(1)
Research Oncology, Guy’s Hospital, London, United Kingdom
Abstract
Most males with breast cancer have been treated by mastectomy irrespective of the psychological impact of changed body image. Nowadays selected cases can be treated by breast conserving surgery (BCS), that is, nipple conserving surgery for MBC. In the absence of controlled randomised trials, large databases such as SEER have been analysed and results suggest similar cancer specific survival in males treated with lumpectomy and radiotherapy compared with mastectomy. In another study there was reduced morbidity after BCS in terms of lymphoedema or shoulder movement limitation but with no difference detected in disease-free and overall survival. Sentinel node biopsy using dye and/or isotope has been shown to achieve comparable identification rates in MBC compared with FBC and this will serve to reduce subsequent lymphoedema risk. Reconstruction using skin flaps can be useful to obtain skin closure after mastectomy for extensive chest wall disease. Transverse rectus abdominis (TRAM) flaps are useful because they not only replace the skin and fat but also provide hair-bearing cover similar to the male breast skin. Ductal carcinoma in situ (DCIS) comprises up to 10% of MBC usually presenting as a lump or nipple discharge. Nipple preserving surgery is a valid option for selected cases of male DCIS, provided that tumour-free margins can be achieved and this should be followed by breast irradiation.
I am in this earthly world where to do harm is often laudable – to do good sometimes accounted dangerous folly. William Shakespeare
Surgical management of MBC, like other treatment modalities, has been largely copied from results of large studies of FBC. Since the 1980s, FBC has whenever possible been treated with breast conserving therapy with a shift from axillary clearance for all cases of invasive disease to selective clearance after either pre-operative confirmation of cytological/histological involvement or following sentinel node positivity. For those individuals needing mastectomy because of extent of disease or recurrence after breast-conserving therapy, breast reconstruction is being considered for most cases. Treatment of MBC is taking a considerable time to catch up with the advances that have been made in women with breast cancer. Bedevilling the available results is the lack of randomised controlled trials because of the, until recently, minimal cooperation between groups in investigating this rare disease.
Mastectomy and Breast Conserving Surgery
Mastectomy has been the standard offer to males with operable breast cancer with scant regard for the psychological impact of change in body image. There has been a gradual emergence of breast conserving, that is, nipple conserving surgery for MBC. In 1973, 257 Danish MBC cases diagnosed between 1943 and 1972 were reported, with the majority, 197 (78%) having operable disease [1]. Of these only 15 (8%) had local excision (Table 8.1). Radiotherapy was administered to 77% but was sole primary treatment in six cases. Between 1942 and 1871 there were 200 MBC treated at the Christie Hospital Manchester [2]. Of these 159 had local treatment 76 stage I, 38 stage II and 45 stage III. Radiotherapy alone was used in five patients with stage I disease because of comorbidity contraindicating general anaesthesia.
In a remarkable collaboration between 11 cancer centres taking part in the International Patient Data Exchange System a cohort of 335 MBC was assembled [3]. Of these 308 had operable disease and being slightly more recent there was a drift from radical surgery and breast conserving surgery was used in 30 (10%). Goss reported 229 Canadian cases, of whom 168 were treated by radical or simple mastectomy and 20 had a local excision combined with axillary clearance in 8 (3.5% of total) [4].
Golshan et al. reported seven cases of MBC in whom lumpectomy alone was used to extirpate the primary tumour [6]. Average age at diagnosis was 61 years (range 38–86). The mean tumour size was 1.7 cm (T1 5, T2 1, Tis 1). Of the six invasive cancers all were ER+ve and interestingly, two (33%) proved to be HER2+ve. All received adjuvant tamoxifen and radiotherapy with three receiving adjuvant chemotherapy. After a median follow-up of 67 months there had been no recurrences.
Lanitis et al. described a 50 year-old male with a 1 cm cancer at 6 o’clock to the left nipple who refused any operation to remove the nipple [7]. He was treated by wide excision, sentinel node biopsy and axillary clearance. Histology showed a 7 mm grade II ductal cancer with associated intermediate grade DCIS, completely excised, with 1/9 axillary nodes involved. He received 4 cycles of adjuvant chemotherapy (adriamycin and cyclophosphamide) followed by chest wall irradiation then tamoxifen for 5 years subsequently switching to letrozole. There had been no evidence of recurrence 8 years after surgery. Subsequently Niikura et al. reported a case of non-invasive intracystic carcinoma in a 70 year old man, treated by excision, negative sentinel node biopsy and post-operative radiotherapy [8]. This achieved a very good cosmetic result with no reported recurrence.
The largest series consisted of 489 French cases diagnosed between 1990 and 2005 but even with this relatively recent cohort only 42 (8.6%) had breast conserving surgery [5]. Nevertheless the importance of the axillary nodal status was becoming better appreciated and axillary surgery was performed in 469 (96%). The procedure was a clearance in 436 (90%), sentinel node biopsy in 33 (7%) with completion axillary clearance in 24 (5%).
There were 22 new MBC cases treated at Stanford University Medical Center between 1960 and 2011 and 14 (64%) were treated by radical or modified radical mastectomy, 4 (18%) by simple mastectomy and 4 (18%) with breast conserving surgery [9]. Some form of axillary surgery was performed for 21 (95%).
