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Case report: Intracystic papillary carcinoma of the breast in a male patient
Clinical Radiology (1996)51, 438-439
Case Report: Intracystic Papillary Carcinoma of the Breast in a Male Patient C. J. SONKSEN, M. MICHELL and M. SUNDARESAN*
Departments of Radiology and *Histopathology, Kings College Hospital, London, UK
CASE REPORT
relevant features in the history. His past medical history included diabetes mellitus, hypertension and tuberculosis. Physical examination revealed a 3 cm mobile lump in the right breast with no palpable axillary lymphadenopathy and no other significant findings. M a m m o g r a m s were performed initially which showed a well circumscribed mass of intermediate soft tissue density posterior to the nipple. The margin was slightly illdefined superiorly and areas o f microcalcification were noted (Fig. 1). Ultrasound, using a 7.5 M H z probe, showed the 2.1 cm lesion to be predominately cystic but an irregular soft tissue mass was demonstrated projecting from the wall into the lumen (Fig. 2). This contained some discrete areas of increased reflectivity consistent with microcalcification. Other parts of the wall were thickened and ill-defined. On aspiration blood stained fluid was obtained and cytological examination showed malignant cells. A right mastectomy and level 1 axillary clearance were performed through a single incision from which the patient made a rapid and complete recovery. Adjuvant radiotherapy a n d hormonal manipulation were felt unnecessary. At one year follow-up the patient remained wetl with no evidence o f local recurrence or metastatic disease.
A 62-year-old m a n represented with a painless lump in the right breast which had been present for three months. There were no other
Pathological Findings
Carcinoma of the male breast is an uncommon disease with an incidence between 0.5% and 2.4% of that in women [1]. Intracystic papillary carcinomas form a small subgroup [2] with favourable prognosis [3]. In men the xerographic [4] and pneumocystographic [5] findings have previously been described and the imaging appearances used in the diagnosis of these malignancies. We describe the ultrasonographic appearances and advocate the use of mammography and ultrasound followed by fine needle aspiration (FNA) where appropriate in the investigation of a male patient presenting with a breast lump. This is the first report in a male patient correlating the ultrasonographic and mammographic findings with the histology [6].
The macroscopic specimen consisted of a nipple elipse of skin with 18.0 x 7.0 x 4.5 cm of attached breast tissue. The lesion was palpable l cm lateral to the nipple and 1 cm beneath the skin. Cut section revealed a 1.5cm blood filled cyst within which was a 1 cm soft grey papillary lesion.
Fig. 1 - Right breast m a m m o g r a m shows a well defined 3 cm mass of intermediate soft tissue density. T h e margin is slightly ill defined superiorly and areas o f microcalcification are noted. Correspondence to D r C. J. Sonksen, Department of Radiology, The Royal Sussex County Hospital, Eastern Road, Brighton, East Sussex, BN2 5BE, U K .
Fig. 2 - Ultrasound shows a 2.1 cm predominantly cystic lesion with an irregular soft tissue mass projecting from the wall into the lumen. © 1996 The Royal College of Radiologists.
CASE REPORTS
Fig. 3 - Low power (x40) photomicrograph shows the intracystic papillary proliferation of cells with cribriform areas (haematoxylin & eosin).
439
factors may be contributary [9]. The overall prognosis of breast cancer in men is similar to that in women with 40% surviving at 10 years. The rate of survival for men when there is lymph node involvement at diagnosis is, however, significantly lower. The ten year survival for men who are node negative at diagnosis is 79% and those who are node positive 11% with respective values o f 7 1 % and 43 % for women [7]. Intracystic papillary carcinomas tend to be of better prognosis than other histological types and prompt accurate diagnosis is important. Mammographically, as was the case in our patient, intracystic papillary carcinomas tend to be well circumscribed masses and have features more in keeping with a benign lesion. A hazy margin is suggestive of tumour invasion. When ultrasound shows an intracystic mass with associated thickening of the cyst wall an intracystic carcinoma should be suspected. F N A of these lesions often shows blood stained fluid and malignant cells. In a male patient presenting with a lump in the breast we would advocate the use of mammography and ultrasound as the primary imaging investigations. Mammography ensures that associated in situ or multicentric disease is detected and sonography allows the accurate differentiation of cystic from solid masses. In patients with complex cystic lesions, the appearances may be highly suggestive of intracystic carcinoma. With complex cystic lesions as well as solid lesions, F N A should be carried out to confirm the diagnosis.
Acknowledgement. We would like to thank Dr S. Humpheries for preparing the original histology. Fig. 4 High power (>?400) photomicrograph of tumour shows the regular nuclei with prominent nucleoli (haematoxylin & eosin). Microscopic sections of the cyst showed it to be lined with a tubulopapillary proliferation of cells with solid sheets of cells present in some areas. There was a moderate degree of cytological atypia with plump cell nuclei and prominent nucleoli although the nuclear outlines were regular. Adjacent to the cyst there were foci of cribriform type ductal carcinoma in situ (Figs 3 & 4). Appearances were those of an intracystic papillary carcinoma. All 14 lymphnodes were free of tumour and excision of the carcinoma in situ appeared complete.
