How I Treat: A 50-Year-Old Man With a Right Breast Mass

Micaela Weaver, DO, FACS I Brown University (Providence, RI)

Introduction. A 50-year-old man presented to his primary care provider with a palpable right breast mass, which he had first noted approximately 3 months prior. It had not increased in size but had become increasingly tender. He had no other palpable masses, areas of pain, or other breast or systemic symptoms.

Patient history. His medical history was notable for stage IIA nodular sclerosing Hodgkin lymphoma at the age of 12 years, for which he underwent a splenectomy followed by total mantle/lymphoid radiation for a total dose of 40 Gy. He experienced a recurrence in the auricular region 18 months after index treatment and was managed with right axillary excisional biopsy, local auricular radiation therapy, and chemotherapy with nitrogen mustard, vinblastine, vincristine, and procarbazine. The dose of the auricular radiation was unknown. There have been no other recurrences of lymphoma or other significant health concerns in the 38 years following the childhood Hodgkin lymphoma, except for right upper extremity lymphedema related to his Hodgkin axillary surgery and radiation. This was stage I-II and relatively asymptomatic.

Physical examination. His physical examination at time of presentation demonstrated a palpable right retroareolar mass with adherence to the skin.  He underwent a bilateral mammogram and axillary ultrasound, which confirmed the presence of a suspicious mass in the retroareolar region. Axillary lymph nodes were within normal limits and given no other systemic symptoms, no metastatic work-up was performed.

Differential diagnosis. The differential diagnosis for a man with a breast mass includes a cyst, fibroadenoma, gynecomastia, lipoma, fat necrosis, lymphoma, and breast cancer. The most common of these is gynecomastia. Imaging characteristics can further narrow the differential diagnosis. Definitive diagnosis is typically obtained by core-needle biopsy, which in this case was positive for cancer.

Ultrasound-guided core-needle biopsy of the mass demonstrated invasive ductal carcinoma, Nottingham histologic grade 2, estrogen receptor and progesterone receptor positive, HER2/neu negative. He was staged as clinical stage T1cN0.

Treatment and management. He was treated with right simple mastectomy with sentinel lymph node biopsy. A single focus of invasive carcinoma was found within the breast measuring 19 x 18 x 17 mm and two out of three sentinel lymph nodes were positive for macrometastases, with the largest deposit being 2.5 mm with extranodal extension--pathologic stage T1cN1aM0 (American Joint Committee on Cancer stage IA).