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    Case challenge| 64-year-old man, what is the cause of back pain after modified radical mastectomy for breast cancer?

    • Last Update: 2023-01-07
    • Source: Internet
    • Author: User
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    Patient, male, 64 years old, working as an electrician

    Complaints: The patient feels pain
    in the lower right side of the back.

    Present medical history: the patient complained of a right breast mass for 4 months 7 years ago, and after hollow core needle biopsy, the pathology showed estrogen receptor (ER) positive and HER2-negative breast cancer
    Modified radical resection of right breast cancer, pathological stage IIA
    Adjuvant tamoxifen was used for 5 years
    after surgery.
    Two years after treatment, the patient reported pain
    in the lower right side of the back.

    Past medical and drug history: previous health
    Patients have a history of alcohol consumption (up to 1-2 drinks 2 to 3 times per week).

    Family history: Denial of family history
    of breast or other cancers.

    physical examination

    Vital signs: temperature: normal; Pulse: 74 beats/min; Blood pressure: 138/87mmHg; Oxygen saturation: 98%.

    General examination: the patient has a clear expression and answers correctly
    The oral mucosa is moist and normal
    The respiratory movement of both lungs in the chest is consistent, and the breath sounds of both lungs are clear on auscultation, and there are no dry and wet rales
    The heart rhythm is aligned, and no murmurs and other abnormal heart sounds
    are heard.
    The abdomen is flat, non-tender, and the liver and spleen are not palpable
    Both upper and lower limbs have normal muscle strength and free movement

    Ancillary examination

    Blood routine and biochemical tests: no abnormalities

    Imaging tests:

    MRI of the pelvis showed complex osteolytic changes in the right iliac wing, with lesion sizes of 5.
    5 × 2.
    6 × 3 .


    PET/CT showed a heterogeneous mass in the lower right lobe of the liver, with a maximum standardized uptake value (SUV) of 7.
    1, a maximum SUV value of 8.
    8 for anterior hepatic lesions, and a maximum SUV value of 5.
    for right iliac anterior wing lesions.


    Current diagnosis:

    Postoperative metastasis of breast cancer

    Metastasis of bone (right iliacium).

    Liver metastases

    Diagnosis basis: liver and bone tissue biopsy pathology is the gold standard
    for diagnosis.


    Characteristics of the disease

    Male breast cancer is rare, accounting for less than 1%
    of all breast cancer cases.
    The American Cancer Society estimates 2,710 new cases of invasive breast cancer in the United States in 2022 and 287,850 in women [2].

    Because male breast cancer is rare, most disease information is obtained from single-center retrospective studies and extrapolated from clinical practice in female breast cancer


    Studies have shown that the following risk factors are associated with male breast cancer:


    Genetic predisposition: a major risk factor
    for breast cancer in men.
    About 15% to 20% of men with breast cancer have a family history
    of breast or ovarian cancer.
    BRCA2 mutations account for approximately 15 percent of all breast cancers in men, and men with BRCA2 mutations have a lifetime risk (LR) of 5 to 10 percent, compared with 0.
    1 percent in the general population [3].

    In addition, BRCA1 mutations are associated with male breast cancer less than BRCA2, with an LR of about 1% to 5%.

    Other gene mutations, including PTEN, p53 and CHEK2, have been linked
    to the development of male breast cancer.


    Klinefelter syndrome: also known as XXY syndrome or Kirschner syndrome, it is characterized by 47,XXY karyotype, small testicles, azoospermia, and dysplasia
    of secondary sexual characteristics.
    Klinefelter syndrome increases the risk of breast cancer in men by more than
    50 times.
    About 4%-20% of male breast cancer patients have Klinefelter syndrome

    Other: cryptorchidism, congenital inguinal hernia, orchiectomy, orchitis, testicular injury, and infertility
    Lifestyle risk factors include obesity and alcohol


    Male breast cancer often presents with painless breast lumps, pain, inverted nipples, and nipple discharge
    Differential diagnoses include breast development, infection, lipoma, fibroid, granuloscytoma, or single metastases
    of rare primary tumors.


    Due to poor understanding of male breast cancer, male breast cancer is generally staged later than female at presentation, and the prognosis is relatively poor
    The Male Breast Cancer Database suggests that from 2005 to 2010, the 5-year survival rate for male breast cancer was 82.
    8%, compared with 88.
    for female breast cancer.
    In addition, men have a 43% higher risk of dying from breast cancer than women


    Examination for suspicious lumps in the male breast is similar to that of women, with mammary molybdenum and palladium being
    Previous studies have shown that the sensitivity and specificity of mammary molybdenum palladium examination for the diagnosis of malignant breast cancer in men is 92% and 90%,


    The main pathological classification of male breast cancer is invasive ductal carcinoma, which accounts for more than
    80% of all cases.
    The second most common subtype is ductal carcinoma
    in situ.
    Other less common subtypes include invasive papillary carcinoma and lobular carcinoma
    Male breast cancer tends to have a higher rate of hormone receptor (HR) positivity compared to female breast cancer, with about 80% of male breast cancers being ER-positive and nearly 75% being progesterone receptor (PR) positive


    The staging system for male breast cancer is the same as for women, with stages based on the size of the primary lesion, lymph node status, and the presence of distant metastatic disease
    Prognostic factors for male breast cancer are also similar to female breast cancer, including axillary lymph node status, tumor size, histological grade, and HR status


    Male breast cancer is treated similarly
    to female breast cancer.
    Because male breast cancer tends to be located behind the nipple, modified radical mastectomy is the most common surgical modality
    Also, due to the limited breast tissue in men, breast lumpectomy
    is usually not performed.
    However, radiotherapy after modified radical mastectomy for male breast cancer remains controversial
    Radiation therapy has been shown to reduce local recurrence, but overall survival has not improved
    At the same time, it is also believed that male breast cancer is basically central breast cancer, and the tumor is closer to the inner breast lymph nodes, so radiotherapy
    for the inner breast lymph nodes should be considered.
    In addition, due to limited data on adjuvant therapy for male breast cancer, male breast cancer patients also follow guidelines
    for adjuvant therapy for female breast cancer.
    Endocrine therapy is the most common systemic treatment for early-stage HR-positive male breast cancer
    Tamoxifen is the most widely studied endocrine therapy drug and is associated with
    improved overall survival.
    There is not enough evidence to support the use of
    aromatase inhibitors (AI) in male breast cancer.
    A retrospective study suggests that AI may be detrimental to
    overall survival of male breast cancer.
    The mechanism of action of AI is to inhibit ER production, unlike postmenopausal women, AI does not inhibit male testicular production of ER.


    Metastatic male breast cancer is treated in the same way as in
    Endocrine therapy can be used in patients with
    HR-positive breast cancer.
    Chemotherapy is also a treatment option, but because men generally respond well to endocrine therapy, chemotherapy is often used for late-line therapy


    The patient underwent modified radical resection for right breast cancer and completed 5 years of tamoxifen treatment
    This time, bone and liver tissue biopsy was performed and bone (right iliac) and liver metastases
    were diagnosed.
    Patients have been started on fulvestrant


    [1] Avan Armaghani.
    A 64-Year-Old Man With Back Pain After Mastectomy.

    [2] American Cancer Society.
    Cancer Facts and Statistics.

    [3] Cancer risks in BRCA2 mutation carriers.
    The Breast Cancer Linkage Consortium.
    J Natl Cancer Inst.
    1999; 91:1310–1316.

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