MBC Published Article

Published December 10, 2014 at www.eRADIMAGING.com.
Available at:
http://www.eradimaging.com/site/article.cfm?ID=823&mode=ce#.VJhz-l4AA.
Challenges of Diagnosing and Treating Male

Breast Cancer:
Radiation Oncology Case Studies
Lee Culp, BA, RT(T),* Andy Kressin, BS,* and Nishele Lenards, MS, CMD, RT(R)(T), FAAMD
*Graduate Student, Medical Dosimetry Program, University of Wisconsin - La Crosse,

La Crosse, Wisconsin.
Medical Dosimetry Program Director, University of Wisconsin - La Crosse, La Crosse,

Wisconsin; Past President, American Association of Medical Dosimetrists.
Disclosures: The authors report having no significant financial or advisory
relationships with corporate organizations related to this activity.
ABSTRACT
Male breast cancer (MBC) is a rare disease that has become more prevalent over the
past decade. Because MBC is so rare, most of the published information regarding
the disease is extrapolated from female breast cancer data. It appears that males do
not benefit from the advancements leading to earlier breast cancer diagnosis and
improved cancer care in the same way females have in the last 10 years. Male
patients are often misdiagnosed at initial presentation or imaging results are
inconclusive. Although mammograms and sonograms are the standard for initial
breast examination in both men and women, it may be possible that an alternative
form of imaging such as magnetic resonance imaging could be more effective at
diagnosing breast cancer in males in earlier stages. This article presents an overview
of the epidemiology and etiology of MBC and uses 2 case studies to illustrate
challenges in the initial diagnosis of MBC and the role of imaging and postoperative
radiation therapy in breast cancer treatment.
Introduction
Epidemiology
Male breast cancer (MBC) is a rare disease, accounting for only 1% of total breast
cancers worldwide; however, the incidence of MBC has increased in the past 10
years.1-4 More specifically, there has been a 45% increase seen in the United States,
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Published December 10, 2014 at www.eRADIMAGING.com. Available at:

with the average age for MBC diagnosis at 60 years.3 It is expected that more than
2300 men will be diagnosed in 2014 with breast cancer, including a death toll
between 400 and 500.5Because of the rarity of the disease, most of the published
information regarding MBC is based on small, single institutional data or
extrapolated from data on female breast cancer (FBC). Traditional imaging and
treatments for FBC are the current standards of care for MBC patients as a result of
the lack of data.
Due to the lack of public awareness, as well as the rarity of disease, MBC is usually
diagnosed in late stages-either stages III or IV. Perhaps feelings of humiliation in
males presenting with breast cancer symptoms also plays a role and leads to refusing
to seek medical attention immediately upon presentation of symptoms. As a result,
MBC generally has a worse prognosis than FBC.2,6 As with FBC, survival is correlated
with tumor size and status of lymph node involvement, and men with negative
lymph nodes have an excellent prognosis.7 As is diagnostically customary in the initial
workup for women, men who present with possible breast cancer typically receive
mammograms, ultrasound, magnetic resonance imaging (MRI), fine-needle
aspiration (FNA), or some combination thereof. However, current statistics and
evidence show that males do not benefit from the advancements leading to earlier
breast cancer diagnosis and improved cancer care in the same way females have in
the past decade.3 This may be due to greater awareness and preventive screening
programs currently in place for women, in addition to the rarity of MBC. Some
studies have shown that MBC diagnoses are delayed 6 to 10 months on
average.8 This leads to a late-stage diagnosis and poorer outcomes for patients with
MBC. Perhaps, alternative imaging and diagnostic approaches should be taken when
male patients present in the clinic.
Etiology
Currently, there are no definitive etiological risk factors known to be solely
responsible for the onset of MBC, although certain criteria have been known to be
linked. The strongest link for MBC is the breast cancer 2 (BRCA2) gene mutation. The
BRCA2 gene is a gene that produces tumor suppressing proteins. These proteins aid
in repairing damaged DNA in the nucleus of each cell. When these genes are
mutated, the damaged DNA may not be repaired accurately, resulting in
uncontrolled cell growth.9 BRCA2 increases the overall risk of breast cancer for both
men and women. Nonetheless, women statistically present more often with BRCA1,
whereas male BRCA1 mutations are uncommon. Perhaps genetic differences


