Surg Today (2011) 41:837–840DOI 10.1007/s00595-010-4366-1Case ReportSentinel Lymph Node Biopsy in Patients with Male Breast Carcinoma:Report of Two CasesMASAHIRO KITADA, KEISUKE OZAWA, KAZUHIRO SATO, SATOSHI HAYASHI, and TADAHIRO SASAJIMADepartment of Surgery, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, JapanAbstract gies similar to those used for female breast cancer typi-The incidence of male breast cancer is low, and treat- cally provide successful effects and similar toxicity toment strategies similar to those used for female breast that observed in women. In addition, lymph node dis-cancer patients are frequently used for male patients. section and SLNB have been reported in some preop-However, the safety and utility of sentinel lymph node erative N0 patients. In our hospital, among the 1230biopsies (SLNBs) for male breast cancer have not been surgeries performed for breast cancer between Januaryproven. Among the ﬁve cases of male breast cancer who 2000 and December 2009, ﬁve (0.41%) were male breastreceived surgery at our hospital, mastectomy with SLNB cancer patients. This paper reviews the surgical proce-was performed in two of the cases. The ﬁrst patient was dure selected for these ﬁve patients, as well as their77 years old and the second was 74 years old, and both breast tumor tissue type and their histopathologicalpresented as outpatients with chief complaints of a diagnosis. We also report the details for two patientsmammary mass. Clinical diagnoses were T1N0 in both who received SLNB, both of whom were found tocases, and mastectomies with SLNB were performed. be lymph node negative during the preoperativeThe sentinel lymph node was identiﬁed using the dye diagnosis.method. Postoperatively, the patients were hormonereceptor-positive, and they are now being followedwhile continuing to take oral tamoxifen. Case ReportsKey words Male breast cancer · Sentinel lymph nodebiopsy Male Breast Cancer Surgical Cases The mean age of male breast cancer patients was higher (74.1 years) than for females (51.4 years) with breast cancer. One patient showed intracystic papillary carci-Introduction noma. In all cases, masses were palpable and identiﬁed on ultrasonography. The cytology was class 3 in theRecently the number of cases of breast cancer has patient with intracystic papillary carcinoma and class 5increased, but clinical advances in the treatment of in the other four patients. In the patient with class 3breast cancer have also been made, including improved disease, an excisional biopsy of the mass was performedbreast conservation rates and increased use of sentinel for deﬁnitive diagnosis. All ﬁve patients underwent alymph node biopsy (SLNB), molecular targeted therapy, mastectomy, and SLNB was performed in two casesand preoperative chemotherapy (primary systemic (cases 3 and 4).therapy). Conversely, male breast cancer is a rare disor- The tissue type was found to be intracystic papillaryder, accounting for <1% of all breast cancers, making it carcinoma in one patient, papillotubular carcinomadifﬁcult to conduct large-scale clinical trials or establish in one patient, and solid-tubular carcinoma in threean optimal standard of care. However, treatment strate- patients. Patient 1 (who had intracystic papillary carci- noma) had stage TisN0 disease, Patient 2 was classiﬁed as having T4bN1, patient 5 as having T2N1, and patientsReprint requests to: M. Kitada 3 and 4 were classiﬁed as having T1N0 disease. PatientsReceived: April 5, 2010 / Accepted: June 30, 2010 3 and 4 underwent SLNB. All ﬁve patients were hormone
