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Ductal carcinoma in situ (DCIS) of the male breast treated by lumpectomy and breast irradiation
Clinical Oncology (1998) 10:204-205 © 1998 The Royal College of Radiologists
Clinical Oncology
Case Report Ductal Carcinoma in situ (DCIS) of the Male Breast Treated by Lumpectomy and Breast Irradiation M. Deutsch and M. M. Rosenstein University of Pittsburgh Medical Center, Pittsburgh, USA
Abstract. A male patient with ductal carcinoma in situ (DCIS) of the breast, treated with lumpectomy and postoperative breast irradiation, is presented. Because of associated obesity, the patient felt that mastectomy would leave him with a noticeable cosmetically unacceptable deformity. Radiotherapy was administered using the exact techniques used to treat the female breast. At 44 months following completion of radiotherapy, the patient is free of disease and has an excellent cosmetic result. Thus, if there are compelling reasons to avoid mastectomy in a male patient, lumpectomy and breast irradiation should be considered a s a reasonable alternative for treatment of DCIS.
Keywords: Breast irradiation; Ductal carcinoma in situ; Male breast cancer Fig. 1. The left breast in a male 44 months following completion of radiotherapy post-lumpectomy for DCIS.
INTRODUCTION Ductal carcinoma in situ (DCIS) accounts for about 5%-7% of all cancers of the male breast [1]. The most commonly recommended treatment is total mastectomy without axillary dissection [1,2]. These two recently published reviews of DCIS in the male consisted of only eight patients treated by lumpectomy alone, of which there were five local failures. The conclusion of these two reports was that mastectomy is the treatment of choice. We present a case of DCIS of the male breast treated by lumpectomy and radiotherapy, which we believe to be the first reported case of male DCIS thus treated.
CASE HISTORY This black male patient, aged 53 years, first discovered a lump in the left breast in the lateral aspect of the areola in June 1993. A subsequent mammogram showed dense tissue, which obscured the palpable lesion. In September 1993 he underwent excisional biopsy through a lateral circumareolar incision, which revealed DCIS 'focally present close to [the] margin [of excision]'. Since the margin of resection was actually free of tumour, further excision was not considered necessary. Because of his size and body habitus (height 6 ft, weight 265 lb, and associated obesity), the Correspondence and offprint requests to: Dr M. Deutsch, Department of Radiation Oncology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
patient wished to avoid a mastectomy, which he felt would leave him with a cosmetically undesirable result. There was no family history of breast cancer and his past medical history was otherwise non-contributory.. The patient was treated with radiotherapy with the same technique as used for the treatment of the female breast. Medial and lateral tangential portals were used to deliver a total dose of 50 Gy in 25 fractions to the entire breast. The operative area on the lateral aspect of the left breast was then treated with an additional 10 Gy in five fractions using 9 MeV electrons. Radiotherapy was completed in January 1994. The patient has been continually free of disease for 44 months after completion of the radiotherapy. The cosmetic result is excellent (Fig. 1).
DISCUSSION The most common treatment for invasive carcinoma of the male breast is mastectomy and axillary dissection. In a large review of 335 cases of invasive carcinoma of the male breast reported by Guinee et al., less than 10% were treated by lumpectomy with or without breast irradiation [3]. The outcome for invasive carcinoma of the male breast appears to be equal to that for cancer of the female breast when comparisons are made according to nodal status and number of involved nodes. Similarly, the prognosis for DCIS of the male breast appears to be as favourable as that of DCIS of the female breast [1]. According to the review of the literature by Cutuli et al., a total of eight cases treated by lumpectomy alone have been reported, of which there
DCIS of the Male Breast Treated by Lumpectomy and Breast Irradiation were five local failures [1,2]. No details were presented on the margins of resection in these five patients with local failure and thus it is not clear why the local recurrence rate was so high in this group of eight patients treated by lumpectomy alone. Conversely, as would be expected, local recurrence after mastectomy is unusual, this having occurred in only one of 31 patients in the series reported by Cutuli et al. [1]. Camus et al. believe that the cosmetic and psychological morbidity of mastectomy in the male is 'minimal' and consider lumpectomy and radiotherapy as 'excessive and unreasonable' [2]. However, the authors' patient, because of his size and shape, wanted very much to avoid mastectomy, which would have left a noticeable defect. At 3.5 years following treatment, he has a very good 'cosmetic' result. By extrapolating from the results of lumpectomy and radiotherapy for DCIS of the female breast [4], it would seem that a similar good result should be obtainable with this treatment in the male breast. Thus, if
205
there are compelling reasons to avoid mastectomy in a male patient, lumpectomy and breast irradiation should be considered a reasonable alternative.
References
1. Cutuli B, Dilhuydy JM, DeLafontan B, et al. Ductal carcinoma in situ of the male breast. Analysis of 31 cases. Eur J Cancer 1997;33:35-8. 2. Camus MG, Joshi MG, Mackarem G, et al. Ductal carcinoma in situ of the male breast. Cancer 1994;74:1289-93. 3. Guinee VF, Olsson H, Moller T, et al. The prognosis of breast cancer in males. A report of 335 cases. Cancer 1993;71:154-61. 4. Fisher B, Costantino J, Redmond C, et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993;328:1581-6.