DISCUSSION Intracystic papillary carcinomas are a small subgroup of breast cancers and account for 0.5% to 2.0% of breast cancers in women [2]. Some studies suggest they form a higher percentage in men with an incidence of between 5% and 7.5% [7,8]. The average age at which breast cancer develops in men is 65 as compared to 55 years in women. The recent literature suggests that the incidence may be increased in patients with gynaecomastia, high endogenous oestrogen levels and Kleinfelters syndrome. Trauma and radiation could predispose and hereditary
© 1996 The Royal College of Radiologists, ClinicalRadiology, 51,438 439.
REFERENCES 1 Norris H J, Taylor HB. Carcinoma of the male breast. Cancer 1969; 23:1428 1435. 2 Czernobilsky B. Intracystic carcinoma of the female breast. Surgery, Gynaecology and Obstetrics 1967; 124:93-98. 3 Carter D, Orr SL, Merino M. Intracystic papillary carcinoma of the breast after mastectomy, radiotherapy or excision biopsy alone. Cancer 1983;52:14-19. 4 Chinn K, Kalisher L, Rickert R. Case Reports. Intracystic papillary breast carcinoma in a 55 year old man: Radiologic and Pathologic correlation. Journal of the Canadian Association of Radiology 1989; 40:40-42. 5 Goblyos P, Kaszas I, Szekely Let al. Intracystic Tumour of the Male Breast. Case Report. European Journal of Radiology 1987;7:279 280. 6 Estabrook A, Asch T, Gump F et al. Mammographic features of intracystic papillary lesions. Surgery, Gynecology & Obstetrics 1990; 170:113 116. 7 Heller K, Rosen PP, Schottenfeld D et al. Male breast cancer: A clinicopathotogic study of 97 cases. Annals of Surgery 1978;188:60 65. 8 Wolff M, Reinis MS. Breast cancer in the male: Clinicopathological study of 40 patients. In Fenoglio C, Wolff M, eds. Progress in Surgical Pathology. New York: Masson Publishing Co Inc, 1981: vol. 3, 77 107. 9 De Rosa G, Giovanna G, Amedeo B, Terracciano L, Donofrio V, De Dominicis. Intracystic papillary carcinoma of the male breast. A case report. (Histochemical, immunochemical and ultrastructural study). Turnori 1992;78:37-42.
Case Report: Intracystic Papillary Carcinoma of the Breast in a Male Patient C. J. SONKSEN, M. MICHELL and M. SUNDARESAN*
Departments of Radiology and *Histopathology, Kings College Hospital, London, UK
CASE REPORT
relevant features in the history. His past medical history included diabetes mellitus, hypertension and tuberculosis. Physical examination revealed a 3 cm mobile lump in the right breast with no palpable axillary lymphadenopathy and no other significant findings. M a m m o g r a m s were performed initially which showed a well circumscribed mass of intermediate soft tissue density posterior to the nipple. The margin was slightly illdefined superiorly and areas o f microcalcification were noted (Fig. 1). Ultrasound, using a 7.5 M H z probe, showed the 2.1 cm lesion to be predominately cystic but an irregular soft tissue mass was demonstrated projecting from the wall into the lumen (Fig. 2). This contained some discrete areas of increased reflectivity consistent with microcalcification. Other parts of the wall were thickened and ill-defined. On aspiration blood stained fluid was obtained and cytological examination showed malignant cells. A right mastectomy and level 1 axillary clearance were performed through a single incision from which the patient made a rapid and complete recovery. Adjuvant radiotherapy a n d hormonal manipulation were felt unnecessary. At one year follow-up the patient remained wetl with no evidence o f local recurrence or metastatic disease.
A 62-year-old m a n represented with a painless lump in the right breast which had been present for three months. There were no other
Pathological Findings
Carcinoma of the male breast is an uncommon disease with an incidence between 0.5% and 2.4% of that in women [1]. Intracystic papillary carcinomas form a small subgroup [2] with favourable prognosis [3]. In men the xerographic [4] and pneumocystographic [5] findings have previously been described and the imaging appearances used in the diagnosis of these malignancies. We describe the ultrasonographic appearances and advocate the use of mammography and ultrasound followed by fine needle aspiration (FNA) where appropriate in the investigation of a male patient presenting with a breast lump. This is the first report in a male patient correlating the ultrasonographic and mammographic findings with the histology [6].
The macroscopic specimen consisted of a nipple elipse of skin with 18.0 x 7.0 x 4.5 cm of attached breast tissue. The lesion was palpable l cm lateral to the nipple and 1 cm beneath the skin. Cut section revealed a 1.5cm blood filled cyst within which was a 1 cm soft grey papillary lesion.
