Male breast cancer (MBC) is a rare disease and constitutes less than 1% of all breast carcinoma cases. Although MBC most often presents with a palpable mass, failure to recognise the significance of other symptoms may lead to a delay in diagnosis. Nipple discharge (ND) is a rare symptom in men, but it may herald an underlying malignancy. We present two cases of (MBC) presenting with ND and emphasise the importance of this clinical sign in suspecting underlying malignancy and an opportunity for early diagnosis. We also discuss the clinical significance of ND in men in relation to current literature

Farooq, A.

Horgan, K.

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A. Farooq

K. Horgan

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Case Reports in Surgery

Male Breast Cancer Presenting as Nipple Discharge

Male breast cancer (MBC) is a rare disease and constitutes less than 1% of all breast carcinoma cases. Although MBC most often presents with a palpable mass, failure to recognise the significance of other symptoms may lead to a delay in diagnosis. Nipple discharge (ND) is a rare symptom in men, but it may herald an underlying malignancy. We present two cases of (MBC) presenting with ND and emphasise the importance of this clinical sign in suspecting underlying malignancy and an opportunity for early diagnosis. We also discuss the clinical significance of ND in men in relation to current literature.</jats:p

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Hindawi Publishing CorporationCase Reports in SurgeryVolume 2011, Article ID 804843, 3 pagesdoi:10.1155/2011/804843Case ReportMale Breast Cancer Presenting as Nipple DischargeA. Farooq and K. HorganDepartment of Surgery, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3BR, UKCorrespondence should be addressed to A. Farooq, afarooq@nhs.netReceived 22 July 2011; Accepted 18 September 2011Academic Editors: F. A. Abantanga, C. Foroulis, and F.-M. HaeckerCopyright © 2011 A. Farooq and K. Horgan. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Male breast cancer (MBC) is a rare disease and constitutes less than 1% of all breast carcinoma cases. Although MBC most oftenpresents with a palpable mass, failure to recognise the significance of other symptoms may lead to a delay in diagnosis. Nippledischarge (ND) is a rare symptom in men, but it may herald an underlying malignancy. We present two cases of (MBC) presentingwith ND and emphasise the importance of this clinical sign in suspecting underlying malignancy and an opportunity for earlydiagnosis. We also discuss the clinical significance of ND in men in relation to current literature.1. IntroductionMale breast cancer (MBC) is a rare disease accounting forless than 1% of all breast cancers [1, 2]. In central Africancountries, there is a much higher proportion of cases of MBCbut the reasons for this geographical variation are unclear[3, 4]. The incidence of both male and female breast cancerseems to be rising [5]. While this trend may simply reflectincreasing life expectancy, it is likely that other explanationsexist. The average age at diagnosis of MBC is 68 years, whichis older than the typical presentation of female breast cancerat mean age of 58 years. Furthermore, MBC has a unimodalage distribution as opposed to female breast cancer whichhas a bimodal peak at age 52 and 71 [2, 6–8]. This is notnecessarily due to a biological cause but is likely to be relatedto the onset of breast screening in women at age 50.Literature on MBC is limited due to its rarity, andmanagement is largely based on evidence from data of femalebreast cancer. However, MBC is not exactly the same asfemale breast cancer [7, 8]. Although most cases present asa palpable mass, it is imperative to be aware of other signsand symptoms of MBC so that the disease may potentiallybe detected at an earlier stage conferring a survival benefit tothe patient [9]. One such sign of underlying MBC is nippledischarge (ND). Data on ND inmen in the current literature,however, is very limited. We present two cases of MBCpresenting with ND and discuss the clinical significance ofthis sign in men.2. Case Report(1) A healthy 87-year-old man presented with a three-monthhistory of spontaneous, clear, left-sided ND. There was asignificant family history of breast cancer as a maternalaunt, and two sisters were diagnosed in their early 60’s. Onexamination, he had a firm, 2 cm mass in the upper outerquadrant of the left breast. There was no skin ulceration ortethering, no nipple retraction, and there were no enlargedaxillary lymph nodes. The discharge came from the centre ofthe nipple, and, clinically, it was not possible to say if thiswas uniductal. The discharge was sent for cytology, and acore biopsy of the mass was also performed. ND cytologywas inconclusive with no evidence of any epithelial cells, butcore biopsy of the lump revealed the presence of invasiveadenocarcinoma.After counselling, the patient went on to have a mas-tectomy and axillary sentinel lymph node biopsy (SLNB).Histology showed a grade 2 invasive papillary carcinoma19mm in maximum dimension, with clear margins. Nolymphovascular invasion was seen, and the one SLNBwas negative for metastatic tumour. Immunohistochemistrydemonstrated the tumour was strongly oestrogen receptor2 Case Reports in Surgery(ER) positive without HER2 over amplification. The patientmade a good postoperative recovery and had adjuvantendocrine treatment with tamoxifen. Due to his strongfamily history, he was oﬀered genetic counselling but herefused and remained well 2 years postoperatively.