Recently, “New England Medical Magazine” reported a rare case: a 52 -year -old man was diagnosed with breast cancer at Massachusetts General Hospital. Five doctors from the Massachusetts General Hospital and Harvard Medical College participated in the consultation and discussion. In addition to analyzing the patient’s condition and examination results, they also explored the characteristics of male breast cancer in detail, related genetic testing and treatment strategies, and believed that it was greatly inspired by clinicians.
Jie Mei will take you to see this quite strange case!
Dr. M: 52 -year -old male patient, he found a painless mass in left milk 7 weeks ago. After 3 weeks, he had a breast cancer -related examination at the primary health doctor. The basic situation is as follows:
Body temperature: 36.2 ℃
Heart rate: 91 times/minute
Blood pressure: 126/90mmHg
Blood oxygen: 98%
Physical Index (BMI): 25.2kg/m2
Examination: Left milk can touch 2cm hard nodules in the diameter and did not touch lymph nodes. Yu Wuwu.
Doctor L: The patient conducted a imaging examination 19 days ago in this evaluation. According to the US Radiation Society (ACR) guide, men 25 and above in the breast examination should first perform bilateral breast X -ray shadows. If the film creation cannot be concluded, the breast ultrasound is recommended. Breast angiography has high sensitivity and specificity among men, and is the first choice for identifying breast cancer and benign lesions.
From the patient’s breast X -ray tablets, the left milk has an irregular boundary round nodule, accompanied by heterogeneous calcification. Under the opposite areola, high -density shadows have the characteristics of male breast enlarged imaging. Ultrasonic examinations are confirmed that the suspicious lesions are unsatisfactory lumps, 2.5cm × 1.5cm. According to the ACR breast imaging report and data system (BI-RADS), it can be determined as BI-RADS level 4, prompting malignant, and conducting ultrasound guidance to the lesion of the lesion. The rough needle puncture biopsy. Ultrasonic examination also found suspicious lymph nodes under the left axillary and conducted biopsy.
Dr. B: The left milk biopsy specimen is historically checked. It can be seen that the malignant cells are tight nest and cable -shaped structures, which are multi -state to severe cells, and occasionally there are silk divisions. These features conform to moderate infiltration duct cancer. Perform fine needle drawing inspections of abnormal lymph nodes under the left axillary. Large and tight, three -dimensional atypical cell clusters can be seen on the cell coating. Small lymphocytes, these manifestations conform to metastatic adenocarcinoma.
Dr. M: After obtaining the biopsy results, further examination and treatment of patients are conducted, and they know that their past history (virus infection is deaf from the left ear, rhinitis), and family history. There is no history of smoking and almost no alcohol (living habits can be said to be healthy). The patient lives with his wife and two children, and his occupation is accounting.
It is worth noting that his family history: Father (86 years old) was diagnosed with breast cancer when he was 81 years old. Aunt (87 years old) was diagnosed with bilateral breast cancer at the age of 50 and 65. For malignant bone tumors, an uncle was diagnosed with brain tumors at the age of 65 and died, and an uncle suffered from brain tumor and kidney cancer (the age of death was unknown); He died of pancreatic cancer at 57 years old, and another cousin suffered from prostate cancer; his mother was 65 years old diagnosed with breast cancer, died at the age of 85, and a aunt (91 years old) was 90 -year -old diagnosis of colon cancer. The patient was German Jews.
The results of the laboratory inspection are as follows:
Blood calcium: 11.1mg/dl ↑ (8.2 ~ 10.5)
Total bilirubin: 1.5mg/dl ↑ (0 ~ 1.0)
Gulfanase: 46U/L (10 ~ 55)
Grassamotrase: 46U/L ↑ (10 ~ 40)
Alkaline phosphatase: 45U/L (45 ~ 115)
The results of the remaining basic metabolic examinations are normal. The results of the chest, abdomen, and pelvic CT examination are normal, and the 锝-99M bone scan shows no metastasis. Suggestion gene consultation. After 9 days, the left breast cancer improvement was performed.
