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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 128-131

An overview of male breast cancer in North East India: A hospital-based study


1 Department of Pathology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Hospital Cancer Registry, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Gynecologic Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Nizara Baishya
Department of Hospital Based Cancer Registry, Dr. B Borooah Cancer Institute, Guwahati - 781 016, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_8_19

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  Abstract 


Background: Breast cancer in males is a rare disease and accounts for <1% of all cancers in men. The objective of this study was to analyze the incidence and clinicopathological behavior of male breast cancer (MBC) at a tertiary cancer center of North East India.
Patients and Methods: The medical records of 60 histologically confirmed that MBC was retrospectively reviewed for the period from January 2010 to December 2015.
Result: MBC accounted for 1.9% of the total breast cancer cases. The median age of presentation was 50 years. Left and right breast were almost equally affected (51.6% vs 48.4%). Central quadrant involvement was found in 19 (31.7%) patients followed by 15 (25%), 11 (18.3%), 8 (13.3%), and 7 (11.7%) in upper outer, lower outer, lower inner, and upper inner quadrants, respectively. Most of the patients presented in advanced stage. About 80% (48) patients had nodal metastasis and 18.3% had distant metastasis at presentation. Hormone receptor and human epidermal growth factor receptor 2 (HER2)/neu was found to be positive in 53.3% and 15%, respectively. Triple negative breast cancer constituted 18.3% of cases.
Conclusion: MBC is seen at a relatively younger age in our subset of population. Late presentation with advanced disease is a common feature in our population. Feasibility of clinical trials was limited because of the rarity of the disease. But for better understanding of the clinical spectrum of this rare disease comprehensive, multi-institutional collaborative studies are warranted.

Keywords: Breast, cancer, hormone receptors, male, north east


How to cite this article:
Sharma JD, Baishya N, Kataki AC, Kalita CR. An overview of male breast cancer in North East India: A hospital-based study. Arch Int Surg 2018;8:128-31

How to cite this URL:
Sharma JD, Baishya N, Kataki AC, Kalita CR. An overview of male breast cancer in North East India: A hospital-based study. Arch Int Surg [serial online] 2018 [cited 2019 Oct 20];8:128-31. Available from: http://www.archintsurg.org/text.asp?2018/8/3/128/268130




  Introduction Top


Male breast cancer (MBC) is a rare disease, accounting for 1% of all breast cancers and 0.5% of all malignancies in men.[1] The incidence of MBC has been considered as stable for long time. But it has been observed that over the past 25 years, the incidence of MBC has increased by 26%.[2] The incidence is higher in North America and Europe in comparison to the other Asian countries.[3] MBC is common in the elderly males in the sixth to seventh decade of life. The mean age of presentation is 67 years, which is approximately 5–10 years older than that in females. Family history of first-degree relatives, single marital status, previous benign disease of the breast, and history of previous chest wall irradiation are the potential risk factors that have been attributed to MBC. Smoking, alcohol consumption, obesity, hormonal therapy, and liver disease causing hyperestrogenism, and gynecomastia have been implicated as additional possible risk factors. Because of the paucity of breast tissue in males and poor level of awareness, breast cancer in males often presents at an advanced stage as compared with that in females. Due to the rarity of this disease, epidemiological studies regarding MBC are very few in our country.


  Patients and Methods Top


This is a retrospective study conducted at Dr. B. Borooah Cancer Institute for the period from January 2010 to December 2015. In total, 4,064 patients with breast cancer were registered during a period of 6 years (January 2010 to December 2015). About 73 cases of MBC were diagnosed over this 6-year period. Only histologically confirmed cases of MBC were included in this study. Patients having synchronous primary tumors and those treated previously were excluded from the study. Finally, 60 patients of MBC having the details of the clinical and pathological parameters were included in the study. Patients were considered HER2-positive if they had immunohistochemistry (IHC) 3++. Triple negative breast cancer was defined as negative for estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal receptors (HER2/neu), if the IHC score is 0 or 1+ or FISH is nonamplified. Clinicopathological parameters and hormonal status were evaluated in this study. The study was approved by the Institutional Review Board.


  Results Top


MBC accounted for 1.9% of the total breast cancer cases in our series. The age of presentation ranged from 25 to 75 years with a median age of 50 years. About 83.3% (50) patients were from the rural habitat. About 40% of the patients presented with a hard palpable mass. Left and right breast were almost equally affected (51.6% vs 48.4%). Central quadrant of the breast was found to be involved in 19 (31.7%) patients followed by the upper outer quadrant in 15 (25%) patients. Most of the patients presented in advanced stage (III and IV). Overall, 2 patients presented in stage I, 14 in stage II, 33 in stage III, whereas 11 patients presented in stage IV with distant metastasis. About 80% (48) patients had axillary node metastasis and 18.3% (11 patients) had distant metastasis at presentation [Table 1]. Out of the 11 patients presenting with distant metastasis, 8 had bony metastasis and 3 had visceral metastasis. Invasive duct carcinoma (IDC) was the common histological variant observed in almost all of our patients (100%). ER/PR hormone receptors (HRs) were positive in 32 patients (53.3%). HER-2/neu status was positive in 9 (15%) patients on IHC. ER, PR, and HER2/neu positivity rates were 63.3%, 55%, and 15%, respectively. ER positive but PR negative was observed in 6 (10%) patients, whereas ER negative but PR positive and both ER/PR negative were observed in 1.7% and 35% patients, respectively [Table 2]. HER-2/neu status was positive in 9 (15%) patients on IHC. However, borderline positivity and negative status of HER-2/neu was observed in 36.7% and 48.3%, respectively. Triple-negative MBC constituted 18.3% (11); however, 3 (5%) patients had triple-positive MBC. About 49 patients underwent surgery in the form of modified radical mastectomy along with axillary nodal clearance (levels I, II, and III). Adjuvant therapy, such as chemotherapy, radiotherapy, and hormone therapy (HT), was instituted depending on the postoperative histopathology report and HR positivity status. Since most of the patients in our series presented in a more advanced stage at diagnosis, so postmastectomy irradiation is being considered in all the cases in view of the advance stage at presentation. Moreover, sentinel node biopsies were performed for clinically negative axillary nodes in the present series. HT was used as an adjuvant postmastectomy and as neoadjuvant in metastatic MBC. Medical therapy was used post operatively depending on the prognostic factors. Ki-67 was used as a prognostic marker for HR and HER 2.
Table 1: Clinical and demographic characteristics of male breast cancer patients