(2) A 77-year-old gentleman presented with bloody NDand a lump in the left breast for 6 weeks. There was no historyof trauma and no family history of note. On examination,there was a cord-like mass beneath the areola extending intothe upper outer quadrant of the left breast, with no skin ornipple abnormality. The patient underwent a mammogramand ultrasound scan both of which were highly suggestivethat the mass was malignant. The ND cytology revealedatypical epithelial cells. Core biopsy of the mass revealedthe presence of invasive adenocarcinoma. The patient wastreated with mastectomy and SLNB. Histology revealed agrade 2 invasive ductal carcinoma with clear margins and nolymphovascular invasion present. A single node was retrievedat SLNB which was negative for metastatic carcinoma.Immunohistochemistry showed the tumour was ER positive.He was prescribed adjuvant tamoxifen and remained well 4years postoperatively.3. DiscussionMBC is often diagnosed at a later stage than in womenwith more than 40% of men presenting with stage III or IVdisease [10]. Published series have also consistently reportedlong median time intervals between onset of symptomsand diagnosis of MBC [10, 11]. Prolonged duration ofsymptoms and advanced stage at presentation is important asit correlates with decreased survival [11]. Delays in diagnosisof MBC are likely to result from a lack of awareness ofthe risk of MBC and the signs and symptoms that mayindicate an underlying malignancy. Although the typicalpresentation of MBC in 75% of patients is a painless, firm,retroareolar breast lump, it is important to recognise theother less obvious signs and symptoms of MBC includingnipple retraction, ulceration, Paget’s disease of the nipple,axillary lymphadenopathy, breast pain, and ND [10–12].ND alone is an uncommon presenting complaint in men,and published data is limited. Morrogh and King from theMemorial Sloane Kettering Centre, New York, presents theonly significant series of MBC patients presenting with ND[13]. They found that among 430 patients who presentedto their institution with ND over a 10-year period only 3%were male. However, 57% of these men presenting withND had an underlying malignancy. This is in contrast tothe female population in whom only 16% of patients whopresented with ND had an underlying malignancy. Othersmaller studies looking at the presence of ND in associationwith a palpable mass have found cancer rates of between 15–75% [14, 15]. Therefore, although ND of the male breast isuncommon, it warrants detailed evaluation due to its strongassociation with underlying malignancy.Morrogh and King also found a significant delay inpresentation inmenwho present with ND compared to thosewho present with a palpable mass. The median time intervalbetween onset of symptoms and diagnosis was 16 weeks forpatients presenting with ND and 3 weeks for those presentingwith a palpable mass, raising the possibility that had thisgroup recognised the significance of the ND they may havepresented at an earlier stage [13].For a male presenting with ND, the diagnostic pathwayfollows the same principles for breast cancer in womenwhichis based on triple assessment. Clinical suspicion of malig-nancy is confirmed by clinical examination. Approximatelyhalf of men with a primary presenting complaint of ND havean underlying palpable mass [13]. Additional investigationssuch as mammography and targeted ultrasoundmay assist indiagnosis. However, definitive diagnosis relies on pathologi-cal assessment either with nipple fluid cytology, fine needleaspiration cytology, or core biopsy of a mass.The use of nipple fluid cytology to distinguish betweenpatients with cancer and those with a benign ND has beena subject of ongoing debate. Current data suggest that NDcytological examination is only useful when positive and canhave a false-negative rate for cancer of up to 50% [16, 17].In our two patients, both underwent ND cytology, withcytology detecting suspicious malignant epithelial cells inone of the two patients. Although there are case reportsdescribing the diagnosis of MBC on the basis of nipplecytology alone [17], the overall clinical utility of thisinvestigation is questionable.Although a high proportion of male patients presentingwith ND will have an underlying malignancy, approximately43% have a benign cause for their ND [13]. A numberof benign causes for male ND have been described in theliterature [18–21]. Duct ectasia is benign dilatation andshortening of the terminal ducts within 3 cm of the nipple.It is a common cause of ND in women increasing inincidence with age but rare in