- Email: [email protected]
Breast conservation for male breast carcinoma
ARTICLE IN PRESS The Breast (2007) 16, 653–656
THE BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
Breast conservation for male breast carcinoma Mehra Golshan, MDa,, Jennifer Rusby, MRCSb, Francisco Dominguez, MDb, Barbara L. Smith, MD, PhDb a
Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA Massachusetts General Hospital, USA
b
Received 7 March 2007; received in revised form 8 May 2007; accepted 29 May 2007
KEYWORDS Male breast cancer; Lumpectomy; Local therapy
Summary Male breast cancer in general is treated by modified radical mastectomy. Data have emerged supporting the replacement of the axillary lymph node dissection by a sentinel lymph node biopsy in the male patient with breast carcinoma. Local therapy in the breast continues to be primarily mastectomy. The reasons suggested for this include the central location of many of the male breast tumors and the paucity of breast tissue. Our experience with breast conservation over the last decade in male breast carcinoma and a review of the literature is outlined here. Between 1996 and 2006, seven men underwent breast conservation for breast carcinoma and to date with a median follow-up of 67 months, there have been no local recurrences. Breast carcinoma in males can be treated with breast conservation with acceptable local recurrence. Breast-conserving surgery in male breast cancer patients should be considered an option in patients without overt nipple/areolar involvement. & 2007 Elsevier Ltd. All rights reserved.
Introduction The annual incidence of invasive male breast carcinoma in the United States is only 1700 as compared to over 214,000 cases in women.1 In general, modified radical mastectomy has been the standard of care, due to the paucity of breast tissue Corresponding author. Tel.: +1 617 632 5043;
fax: +1 617 582 7740. E-mail address: [email protected] (M. Golshan).
in men and the central location of many of the tumors. In women with breast cancer, breast conservation is an accepted standard in the appropriately selected patient with outstanding local control and equivalent survival to mastectomy.2–7 Over the past decade, sentinel lymph node biopsy has come to replace axillary lymph node dissection in clinically node-negative women. With the advent of this minimally invasive evaluation of the axilla, the technique is being increasingly applied to the male patient with breast cancer.8–13.
0960-9776/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.05.012
ARTICLE IN PRESS 654 The change in evaluation of the axilla in men has lagged in comparison to women and similarly local therapy in the male breast has been slow to change. We reviewed our experience with breast conservation in seven of our male patients over a 10-year period of time.
Material and methods A review of prospectively collected data was performed to identify all male patients undergoing breast conservation at the Brigham and Women’s Hospital and Massachusetts General Hospital; Boston, MA. Patient records were reviewed to obtain information on symptoms at presentation, diagnostic and operative procedures, pathologic staging and recurrence data. In addition all other published series were identified by an English language PubMed search for the terms ‘‘male breast cancer’’ and ‘‘lumpectomy’’ or ‘‘breast conservation’’. The surgery technique was a standard lumpectomy without removal of skin or nipple, and excision of the tumor to clear margins. Clear margins were defined as greater than 2 mm. The radiation technique used was whole breast irradiation for a dose of 4500 cGY, the tumor bed received a total dose of 6100 cGY similar to the technique used in woman with breast carcinoma. Patients were considered for breast conservation if the surgeon felt there was sufficient tissue between the nipple/ areolar complex and tumor to achieve clear margins.
Results Seven male patients who underwent breast preservation for staging of breast carcinoma were identified at our institution between May 1996 and October 2006. The mean age was 61 years (range 38–86) (Table 1). Five patients presented with a palpable mass, two with nipple inversion or retraction. Five of the patients were diagnosed by fine needle aspiration (FNA) or needle core biopsy. A sentinel lymph node biopsy was performed in the six patients with invasive breast cancer and a sentinel lymph node was identified in each patient; one patient had ductal carcinoma in situ only and did not undergo axillary evaluation. Five of the six patients had a positive sentinel lymph node on frozen section and underwent an immediate axillary lymph node dissection (ALND), a mean of 25 lymph nodes were harvested at the time of ALND.
M. Golshan et al. The mean invasive tumor size was 1.7 cm (range 0.8–3.0 cm) with five being invasive ductal carcinomas and one an invasive lobular breast cancer; one patient with DCIS had 1 cm of disease. Margins were clear by at least 0.2 cm and all invasive carcinomas underwent radiation therapy; the patient with DCIS underwent wide excision only. To date with a median follow-up of 67 months (range 36–97 months), there have been no local recurrences. One patient died of metastatic disease. All patients with invasive breast cancer were estrogen receptor positive and have received hormonal therapy in the form of Tamoxifen and three of these patients also received systemic chemotherapy.