between male and female breast cancers suggest different diagnostic approaches
should be utilized when males present with breast cancer symptoms.
Imaging Modalities
A mammogram of the breast is an actual X-ray examination of the breast. The breast
is compressed between 2 plates to allow for the X-ray to penetrate the whole breast
tissue. During a mammogram, the patient is exposed to a dose of radiation.
However, this dose of radiation is very low, and much lower than mammograms in
the past. Mammograms are useful for detection and evaluation of possible breast
cancer, in that they provide a look inside the breast and skin. There are 2 types of
mammograms: screening and diagnostic. Screening mammograms are completed
yearly for a patient and are done proactively. The patient has no signs of breast
cancer, but these studies are completed to look for possible early stages and signs.
Diagnostic mammograms are done for patients in which an abnormal finding has
occurred. A diagnostic mammogram can take more images than a screening
mammogram, and can also magnify problematic areas for further detail and
evaluation. Mammograms are known to have limitations, especially in regard to
larger breasted women.
For women at high risk of breast cancer, an MRI is often completed at the same time
as the yearly mammogram. An MRI can better examine a suspicious area in a
mammogram, as well as serve as a secondary imaging modality in someone already
diagnosed with breast cancer. MRIs use very large magnets, as well as radio waves,
to produce the detailed images instead of X-rays, therefore minimizing the ionizing
radiation dose to the patient. The most useful MRI examinations for breast imaging
use a contrast material (called gadolinium) that is injected into a catheter in a vein
(intravenously) in the arm before or during the examination. This improves the
ability of the MRI to clearly show breast tissue details.10
An ultrasound is a diagnostic imaging modality that uses sound waves to look inside
the body. A transducer is placed on the skin and emits sound waves. The sound
waves are reflected back to the receiver as they recoil off body tissues. The reflected
sound waves, or echoes, are then transformed to images in black and white and
displayed on a computer screen for visual observation. Due to the nature of the
procedure, ultrasound is considered noninvasive and less expensive than most other
diagnostic modalities. For breast cancer, ultrasounds are used to evaluate a mass
and determine whether it is a fluid-filled cyst without having to use a needle for


biopsy. Ultrasounds are also useful for physicians when performing image-guided
biopsies of breast tissue.
After a lump in the breast is discovered, an FNA biopsy may be performed. The FNA
biopsy is used to assess whether or not the tissues within the lump are cancerous. A
fine, small needle is placed within the lump to take a sample. The sample is then
looked at under a microscope to assess the differentiation of the cells within the
sample. The FNA is very accurate when performed by an experienced professional,
and results in less bruising than other types of biopsies. However, there can be some
drawbacks to the FNA, especially if not enough of the tissue sample is obtained
during the procedure. Thus, if a FNA does not find cancer, it may need to be followed
up with different imaging modalities.11
Case Description
Patient Selection
This case study compares 2 patients with MBC who are receiving radiation therapy
(RT) in 2 different locations across the United States. Patient DF was treated in New
York, whereas the other patient (patient PP) was treated in Wisconsin. Both patients
presented with abnormalities in their breasts and both were initially told that their
symptoms were non-cancerous. However, after later follow-up visits regarding their
concerns, as well as numerous imaging studies and procedures, both men were
diagnosed with MBC.