the male breast. Tedeschiand McCarthy reported the first male case in 1974 sincewhen only a handful of cases have been reported in theliterature [22]. Recently, duct ectasia has been reported ina man in association with the human immunodeficiencyvirus infection and Bechet’s disease suggesting a possibleimmune mechanism being responsible [21]. Papillomas arecharacterised by formation of epithelial fronds that haveboth a luminal epithelial and outer myoepithelial cell layerssupported by a fibrovascular core. The epithelial componentcan be subject to a spectrum of morphological changesranging from metaplasia to hyperplasia atypical intraductalhyperplasia, and in situ carcinoma. Papillomas are againcommon in the female population and the commonest causefor bloody ND, but only a handful of cases occurring in menhave been reported in the literature [19]. Most recently, twocases of intracystic papilloma causing ND in males on long-term phenothiazine treatment for schizophrenia and elevatedprolactin levels have been reported [20]. Other more rarecauses for benign ND in men include fibrocystic change,gynaecomastia, and various kinds of skin adnexal tumoursarising in breast tissue [18–23].In conclusion, ND in men is rare but when presentcarries a high probability of underlying malignancy. Inthe absence of screening mammography, we rely on thepresence of clinical symptoms to detect MBC. Prognosisis largely determined by the stage at diagnosis; thus, anyCase Reports in Surgery 3delay in presentation or diagnosis may reduce survival. Byrecognising subtle clinical features of early disease such asND, there may be a window of opportunity to improveoutcomes for male patients. An increased awareness of thesignificance of ND as an important symptom in men musttherefore be highlighted to physicians and patients alike.References[1] H. K. Weir, M. J. Thun, B. F. Hankey et al., “Annual report tothe nation on the status of cancer, 1975–2000, featuring theuses of surveillance data for cancer prevention and control,”Journal of the National Cancer Institute, vol. 95, no. 17, pp.1276–1299, 2003.[2] A. J. Sasco, A. B. Lowenfels, and P. Pasker-De Jong, “Reviewarticle: epidemiology of male breast cancer. A meta-analysisof published case-control studies and discussion of selectedaetiological factors,” International Journal of Cancer, vol. 53,no. 4, pp. 538–549, 1993.[3] E. A. Ojara, “Carcinoma of the male breast inMulago hospital,Kampala,” East African Medical Journal, vol. 55, no. 10, pp.489–491, 1978.[4] J. Waterhouse, C. Muir, P. Correa, and J. R. Powell, Eds.,Cancer Incidence in Five Continents, vol. 3, IARC ScientificPublications, 1976.[5] V. Speirs and A. M. Shaaban, “The rising incidence of malebreast cancer,” Breast Cancer Research and Treatment, vol. 115,no. 2, pp. 429–430, 2009.[6] C. La Vecchia, F. Levi, and F. Lucchini, “Descriptive epidemi-ology of male breast cancer in Europe,” International Journalof Cancer, vol. 51, no. 1, pp. 62–66, 1992.[7] W. F. Anderson, I. Jatoi, J. Tse, and P. S. Rosenberg, “Malebreast cancer: a population-based comparison with femalebreast cancer,” Journal of Clinical Oncology, vol. 28, no. 2, pp.232–239, 2010.[8] W. F. Anderson, M. D. Althuis, L. A. Brinton, and S. S. Devesa,“Is male breast cancer similar or diﬀerent than female breastcancer?” Breast Cancer Research and Treatment, vol. 83, no. 1,pp. 77–86, 2004.[9] R. M. Simmons, “Male ductal carcinoma in situ presenting asbloody nipple discharge: a case report and literature review,”Breast Journal, vol. 8, no. 2, pp. 112–114, 2002.[10] I. S. Fentiman, A. Fourquet, and G. N. Hortobagyi, “Malebreast cancer,” Lancet, vol. 367, no. 9510, pp. 595–604, 2006.[11] C. Go´mez-Raposo, F. Zambrana Te´var, M. Sereno Moyano,M. Lo´pez Go´mez, and E. Casado, “Male breast cancer,” CancerTreatment Reviews, vol. 36, no. 6, pp. 451–457, 2010.[12] A. Agrawal, A. A. Ayantunde, R. Rampaul, and J. F. R. Robert-son, “Male breast cancer: a review of clinical management,”Breast Cancer Research and Treatment, vol. 103, no. 1, pp. 11–21, 2007.[13] M. Morrogh and T. A. King, “The significance of nippledischarge of the male breast,” Breast Journal, vol. 15, no. 6, pp.632–638, 2009.[14] W. L. Amoros, G. F. Robbins, andN. Treves, “Serous and seros-anguineous discharge from the male nipple,” A.M.A. Archivesof Surgery, vol. 73, no. 2, pp. 319–329, 1956.[15] P. I. Borgen, G. Y. 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Taniguchi et al., “Intracystic papil-loma in the breast of a male given long-term phenothiazinetherapy: a case report,” Breast Cancer, vol. 13, no. 1, pp. 84–88,2006.[21] A. Downs, M. Fisher, D. Tomlinson, and A. Tanner, “Maleduct ectasia associated with HIV infection,” GenitourinaryMedicine, vol. 72, no. 1, pp. 65–66, 1996.[22] L. G. Tedeschi and P. E. McCarthy, “Involutional mammaryduct ectasia and periductal mastitis in a male,” HumanPathology, vol. 5, no. 2, pp. 232–236, 1974.[23] K. Kapila and K. Verma, “Cytology of nipple discharge in floridgynecomastia,” Acta Cytologica, vol. 47, no. 1, pp. 36–40, 2003.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