Discussion To our knowledge, this is the first specific review of breast-conserving therapy in male patients with invasive breast carcinoma. Male breast carcinoma is an uncommon condition and although many of the management recommendations are based on those used for women with breast carcinoma, innovations in management for men tend to lag well behind those of women. Male breast cancer accounts for 1% of all breast cancers and less than 1% of all annual cancer death is males. The majority of the rudimentary breast tissue in men exists in the subareloar region and cancers often present as a painless, subareloar mass. Radiological evaluation should include mammography and ultrasound and diagnosis is usually confirmed by excisional biopsy. In our series, the majority were confirmed by FNA or needle core biopsy. The majority of carcinomas are invasive ductal and most are estrogen receptor (ER) positive. While breast-conserving therapy is considered strongly for women with breast carcinoma, the small volume of breast tissue in men is thought to be a contraindication to lumpectomy.14–16 However, a high percentage of men who develop breast cancer have some degree of breast enlargement that may permit lumpectomy making breast conservation feasible in the appropriately selected patient. Men without overt nipple/areolar involvement can safely undergo wide excision to clear margins and radiation therapy with reasonable local recurrence rates and acceptable cosmesis. Unfortunately, validation of such data will not be possible because of the small number of male breast cancers. None of our patients would have met standard criteria for post-mastectomy radiation based on cancer size or lymph node
ARTICLE IN PRESS Lumpectomy in male breast cancer
655
Table 1 Demographic, treatment and pathologic features on men treated with breast conservation between 1996 and 2006. Characteristic
No.
Percent
Number of patients Number of SNB procedures Presents with palpable mass or nipple retraction Diagnosis by FNA or core Sentinel node identified (invasive breast cancer) Mean nodes in ALND
7 6 7 5 6 25
100 86 100 71 100
Definitive breast surgery Lumpectomy
7
100
Pathological subtype Invasive ductal Invasive lobular DCIS
5 1 1
71 14 14
Tumor size mean ¼ 1.7 cm (range 0.8–3 cm) T1 T2 Tis
5 1 1
71 14 14
Adjuvant therapy (invasive only) Hormonal Radiation Chemotherapy
6 6 3
86 86 43
Grade (invasive only) 1 2 3
0 4 2
0 67 33
Receptor status (invasive only) ER positive PR positive HER 2 positive
6 5 2
100 83 33
Stage 0 I II III
1 1 5 0
14 14 71 0
involvement. No patients have shown radiationinduced toxicities including lung, cardiac or significant breast volume loss. Other series have reported breast-conserving therapy in male patients with breast carcinoma for ductal carcinoma in situ and invasive breast carcinoma with poor results. Goss et al. reviewed the Princess Margaret Hospital data from 1955–1996 and found eight male breast cancer patients who underwent lumpectomy and axillary lymph node dissection and found that the overall and disease free survival were similar to patients who had
undergone mastectomy.17 Local control was superior in the mastectomy group but radiation and margin status was not reported. In another study of ductal carcinoma in situ in the male breast, local recurrence occurred in three of six patients treated with lumpectomy; however, use of radiation and margin status was not reported.18 Extensive data in women treated with breast-conserving therapy with adequate surgical margins and radiation therapy demonstrate outstanding local control and we report no local recurrences in our cohort of male patients treated with breast-conserving
ARTICLE IN PRESS 656 therapy. The preservation of the nipple areolar complex in male patients may also have a positive psychological impact in men as is the case in women treated for breast cancer. All of our patients report a good or outstanding cosmetic result.
Conclusions We believe that in the appropriately selected patient, breast conservation with radiation therapy is a viable alternative to mastectomy. The continued advances in local therapy offered to women should also be considered in the management of male breast carcinoma.
References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics 2006. CA Cancer J Clin 2006;56:106–30. 2. Arriagada R, Le M, Rochard F, et al. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. J Clin Oncol 1996; 14:1558. 3. Veronesi U, Luini A, Galimberti V, et al. Conservation approaches for the management of stage I/II carcinoma of the breast: Milan Cancer Institute trials. World J Surg 1994;18:70. 4. Fisher B, Anderson S, Redmond C, et al. Reanalysis and results after 12 years of follow-up in a randomized trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456. 5. Jacobson J, Danforth D, Cowan K, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 1995;332:907.