Received for publication September 1997 Accepted following revision December 1997
Clinical Oncology
Case Report Ductal Carcinoma in situ (DCIS) of the Male Breast Treated by Lumpectomy and Breast Irradiation M. Deutsch and M. M. Rosenstein University of Pittsburgh Medical Center, Pittsburgh, USA
Abstract. A male patient with ductal carcinoma in situ (DCIS) of the breast, treated with lumpectomy and postoperative breast irradiation, is presented. Because of associated obesity, the patient felt that mastectomy would leave him with a noticeable cosmetically unacceptable deformity. Radiotherapy was administered using the exact techniques used to treat the female breast. At 44 months following completion of radiotherapy, the patient is free of disease and has an excellent cosmetic result. Thus, if there are compelling reasons to avoid mastectomy in a male patient, lumpectomy and breast irradiation should be considered a s a reasonable alternative for treatment of DCIS.
Keywords: Breast irradiation; Ductal carcinoma in situ; Male breast cancer Fig. 1. The left breast in a male 44 months following completion of radiotherapy post-lumpectomy for DCIS.
INTRODUCTION Ductal carcinoma in situ (DCIS) accounts for about 5%-7% of all cancers of the male breast [1]. The most commonly recommended treatment is total mastectomy without axillary dissection [1,2]. These two recently published reviews of DCIS in the male consisted of only eight patients treated by lumpectomy alone, of which there were five local failures. The conclusion of these two reports was that mastectomy is the treatment of choice. We present a case of DCIS of the male breast treated by lumpectomy and radiotherapy, which we believe to be the first reported case of male DCIS thus treated.
CASE HISTORY This black male patient, aged 53 years, first discovered a lump in the left breast in the lateral aspect of the areola in June 1993. A subsequent mammogram showed dense tissue, which obscured the palpable lesion. In September 1993 he underwent excisional biopsy through a lateral circumareolar incision, which revealed DCIS 'focally present close to [the] margin [of excision]'. Since the margin of resection was actually free of tumour, further excision was not considered necessary. Because of his size and body habitus (height 6 ft, weight 265 lb, and associated obesity), the Correspondence and offprint requests to: Dr M. Deutsch, Department of Radiation Oncology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
patient wished to avoid a mastectomy, which he felt would leave him with a cosmetically undesirable result. There was no family history of breast cancer and his past medical history was otherwise non-contributory.. The patient was treated with radiotherapy with the same technique as used for the treatment of the female breast. Medial and lateral tangential portals were used to deliver a total dose of 50 Gy in 25 fractions to the entire breast. The operative area on the lateral aspect of the left breast was then treated with an additional 10 Gy in five fractions using 9 MeV electrons. Radiotherapy was completed in January 1994. The patient has been continually free of disease for 44 months after completion of the radiotherapy. The cosmetic result is excellent (Fig. 1).
DISCUSSION The most common treatment for invasive carcinoma of the male breast is mastectomy and axillary dissection. In a large review of 335 cases of invasive carcinoma of the male breast reported by Guinee et al., less than 10% were treated by lumpectomy with or without breast irradiation [3]. The outcome for invasive carcinoma of the male breast appears to be equal to that for cancer of the female breast when comparisons are made according to nodal status and number of involved nodes. Similarly, the prognosis for DCIS of the male breast appears to be as favourable as that of DCIS of the female breast [1]. According to the review of the literature by Cutuli et al., a total of eight cases treated by lumpectomy alone have been reported, of which there
DCIS of the Male Breast Treated by Lumpectomy and Breast Irradiation were five local failures [1,2]. No details were presented on the margins of resection in these five patients with local failure and thus it is not clear why the local recurrence rate was so high in this group of eight patients treated by lumpectomy alone. Conversely, as would be expected, local recurrence after mastectomy is unusual, this having occurred in only one of 31 patients in the series reported by Cutuli et al. [1]. Camus et al. believe that the cosmetic and psychological morbidity of mastectomy in the male is 'minimal' and consider lumpectomy and radiotherapy as 'excessive and unreasonable' [2]. However, the authors' patient, because of his size and shape, wanted very much to avoid mastectomy, which would have left a noticeable defect. At 3.5 years following treatment, he has a very good 'cosmetic' result. By extrapolating from the results of lumpectomy and radiotherapy for DCIS of the female breast [4], it would seem that a similar good result should be obtainable with this treatment in the male breast. Thus, if
205
there are compelling reasons to avoid mastectomy in a male patient, lumpectomy and breast irradiation should be considered a reasonable alternative.
References
1. Cutuli B, Dilhuydy JM, DeLafontan B, et al. Ductal carcinoma in situ of the male breast. Analysis of 31 cases. Eur J Cancer 1997;33:35-8. 2. Camus MG, Joshi MG, Mackarem G, et al. Ductal carcinoma in situ of the male breast. Cancer 1994;74:1289-93. 3. Guinee VF, Olsson H, Moller T, et al. The prognosis of breast cancer in males. A report of 335 cases. Cancer 1993;71:154-61. 4. Fisher B, Costantino J, Redmond C, et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993;328:1581-6.
Received for publication September 1997 Accepted following revision December 1997