Cloyd et al. analysed the Surveillance, Epidemiology and End Results (SEER) of MBC patients treated between 1983 and 2009 [10]. Of 5425 males 4707 (87%) were treated by mastectomy and 718 (13%) underwent lumpectomy. Lumpectomy became used more frequently with time: 11% between 1983–1986 increasing to 15% in 2007–2009. No lymph node sampling was performed in 34% and only 35% had adjuvant radiotherapy after lumpectomy. Ten-year breast cancer-specific survival was 83% in lumpectomy patients and 77% in those treated by mastectomy patients. There was no independent association of lumpectomy with worse breast cancer-specific survival.
In a partially overlapping study, 2013 Fields et al. reported a stage specific analysis of surgical management of MBC in the USA, using the SEER database of 4276 cases diagnosed between 1973 and 2008 [11]. Most cases were treated by mastectomy with breast conserving surgery being used in only10%. For those with localised disease, there was similar cancer specific survival in males treated with lumpectomy and radiotherapy compared with mastectomy (hazard ratio 1.33; 95% CI 0.49–3.61; P = 0.57).
Fogh et al. reported a series of 42 MBC cases treated at Massachusetts General Hospital or Boston Medical Center between 1990 and 2003 [12]. Surgery comprised modified radical mastectomy (MRM) in 30, simple mastectomy (SM) in 4 and breast conserving surgery (BCS) in 8 (19%). Musculoskeletal function including tissue fibrosis, arm oedema, and range of shoulder movement were assessed by a multidisciplinary group. Results are summarized in Table 8.2 which shows the reduced morbidity after BCS with no lymphoedema or limitation of shoulder movement. There was no difference detected between the three procedures in terms of disease-free and overall survival.
Procedure | Fibrosis | Lymphoedema | Shoulder restriction |
|---|---|---|---|
MRM (n = 30) | 4 (13%) | 7 (23%) | 8 (27%) |
TM (n = 4) | 2 (25%) | 0 | 2 (50%) |
BCS (n = 8) | 1 (13%) | 0 | 0 |
Zaenger et al. conducted another analysis of the SEER database focusing on the 1777 males with stage I/II, T1/2, node negative disease, treated between 1998 and 2011 [13]. The majority were treated by radical or simple mastectomy, with or without post-operative radiotherapy. As is shown in Table 8.3, only 296 (17%) were treated by breast conserving surgery with post-operative radiotherapy being given to 135 (46%). Early results showed no deaths in those treated by mastectomy or BCS when post-operative radiotherapy was given. There was no difference in survival and no deaths in those with stage I or stage II disease who were treated by BCS and radiotherapy. This needs to be interpreted with caution because of the relatively short duration of follow-up.
Local treatment | Stage I disease | Stage II disease | ||
|---|---|---|---|---|
N | 5 year survival | N | % 5 year survival | |
MRM | 490 | 97% | 275 | 91% |
MRM + RT | 33 | 100% | 42 | 94% |
SM | 399 | 97% | 198 | 91% |
SM + RT | 23 | 100% | 21 | 73% |
BCS | 117 | 96% | 44 | 92% |
BCS + RT | 103 | 100% | 32 | 100% |
MRM alone had an actuarial 5-year CSS of 97.3% for stage I and 91.2% for stage II patients. No deaths were recorded in the BCT group, regardless of stage, or in the three stage I surgical groups if the men received RT, with an actuarial 5-year CSS of 100% in each BCT group.
Sentinel Node Biopsy
Over a 3 year period ending November 2009, 16 MBC cases underwent sentinel node biopsy (SNB) at the Memorial Sloan-Kettering Cancer Center (MSKCC), using both dye (isosulfan blue) and radioisotope (Tc-99m unfiltered sulphur colloid) [14]. The sentinel node was correctly identified in 15 (94%) being hot and blue in 14, and blue only in 1 case. There was nodal positivity in 5 (33%), (2 on frozen section and 3 on deeper sectioning or immunohistochemistry). Results of this and other series are shown in Table 8.4 [14–22]. The MSKCC experience was updated by Flynn et al. when a 97% identification rate was achieved in 77 SNB procedures [21].
Table 8.4
Results of sentinel node biopsy in MBC
Author | N | Technique | Identification | Node positive |
|---|---|---|---|---|
Port 2001 [14] | 16 | IB & Tc | 94% | 33% |
Cimmino 2002 [15] | 6 | IB & Tc | 100% | 50% |
Albo 2003 [16] | 7 | IB & Tc | 100% | 14% |
De Cicco 2004 [17] | 18 | Tc | 100% | 33% |
Boughey 2006 [18] | 30 | IB & Tc | 100% | 37% |
Rusby 2006 [19] | 31 | IB/Tc 16 IB 5 Tc 10 | 90% | 55% |
Gentilini 2007 [20] | 32 | Tc | 100% | 19% |
Flynn 2008 [21] | 78 | IB & Tc | 97% | 49% |
Maraz 2014 [22] | 25 | IB & Tc | 100% | 48% |
The University of Michigan Comprehensive Cancer Center reported 6 SNBs performed for MBC with a 100% identification rate. In a first report from the MD Anderson Cancer Center of 7 cases SNB was identified in every one [16] and this was maintained in a follow-up report of 30 SNBs [18]. The European Institute of Oncology also reported 100% identification rates in 2004 [17] and 2006 [20]. In a Hungarian study conducted at Bács-Kiskun County Teaching Hospital SNB was performed with both dye and isotope successfully in all 16 cases [22]. After a median follow-up of 48 months, there had been no axillary recurrence after SNB.
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