M. Golshan et al. 6. Van Dongen J, Bartelink H, Fentiman I, et al. Factors influencing local relapse and survival and results of salvage treatment after breast conserving therapy in operable breast cancer: EORTC trail 1081, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer 1992;28:801. 7. Bilchert-Toft M, Rose C, Anderson J, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. J Natl Cancer Inst Monogr 1992;11:19. 8. Port E, Fey J, Cody H, et al. Sentinel lymph node biopsy in patients with male breast carcinoma. Cancer 2001; 91:319–23. 9. Albo D, Ames F, Hunt K, et al. Evaluation of lymph node status in male breast cancer patients: a role for sentinel lymph node biopsy. Breast Cancer Res Treat 2003;77:9–14. 10. Cimmino V, Degnim A, Sable M, et al. Efficacy of sentinel lymph node biopsy in male breast cancer. J Surg Oncol 2004;86:74–7. 11. De Cicco C, Baio S, Veronesi P, et al. Sentinel node biopsy in male breast cancer. Nucl Med Commun 2004;25:139–43. 12. Goyal A, Horgan K, Kissin M, et al. Sentinel lymph node biopsy in male breast cancer patients. Eur J Surg Oncol 2004;30:480–3. 13. Boughey JC, Bedrosian I, Meric-Bernstam F, et al. Comparative analysis of sentinel lymph node operation in male and female breast cancer patients. J Am Coll Surg 2006;203: 475–80. 14. Harris J, Lippman M, Morrow M, Osborne C. Disease of the breast: male breast cancer, 2nd ed. Lippincott Williams and Wilkins; 2000. p. 663. 15. Bland K, Copeland E. The breast: comprehensive management of benign and malignant disease: cancer of the male breast, 2nd ed. London: W.B. Saunders Co.; 1998. p. 1417–8. 16. Agrawal A, Ayantunde A, Rampaul R, et al. Male breast cancer: a review of clinical management. Breast Cancer Res Treat, 2006 [epub ahead of print]. 17. Goss P, Reid C, Pintilie M, et al. Male breast carcinoma: a review of 229 patients who presented to the Princess Margaret Hospital during 40 years: 1955–1996. Cancer 1999;85:629–39. 18. Cutuli B, Dilhuydy J, Delafontan B, et al. Ductal carcinoma in situ of the male breast, analysis of 31 cases. Eur J Cancer 1997;33:35–8.
THE BREAST www.elsevier.com/locate/breast
ORIGINAL ARTICLE
Breast conservation for male breast carcinoma Mehra Golshan, MDa,, Jennifer Rusby, MRCSb, Francisco Dominguez, MDb, Barbara L. Smith, MD, PhDb a
Department of Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA Massachusetts General Hospital, USA
b
Received 7 March 2007; received in revised form 8 May 2007; accepted 29 May 2007
KEYWORDS Male breast cancer; Lumpectomy; Local therapy
Summary Male breast cancer in general is treated by modified radical mastectomy. Data have emerged supporting the replacement of the axillary lymph node dissection by a sentinel lymph node biopsy in the male patient with breast carcinoma. Local therapy in the breast continues to be primarily mastectomy. The reasons suggested for this include the central location of many of the male breast tumors and the paucity of breast tissue. Our experience with breast conservation over the last decade in male breast carcinoma and a review of the literature is outlined here. Between 1996 and 2006, seven men underwent breast conservation for breast carcinoma and to date with a median follow-up of 67 months, there have been no local recurrences. Breast carcinoma in males can be treated with breast conservation with acceptable local recurrence. Breast-conserving surgery in male breast cancer patients should be considered an option in patients without overt nipple/areolar involvement. & 2007 Elsevier Ltd. All rights reserved.
Introduction The annual incidence of invasive male breast carcinoma in the United States is only 1700 as compared to over 214,000 cases in women.1 In general, modified radical mastectomy has been the standard of care, due to the paucity of breast tissue Corresponding author. Tel.: +1 617 632 5043;
fax: +1 617 582 7740. E-mail address: [email protected] (M. Golshan).
in men and the central location of many of the tumors. In women with breast cancer, breast conservation is an accepted standard in the appropriately selected patient with outstanding local control and equivalent survival to mastectomy.2–7 Over the past decade, sentinel lymph node biopsy has come to replace axillary lymph node dissection in clinically node-negative women. With the advent of this minimally invasive evaluation of the axilla, the technique is being increasingly applied to the male patient with breast cancer.8–13.
0960-9776/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2007.05.012
ARTICLE IN PRESS 654 The change in evaluation of the axilla in men has lagged in comparison to women and similarly local therapy in the male breast has been slow to change. We reviewed our experience with breast conservation in seven of our male patients over a 10-year period of time.