838 M. Kitada et al.: SLNB in Patients with Male Breast CarcinomaTable 1. Cases of male breast cancerCase Age (years) Pathology Surgery Stage T N Grade ER PgR HER21 65 Papi-tub Bt+Ax 1 1 — 1 1+ 2+ 3+2 81 Solid-tub Bt+Ax 3b 4b 1 3 2+ 1+ —3 77 Papi-tub Bt+SN 1 1 — 1 2+ 3+ —4 74 Solid-tub Bt+SN 1 1 — 2 3+ 2+ 2+5 78 Solid-tub Bt+Ax 3b 4b 1 3 3+ — 2+Papi-tub, papillotubular carcinoma; solid-tub, solid tubular carcinoma; Bt, breast resection; Ax, dissection of axillary lymph node; SN, sentinelnode sampling resection; ER, estrogen receptor; PgR, progesterone receptor; HER2, human epidermal growth factor receptor 2receptor-positive, and all received oral tamoxifen aspostoperative chemotherapy. One patient died 4 years3 months after surgery due to another disease. Theremaining patients have survived without recurrence(Table 1).Cases of Patients Who Underwent SLNBCase 1: 77-Year-Old ManIn early June of 2009, the patient noticed a mammarymass and was evaluated in the outpatient breast clinic.Fine-needle aspiration cytology revealed class V disease.The patient was being followed for Hunt’s syndrome. Hisheight was 174 cm and his weight 64 kg. Breast examina-tion of the right E area showed a 1.5 × 1.8-cm elastic-hard, awell-deﬁned, somewhat poorly mobile mass. No axillarylymph nodes were palpable. Ultrasonography showed alobulated solid mass in the right breast. The interior washypoechoic, the margins were partially irregular andindistinct, posterior echoes were enhanced, halo(+), andthe patient was given a diagnosis of category 4 disease(Fig. 1a). Computed tomography revealed a mass in theright breast, but no enlargement of axillary or cervicallymph nodes (Fig. 1b). In addition, no evidence of distantmetastasis was seen. The patient was diagnosed as havingstage T1N0M0 disease, and a mastectomy with SLNB(using the dye method with measurement of indocyaninegreen [ICG] ﬂuorescence) was performed. On intraop-erative rapid pathologic diagnosis, the sentinel node (SN) bshowed no metastases (2/0), and therefore we carried outa sampling resection around the SN while an axillary Fig. 1. a Ultrasonography showed a solid mass in the rightlymph node dissection was omitted. The patient’s breast. b Chest computed tomography revealed a mass in the right breasthistopathological diagnosis was p-stage (T1cN0(sentinelnode(0/2), level I (0/1)M0), papillotubular carcinoma,Grade I, ly(−) v(−), 1.4 cm, n(−), ER(2+), PgR(3+),HER2(−). Postoperatively, the patient has been treatedwith oral tamoxifen. As of the time of writing, no signs of Fine-needle aspiration cytology revealed class V disease.recurrence have been identiﬁed. During this same period, in February 2009, the patient underwent a total gastrectomy for gastric cancer (p-stageCase 2: 74-Year-Old Man I). The patient’s height was 165 cm and weight 72 kg.Starting in February of 2009, the patient noticed a lump Breast examination of the BD area below the nipplebelow the left nipple that gradually increased in size. showed a 2.5 × 3.0-cm elastic-hard, well-deﬁned, poorlyHe was evaluated at our hospital in June of 2009. mobile mass. No enlarged axillary lymph nodes were
M. Kitada et al.: SLNB in Patients with Male Breast Carcinoma 839 Discussion The overall number of breast cancer cases is increasing, but male breast cancer remains rare, accounting for <1% of all breast cancers.1 In our case experience over the last 10 years, the incidence has only been 0.41%. Causes of male breast cancer include Klinefelter’s syn- drome, gynecomastia, trauma, and effects of irradiation, but no speciﬁc etiology was apparent in any of our patients. In terms of past medical history, one patient had multiple cancers of the stomach. All patients had noticed the masses themselves and were diagnosed within 6 months. With regard to diagnosis, the masses were readily detectable on ultrasonography. Foura patients had solid masses with class 5 cytology. One patient with intracystic papillary carcinoma had class 3 cytology, so an excisional biopsy was performed. In male breast cancer surgery, because males have little breast tissue, breast-conservation surgery is of little signiﬁcance. A mastectomy is performed in most cases, but few established reports have described minimal axillary dissection. In early-stage N0 breast cancer in women, SLNB is already used as standard care in many medical centers. The safety and usefulness of SLNB