CANCER OF ‘I’HE MALE BKEAS‘I‘

A Report 01 146 Cases

NORMAN TREVES, M.D., ASD AKIITICK I. HOLLEB, m n .

A ~ Y practitioners have looked upon can- cer of the male breast as extrenicly rare.

Surgeons in general, and particularly those

cancer of the male breast as having a more serious prognostic import than the corre- -

Cdtholic 14 sponding disease in women. Many reasons have been advanced to explain the difference. Ireland Catholic 8

Protestant 1 1 6 None to our knowledge has a fat tual basis. Catholic

TABLE 1 100 CASES OF CAXCCR OF THE MALE BREAST

CLASSIFIED ACCORDING TO COUNTRY OF

PATIENTS I m n I AXD RELIGIOUS AFFII~IATION OF

M X few have riever heard of it.

interested in cam cr treatment, have regarded __- Krligious affiliation Yo country of birth

Europe (mainly Russia) Jewish 37 ~~~l~

:$:! ~~~i~~ ‘l’he following study was undertaken to clear United States Jewish 5

up many of the current irnprrssions relating Other Other 19

are comprised of isolated cases, sniall series, - - ~ ___

-- 100 to cancer of the malt, breast. Yretious reports

or compilations dericed froin many different institutions. Because 01 the relatively largr amount of clinical material seen at Memorial (:enlei-, we hate been able to assemble reasorl- ably adequate data on the rlatural history arid the behavior of this form of cancer.

One hundred and filty-six patients whose disease lb7as diagnosed clinically as male-breast cancer Ivere seen at nlemorial (:enter fro111 1924 t]lrougll 1954. Of this number, 1.16 cases were confirmed histologically as primary rriarn- mary canter. ‘l’his is, perhaps, the largest series of rrliLroscopically proved male-breast cancer reported from a single institution. It includes patients reported prepiously bp ‘I‘reves in 1949, 1953, and 1951.4r 6,

T h i s study deals orlly wit11 those cases in whicll rllicroscopic proof ot canter was oil- tained. The ten cas(’s excluded from the study had cli1li(al e\ridellce of breast cancer, but biopsy suggested othrr prirriary sites or lesions, such as skin cancer, situated in the breast re- gion.

IscIDaucE

,roTaL

(1943), while only one ( ase was seen in another (1937). During the past ten )ears, however, the average has been almost six cases per year. ?I’his suggests that there has not been any notable increase recently.

P T O p O r t i O n to Cancer Of tile ~ e r M d e f i ? e U S t .

When compared with all primary breast can- cer (rrialc arid fernale), the incidence for the male has been less than 1 per cent at Memorial C(m ter.

Age. ‘1 he youngest patient in the series T V ~ S

24 years of age and the oldest 8.5. ?‘he average age of the group was 52.1 years, corresponding closely to hhguies reported in other series.

40 yrars Of age or youngcr (two patients were in their late twenties). T h e fact that male- breast (antvr does oc(ur in the earlier year3 5hOUld caution the physician against making a diagnosis of benign gynecomastia without first taking a biopsy.

Race. A11 but seven of the patients in the series were white. These y even were Negroes, an incidence of 4 per cent. ‘Two of the Kegroes were very light-colored mulattoes and wrere often described as white 011 the llospital let-

ords. No other races were encountered. Nationality and Religion. Ilata relating to

place of birth arid religious affiliation were lacking in forty-six cases. The remaining 100 cases were used for reporting purposes (Table

the total number; the American born, 2.3 per

I t should be noted that ten patients were -

Sunaber of Cuseb Yearly. An average of ap- proximately five cases of male-breast cancer were seen per year, but the number varied ( onsiderably fioin one year to another. ~ 1 5

many as twelve cases were seen in one year

From thc Breast Service, Mernoridl Center for Carirer and Allied Diseases, New York, Krw York.

of thc- Jarney Ewing Society, April 15, 1953. Presented at the Eighth Annual Cancer Symposium 1). The foreign born comprised $7 per cent of Rcccircd for publication, January 21, 1955.

1239

1240 Cancer hTovember-December 1955 VOl. 8

cent. ‘The over-all incidence for Jews was 42 per cent; for Catholics, 36 per cent.

The significance ol these figures is open to question, in view of the population trends in the New York City area, the tendency to report descent rather than nativity, and the evidence 01 increasing intermarriage among members ol various religious groups.

Occu&ution. A wide variety ol occupations were reported, none of which showed any apparent rela tionship to male breast cancer. ‘I‘wo physicians are included in the case re- ports.

Luterality. On admission, eighty-two pa- tients had cancer of the left breast; sixty-three, of the right breast. One patient presented bi- lateral iriflamrnatory breast canccr.