A n d e r s o n ,I .J a t o i ,J .T s e ,a n dP .S .R o s e n b e r g ,“ M a l e breast cancer: a population-based comparison with female breast cancer,”

Annual report to the nation on the status of cancer, 1975–2000, featuring the uses of surveillance data for cancer prevention and control,”

Current management of male breast cancer: a review of 104 cases,”

Cytology of abnormal nipple discharge: a cytohistological correlation,”

Descriptive epidemiology of male breast cancer in

e, “Solitary intraductal papilloma of the male breast: diagnostic value of galactography,”

Eds., Cancer Incidence in Five Continents,

H.Yamamoto,Y.Okada,H.Taniguchietal.,“Intracysticpapilloma in the breast of a male given long-term phenothiazine therapy: a case report,”

Intraductal carcinoma in a male breast: diagnosis by nipple discharge cytology,”

Involutional mammary duct ectasia and periductal mastitis in a male,”

Is male breast cancer similar or diﬀerent than female breast cancer?”

Male breast cancer,”

Male breast cancer: a review of clinical management,”

Male duct ectasia associated with

Male ductal carcinoma in situ presenting as bloody nipple discharge: a case report and literature review,”

Nodular hidradenoma of the breast: report of two cases with literature review,”

Review article: epidemiology of male breast cancer. A meta-analysis of published case-control studies and discussion of selected aetiological factors,”

The rising incidence of male breast cancer,”

The signiﬁcance of nipple discharge of the male breast,”

W.L.Amoros,G.F.Robbins,andN.Treves,“Serousandserosanguineous discharge from the male nipple,” A.M.A.

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Male Breast Cancer Presenting as Nipple Discharge

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