has also been reported for male patients.2–4 In addition, although few data are available, the American Society of Clinical Oncology guidelines recommend that SLNB be performed the same as in female breast cancer.5 We currently use dye injection of ICG with subsequent measurement of ﬂuorescence to differenti-b ate malignant from normal lymph nodes. For intraop- erative rapid pathological diagnosis, the SNs are sliced Fig. 2. a Ultrasonography showed a solid mass in the left at 2-mm intervals and stained with hematoxylin and breast. b Chest computed tomography revealed a mass in the eosin. We performed the same procedure in our two left breast male breast cancer patients. The SNs were identiﬁed, and no false negatives were observed. The postoperative course of treatment for male evident. Ultrasonography showed an isoechoic mass patients is also the same as in female breast cancer.6 with a solid interior. The margins were generally well Hormone receptor positivity tends to be higher than in deﬁned, with some partial irregularity (Fig. 2a). Com- women, and tamoxifen is the mainstay of treatment.7 puted tomography revealed a mass in the left breast, but However, hormone-sensitivity patterns in male breast no enlargement of axillary or cervical lymph nodes cancer are thought to be similar to postmenopausal (Fig. 2b). No metastases to other organs were identiﬁed. breast cancer, and because aromatase activity in male Stage T2N0M0 disease was diagnosed, and a mastec- breast cancer tissue is higher than in females, it is not tomy with SLNB was performed. Intraoperative patho- surprising that aromatase inhibitors have been shown to logical diagnosis showed no lymph node metastases, and be effective against male breast cancer.8,9 Although the therefore we performed a sampling resection around number of cases seen at our institution was small, and no the SN, and an axillary lymph node dissection was results have yet been achieved that will lead to standard- omitted. The patient’s histopathological diagnosis was ized treatment, the use of SLNB should continue to be stage I (T1cN0(sentinel node(0/2), level I (0/3))M0), investigated in the future, including for recurrent cases. solid-tubular carcinoma, grade II, 1.7 cm, ly(+), v(−), ER(3+), PgR(2+), HER2(2+), n0(0/2). His postopera- References tive course was satisfactory, and tamoxifen was admin- istered orally. No signs of recurrence have been seen to 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer date. statistics. CA Cancer J Clin 2007;57:43–66.
840 M. Kitada et al.: SLNB in Patients with Male Breast Carcinoma2. Cimmino VM, Degnim AC, Sabel MS, Diehl KM, Newman LA, 6. Anderson WF, Althuis MD, Brinton LA, Devesa SS. Is male breast Chang AE. Efﬁcacy of sentinel lymph node biopsy in male breast cancer similar or different than female breast cancer? Breast cancer. J Surg Oncol 2004;86:74–7. Cancer Res Treat 2004;83:77–86.3. Boughie JC, Bedrosian I, Meric-Bernstam F, Ross MI, Kuerer HM, 7. Friedman MA, Hoffman PG, Dandolos EM, Lagios MD, Johnston Akins JS, et al. Comparative analysis of sentinel lymph node opera- WH, Siiteri PK. Estrogen receptors in male breast cancer: clinical tion in male and female breast cancer patients. J Am Coll Surg and pathologic correlations. Cancer 1981;47:134–7. 2006;203:474–80. 8. Zabolotny BP, Zalai CV, Meterissian SH. Successful use of letrozale4. Flynn LW, Park J, Patil SM, Cody HS III, Port ER. Sentinel lymph in male breast cancer; a case report and review of hormonal therapy node biopsy is successful and accurate in male breast carcinoma. J for male breast cancer. J Surg Oncol 2005;90:26–30. Am Coll Surg 2008;206:616–21. 9. Giordano SH, Valero V, Buzdar AU, Hortobagyi GN. Efﬁcacy of5. Lyman GH, Builiano AE, Somerﬁeld MR, Clarke-Pearson D, anastrozole in male breast cancer. Am J Clin Oncol 2002;25: Flowers C, Jahanzeb M, et al. American Society of Clinical Oncol- 235–7. ogy guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005;23:7703–20.