Patient DF
Patient DF is a 57-year-old male who
presented in December of 2013 with
a sudden onset of moderate pain in
his left breast. At the time of his
initial consult, the pain had been
present for 2 months; he described it
as shooting and sore to the touch but
not radiating. The patient also
denied any associated mass, nipple
discharge, axillary lump, axillary
swelling, or skin changes. He
believed the pain was due to a
change in activity or exercise
because the pain was alleviated by
medication and rest. During initial
consultation, a breast examination
was performed while DF was
standing, in the supine position, and
in a sitting position. The breasts were
found to be normal on inspection,
with no skin changes. However, the
left breast was found to be tender,
with no dominant mass noted. At the
time of initial consult, a bilateral mammogram was completed with findings of a focal
density on the left side in the retroareolar region and 25-mm adjacent lymph nodes
at the lateral aspect of the left breast (Figure 1). Following the mammogram study,
an ultrasound was completed which demonstrated a 2.2-cm ill-defined retroareolar
area, likely a focal mastitis, with no definite lump or erythema (Figure 2).
A mammogram usually shows a dense mass without calcifications. For males, the
mass is usually situated in the retroareolar region, as MBC often originates in the
central ducts. A peripheral mass is highly suspicious for malignancy because it cannot
be gynecomastia.12 Gynecomastia is a common condition in patients with MBC, in
which hormonal changes cause the male breast tissue to enlarge.
Final assessment from the initial mammogram and ultrasound was Breast ImagingReporting and Data System (BI-RADS) category 3, probably benign. The BI-RADS was


developed by radiologists for reporting mammogram results using a common

language. A BI-RADS category 3 means that the mammogram is probably normal, but
a repeat mammogram should be completed in 6 months. The chance of breast
cancer is approximately 2% in this category.13 A chest X-ray was also completed at
this time showing no invasion into the chest.
One month later, in January
2014, DF had a follow-up
ultrasound of the left breast
because of continued
associated pain. This
ultrasound study revealed the
previously noted changes in
the left retroareolar region
once again, but they appeared
less prominent. This time the
density was found to measure
1.6 cm. The previously
mentioned lymph nodes
remained the same, at 5 mm
again. In February 2014, the
patient had another
consultation regarding the
pain that still resided in his
left breast. Pathology at this
appointment was found to show gynecomastia and focal atypia with no evidence for
malignancy. Another series of breast examinations was performed with no dominant
masses noted. An MRI was ordered for further evaluation which showed no evidence
of active disease. At this point, excision was recommended to DF, along with a partial
mastectomy. The patient declined partial mastectomy and elected to have a
lumpectomy in late February 2014.
A post-lumpectomy pathology report was completed on the mass, and it was
determined to be ductal carcinoma in situ (DCIS) with a nuclear grade of 1 to 2,
measuring 4.7 mm. No lymph nodes were taken for sampling. Necrosis was not
detected in the sample, and margins were negative. The architectural pattern of the
DCIS was that of cribriform. With cribriform carcinoma, the cancer cells invade the
stroma (connective tissues of the breast) in nest-like formations between the ducts


and lobules. Within the tumor, there are distinctive holes in between the cancer
cells. Cribriform carcinoma is usually low grade, meaning that the cells look and
behave somewhat like normal, healthy breast cells.14Estrogen and progesterone
receptor (ER/PR) assays were performed, and both receptors were found to be
positive. The ER/PR assays are immunohistochemical levels that grow in response to
the endocrine system. The ER-positive tumors grow in response to the hormone
estrogen, and the PR-positive tumors grow in response to the hormone
progesterone. These levels can estimate and help determine a potential survival rate
for a patient with breast cancer. Overall survival, disease-free survival, recurrence/relapse-free survival, 5-year survival, and response to endocrine therapy are all
positively associated with ER levels. Overall survival, time-to-treatment
failure/progression, and time to recurrence are positively related to PR levels. 15 It is
believed that patients with breast cancer who have higher hormone receptor levels
(ER/PR) will have a higher probability of positive outcomes and survival. If a tumor is
ER/PR positive, it will likely to respond to hormonal therapies which are to be
administered at the completion of chemotherapy, surgery, and RT.
Patient DF was informed of his treatment options, which included mastectomy or
lumpectomy followed by postoperative radiation. The patient refused a mastectomy
due to chest deformity concerns and his rather young age. In March 2014, patient DF
was referred to radiation oncology for post-lumpectomy RT of the left breast. Breast
conservation therapy, involving lumpectomy and postoperative RT, is currently the
treatment of choice for many women with early breast cancer. Post-lumpectomy RT
reduces the risk of local recurrence and the need for salvage mastectomy, as well as
long-term breast cancer mortality.16 After review of patient DF's records, the
radiation oncologist had a long discussion with DF about his diagnosis and various
treatment options, including post-lumpectomy irradiation of the whole breast, with
the addition of an electron boost to the tumor bed. Because MBC treatment is
similar to that of FBC, post-lumpectomy RT was recommended to DF. The radiation
oncologist discussed the benefits, as well as the acute and chronic side effects of
whole breast irradiation. Some of the acute side effects of whole breast irradiation
can include skin erythema and fatigue, while long-term side effects may include
fibrosis of the irradiated tissue and arm lymphedema. These long-term side effects
can severely affect the patient's quality of life in the future. Patient DF elected to
proceed with the post-lumpectomy RT treatments.
Patient PP
Patient PP is a 73-year-old male who presented at an outside institution in August


