SymptomNo.casesBreast

mass only89(67.4%)BreastmassplusRetracted

nipple7Dischargingnipple4Discharging

nipple,painIEncrustednipple

Encrusted nipple, pain3INippledischargeonly8Nippleencrustationonly5Nippleretractiononly4Nippleencrustation,retraction0Ulceration7Axillary

swelling3Painonly0Pain,

breastmass0TOTAL132Uncertain14TOTAL146

Many practitioners have looked uponcancer of the male breast as extremelyrare. A few have never heard of it.

Surgeons in general, and particularlythose interested in cancer treatment, haveregarded cancer of the male breast as having a more serious prognostic import thanthe corresponding disease in women.Many reasons have been advanced to explain the difference. None to our knowledge has a factual basis.

One hundred and fifty-six patientswhose disease was diagnosed clinicallyas cancer of the male breast were seen atMemorial Center from 1924 through1954. Of this number, 146 cases wereconfirmed histologically as primary mammary cancer. This is, perhaps, the largestseries of microscopically proved cancerof the male breast reported from a singleinstitution.

Frequency

Number of Cases Yearly. An average ofapproximately five cases of cancer of themale breast were seen per year, but thenumber varied considerably from one yearto another. As many as twelve cases wereseen in one year (1943), while only onecase was seen in another (1937). Duringthe past ten years, however, the averagehas been almost six cases per year. Thissuggests that there has not been any notable increase recently.

Proportion to Cancer of the FemaleBreast. When compared with all primarybreast cancer (male and female), the incidence for the male has been less than 1per cent.

Age. The youngest patient in the series

Frommi time Breast Service, ,‘slemm:onialCemmten forCammcen and Allied Diseases, Nyu, Yank, New York.

Acknowledgmnent is mmmdc of time collahonatiomm ofAntimun I. Holleb, M.D., in time preparation of ther,niginal article /no,n which time present report i.cderived.

TABLE 1

Initial Symptom in 146 Cases ofCancer of the Male Breast

was 24 years of age and the oldest, 85.The average age of the group was 52.1years, corresponding closely to figures reported in other series. It should be notedthat ten patients were 40 years of age oryounger (two patients were in their latetwenties). The fact that cancer of themale breast does occur in the earlier yearsshould caution the physician against making a diagnosis of benign gynecomastiawithout first taking a biopsy.

Race. All but seven of the patients inthe series were white. These seven wereNegroes, an incidence of 4 per cent. Twoof the Negroes were very light-coloredmulattoes and were often described aswhite on the hospital records. No otherraces were encountered.

Occupation. Occupations of a wide variety were reported. none of which showedany apparent relationship to cancer of themale breast. Two physicians are includedin the case reports.

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Cancer of the Male Breast

Norman Treves, M.D.

FIGURE 1. F. M., a 43-year-old white man, in 1935 had nipple retraction and a 3-cm. mass.Aspiration biopsy revealed mammary carcinoma. He was treated elsewhere by roentgen raysand died three years later of disseminated metastatic disease.

FIGURE 2. E. S., an 80-year-old man, in 1945 had an indurated ulcer and a 3-cm. mass:Paget's disease of the nipple and infiltrating duct carcinoma, with normal axillary nodes. Hedied of metastatic disease four years after radical mastectomy.

Laterality. On admission, eighty-twopatients had cancer of the left breast;sixty-three, of the right breast. One patient presented bilateral inflammatorybreast cancer. Three patients subsequentlydeveloped cancer in the opposite breast.The total incidence of bilateral breast cancer was 2.7 per cent, thus approximatingthe incidence in females.

Etiology

Cancer of the male breast has been reported to develop during the course ofestrogen therapy for advanced prostaticcarcinoma. There are reasons for doubting this, at least in a causal sense. Onlyone patient in this series had cancer of theprostate, and this was diagnosed simultaneously with the breast cancer—no hormone therapy had been given. One patientreceived female-hormone therapy elsewhere after the diagnosis of breast cancerhad been made, and one patient had beengiven six injections of testosterone forpsoniasis prior to the appearance of anulcerated nipple (interval not stated).