Three patients subsequently developed can- cer in the opposite breast. l ’he total incidence ol bilateral breast cancer was 2.7 per cent, thus approximating the incidence in females.

MULTIPLE PRIMARY CANCER

Ten patients had an associated primary can- cer arising in another anatomical site. The dis- tribution is shown in Table 2. Two skin can- cers were found in the group. Excluding these, the incidence of a significant second primary cancer was 5.4 per cent. The average age ol the group, however, was 59.7 years, which may account for this finding.

ETIOLOGY

Cancer of the male breast has been reported to develop during the course of estrogen ther- apy for advanced prostatic carcinoma.1 There are reasons for doubting this, at least in a causal sense. Only one patient in this series had cancer of the prostate, and this was diagnosed simultaneously with the breast cancer-no hormone therapy had been given. One patient received female-hormone therapy else- where after the diagnosis of breast cancer had been made, and one patient had been given six injections of testosterone for psoriasis prior to the appearance of an ulcerated nipple (interval not stated).

Approximately 12 per ccnt of the patients volunteered or responded with a history of trauma that raried widely, not only in type and frequency, but also in duration from onset ol breast symptoms (one day to forty-four years). It was impossible to establish any defi- nite correlation between trauma and the de-

TABLE 2 MULTIPLE PRIMARY CANCERS J N MALE

BREAST-CANCER PATIENTS __-__

Second primarv diamosed No. cases Prior to breast ca.

Kectosigmoid ca. Lymphosarcoma

Prostatic ca. Buccal mucosa ca. (metastases to node)

Rectal ca. Li~igual ca. Chronic lyniphatic leukemia Face, basal-cell ca.

Simultaneous with breast ca.

Subsequent to breast ca.

velopment of male-breast cancer by a review of the hospital records. I t is the authors’ opin- ion, based on the physical findings on admis- sion, that iii most cases the traumatic incident merely called attention to a pre-existing lesion.

There was no anamnestic evidence of a pre-existing gynecornastia in the entire series. Only one patient gave a history of antiluetic therapy and on admission his Kahn test was negative. ‘I‘wo patients had positive serological tests for syphilis.

A~~AMILIARY HISTORY

A review oP the histories yielded the follow- ing major symptoms, either alone or in com- bination: breast mass or swelling; serous or bloody discharge from the nipple; nipple re- traction, encrustation, or ulceration; axillary swelling; and local or distant pain. The more advanced the disease, the larger was the symp- tom complex.

The histories were also examined to elicit the first symptoni noted by the patient. In fourteen cases the type of onset was uncertain. In more than two thirds of the cases the first symptom noted by the patient was a mass in the breast and nothing more. Not one patient complained of pain as the solitary symptom. Pain was an insignificant initial complaint even when associated with nipple changes (two cases).

The initial symptom complexes (Table 3) indicated that a breast mass was noted in 105 of 132 cases. Nipple abnormalities occurred in thirty-three cases, with almost equal dis- tribution among discharging nipple (thirteen cases), retracted nipple (eleven cases), and en- crusted nipple (nine cases).

In only two patients, both unaware of a

No. 6 CANCER OF THE MALE BREAST Treves Q Holleb 1241

TABLE 3 INITIAL SYMPTOM IN 146 CASES OF CANCER

OF THE MALE BREAST Symptom No. cases

Breast mass only Breast mass plus

Retracted nipple Discharging nipple Discharging nipple, pain Encrusted nipple Encrusted nipple, pain

Nipple discharge only Nipple encrustation only Nipple retraction only Nipple encrustation, retraction Ulceration Axillary swelling Pain only Pain, breast mass

89 (67.4%)

7 4 1 3 1 8 5 4 0 7 3

i o F O

TOTAL Uncertain

132 1 14

TOT.4L 146

breast mass, was cancer detected during the course of a routine physical examination. The remainder of the patients had found a “lump” or “swelling” through self-examination.

Thirteen patients noted true nipple dis- charge not associated with ulceration as an initial finding. Nine others developed it sub- sequently. The discharge was most often bloody, although at times it was serous. A detailed report of the significance of nipple discharge in benign and malignant breast tumors has been prepared by Robbins, Treves, and Amoroso. It has become apparent that nipple discharge in the adult male frequently indicates an underlying cancer and warrants immediate and thorough investigation.

DURATION OF SYMPTOMS

Symptoms varied from two days to forty- four years in duration. In twenty-five cases the duration was uncertain. In the remaining 121 cases the median duration was nine months before the first medical consultation. Only 22 per cent of the patients sought treatment within three months of the onset of symptoms. Thirteen per cent related a duration of four or more years between the onset of symptoms and the time they sought medical advice. In one instance, a patient was observed by his brother, a physician, for two years before admission, at which time examination dis- closed a 3-cm. ulceration at the former site of the nipple and metastatic involvement of the axillary lymph nodes.