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Table 2: Histopathological characteristics of male breast cancer patients

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  Discussion Top


Male breast cancer (MBC) is a rare cancer worldwide accounting for only 1% of all breast cancers. The incidence of MBC in our series is 1.8%, which is slightly higher than the world-wide incidence. However, the studies of MBC available from India have variably reported the incidence. An incidence rate of 0.4% MBC of all breast cancer has been reported by Chikaraddi et al. Moreover, Rai et al. from north India reported an incidence of 0.5%; further a relatively high incidence of 4.1% had been reported by Shah Pet al. from Kashmir.[4],[5],[6] MBC is usually seen in the elderly population between sixt and seventh decade. The median age at presentation in our study was 50 years (25–75), which is almost a decade earlier than what is being reported in the west and other Indian studies.[4],[5],[6],[7] In our series, the maximum number of cases was seen in the age group below 40 years, i.e., 17 patients (28.3%).

A family history of breast cancer confers a relative risk of 2.5. About 20% of men with breast cancer have a positive family history, which is similar to the pattern observed in female breast cancer.[4] However, in our series none of our patients had a positive family history. Palpable mass in the central retroareolar region is the most common presenting symptom in our series, which is consistent with the study by Sundriyal et al.[8] Left breast was commonly in our study which is in contrast to the study by Sundriyal et al.[8] Central quadrant was frequently involved in our series, which is consistent with the other previous studies.[4]

IDC was the most common histological variant observed in our series which was similar to the study by Sundriyal et al.[8] Lobular carcinoma was thought previously that it does not occur in men due to lack of lobular differentiation, but few cases has been reported in literature.[9] Most of the studies in Indian context had shown that most of the patients presented in stage III disease. This is consistent in our series as well which accounts for 33 patients (55%) in stage III. However, in a recent study by Ram et al. the predominant stage at presentation was found to be stage II, which may be due to the raising awareness among the population in the metro cities.[10]

MBC were more likely to have axillary lymph node positivity as stated by Chikaraddi et al.[4] About 80% of the patients in our series had axillary lymph node metastasis. The prognosis of MBC depends upon tumor size, histological grade, nodal status, and HR status.[11]

ER, PR, and HER2/neu are IHC markers of prognosis as well as predictors of response to therapy. At present also, determining ER, PR, and HER2/neu receptor status in breast cancer have become common practice as there is a survival advantage for patients with HR-positive status by treatment with adjuvant hormonal or chemotherapeutic regimens. Patients with ER PR–positive tumors have a better prognosis than patients with ER PR–negative tumors.[12] MBCs have high rate of HR expression compared with FBC. Approximately 90% are ER positive and 81% are PR positive in MBC. Recent studies have shown that HER2-neu overexpression rate is lower in males (2%–15%) in comparison to females (18-20%).[4],[13] In our series, 32 (53.3%) patients had both ER/PR HRs positive, which is lower in comparison to the other Indian studies.[4],[5],[6],[8],[14],[15] HER-2/neu status was positive in 9 (15%) patients in our series. TNBC constituted 18.3% (11/60), which is consistent with the study by Ram et al.[10]; however, 3 (5%) patients had triple-positive MBC. which is much higher in comparison to other Indian studies.[10] Assessment of HR for clinical management of MBC is strongly recommended to provide prognostic information and therapeutic management. In developing countries, most of the patients present at a fairly advanced disease with large tumors and nodal involvement leading to poor survival rates. This can be attributed to the lack of effective screening programs and lack of awareness regarding signs and symptoms of breast lump in males.

The limitations of this study are the retrospective nature of the study with small sample size.


  Conclusion Top


MBC is seen at a relatively younger age in our subset of population. Late presentation with advanced disease is a common feature in our population. Feasibility of clinical trials was limited because of the rarity of the disease. But for better understanding of the clinical spectrum of this rare disease comprehensive, multi-institutional collaborative studies are warranted.

Acknowledgements

The authors would like to thank the National Centre for Disease Informatics and Research under Indian Council of Medical Research for providing the necessary technical support to our hospital cancer registry.

Author contributions

Dr. Nizara Baishya drafted the article and did literature search and arrived at the conclusion of the article. Dr. Jagannath Dev Sharma and Dr. Amal Chandra Kataki did critical review of the manuscript. Chandi Ram Kalita did statistical analysis of the data. All the authors approved the final version of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Bardou VJ, Arpino G, Elledge RM, Osborne CK, Clark GM. Progesterone receptor status significantly improves outcome prediction over estrogen receptor status alone for adjuvant endocrine therapy in two large breast cancer databases. J Clin Oncol 2003;21:1973-9.  Back to cited text no. 13
    
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Mitra D, Manna A, Sikdar SK, Sur PK. Clinicopathological study and its prognostic implication in male breast carcinoma. J Indian Med Assoc 2007;105:681-6.  Back to cited text no. 14
    
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