Mammography - The first step in the evaluation of a suspicious breast mass in a man is mammography. The mammogram is abnormal in 80 to 90 percent of MBCs, and can usually distinguish between malignancy and gynecomastia. In one study, the reported sensitivity and specificity rates of mammography for the diagnosis of MBC were 92 and 90 percent, respectively.
Radiographic features suggestive of malignancy include eccentricity to the nipple, spiculated margins, and microcalcifications. In contrast, gynecomastia typically appears as a round or triangular area of increased density positioned symmetrically in the retroareolar region. In rare cases, concurrent gynecomastia can mask a malignant lesion.
FNA cytology - Any suspicious mass requires biopsy to confirm the diagnosis and to assay for ER and PR content as well as HER2 status. Although fine needle aspiration (FNA) cytology can provide adequate diagnostic material in many cases, avoiding open or surgical biopsy, up to one-fourth of samples are insufficient for diagnosis. If inadequate tissue is obtained, or FNA is not feasible, a core or open biopsy should be performed.
Staging work-up - The diagnostic evaluation and staging system used for MBC are the same as for women with breast cancer. In brief, the extent of disease is established by laboratory evaluation, chest radiography, bone scan, and CT scan of the abdomen and pelvis, as clinically appropriate.
The staging system developed by the American Joint Committee on Cancer (AJCC) classifies breast malignancies by tumor (T) node (N) and metastasis (M) categories, and stage groupings with similar prognoses are combined. As in women, AJCC stage, tumor size and axillary lymph node status are the most important factors influencing outcome in MBC.
As with female breast cancer, the following definitions are used to connote early stage and more advanced stage invasive breast cancer in men:
" Early stage invasive breast cancer - Stages I (tumor <2 cm in size, axillary node-negative) and II (positive but ipsilateral and mobile axillary nodes, or tumor size >2 cm); a tumor >5 cm must be node-negative to be considered early stage
" Locally advanced - Stage III disease (extensive axillary nodal disease, supraclavicular nodal involvement, direct tumor extension to the chest wall or skin, or inflammatory breast cancer)
" Metastatic breast cancer - Stage IV disease
Treatment for early stage, locally advanced, and metastatic breast cancer will be discussed separately.
Evans, GF, Anthony, T, Turnage, RH, et al. The diagnostic accuracy of mammography in the evaluation of male breast disease. Am J Surg 2001; 181:96.
Dershaw, DD, Borgen, PI, Deutch, BM, Liberman, L. Mammographic findings in men with breast cancer. AJR Am J Roentgenol 1993; 160:267.
Appelbaum, AH, Evans, GF, Levy, KR, et al. Mammographic appearances of male breast disease.. Radiographics 1999; 19:559.
Westenend, PJ, Jobse, C. Evaluation of fine-needle aspiration cytology of breast masses in males. Cancer 2002; 96:101.
Vetto, J, Schmidt, W, Pommier, R, et al. Accurate and cost effective evaluation of breast masses in males. Am J Surg 1998; 175:383.
National Comprehensive Cancer Network (NCCN) guidelines available online at www.nccn.org/professionals/physician_gls/default..asp.
AJCC Cancer Staging Manual, 6th ed, Greene, FL, Page, DL, Fleming, ID, et al (Eds), Springer-Verlag, New York, 2002.
Updated by Medical Writers Group, LLC, New York, for John W. Nick Foundation, Inc. - January, 2008. (Made possible through a grant provided by Cancer Research and Prevention Foundation.)