Approximately 12 per cent of the patients volunteered or responded with a

history of trauma that varied widely, notonly in type and frequency but also induration from onset of breast symptoms(one day to forty-four years). It was impossible to establish any definite correlation between trauma and the developmentof male-breast cancer by a review of thehospital records. It is the author's opinion.based on the physical findings on admission, that in most cases the traumatic incident merely called attention to a preexisting lesion. There was no evidence of

TABLE 2

Physical Findings on Admission inEighty-four Operable Cases of Cancer

of the Male Breast

Symptom No. cases %

Palpable massNipple abnormalities

RetractionUlcerationDischargeEncrustation

Mass and nipple abnormalitySkin fixation

(without ulceration)Ulceration only

76 90.461 72.631 36.921 25.014 16.63 3.5

43 51.1

19 22.68 9.5

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cases were a@early as one might wish. Theterm @‘¿�skinfixation― implies attachment ofthe breast mass to the overlying skin butdoes not include frank ulceration. Ulceration, when present, was almost alwayswithin the confines of the areolar marginand presented as nipple destruction. Ulceration has been included, therefore, asa nipple abnormality. Encrustation impliesa superficial scaling or eczematoid appearance of the nipple and/or the areola.True nipple discharge (without ulceration) was discovered during the course ofroutine palpation. Undue pressure was notapplied to the breast mass to elicit nippledischarge. Figures 1 to 5 show some ofthe more typical physical findings.

Table 2 is a further breakdown of thesignificant physical signs in the primaryoperable group. A discrete mass was notedin 90.4 per cent of the cases and 72.6per cent of the entire group showed nippleabnormalities of one type or another. Ifa mass in the adult male breast warrants

FIGURE 3. P. D., a 64-year-old white man,in 1939 had a 5-cm. ulcer fixed to the chestwall: mammary carcinoma infiltrating theskin. He died ten months later of metastaticdisease.

a pre-existing gynecomastia in the entireseries.

Clinical History

Mammary History. A review of thehistories yielded the following majorsymptoms, either alone or in combination:breast mass or swelling; serous or bloodydischarge from the nipple; nipple retraction, encrustation, or ulceration; axillaryswelling; and local or distant pain. Themore advanced the disease, the larger wasthe symptom complex.

The histories were also examined toelicit the first symptom noted by the patient. In fourteen cases, the type of onsetwas uncertain. In more than two thirdsof the cases the first symptom noted by thepatient was a mass in the breast and nothing more. Not one patient complained ofpain as the solitary symptom. Pain wasan insignificant initial complaint evenwhen associated with nipple changes (twocases).

The initial symptom complexes (Table.I) indicated that a breast mass was notedin 105 of 132 cases. Nipple abnormalitiesoccurred in thirty-three cases, with almostequal distribution among discharging nipple (thirteen cases), retracted nipple(eleven cases), and encrusted nipple (ninecases).

In only two patients, both unaware ofa breast mass, was cancer detected duringthe course of a routine physical examination. The remainder of the patients haddiscovered a “¿�lump―or “¿�swelling―throughself-examination.

Thirteen patients noted true nippledischarge not associated with ulcerationas an initial finding. Nine others developedit subsequently. The discharge was mostoften bloody, although at times it wasserous. It has become apparent that nippledischarge in the adult male frequently indicates an underlying cancer and warrants immediate and thorough investigation.

Physical Findings. In only thirteen ofthe eighty-four primary operable caseswas a mass present without an associatedfinding. This would suggest that few of the

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suspicion of cancer, then certainly the disclosure of a mass and nipple abnormality(51.1 per cent) should confirm that suspicion clinically, especially when nippleretraction is noted (36.9 per cent). Ulceration, as a solitary finding, was present inonly 9.5 per cent of the cases, yet 25 percent of the primary operable groupshowed cancer invading and ulcerating theoverlying skin at the time of admission.Skin fixation without ulceration was present in 22.6 per cent and peau d'orange inonly 2.3 per cent.