CLINICAL CLASSIFICATION

Each patient was assigned to a specific clin- ical category, based on the physical findings at the time of admission. Age was not considered a determining factor. This classification is, in general, similar to that used in classifying female breast-cancer patients at Memorial Center. ‘I’he requirements for grouping follow:

Primary Operable Breast Cancer 1. No previous surgical therapy. 2. Absence of findings listed in the inoper-

able category. Recurrent Operable Breast Cancer

1. Previous local excision of tumor or sub- total mastectomy.

2. Clinical evidence of recurrent disease limited to breast or homolateral axilla.

3. Absence of findings listed in the inoper- able category.

Prophylactic Breast Cancer 1. Previous radical or simple mastectomy. 2. No evidence of recurrent disease, local or

distant. Primarv Inoperable Breast Cancer

1. 2.

3. 4.

5.

6. 7.

No previous surgical therapy. Clinical evidence of metastases beyond the homolatera1 axilla (e.g., supraclavicu- lar, pulmonary, osseous, etc.). Inflammatory cancer. Fixation of the primary tumor to the chest wall. (The recent performance of chest-wall resection as a part of radical mastectomy, in certain instances of oper- able mammary cancer, may some day exclude this finding as a criterion of inoperabili ty.) Local extension or ulceration beyond the reasonable scope of surgical ablation. (Ulceration alone did not warrant a conclusion of inoperability. The small size of the male breast seems to result in ulceration earlier and more frequently than in the female.) Multiple satellite metastases. Ulceration or fixation of axiIlary metas- tases. (Lymph-node size per se was not a determining factor.)

Recurrent Inoperable Breast Cancer 1. Previous surgical therapy of any type. 2. Presence of findings listed in the inoper-

The distribution of cases according to clin-

able category.

ical classification is given in Table 4.

1242 Cancer Nooember-December 1955 Vol. 8

.1‘.4BLE 4 CLINICAL CLASSIFICATION AND GROUP

DISTRIBU’I‘ION I N CANCER OF THE MALE BREAST

No. % cases (approx.)

Inoperable Primary inoperable Recurrent inoperable

TOTAL Operable

Primary operable Operable after local excision Recurrent operable

TOTAL

TOTAL

Prophylactic

20 26 -

46

84 8 5

97 3 3

146

-

- --

14 18 -

32

58 5 3 -

66 2 2

100 _ -

PHYSICAL FINDINGS

Ino@erable Group. The physical findings in the primary inoperable and recurrent inoper- able groups included a wide range of clinical pictures varying from massive local disease to widcspread diswmination or a combination of both. The appearance of advanced mammary cancer is familiar to all, therefore no statistical evaluation was made in these groups.

Operable Group. Of greater interest weie the physical findings in the “earlier” group- the primary operable cases. These have been tabulated in an effort to encourage an attitude of suspicion on the part of the physician who makes the first examination. The T. arious com- binations of findings are listed in Table 5.

In only thirteen of the eighty-four primary operable cases was a mass present without an associated finding. This would suggest that few ol- the caws were as early as one might wish. The term “skin fixation” implies attach- ment oE the breast mass to the overlying skin but does not include frank ulceration. Ulcera- tion, when present, was almost always within the confines of the areolar margin and pre- sented as nipple destruction. Ulceration has been included, therefore, as a nipple abnor- mality. Encrustation implies a superficial scal- ing or eczematoid appearance of the nipple and/or the arcola. True nipple discharge (without ulceration) was discovered during the course of routine palpation. Undue pressure was not applied to the breast mass to elicit nipple discharge. Figures 1 to 14 show some of the more typical physical findings.

Table 6 is a further breakdown of the sig- nificant physical signs in the primary operable

TABLE 5 I’HVSICAL FINDINGS ON ADMISSION I N EIGHTY-FOUR PRIMARY OPERABLE CASES

OF CANCER OF THE MALE BREAST

No. cases

Breast mass only Breast mass plus

Nipple retraction Nipple retraction, skin fixation Nipple retraction, nipple discharge Nipple retraction, ulceration Nipple retraction, encrustation Nipple retraction, skin fixation, peai

d’orange Ulceration Skin fixation Nipple discharge Nipple discharge, skin fixation Encrustation Skin fixation, peau d’orange