Material and methods A review of prospectively collected data was performed to identify all male patients undergoing breast conservation at the Brigham and Women’s Hospital and Massachusetts General Hospital; Boston, MA. Patient records were reviewed to obtain information on symptoms at presentation, diagnostic and operative procedures, pathologic staging and recurrence data. In addition all other published series were identified by an English language PubMed search for the terms ‘‘male breast cancer’’ and ‘‘lumpectomy’’ or ‘‘breast conservation’’. The surgery technique was a standard lumpectomy without removal of skin or nipple, and excision of the tumor to clear margins. Clear margins were defined as greater than 2 mm. The radiation technique used was whole breast irradiation for a dose of 4500 cGY, the tumor bed received a total dose of 6100 cGY similar to the technique used in woman with breast carcinoma. Patients were considered for breast conservation if the surgeon felt there was sufficient tissue between the nipple/ areolar complex and tumor to achieve clear margins.
Results Seven male patients who underwent breast preservation for staging of breast carcinoma were identified at our institution between May 1996 and October 2006. The mean age was 61 years (range 38–86) (Table 1). Five patients presented with a palpable mass, two with nipple inversion or retraction. Five of the patients were diagnosed by fine needle aspiration (FNA) or needle core biopsy. A sentinel lymph node biopsy was performed in the six patients with invasive breast cancer and a sentinel lymph node was identified in each patient; one patient had ductal carcinoma in situ only and did not undergo axillary evaluation. Five of the six patients had a positive sentinel lymph node on frozen section and underwent an immediate axillary lymph node dissection (ALND), a mean of 25 lymph nodes were harvested at the time of ALND.
M. Golshan et al. The mean invasive tumor size was 1.7 cm (range 0.8–3.0 cm) with five being invasive ductal carcinomas and one an invasive lobular breast cancer; one patient with DCIS had 1 cm of disease. Margins were clear by at least 0.2 cm and all invasive carcinomas underwent radiation therapy; the patient with DCIS underwent wide excision only. To date with a median follow-up of 67 months (range 36–97 months), there have been no local recurrences. One patient died of metastatic disease. All patients with invasive breast cancer were estrogen receptor positive and have received hormonal therapy in the form of Tamoxifen and three of these patients also received systemic chemotherapy.
Discussion To our knowledge, this is the first specific review of breast-conserving therapy in male patients with invasive breast carcinoma. Male breast carcinoma is an uncommon condition and although many of the management recommendations are based on those used for women with breast carcinoma, innovations in management for men tend to lag well behind those of women. Male breast cancer accounts for 1% of all breast cancers and less than 1% of all annual cancer death is males. The majority of the rudimentary breast tissue in men exists in the subareloar region and cancers often present as a painless, subareloar mass. Radiological evaluation should include mammography and ultrasound and diagnosis is usually confirmed by excisional biopsy. In our series, the majority were confirmed by FNA or needle core biopsy. The majority of carcinomas are invasive ductal and most are estrogen receptor (ER) positive. While breast-conserving therapy is considered strongly for women with breast carcinoma, the small volume of breast tissue in men is thought to be a contraindication to lumpectomy.14–16 However, a high percentage of men who develop breast cancer have some degree of breast enlargement that may permit lumpectomy making breast conservation feasible in the appropriately selected patient. Men without overt nipple/areolar involvement can safely undergo wide excision to clear margins and radiation therapy with reasonable local recurrence rates and acceptable cosmesis. Unfortunately, validation of such data will not be possible because of the small number of male breast cancers. None of our patients would have met standard criteria for post-mastectomy radiation based on cancer size or lymph node
ARTICLE IN PRESS Lumpectomy in male breast cancer
655
Table 1 Demographic, treatment and pathologic features on men treated with breast conservation between 1996 and 2006. Characteristic
No.