2009 with left nipple discharge but no palpable lump. In August 2009, PP underwent
a mammogram and an ultrasound of the left breast. The mammogram showed a 4mm indeterminate density, while the ultrasound showed no sonographic evidence of
malignancy. Patient PP was noted to have gynecomastia in both breasts. In March
2010, PP was seen for follow-up and was found to have a new 1.5 x 1 cm lump in the
4 o'clock position of the left breast. The patient underwent an additional
mammogram and ultrasound. The mammogram showed no abnormality in the left
breast corresponding to the palpable lump. Ultrasound on the same day also showed
no sonographic abnormalities in the left breast. The patient returned for follow-up in
June 2010, and was found to have no more bloody discharge and no palpable
abnormalities. In March 2014, the patient presented with a self-identified lump in
the left breast that had been problematic. A diagnostic bilateral mammogram was
completed in March 2014 (Figure 3). The mammogram showed a 4-cm density in the
upper inner quadrant of the left breast. In the same month, the patient underwent a
left breast ultrasound demonstrating a hypoechoic mass corresponding to the
location of the palpable lump (Figure 4). Some margins demonstrated nodularity
with small nodules not connected to the larger mass. Therefore, the possibility of
additional disease further away from the palpable mass could not be ruled out.


An ultrasound-guided
biopsy took place in March
2014 and revealed
intermediate-grade
infiltrating mammary
carcinoma of no special
type. The ER/PR assays
were positive and human
epidermal growth factor
receptor (HER-2) was
negative. When HER-2 is
found to be positive in a
specimen, endocrine
therapy agents targeting
this receptor may be an
additional treatment
option to RT.17 The HER-2
receptor has been found to
be positive in up to 20% of
all breast cancers and
generally leads to a worse
prognosis compared to HER2 negative cancers. The
patient underwent total left
breast mastectomy along
with left axillary sentinel
lymph node biopsy in late
March 2014. The sentinel
lymph node was positive,
leading to complete axillary
dissection.
Sentinel lymph node
biopsies have become the
standard of care for patients
with breast cancer in order to determine the status of nearby lymph nodes. 18 This

type of biopsy plays an important role in accurately staging breast cancers. There has
been some controversy about whether or not disease-free survival and overall
survival are affected by the presence or absence of micrometastasis revealed via
sentinel lymph node biopsies.19 Some studies have shown that women with
micrometastasis have similar 8-year disease-free survival and overall survival
compared to women with no micrometastasis present. On the other hand, additional
studies have shown that there is a reduction in disease-free survival and overall
survival with the presence of micrometastasis.19
A small piece of the superficial layer of the pectoralis muscle was also removed in
order to ensure an adequate deep margin. Pathology revealed grade 2 invasive
ductal carcinoma that was 3.8 cm in dimension. All margins were negative and the
final deep margin was benign skeletal muscle. Malignant cells were present in the
lymph nodes with 1 macrometastasis and 1 micrometastasis. The largest metastatic
focus was 15 mm. A total of 44 lymph nodes were evaluated, 2 of which were
positive. Extranodal extension was present. The patient was diagnosed with
pathologic T2N1a disease. Patient PP underwent genetics evaluation and was
advised to have genetic testing. Genetic tests were negative for BRCA1 and BRCA2
mutations.
Patient PP was informed of his many treatment options including mastectomy or
lumpectomy followed by postoperative RT and opted to undergo a mastectomy. In
March 2014, the patient was referred to radiation oncology for postoperative
treatment of the left chest wall. Post-surgery RT can decrease local recurrence in
patients with high-risk breast cancer and improve the overall survival rate.20 The
radiation oncologist reviewed the patient's records and discussed various treatment
regimens with PP. RT to the left chest wall and regional lymph nodes was
recommended to the patient. The radiation oncologist further recommended to PP
that an electron boost plan treating the mastectomy scar be added after the chest
wall and lymph node irradiation. The radiation oncologist discussed the benefits and
side effects of chest wall and lymph node irradiation. The patient elected to proceed
with the chest wall and lymph node RT treatments.
Patient Setup/Immobilization for RT
Both patients underwent a computed tomography (CT) simulation scan for RT
treatment planning. The patients were placed in the supine position on the CT
simulation couch on a breast or wing board and VacLoc with arms above their heads.
A triangle sponge was placed under the knees for added support and comfort. In