Ulceration only

13

16 6 3 3 2

1 10 9 9 2 1 1 8

U

- TOTAL 84

Palpable axillary nodes (homolateral: 39 Normal axilla 45 _ -

group. A discrete mass was noted in 90.4 per cent of the cases and 72.6 per cent of the entire group showed nipple abnormalities of one type or another. If a mass in the adult male breast warrants suspicion of cancer, then cer- tainly the disclosure of a mass and nipple abnormality (51.1 per cent) should confirm that suspicion clinically, especialIy when nip- ple retraction is noted (36.9 per cent). Ulcera- tion, as a solitary finding, was present in only 9.5 per cent of the cases, jet 25 per cent o€ the primary operable group showed cancer invad- ing and ulcerating the overlying skin at the time of admission. Skin fixation without ul- ceration was present in 22.6 per cent and peau d’orangc in only 2.3 per cent.

The incidence of true nipple discharge (16.6 per cent) was surprising, in view of the vestigial nature of the male breast. Since some patients, in addition, gave a history of nipple discharge prior to ulceration or prior to the develop-

TABLE 6 PHYSICAL FINDINGS ON ADMISSION IN

OF THE MALE BREAST EIGHTY-FOUR OPERABLE CASES OF CANCER

No. cases % Palpable mass 76 90.4 Nipple abnormalities 61 72.6

Retraction 31 36.9 Ulceration 21 25.0 Discharge 14 16.6 Encrustation 3 3.5

Mass and nipple abnormality 43 51.1

Ulceration only 8 9.5 Skin fixation (without ulceration) 19 22.6

No. 6

ment of an inoperable situation, it is the authors' opinion that the importance of nipple discharge as a symptom or physical sign has been underrated in the diagnosis of male-

C;ANC~.R OF THE MALE BREAST - Treves dr Holler', 1243 breast carcinoma and should be considered as a possible early manifestation of the disease. Perhaps the wider use of cytological study ol breast secretions will confirm this opinion.

Figures 1 to 4. Nipplc retraction. FIG. 1. W. P., a 43-year-old white man, in 1946 had nipple retraction and a 4-cm. subareolar

mass: infiltrating duct carcinoma, with axillary node metastaws. He is alive cight years after radical mastectomy.

FIG. 2. G . F., a 79 year-old white man, in 1950 had nipple retraction, with bloody discharge and a 2-cm. maw infiltrating duct carcinoma, with axillary node metastases. He is alive with recurrent diseasc three years after radical mastectomy.

FIG. 3. A. K., a 57-year-old white man, in 1940 had nipple retraction and a 2-cm. mass in- filtrating duct caicinoma, with normal axillary nodes. He died of coronal) occlusion two years after radical mastectomy. There Has no recurrent disea.;e.

FIG. 4. F. M., a 45-year-old white man, in 1935 had nipple retraction and a 3-cm. mass. Aspira- tion biopsy rcvealed mammary carcinoma. He was treated elsewhere by ioentgen rays and died three years later of disseminated metastatic disease.

1244 Cancer November-December 1955

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

T h e smallest breast mass described was 4 to

5 mm. arid the largest, a sarcoma, was 12 cm. (Fig. 13). The median oC the maximum di- ameters was 3 cm. (ii one assumes estimated size, based on palpation, to be reasonably

Figures 5 to 9. Ulceration. FK. 5. T. P., a Glyear-old white man, in 1948 bad a completely destroyed nipple and a 4-cm.

mass: infiltrating duct carcinoma, with axillary node metastases. He died of metastatic disease four years after radical mastectomy.

FIG. 6. A. S., a 78-year-old white man, in 1952 had an eroded nipple and a 5-cm. mass: infiltrat- ing duct carcinoma, with axillary node metastases. He is alive with no recurrent disease two years after radical mastectomy.

FIG. 7. 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. He died of metastatic disease four years after radical mastectomy.

FIG. 8. I. S., a 74-year-old while man, in 1943 had a completely destroyed nipple and a 4-cm. mass: infiltrating duct carcinoma, with axillary node metastases. He died at the age of 80, six years after radical mastectomy.

No. (i CANCEK OF THF. MALE BREAST - Tre-oes & HoEleb 1245

T.413~72 7 PA4THOLOGICAL CLASSIFICATIOK I N

CANCER OF T H E MiILE BREAST

FIG. 9. P. D., a 64-year-old white man, in 1939 had a 5-cm. ulcer fixed to the chest wall: mammary carcinoma infiltrating the skin. He died ten months later of metastatic disease.

accurate). This was about the same average diameter as that of the male areola. However, the median siLe of the breast mass is misleading when considered in terms of early diagnosis, since some patients with a 3-cm. mass had complete destruction of the nipple and others showed ( linical evidence of axillary involve- ment. Fourteen patients in the primary in- operable group presented 3- to 5-cm. breast masses, yet showed evidence of supraclavicu- lar, pulmonary, or osseous dissemination.