Fig. 1 - Right breast m a m m o g r a m shows a well defined 3 cm mass of intermediate soft tissue density. T h e margin is slightly ill defined superiorly and areas o f microcalcification are noted. Correspondence to D r C. J. Sonksen, Department of Radiology, The Royal Sussex County Hospital, Eastern Road, Brighton, East Sussex, BN2 5BE, U K .
Fig. 2 - Ultrasound shows a 2.1 cm predominantly cystic lesion with an irregular soft tissue mass projecting from the wall into the lumen. © 1996 The Royal College of Radiologists.
CASE REPORTS
Fig. 3 - Low power (x40) photomicrograph shows the intracystic papillary proliferation of cells with cribriform areas (haematoxylin & eosin).
439
factors may be contributary [9]. The overall prognosis of breast cancer in men is similar to that in women with 40% surviving at 10 years. The rate of survival for men when there is lymph node involvement at diagnosis is, however, significantly lower. The ten year survival for men who are node negative at diagnosis is 79% and those who are node positive 11% with respective values o f 7 1 % and 43 % for women [7]. Intracystic papillary carcinomas tend to be of better prognosis than other histological types and prompt accurate diagnosis is important. Mammographically, as was the case in our patient, intracystic papillary carcinomas tend to be well circumscribed masses and have features more in keeping with a benign lesion. A hazy margin is suggestive of tumour invasion. When ultrasound shows an intracystic mass with associated thickening of the cyst wall an intracystic carcinoma should be suspected. F N A of these lesions often shows blood stained fluid and malignant cells. In a male patient presenting with a lump in the breast we would advocate the use of mammography and ultrasound as the primary imaging investigations. Mammography ensures that associated in situ or multicentric disease is detected and sonography allows the accurate differentiation of cystic from solid masses. In patients with complex cystic lesions, the appearances may be highly suggestive of intracystic carcinoma. With complex cystic lesions as well as solid lesions, F N A should be carried out to confirm the diagnosis.
Acknowledgement. We would like to thank Dr S. Humpheries for preparing the original histology. Fig. 4 High power (>?400) photomicrograph of tumour shows the regular nuclei with prominent nucleoli (haematoxylin & eosin). Microscopic sections of the cyst showed it to be lined with a tubulopapillary proliferation of cells with solid sheets of cells present in some areas. There was a moderate degree of cytological atypia with plump cell nuclei and prominent nucleoli although the nuclear outlines were regular. Adjacent to the cyst there were foci of cribriform type ductal carcinoma in situ (Figs 3 & 4). Appearances were those of an intracystic papillary carcinoma. All 14 lymphnodes were free of tumour and excision of the carcinoma in situ appeared complete.
DISCUSSION Intracystic papillary carcinomas are a small subgroup of breast cancers and account for 0.5% to 2.0% of breast cancers in women [2]. Some studies suggest they form a higher percentage in men with an incidence of between 5% and 7.5% [7,8]. The average age at which breast cancer develops in men is 65 as compared to 55 years in women. The recent literature suggests that the incidence may be increased in patients with gynaecomastia, high endogenous oestrogen levels and Kleinfelters syndrome. Trauma and radiation could predispose and hereditary
© 1996 The Royal College of Radiologists, ClinicalRadiology, 51,438 439.
REFERENCES 1 Norris H J, Taylor HB. Carcinoma of the male breast. Cancer 1969; 23:1428 1435. 2 Czernobilsky B. Intracystic carcinoma of the female breast. Surgery, Gynaecology and Obstetrics 1967; 124:93-98. 3 Carter D, Orr SL, Merino M. Intracystic papillary carcinoma of the breast after mastectomy, radiotherapy or excision biopsy alone. Cancer 1983;52:14-19. 4 Chinn K, Kalisher L, Rickert R. Case Reports. Intracystic papillary breast carcinoma in a 55 year old man: Radiologic and Pathologic correlation. Journal of the Canadian Association of Radiology 1989; 40:40-42. 5 Goblyos P, Kaszas I, Szekely Let al. Intracystic Tumour of the Male Breast. Case Report. European Journal of Radiology 1987;7:279 280. 6 Estabrook A, Asch T, Gump F et al. Mammographic features of intracystic papillary lesions. Surgery, Gynecology & Obstetrics 1990; 170:113 116. 7 Heller K, Rosen PP, Schottenfeld D et al. Male breast cancer: A clinicopathotogic study of 97 cases. Annals of Surgery 1978;188:60 65. 8 Wolff M, Reinis MS. Breast cancer in the male: Clinicopathological study of 40 patients. In Fenoglio C, Wolff M, eds. Progress in Surgical Pathology. New York: Masson Publishing Co Inc, 1981: vol. 3, 77 107. 9 De Rosa G, Giovanna G, Amedeo B, Terracciano L, Donofrio V, De Dominicis. Intracystic papillary carcinoma of the male breast. A case report. (Histochemical, immunochemical and ultrastructural study). Turnori 1992;78:37-42.