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 Table of Contents  
LETTER TO EDITOR
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 72-74

Male breast cancer presenting with bilateral pleural effusion


1 Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication17-Jan-2013

Correspondence Address:
Saurabh Karmakar
Department of Pulmonary Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1947-2714.106218

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How to cite this article:
Karmakar S, Chaudhuri T, Nath A, Neyaz Z. Male breast cancer presenting with bilateral pleural effusion. North Am J Med Sci 2013;5:72-4

How to cite this URL:
Karmakar S, Chaudhuri T, Nath A, Neyaz Z. Male breast cancer presenting with bilateral pleural effusion. North Am J Med Sci [serial online] 2013 [cited 2019 Nov 15];5:72-4. Available from: http://www.najms.org/text.asp?2013/5/1/72/106218

Dear Editor,

Bilateral pleural effusion is a common clinical entity, but has never been reported as presentation of male breast cancer. The article reports about a 72-year-old Asian Indian male, who presented with breathlessness and anasarca since 1 year, progressively increasing since 1 month. The patient was breathless at rest and had a room air saturation of 86%. Personal history comprised of weekly intake of 5-6 pegs of whisky (approximately 100-120 g equivalent ethanol) since the past 30 years. The patient never smoked and had no history of illicit drug abuse, but had Type II diabetes mellitus and hypertension for past 5 years.

General physical examination revealed icterus, bilateral pitting pedal edema, and a single left axillary lymph node, which was 2 cm in size, hard, mobile, and nontender on palpation. Respiratory system examination revealed enlarged breasts bilaterally on inspection and diminished air entry in the infra-scapular and infra-axillary regions on both sides. Palpation revealed a 3 × 2 cm nontender lump deep to the left nipple, not fixed to the chest wall. Abdominal examination revealed firm, irregular, nontender hepatomegaly (liver span 16 cm) and ascites. Hemogram and clinical chemistry were normal, except Hb (9 g/dl), s. bilirubin (3.1 g/dl), and albumin (2.2 g/dl) levels. Chest X-ray showed bilateral pleural effusion [Figure 1]. Ultrasonography (USG) whole abdomen revealed ascites and hepatomegaly with coarse echotexture. We did a therapeutic pleural fluid aspiration (800 ml from left and 1 lit from the right). Pleural effusion was exudative lymphocyte predominant with normal sugar and adenosine deaminase (ADA) levels on both sides. Left sided pleural fluid cytology was positive for adenocarcinoma cells. CECT thorax showed bilateral pleural effusion and fracture of rib. [Figure 2]. USG-guided fine needle aspiration cytology (FNAC) of left axillary lymph node was positive for metastatic ductal carcinoma. Core biopsy from the left breast lump revealed invasive ductal carcinoma [Figure 3]. A nodule of soft tissue density was seen in left breast [Figure 4]. Bone scan did not show any abnormal uptake. The patient was diagnosed as a case of metastatic invasive ductal carcinoma of left breast (cT2N1M1), and referred to Oncology department for further management. In view of poor general condition (ECOG 3), he was given palliative chemotherapy with fluorouracil, adriamycin (doxorubicin) and cyclophosphamide (FAC) regimen with 20% dose reduction (5-fluorouracil 500 mg/m 2 i.v. on day 1, doxorubicin 50 mg/m 2 i.v. on day 1, and cyclophosphamide 500 mg/m 2 i.v. on day 1; repeated every 4 weekly). The patient died due to disease progression after receiving two cycles of chemotherapy.
Figure 1: Scanogram showing bilateral pleural effusion

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Figure 2: Contrast-enhanced computed tomography thorax showing fracture of left rib

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Figure 3: High power view of breast nodule biopsy showing invasive ductal carcinoma

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Figure 4: Contrast-enhanced computed tomography thorax showing left breast nodule