PATHOLOGY

The primary breast cancers were classified histologically according to the method of Stew- art, who noted “the only pathological type [of cancer] seen in the lemale breast, but not encounteied up to the present in the male breast material in this hospital, is that diag- nosed as ‘lobular carcinoma,’ presumably be- cause the male breast does not possess lobules.” A rcview of the pathological reports in the 146 cases confirms this statement. However, in addition, there were no cases of malignant cystosarcoma phyllodes. The absence of this lesion may be related to the fact that a fibroade-

No. Cases

Papillary carcinoma-noninfiltrating 7 Infiltrating duct carcinoma 96

Paget’s disease of the nipple (2 cases) Inflammatory carcinoma ( 3 cases)

Infiltrating papillary carcinoma 5 Infiltrating mednllary carcinoma 2 hlyxoliposarcoma (low grade) 1 Giant- & spindle-cell sarcoma 1 “Carcinoma” or “mammary carcinoma” 3 4

TOTAL 146 -

noma 01 the male breast has not been encoun- tered at this institution. Only two cases showed components of colloid carcinoma.

Table 7 presents an analysis of the major pathological types. In thirty-four cases a report ok “mammary carcinoma” or simply “caxi- noma” was obtained without further definition. These included recurrent or primary inoper- able cases in which aspiration biopsy or small lormal biopsies were taken only for confirma- tion of a diagnosis of cancer. The remaining reports are based on breasts removed at Me- morial Center or elsewhere and histological interpretation of the architectural pattern. About 84 per cent of these showed infiltrating duct carcinoma, Grade I1 or 111. The re- mainder included a few cases of papillary car- cinoma (infiltrating or noninfiltrating), medul- lary carcinoma, and sarcoma. The two cases of Paget’s disease of the nipple, with under- lying infiltrating duct carcinoma, have been reported in detail previously.6 Two cases showed areas suggestive of so-called “sweat- gland carcinoma.”

Inflammatory carcinoma, a clinical-patholog- ical entity, was found as a primary manifesta- tion in two cases and as a recurrence in another. These have also been reported previously.5

The pathological findings in the four rases of bilateral breast cancer are listed in Table 8. No valid statistical conclusions can be drawn from such a small number of cases.

TABLE 8 PATHOLOGY IN FOUR CASES OF BILATERAL

CANCER OF THE MALE BREAST Left breast

__I_

Right breast

1. Infiltrating. duct ca. 2. Noninfiltrating papillary ca.

Noninfiltrating duct ca. Noninfiltrating papillary

3. Operated on elsewhere, no Infiltrating duct ca.

4. Infiltrating duct ca.-

submitted slide of radical mastectomy

inflammatory inflammatory Infiltrating duct ca.-

ca.

1246 Cancer November-December 1955 Vol. 8

The presence of nipple discharge did not always indicate a noninfiltrating intraductal papillary carcinoma, although this was true in approximately one third of the cases present- ing serous or bloody discharge from the nipple. In the remaining two thirds, the cancer was infiltrating and most often not papillary but rather the usual infiltrating duct carcinoma, Grade I1 or 111. Since the underlying pathology is so unpredictable, a thorough surgical in-

vestigation of the etiology of nipple discharge in the male becomes mandatory.

TYPES OF T'HERAPY

During the Twenties and the early Thirties some patients in the primary operable group received preoperative roentgen-ray or radium therapy directed to the breast lesion. In 1933 this policy was discontinued in favor of im-

Figures 10 to 14. Exuberant lesions. FIG. 10. H. S., a 64-year-old colored man, in 1940 had a 3-cm. mass attached to the nipple:

infiltrating duct carcinoma and comedocarcinoma, with normal axillary lymph nodes. He is alive and free of cancer thirteen years after radical mastectomy.

FIG. 11. I). L., a 75-year-old white man, in 1936 had a 3-cm., fungating, papillary tumor with an underlying 5-cm. mass. The axillary nodes 1s eie involved and there was roentgenological evidence of pulmonary metastases. Biopsy bhowed mainmary carcinoma. He died one year later.

FIC. 12. 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 four years after radical mastectomy.

FIG. 13. L. H., a 54-year-old white man, in 1935 had a 12-cm. firm mass withont skin fixation. low-wide myxoliposarcoma. He is alive seventeen years after simple mastectomy.