both cases the radiation oncologist marked the superior, inferior, medial, and lateral
field borders with wire.
The goal of the simulation process is to imitate the setup that will be used during
treatment and also utilize a setup that will be reproducible from day to day on the
treatment machine. If the patient is setup differently during simulation or is setup in
a manner that is difficult to reproduce, a geometrical miss of the intended target
may occur when the treatment plan is delivered. This could result in under-dosing
the target, possibly leading to recurrence of disease or unnecessarily treating
surrounding tissues which may lead to destruction of those tissues.
Target Delineation
The CT data set was electronically transferred to the radiation treatment planning
system to begin the treatment planning process. The purpose of the CT data set is to
allow for the treatment planning team to contour/delineate organs and structures
that may be affected by the radiation treatment. The radiation oncologist typically
contours the tumor volumes and planning target volumes (PTVs). Fusions of the
treatment planning CT with MRI, diagnostic CT, or positron emission tomography
scans may assist the radiation oncologist in delineating target volumes. The medical
dosimetrist typically contours critical structures and organs at risk. Contouring
structures allows for tracking of radiation doses received by those structures in the
treatment planning system (TPS). Because certain organs and structures have
specific thresholds for which severe side effects or death can take place, they often
become limiting factors in the type of treatment plan that can be designed and
delivered. CT scans also provide CT numbers (Hounsfield unit, HU) to account for
attenuation through different body tissues and structures for heterogeneity
correction in dose calculations utilized in treatment planning.21
Computed tomography scans for the purposes of radiation treatment differ in setup
from diagnostic CT scans. One of the main differences between the 2 scans is the
physical couch structure. A simulation CT couch is flat in order to imitate the
architecture of the linear accelerator treatment couch, whereas a diagnostic CT
couch is concave. Another major difference is that during simulation the patient
must be scanned in the position in which they will be treated on the linear
accelerators. This means the patient must be scanned with the immobilization or
setup devices that will be used during the course of treatment. Patient DF's CT data
set was transferred to the TPS. The medical dosimetrist contoured the organs at risk,
which included the heart, spinal cord, right lung, left lung, total lung, and ipsilateral


ribs. The carina was also contoured by the medical dosimetrist to assist the radiation
therapists in daily setup on the treatment machine.
Patient PP's CT data set was transferred to the TPS. The medical dosimetrist
contoured the right lung, left lung, total lung, esophagus, spinal cord, carina, and
heart. The physician contoured the left chest wall, axillary vessels, larynx, and the
level 1, 2, and 3 lymph nodes.
Treatment Planning
Both men received
conventional fractionation for
whole breast or chest wall
irradiation. Randomized
clinical trials in patients with
early stage breast cancer have
demonstrated that following
breast-conserving surgery,
adjuvant whole breast
irradiation lowers the relative
risk of ipsilateral breast tumor
recurrence by approximately
70% at 5 years and produces a
5% absolute improvement in
15-year overall
survival.22Conventional
fractionation for whole breast
or chest wall irradiation
consists of 180 cGy per day for
28 days for a total of 5040
cGy, followed by a successive radiation boost to the surgical scar or tumor bed. Both
patients received electron boosts of 1000 cGy at 200 cGy per day for 5 fractions.
Both men received the same radiation dose composite prescriptions delivered to
their post-surgical areas. The composite doses for both locations, including electron
boosts to the postoperative scars, were 6040 cGy in 33 fractions.
For patient DF, the radiation oncologist's plan was to use hybrid intensity-modulated
radiation therapy (IMRT) due to better coverage of the PTV, increased skin dose, and
reduced toxicity to the heart. The medical dosimetrist placed an isocenter for DF