The incidence of true nipple discharge(16.6 per cent) was surprising, in view ofthe vestigial nature of the male breast.Since some patients, in addition, gave ahistory of nipple discharge prior to theulceration or prior to the development ofan inoperable situation, it is our opinionthat the importance of nipple dischargeas a symptom or physical sign has beenunderrated in the diagnosis of mammarycarcinoma in the male and should be considered as a possible early manifestation ofthe disease. Perhaps the wider use of cytological investigation of breast secretionswill confirm this opinion.

Enlarged lymph nodes in the homolateral axilla were encountered in 46.4per cent of the patients.

The smallest breast mass described was4 to 5 mm. and the largest, a sarcoma, was12 cm. (Fig. 6). The median of the maximum diameters was 3 cm. (if one assumesestimated size, based on palpation, to bereasonably accurate). This was about thesame average diameter as that of the maleareola. However, the median size of thebreast mass is misleading when consideredin terms of early diagnosis, since somepatients with a 3-cm. mass had completedestruction of the nipple and othersshowed clinical evidence of axillary involvement. Fourteen patients in the primary inoperable group presented 3- to5-cm. breast masses, yet showed evidenceof supraclavicular, pulmonary, or osseousdissemination.

Pathology

The presence of nipple discharge didnot always indicate a noninfiltrating intraductal papillary carcinoma, although thiswas true in approximately one third of the

j54

FIGURE 4. B. L., a 75-year-old white man, in 1936 had a 3-cm., fungating. papillary tumorwith an underlying 5-cm. mass. The axillary nodes were involved and there was roentgenological evidence of pulmonary metastases. Biopsy showed mammary carcinoma. He died oneyear later.

FIGURE 5. J. M., a 63-year-old white man, in 1933 had an 8-cm. fungating tumor: infiltrating duct carcinoma, with axillary node metastases. He died of metastatic disease almost fouryears after radical mastectomy.

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cases presenting serous or bloody discharge from the nipple. In the remainingtwo thirds, the cancer was infiltrating andmost often not papillary but rather theusual infiltrating duct carcinoma, GradeII or III. Since the underlying pathologyis so unpredictable, a thorough surgicalinvestigation of the etiology of nipple discharge in the male becomes mandatory.

Summary and Conclusions

Cancer of the male breast accounts forless than 1 per cent of cancer of the breastin both sexes.

The average age in our series of 146histologically proved cases was 52.1 years:however, the range extended from 24years to 85 years.

Radical mastectomy was performed onall patients whose general medical statuswould permit major surgery. There wasone postoperative death. No attempt wasmade to evaluate skin grafting in terms ofsurvival rates. Castration was performedas a palliative measure on more thanthirty patients in the series.

The end results vary according to themethod of computation. If one classifiesas successful results only those patientswho were known to he clinically free ofcancer five years after treatment and if allothers (inoperable, lost to follow-up, diedof other causes, died of cancer, refusedtreatment, etc.) are classified as failures,the survival rate is 29.1 per cent. This isthe lowest salvage rate one can calculate.

If only the operable cases are considered and the same failure factors are used,the five-year—survival rate is 41.9 per cent.When the “¿�determinate―cases within theprimary operable group are evaluated, thefive-year—survival rate rises to 55.7 percent.

Papillary breast cancer in the maleseems to offer an excellent prognosis. Thesix determinate patients with this diagnosis

FIGURE 6. L. H.. a 54-year-old white man,in 1935 had a 12-cm. firm mass without skinfixation: low-grade myxoliposarcoma. He isalive seventeen years after simple mastectomy.

have survived five years without recurrence and none had proved axillary metastases. The five-year—survival pattern ofthe more common infiltrating duct carcinoma parallels breast cancer in the female.When the homolateral axillary lymphnodes were invaded by cancer, the survival rate dropped to 30 per cent as opposed to a survival rate of 75 per centwhen the tumor was confined to thebreast. This hiatus should lend added significance to early diagnosis and prompttherapy.

The age of the patient does not seem toinfluence the end results in the operablegroup. The prognosis for all ages is moredependent on the histological type of thecancer and presence or absence of metastases in the axillary lymph nodes.

A plea is made for less cursory examination of the male breast during routinephysical examinations—with the hope ofdetecting cancer in a stage most amenableto cure.

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