No. 6 CANCER OF THE MALE BREAST . Tlaves & Holleh 1247

bidity appears to be lessened, since sloughs of skin flaps and chronic granulating areas that require pinch grafts or long periods of time to heal by secondary intention may be avoided. These facts were learned from many of the earlier cases in which skin grafts were not used. It is admitted that no attempt is made in this report to evaluate skin grafting in terms of survival rates to confirm the theory that more radical extirpation means better end results.

The inoperable groups and the patients who subsequently developed metastatic disease were treated palliatively by roentgcn-ray therapy, castration, and female hormones, either alone or in combination.

END RESULTS

?liere were 120 patients with male-breast cancer admitted from 1924 to 1949 inclusive. Thcse patients make up the basis for calculat- ing the end results, since they had the oppor- tunity to survive, free of disease, for at least five years after admission.

UNSLLECTED END RESULTS

FIG. 14. F. L., a 57-year-old colored man, in 1949 had a 10-cm. mass: infiltrating duct carcinoma, associatcd with a separate primary carcinoma of the prostale. He was treatcd by radical mastectomy and orchiectomy and died eleven months later of disseminatcd metastatic disease.

mediate surgical intervention. Postoperative roentgen-ray therapy was given primarily to those patients in whom axillary lympli-node metastases were deinoiis trable microscopically.

Unless the patient's general medical status contraindicated major surgery, a radical mas- tectomy was usually performed when cancer was diagnosed. In exceptional instances very elderly patients were, of necessity, treated by wide local excision or by modified radical mas- tectomy, e.g., simple mastectomy and axillary dissection. I t is interesting to note that radical mastectomy under local anesthesia alone was performed during the early years of the series on three patients who were considered to be poor operative risks. Improved methods of general anesthesia have obviated the use of local anesthesia for the past twcnty years.

Skin grafting, at thc conclusion of radical mastectomy, has become almost routine in the therapy of male breast cancer. The use of a skin graft permits wider excision of the pri- mary tumor without the subconscious concern on the part of the surgeon over the approxima- tion of wound edges. The postoperative mor-

Eighty-five of the 120 cases were classified as F A I L U R ~ S for the following reasons: lost to fol- low-up, with or without cancer, within five years; died of other causes, with or without cancer, within five years; refused treatment; requested consultation only; died as a result of cancer or its treatment, within five years; living, with cancer, within five years; and inoperable. ?'hirty-five patients were known to survive five years or longer without evidcnce of cancer (29.1 per cent). This figure is obviously the lowest possible five-year survival one can con- clude statistically without bcing selective. It should be notcd that forty-six cases (38 per cent) of the entire series were failures automatically on admission because they were classified as inoperable.

SELECTED END RESULTS

In order to determine the effectiveness of treatment when there was a reasonable hope for cure, the operable cases were evaluated. Eighty-one cases were classified as primary op- erable, operablc after local excision, and re- current operable. Presumably, these patients had an opportunity for long-term survival, with benefit of appropriate therapy.

Using the same factors for FAILURES as those used in estimating the unselected end results, the five-year survival free of disease for the

1243 Cancer L~lo-i/emi,er-necember 1955 Vol. 8

TABLE 9 EIGHTY-ONE OPERABLE CASES OF CANCER

OF THE MALE BREAST No. cases

Indeterminate cases Refused treatment Lost track of without recurrence Died of other causes without recurre

TOTAL INDETERMINATE CASES Determinate cases Failures

Died of cancer or its treatment Living with cancer present Lost track of with cancer present

TOTAL FAILURES 5-year survivals free of disease

TOTAL DETERMINATE CASES

4 9

nce 7

20 -

26 1 0 -

27 34 (55.7%) - 61

entire operable group was 41.9 per cent, or thirty-four cases.

Further statistical breakdown of the oper- able group is presented in Table 9.

A survival rate of 55.7 per cent is the greatest one could claim if the determinate cases only are considered in the statistical evaluation. Of course, if one were to extend the selection fac- tor to include only those patients who received ideal therapy, the survival rate would probably be higher. The relatively small number of cases in the series does not warrant more de- tailed analysis. The five-year survival appar- ently lies somewhere between 41.9 per cent and 55.7 per cent for operable cases, depending upon the method of interpretation.