corresponding to approximately the middle of the left breast (Figure 5). During the
simulation procedure, the radiation oncologist marked the edges of the field to assist
the medical dosimetrist in finding mid-field. Four fields from a linear accelerator
were used: 2 medial left breast fields utilizing 6 and 16 megavoltage (MV) energies
with IMRT and 2 lateral left breast fields utilizing 6 and 16 MV energies with IMRT.
The use of the 16 MV energy photon beams was used to penetrate deep into the
tissue, while the 6 MV energy photons were used to obtain superficial coverage near
the skin surface. A 30owedge was used on the 16 MV medial fields, while a
45o wedge was used on the 16 MV lateral left breast fields. Multileaf collimators
(MLC) were used on the 2 fluence IMRT fields to block areas determined by the
medical dosimetrist with the intention of reducing dose to the heart and ipsilateral
lung. The radiation oncologist made final adjustments to the MLC leaves in order to
begin radiation treatment planning. The medical dosimetrist determined field sizes
of each beam in relation to the upper and lower limits set by the radiation
oncologists during the simulation, as well as to meet the goals of the desired dose
distribution throughout the breast.
The radiation oncologist
outlined for DF the desired
dose prescription and
objectives for the hybrid IMRT
treatment plan. The intention
was to irradiate the breast
tissue with an appropriate
prescription coverage of the
post-lumpectomy breast
without destroying normal
tissues and organs at risk,
which the radiation oncologist
reviewed along with the dose
volume histogram (DVH;
Figure 6). The prescription
dose was prescribed to a
point at mid-breast, and
gantry angles of 303o for the medial fields and 128o for the lateral fields were used.
Each beam was weighted differently and delivered different percentages of the daily
prescription dose. The 16 MV medial left breast beam delivered 55 MU per day,
while the IMRT medial left breast field delivered 141 MU per day. The 16 MV lateral


left breast beam delivered 51 MU per day and the IMRT lateral left breast field
delivered 89 MU per day. A total of 336 MU was delivered daily. The patient received
a total of 180 cGy per day to the 96% isodose line for 28 fractions.
In PP's case, the radiation oncologist's recommendation was a 3-dimensional (3D)
plan utilizing conventional medial and lateral tangential beams for the primary chest
wall and lymph node treatment. The medical dosimetrist placed an isocenter in the
medial left lung approximately 1.3 cm from the chest wall. The right anterior oblique
(RAO) and the left posterior oblique (LPO) chest wall fields had gantry angles of
315o and 134.5o, respectively. The RAO and LPO supraclavicular fields had gantry
angles of 345o and 169o, respectively. All 4 fields utilized 15 MV beams from a linear
accelerator. There were no collimator or couch rotations for any of the fields. The
field size apertures for the left chest wall fields were defined by the radiation
oncologist and designed to include the entire post-mastectomy chest wall region
with an additional margin added for flash. The supraclavicular field size apertures
were also defined by the radiation oncologist.
outlined for PP the dose
prescription along with the
objective for the 3D
conformal treatment. The
objective was to use parallel
opposed supraclavicular fields
in conjunction with
conventional tangential chest
wall fields to maintain an
adequate and homogeneous
dose distribution throughout
the left chest wall tissue and
left neck nodes, while
reducing toxicity to the heart
and left lung (Figure 7). The
radiation oncologist also
requested that the maximum dose to the axillary vessels be kept below 5292 cGy.
The prescription dose for the conventional tangential chest wall fields was prescribed
to a calculation point placed by the medical dosimetrist within the left chest wall
tissue. The prescription dose for the parallel opposed supraclavicular fields was