Dr. B: The overall evaluation of the surgical specimen shows that the patient’s left milk center has a hard, gray -white, and irregular mass in the center of the patient, with a maximum diameter of 2.1 cm. The staining shows that the tumor is composed of nest and cable -like malignant cells. The nucleus form is irregular and variable. Nuclear kernels are prominent and nuclear division is common.
Slim dyeing of the axillary lymph nodes shows that one of the 19 lymph nodes has metastatic cancer. The immunohistochemical dyeing shows strong ER and PR expression in cancer cells, and HER2 is expressed as negative.
Infiltrated duct cancer, level 3, 1 lymph node metastasis; PT1CN1A.
Follow -up discussion
Male patients with breast cancer are also prone to prostate and pancreatic cancer!
Dr. S: It is recommended that the patient conduct genetic consultation based on his personal history and family history. The indication of genetic testing is: the patriarchal or maternalism suffer from the same or related cancer, the family has at least two generations of cancer, and the history of cancer in the early years.
Since 2009, the National Comprehensive Cancer Network (NCCN) Guide has recommended all male breast cancer patients to screen BRCA1/2 gene mutations. Due to the patient’s German Jewish descent and male breast cancer and other BRCA -related cancer families history, he himself has a great increase in carrying the gene (3 gene mutations in the German Jewish population are very common: 185DELAG, 5382INSC, and BRCA2 in BRCA1 6174Delt). The guide recommends the German Jewish population screening such genes. Today’s genetic testing can analyze more than 60 mutant genes. Recent studies have shown that men’s breast cancer may also bring Chek2 and PALB2 mutations. The patient found out 6174DELT mutations in BRCA2, which will affect his current and long -term treatment -men carrying BRCA2 mutations, the risk of prostate cancer is as high as 25%, and tumors are usually early onset, high malignancy is high, and malignant is high. Essence Therefore, the patient needs to conduct prostate cancer screening each year.
Some of the families with BRCA2 mutations can reach 3%of the pancreatic cancer. Therefore, many experts suggest that the BRCA2 carriers with a family history of pancreatic cancer screen pancreatic cancer each year. One of the cousin died of pancreatic cancer, so he should also discuss the problem of pancreatic cancer screening with experts. In addition, the patient’s sister and children also have 50%of the same mutation genes, respectively, and should consider genetic testing (children are advised to be performed in adulthood). The cousin and sisters who are still healthy also need to be tested.
女 Breast cancer is not a “patent” for women!
Doctor I: After surgery, the patient should still emphasize three key points: whether the auxiliary chemotherapy/radiotherapy/endocrine therapy can benefit it. At present, there is no random control clinical trial (RCT) that can clearly guide the treatment strategy of male breast cancer, and can only be used as a reference from the RCT results of female breast cancer.
Male breast cancer accounts for about 1%of all breast cancer cases. It is expected that 2620 male breast cancer cases and 520 deaths in the United States are expected to die, while female breast cancer exceeds 276,000 cases. Male breast cancer patients have a median diagnosis age of 68, 5-10 years older than women. There are multiple risk factors in breast cancer in this case, such as German -Jewish descent, family history of male breast cancer, and mutations in BRCA2. Better benign breast lesions such as male breast enlargement also have a certain relationship with breast cancer.
This case’s discussion of the literature is more special is that in addition to the discussion process of professional doctors, there is also a “inner monologue” of patients. The male breast cancer patient frankly contributed his view.
“When a doctor invites me to participate in the discussion, I think the most important thing is to let everyone know that men may also have breast cancer. If you are a man with a BRCA mutation in a family, you need to do genetic testing. Maybe you It will not be onset, but it is necessary to consider the children. Among my two children, the eldest son has already done testing, and the younger daughter hopes to wait for a long time before testing.
“For junior health doctors, it is important to know if there is a mutation of breast cancer genes in the patient’s family. Even as a male, it does not mean that it is not worried about breast cancer. As long as the test result is not negative, this is a hidden worry. Although I have diagnosed the breast gland Cancer, but I am not too worried -my father is 81 years old after diagnosis of breast cancer, and the treatment is pretty good. “
Patients are confident in future treatment and life, and hope that his optimism can also be passed to other male breast cancer patients.