TABLE 10 PATHOLOGY AND SURVIVAL IN SIXTY-ONE

DETERMINATE CASES OF OPERABLE CANCER OF T H E MALE BREAST

Alive 5 yr., no evidence

No. of Fail- Pathology cases disease ures Injiltrating duct carcinoma

Normal axillary nodes Metastatic axillary nodes Undetermined axillary nodes

Normal axillary nodes Undetermined axillary nodes

Papillary carcinoma-injZtrating Normal axillary nodes

Sarcoma-nzyxoliposnrcoma Undetermined axillary nodes

Alammary carcinoma (see text) Undetermined axillary nodes

TOTAL

Papillary carcinoma- noninfiltrating

16 12 4 31 9 22 5 4 1

4 4 0 1 1 0

1 1 0

1 1 0

2 2 0

61 34 27 - - -

The survey also revealed that many pa- tients who survived the five-year postoperative period without recurrent or metastatic disease continued to do well for a long period of time. Of the thirty-four favorable results, more than one third of the patients (twelve cases) are now more than ten years since therapy and two of these are more than twenty years. The remainder were treated less than ten years ago. Although the critical period seems to be the first five years after treatment, one of the nineteen-year survivors developed supraclavic- ular metastases during his sixteenth postoper- ative year, and one of the twenty-year survivors developed carcinoma of the opposite breast during his eighteenth postoperative year.

Only one of the forty-six patients who were inoperable survived more than five years. He died of cancer eight years after admission and seven years alter bilateral orchiectomy had been performed. The majority of the patients in the inoperable group died within two years of admission in spite of specific therapy and supportive measures.

There was one postoperative death in the operable group. This 6 l-year-old patient, seen in 1930, did not tolerate gcneral anesthesia and had to be returned to the ward. Several days later, radical mastectomy was performed under local anesthesia. The postoperative course was complicated by massive atelectasis and the patient died on the ninth postopera- tile day.

SURVIVAL RELATED TO PATHOLOGICAL FINDINGS

The pathological findings in sixty-one de- terminate cases of the operable group are listed in Table 10. Although this is admittedly a small series, it is encouraging to note that all patients in the determinate group with a diag- nosis of papillary carcinoma survived five years or longer and that none had proved metastases to the axillary lymph nodes. One patient treated by simple mastectomy, hence without study of nodes for possible metastases, never developed evidence of recurrent or me- tastic disease.

The pattern of survival for males with in- filtrating duct carcinoma parallels that for females. When the axilla was not involved, 75 per cent (twelve cases) lived five years or longer; when the axilla contained lymph-node metastases, the rate of survival dropped to 50 per cent (nine cases).

Two cases were limited in histological in-

No. 6 CANCER OF THE MALE BREAST - Treves & HoZZeb 1249

terpretation. One patient was an 86-year-old man who was considered too feeble for major: breast surgery. A positive aspiration biopsy of the breast was secured and an orchiectomy done. The patient is now 94 years old and clinically free of disease. The second patient refused surgery and received roentgen-ray therapy only. He remained clinically lree of disease for eight years, only to die during the ninth year of disseminated metastatic disease.

SURVIVAL RELATED TO AGE

Table 1 1 records the data relating to age and survival in the sixty-one determinate cases of the operable group. The distribution oi cases is such that no definite statistical conclu- sions can be drawn. It is interesting to note that four of the six patients less than 40 years of age survived five years after surgery. This seems to disagree with the belief that patients with male breast cancer in the younger age group do poorly. The good prognosis holds true even when the cases of papillary carcinoma are excluded. Papillary carcinoma occurred in the following distribution: two cases in the 31- to 39-year age group; one case in the 40- to 49-year age group; and three cases in the 50- to 59-year age group.

Similarly good results were obtained in patients more than 70 years of age-seven out of eleven patients surviving five years. The number of cases within each group is too small to learn the significance, il any, ol the age factor.

Prognostication seems to be dependent more on the histological type of the cancer and the absence or presence 01 involved axillary lymph nodes than on the age of the patient.

CASTRATION AS A ‘THERAPEUTIC MEASURE

More than thirty patients with male-breast cancer in this series have had bilateral orchiec- tomy. The results in thirteen of the patients were reported in 1949.4 A detailed report on the therapeutic value of castration is in prep- aration.

Bilateral orchiectomy has been reserved primarily for the inoperable cases and for those patients who develop recurrent or meta- static cancer after surgical therapy. Castration and hormone therapy are not advocated as a substitute for the conventional radical mas- tectomy in cases of primary operable male breast cancer,

TABLE 11

MINATE CASES OF OPERABLE CANCER OF THE MALE BREAST

AGE AND SURVIVAL IN SIXTY-ONE DETER-

~

Alive 5 yr., no evidence of Fail-

Ane NO. disease ures

20-30 31-39 4 0 4 9 50-59 60-69 70-79 80-89

TOTAL

1 0 1 5 4 1

10 6 4 18 10 a 16 7 9 8 6 2 3 1 2

61 34 27 - - -

-

SUMMARY AND CONCLUSIONS

A statistical review of 146 histologically confirmed cases of cancer of the male breast is presented.

Cancer of the male breast accounts for less than 1 per cent of cancer of the breast in both sexes.

