A 64-Year-Old Man With Back Pain After Mastectomy

Avan Armaghani, MD

Disclosures

April 16, 2019

The treatment of male breast cancer is extrapolated from that of female breast cancer. Modified radical mastectomy is the most common surgical modality because of the subareolar location of most male breast cancers.[11] Lumpectomy is generally not performed because of limited breast tissue.[7] Radiation therapy after modified radical mastectomy in male breast cancer remains controversial. Some studies have shown a reduction in local recurrence with radiation therapy, but no improvement in overall survival. However, others suggest that because male breast cancers tend to be more centrally located and close in proximity to the internal mammary nodes, consideration should be given to radiation treatment of the internal mammary lymph nodes.[7]

Given the limited data on the use of adjuvant chemotherapy in male breast cancer, the same guidelines used in female breast cancer for adjuvant chemotherapy are also applied in men. The 21-gene recurrence score test is used to guide decision on use of chemotherapy in the adjuvant setting in hormone receptor–positive, HER2-negative, node-negative, or limited node–positive disease.

Antiestrogen therapy is the most common systemic therapy that is used in early-stage hormone receptor–positive male breast cancers. Tamoxifen is the most widely studied antiestrogen medication and is associated with an improvement in overall survival.[12,13] There are insufficient data to support the use of aromatase inhibitors (AIs) in male breast cancer. In one retrospective study, AIs were actually found to be detrimental to overall survival.[14] In contrast to postmenopausal women, in whom AIs work to block estrogen production, AIs do not block testicular production of estrogen in men.[8]

The treatment of metastatic male breast cancer mirrors the treatment in female breast cancer. Antiestrogen therapy can be used in hormone receptor–positive breast cancer.[1] Systemic chemotherapy is also a treatment option, but often this is used in later lines of therapy, as men generally respond well to antiestrogen therapy.

In this case, the patient had breast cancer treated with a modified radical mastectomy followed by 5 years of tamoxifen therapy. He then had recurrent disease in the bone (right iliac) and liver. Both liver and bone biopsies were performed and confirmed recurrent, metastatic disease. The patient was recently started on and continues to receive therapy with fulvestrant.

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