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Breast cancer is the most common malignancy in females, but it is rare in males. Males comprise 0.7% of all breast cancer patients. [1] The etiology of male breast cancer comprises of hormonal, familial, genetic, and racial factors. Hormonal causes are increased estrogen-testosterone ratio (Klinefelter syndrome); increased estrogen levels (cirrhosis, exogenous administration in transsexuals, and prostate cancer therapy) and decreased androgen levels (testicular diseases like mumps and undescended testis or injury due to trauma or heat and electromagnetic radiation). [2] Familial predisposition occurs by presence of BRCA-2 gene mutations or a first degree female relative with breast cancer. [3] Genetic disorders like Cowden syndrome and hereditary nonpolyposis colonic cancer predispose males to breast cancer. [4] Racial predisposition for male breast cancer is seen in Jews and North American Black males. [5] Other predisposing factors are gynecomastia, alcohol intake of more than 60 g/day and obesity. [5] Bilateral gynecomastia may hide a malignant breast lump and unilateral gynecomastia may mimic one on clinical examination. Male breast cancer manifests as a hard, painless subareolar lump eccentric to the nipple. Pain occurs in 5% cases. Nipple retraction occurs in 9%, discharge in 6%, and ulceration in 6% cases. Paget's disease is the presenting feature in 1% cases. [6] Secondary features of malignancy are nipple retraction, skin ulceration or thickening, increased breast trabeculation, and axillary lymphadenopathy. [7]

Invasive ductal carcinoma is the most common type of male breast carcinoma (90%). Other types include ductal carcinoma in situ (10%), invasive papillary (2%), medulllary (2%), and mucinous carcinomas (1%). [8] Ducts lie close to dermal lymphatics, pectoral fascia, and subareolar lymphatic channels in male breast. Due to lack of sufficient connective tissue, the ducts lie in close proximity to lymphatic system and metastasis occurs earlier in male breast. Estimates suggest 42% of breast cancer cases in men are diagnosed in advanced stages (stage III or IV). [9] Tumor size and lymph node involvement are the most important prognostic factors for male breast cancer. Other factors are histological grade and hormone receptor status. Expression of Her2-neu correlates with probability of increased relapse rates and higher stage and grade of the carcinoma. [2] Local disease is treated by modified radical mastectomy with axillary lymph node dissection or sentinel node biopsy. [9] Adjuvant chemotherapy is given for node positive disease. Tamoxifen is the therapy of choice for estrogen receptor positive cancer and metastatic disease. [10]

An elderly male with co-morbidities (hypertension and diabetes mellitus), history of chronic alcohol intake, and presenting with anasarca and bilateral pleural effusion is usually suspected to have decompensated chronic liver disease or congestive heart failure, as they are most common differential diagnosis. Investigations revealed it to be a male breast cancer presenting with bilateral pleural effusion and pathological rib fracture. Malignancy should be considered among the differential diagnosis of bilateral pleural effusions in elderly.

 
  References Top

1.Nahleh ZA, Srikantiah R, Safa M, Jazieh A, Muhleman A, Komrokji R. Male breast cancer in the veterans affairs population. Cancer 2007;109:1471-7.  Back to cited text no. 1
    
2.Contractor KB, Kaur K, Rodrigues GS, Kulkarni DM, Singhal H. Male breast cancer: Is the scenario changing. World J Surg Oncol 2008;6:58.  Back to cited text no. 2
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3.Diez O, Cortes J, Domenech M, Pericay C, Brunet J, Alonso C, et al. BRCA2 germ-line mutations in Spanish male breast cancer patients. Ann Oncol 2000;11:81-4.  Back to cited text no. 3
    
4.Fackenthal J, Marsh D, Richardson A, Cummings S, Eng C, Robinson B, et al. Male breast cancer in Cowden syndrome patients with germline PTEN mutations. J Med Genet 2001;38:159-64.  Back to cited text no. 4
    
5.Weiss JR, Moysich KB, Swede H. Epidemiology of male breast cancer. Cancer Epidemiol Biomarkers Prev 2005;14:20-6.  Back to cited text no. 5
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6.Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. Lancet 2006;367:595-604.  Back to cited text no. 6
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7.Shi AA, Georgian-Smith D, Cornell LD, Rafferty EA, Staffa M, Hughes K, et al. Radiological reasoning: Male breast mass with calcifications. AJR Am J Roentgenol 2005;185:205-10.  Back to cited text no. 7
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8.Giordano SH, Cohen DS, Buzdar AU, Perkins G, Hortobagyi GN. Breast carcinoma in men: A population-based study. Cancer 2004;101:51-7.  Back to cited text no. 8
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9.Giordano SH, Buzdar AU, Hortobagyi GN. Breast cancer in men. Ann Intern Med 2002; 137:678-87.  Back to cited text no. 9
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10.Doyen J, Italiano A, Largillier R, Ferrero JM, Fontana X, Thyss A. Aromatase inhibition in male breast cancer patients: Biological and clinical implications. Ann Oncol 2010;21:1243-5.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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