Percent
Number of patients Number of SNB procedures Presents with palpable mass or nipple retraction Diagnosis by FNA or core Sentinel node identified (invasive breast cancer) Mean nodes in ALND
7 6 7 5 6 25
100 86 100 71 100
Definitive breast surgery Lumpectomy
7
100
Pathological subtype Invasive ductal Invasive lobular DCIS
5 1 1
71 14 14
Tumor size mean ¼ 1.7 cm (range 0.8–3 cm) T1 T2 Tis
5 1 1
71 14 14
Adjuvant therapy (invasive only) Hormonal Radiation Chemotherapy
6 6 3
86 86 43
Grade (invasive only) 1 2 3
0 4 2
0 67 33
Receptor status (invasive only) ER positive PR positive HER 2 positive
6 5 2
100 83 33
Stage 0 I II III
1 1 5 0
14 14 71 0
involvement. No patients have shown radiationinduced toxicities including lung, cardiac or significant breast volume loss. Other series have reported breast-conserving therapy in male patients with breast carcinoma for ductal carcinoma in situ and invasive breast carcinoma with poor results. Goss et al. reviewed the Princess Margaret Hospital data from 1955–1996 and found eight male breast cancer patients who underwent lumpectomy and axillary lymph node dissection and found that the overall and disease free survival were similar to patients who had
undergone mastectomy.17 Local control was superior in the mastectomy group but radiation and margin status was not reported. In another study of ductal carcinoma in situ in the male breast, local recurrence occurred in three of six patients treated with lumpectomy; however, use of radiation and margin status was not reported.18 Extensive data in women treated with breast-conserving therapy with adequate surgical margins and radiation therapy demonstrate outstanding local control and we report no local recurrences in our cohort of male patients treated with breast-conserving
ARTICLE IN PRESS 656 therapy. The preservation of the nipple areolar complex in male patients may also have a positive psychological impact in men as is the case in women treated for breast cancer. All of our patients report a good or outstanding cosmetic result.
Conclusions We believe that in the appropriately selected patient, breast conservation with radiation therapy is a viable alternative to mastectomy. The continued advances in local therapy offered to women should also be considered in the management of male breast carcinoma.
References 1. Jemal A, Siegel R, Ward E, et al. Cancer statistics 2006. CA Cancer J Clin 2006;56:106–30. 2. Arriagada R, Le M, Rochard F, et al. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. J Clin Oncol 1996; 14:1558. 3. Veronesi U, Luini A, Galimberti V, et al. Conservation approaches for the management of stage I/II carcinoma of the breast: Milan Cancer Institute trials. World J Surg 1994;18:70. 4. Fisher B, Anderson S, Redmond C, et al. Reanalysis and results after 12 years of follow-up in a randomized trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456. 5. Jacobson J, Danforth D, Cowan K, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 1995;332:907.
M. Golshan et al. 6. Van Dongen J, Bartelink H, Fentiman I, et al. Factors influencing local relapse and survival and results of salvage treatment after breast conserving therapy in operable breast cancer: EORTC trail 1081, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer 1992;28:801. 7. Bilchert-Toft M, Rose C, Anderson J, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. J Natl Cancer Inst Monogr 1992;11:19. 8. Port E, Fey J, Cody H, et al. Sentinel lymph node biopsy in patients with male breast carcinoma. Cancer 2001; 91:319–23. 9. Albo D, Ames F, Hunt K, et al. Evaluation of lymph node status in male breast cancer patients: a role for sentinel lymph node biopsy. Breast Cancer Res Treat 2003;77:9–14. 10. Cimmino V, Degnim A, Sable M, et al. Efficacy of sentinel lymph node biopsy in male breast cancer. J Surg Oncol 2004;86:74–7. 11. De Cicco C, Baio S, Veronesi P, et al. Sentinel node biopsy in male breast cancer. Nucl Med Commun 2004;25:139–43. 12. Goyal A, Horgan K, Kissin M, et al. Sentinel lymph node biopsy in male breast cancer patients. Eur J Surg Oncol 2004;30:480–3. 13. Boughey JC, Bedrosian I, Meric-Bernstam F, et al. Comparative analysis of sentinel lymph node operation in male and female breast cancer patients. J Am Coll Surg 2006;203: 475–80. 14. Harris J, Lippman M, Morrow M, Osborne C. Disease of the breast: male breast cancer, 2nd ed. Lippincott Williams and Wilkins; 2000. p. 663. 15. Bland K, Copeland E. The breast: comprehensive management of benign and malignant disease: cancer of the male breast, 2nd ed. London: W.B. Saunders Co.; 1998. p. 1417–8. 16. Agrawal A, Ayantunde A, Rampaul R, et al. Male breast cancer: a review of clinical management. Breast Cancer Res Treat, 2006 [epub ahead of print]. 17. Goss P, Reid C, Pintilie M, et al. Male breast carcinoma: a review of 229 patients who presented to the Princess Margaret Hospital during 40 years: 1955–1996. Cancer 1999;85:629–39. 18. Cutuli B, Dilhuydy J, Delafontan B, et al. Ductal carcinoma in situ of the male breast, analysis of 31 cases. Eur J Cancer 1997;33:35–8.