The average age in this series was 52.1 years; however, the range extended from 24 years to 85 years.

White patients made up 96 per cent of the group; the remainder were Negroes.

European-born Jews (predominantly Rus- sian) comprised 37 per cent of the series.

The Ieft breast was involved more fre- quently than the right. Bilateral breast cancer was found in 2.7 per cent of the cases.

An associated significant primary cancer of another anatomical site occurred in 5.4 per cent of the group.

No rclationship could be established be- tween the development of breast cancer and trauma or a pre-existing benign breast lesion.

In more than two thirds of the cases the first symptom noted by the patient was the presence of a breast mass and nothing more. True nipple discharge was a surprisingly frequent symptom and should be considered as an important early manifestation of breast cancer in the male.

The median duration of symptoms before the first medical consultation was sought was nine months. This would suggest that most male patients and many physicians are not aware of the significance of a breast mass or tend to minimize breast symptoms.

A clinical classification of male-breast cancer is formulated for purposes of statistical and therapeutic evaluation. Approximately two thirds of the patients seen were classified as

1250 Cancer November-December 1955 Vol. 8

operable and presented a reasonablc hope for complete cure.

The physical findings of cases in the primary operable group are tabulated in detail. It be- came apparent that the disclosure of a mass in the adult male breast warrants suspicion of a malignant tumor. When the mass is associated with a nipple abnormality, the diagnosis of cancer is almost assured. In either case im- mediate biopsy is indicated. Examples of the variations in the clinical appearance of can- cer in the niale breast are presented in the accompanying illustrations.

The great majority of the cases were rc- ported histologically as infiltrating duct car- cinoma. With the exception of lobular carci- noma and of cystosarcoma phyllodes, all of the pathological types found in the female breast were encountered in the male. Nipple discharge was more often associated with an infiltrating duct carcinoma than with a papil- lary carcinoma.

Radical mastectoniy was performed on all patients whose general medical status would permit major surgery. There was one post- operative death. No attempt was made to evaluate skin grafting in terms of survival rates. Castration was performed as a palliative measure on more than thirty patients in the series. The results of this procedure will be the subject of a future report.

The end results vary according to the method of computation. If one classifies as successful results only those patients who were known to be clinically free of cancer five years after treatment and if all others (inoperable, lost to follow-up, died of other causes, died of cancer, refused treatment, etc.) are classified as failures, the survival rate is 29.1 per cent, the lowest salvage rate one can calculate.

If only the operable c-ascj are considered and the Same failure factors are used, the five- year-survival rate is 41.9 per cent. When the “determinate” cases (see text) within the pri- mary operable group are evaluated, the five- year-survival rate rises to 55.7 per cent.

The number of patients who have survived ten years or more is too small to be statistically significant. Evidence does seem to indicate that the critical period is the first five years after therapy and that many patients will continue to do well once they have passed the five-year mark.

Almost all the patients in the inoperable category died within two years of admission to the hospital.

Papillary breast cancer in the ni* &t 1 e seems to offer an excellent prognosis. The six deter- minate patients with this diagnosis have sur- vived five years without recurrence and none had proved axillary metastases. The fivc-year- surkival pattcrri 01 the more common infiltrat- ing duct carcinoma parallels breast cancer in the female. When the homolateral axillary lymph nodes were invaded by cancer, the survival rate dropped LO 30 per cent as opposed to a survixal rate of 75 per cent when the tumor was confined to the breast. ‘This hiatus should lend added significance to early diag- nosis and prompt therapy.

The age of the patient does not seem to influence the end result in the operable group. The prognosis for all ages is more dependent on the histological type of the cancer and the prescnce or absence of metastases in the axil- lary lymph nodes.

A plea is made for less cursory examination of the male breast during routine physical examinations-with the hope of detecting can- cer in a stage most amenable to cure.

REFERENCES

1. MCCLURE, J. A., and HIGGINS, C. C.: Bilateral car- cinema Of the male breast after estrogen therapy. J . A . iM. A . 146: 7-9, 1951.

2. ROBBINS, G.; TREVES, N., and AMOROSO, W.: To be published.

3. STEWART, F. W.: Tumors of the breast, Atlas of Tumor Pathology, Sect. IX, Fax. 34. Washington, D.C.,

Armed Forces Institute of Pathology, 1950.

in cancer of the male breast. Cancer 2: 191-222, 1949.

in the male patient. Surgery 34: 810-820, 1953.

report on two cases. Cancer 7: 325-330, 1954.

4. TREV~S, N.: Castration as a therapeutic measure

5 . TREVES, N.: Inflammatory carcinoma of the breast

6. TRE)LS, N.: Paget’s disease of the male mamma; a