomen and lung). However, our patient did not have bone metastatic lesions at presentation, unlike the relatively higher rate found by Xie's team.

This is a nice case which should remind our community of the need to report/describe the subareolar mass in men. Not all subareolar density is gynecomastia. Any suspicious/irregular subareolar mass should be managed accordingly.

Unfortunately, our patient did not survive and passed away of multiorgan failure a week after the acute presentation.

Courtesy of the Body Imaging and Breast Center divisions at MUHC.

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