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Breast Mass in an African American Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 43-year-old African American man presented with a nontender, self-palpated mass in his left breast. He had hypertension, diabetes, hyperlipidemia, and obesity and was a current smoker. His medications included carvedilol, furosemide, lisinopril, metformin, and aspirin but no testosterone or herbal supplements. Family history was significant for a sister with brain cancer, diagnosed in her 40s. On physical examination, his vital signs were within normal limits; his body mass index, calculated as weight in kilograms divided by height in meters squared, was 53. His left nipple was retracted. At the 2-o’clock position of the left breast, 3 cm from the nipple, there was a 3.5 × 3.0–cm firm mass. The right breast was normal without masses, and there was no palpable axillary lymphadenopathy. He underwent a bilateral diagnostic mammogram, which showed a partially obscured mass in the left upper outer quadrant with linear extension to the nipple (Figure, left panel). Targeted ultrasound showed a 2.0 × 1.6 × 1.6–cm irregular hypoechoic mass (Figure, right panel).

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Male breast cancer

A. Perform percutaneous biopsy of the mass

The key to the correct diagnosis in this case was a firm breast mass with nipple retraction. Unlike gynecomastia, which tends to present as unilateral or bilateral rubbery tissue concentric to (directly underneath) the nipple-areolar complex without associated skin changes, breast cancer is usually unilateral, eccentric to (peripheral to) the nipple, firm, and sometimes associated with skin dimpling, adenopathy, or nipple discharge. In male patients with suspicious or indeterminate clinical findings, diagnostic mammography with ultrasound is the recommended initial imaging, not breast MRI,1 and percutaneous biopsy should be performed on suspicious lesions. Surgical excision should only be pursued if percutaneous biopsy is not feasible or if the biopsy result is discordant or incongruent with imaging features.

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Article Information

Corresponding Author: Jean Bao, MD, University of Chicago Medical Center, 5841 S Maryland Ave, MC4052, Chicago, IL 60637 (jbao@surgery.bsd.uchicago.edu).

Published Online: August 29, 2019. doi:10.1001/jama.2019.12698

Conflict of Interest Disclosures: Dr Swoboda reported receiving financial support for an investigator-initiated clinical trial from Lilly and nonfinancial support for an investigator-initiated clinical trial from Bristol-Myers Squibb. No other disclosures were reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
1.
American College of Radiology (ACR). ACR Appropriateness Criteria: evaluation of the symptomatic male breast. ACR website. https://acsearch.acr.org/docs/3091547/Narrative. 2018. Accessed January 29, 2019.
2.
American Cancer Society (ACS). Key statistics for breast cancer in men. ACS website. https://www.cancer.org/cancer/breast-cancer-in-men/about/key-statistics.html. 2018. Accssed August 19, 2019.
3.
O’Malley  C, Shema  S, White  E, Glaser  S.  Incidence of male breast cancer in California, 1988-2000: racial/ethnic variation in 1759 men.  Breast Cancer Res Treat. 2005;93(2):145-150. doi:10.1007/s10549-005-4517-zPubMedGoogle ScholarCrossref
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Cardoso  F, Bartlett  JMS, Slaets  L,  et al.  Characterization of male breast cancer: results of the EORTC 10085/TBCRC/BIG/NABCG International Male Breast Cancer Program.  Ann Oncol. 2018;29(2):405-417.PubMedGoogle Scholar
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Cloyd  JM, Hernandez-Boussard  T, Wapnir  IL.  Outcomes of partial mastectomy in male breast cancer patients: analysis of SEER, 1983-2009.  Ann Surg Oncol. 2013;20(5):1545-1550. doi:10.1245/s10434-013-2918-5PubMedGoogle ScholarCrossref
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Zaenger  D, Rabatic  BM, Dasher  B, Mourad  WF.  Is breast conserving therapy a safe modality for early-stage male breast cancer?  Clin Breast Cancer. 2016;16(2):101-104. doi:10.1016/j.clbc.2015.11.005PubMedGoogle ScholarCrossref
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National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: breast cancer (version 3.2018). NCCN website. https://www.nccn.org. Published 2018. Accessed January 29, 2019.
8.
Rastogi  P, Anderson  SJ, Bear  HD,  et al.  Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project protocols B-18 and B-27.  J Clin Oncol. 2008;26(5):778-785. doi:10.1200/JCO.2007.15.0235PubMedGoogle ScholarCrossref
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