prescribed to a different calculation point placed by the medical dosimetrist in the

upper axilla region. The patient received 180 cGy per day to both the left chest wall
and left supraclavicular regions for 28 fractions.
Plan Analysis and Evaluation
For patient DF, the medical dosimetrist presented a tangential 4-field arrangement,
as well as the hybrid IMRT plan for the radiation oncologist to review. The radiation
oncologist chose the hybrid IMRT plan due to the fact that there was better coverage
of the skin with the prescription dose and more homogeneous dose coverage of the
whole breast. The clinic where DF was treated requires the distance between the
skin and dose coverage be less than 5 mm, and that the maximum dose be less than
5544 cGy after normalization. Hybrid IMRT is chosen for the left breast often due to
the fact that the heart dose can be reduced, as well as the maximum dose, and skin
coverage can be increased without decreasing the conformity of the isodose lines.
It has been known that
radiation to the lungs can
cause pneumonitis. In order
to avoid this, radiation
oncologists try to measure the
percentage of the lung
volume receiving a dose of 20
Gy (V20). For the heart, there
is risk of toxicity. Therefore,
radiation oncologists measure
the percent of the heart
receiving at least 30 Gy (V30).
reviewed the hybrid IMRT
plan and noted that the V20
dose to the total lung was
2.2%, and the V30 dose to the
heart was 0%; both were
within their respective
constraints. The plan was then approved for treatment.
In patient PP's case, a traditional tangential left chest wall and supraclavicular
treatment plan was developed. Once adequate prescription coverage and a


homogeneous dose distribution were achieved to the left chest wall and neck nodal
volumes, the medical dosimetrist reviewed the axillary dose constraint, the isodose
lines, and the DVH (Figure 8). The maximum dose to the axillary vessels was 5288
cGy, which fell within the constraint the radiation oncologist set at 5292 cGy. The
radiation oncologist also reviewed the plan and assigned a normalization of 100% to
both the left chest wall and left supraclavicular prescriptions of the treatment plan
prior to approving the plan.
Discussion
Both patients had initial workups that included mammogram and ultrasound studies,
and both were noted to have gynecomastia. Even when small densities were found
in the initial workups, they were considered non-malignant and the patients were
instructed to closely monitor their areas of concern for any changes. Mammograms
and ultrasounds are the standard for initial breast examination in both men and
women. Mammography is used when ultrasound findings are indeterminate. When
ultrasound and mammography findings are suspicious, or if mammography appears
indeterminate for malignancy, tissue diagnosis is recommended.23 However, a study
by Kuhl et al24 found that MRI used for female breast examinations was far superior
to mammography and ultrasound in detecting cancers, which is a less invasive next
step. Patient DF underwent an MRI which also failed to show malignancy. One
possible explanation for the negative results of the 3 diagnostic studies for patient
DF is that the density was in an undetectable precancerous stage at the time of the
early workups. Unlike patient DF, patient PP never underwent an MRI. After one
diagnostic study for patient PP showed an abnormal density and the second study
returned negative, perhaps a third study in the form of an MRI could have been of
diagnostic benefit for PP.
Because MBC has been on the rise in the past decade, perhaps different imaging
studies for men need to be given more consideration in research
studies.3 Furthermore, imaging features that would normally suggest a benign tumor
in females (mammogram and ultrasound) are not always reliable imaging findings in
men; further investigation is needed to distinguish between a benign and malignant
diagnosis in men.25 Because males do not benefit the same from the advancements
in breast cancer screening and treatment compared to women because of the lack of
understanding of MBC, maybe MRI studies in conjunction with another diagnostic
study should be considered for males at the time of initial examination for MBC. The
answer may be as simple as performing MRIs and mammograms instead of
ultrasounds and mammograms. The research from Kuhl et al24 found that all the


breast cancers in their study were found if MRI was used in conjunction with
mammography. The cost of diagnostic studies should be considered. But there may
be different combinations of studies besides the traditional mammogram and
ultrasound arrangement that could provide for earlier detection of breast cancer in
males. The extrapolation from FBC data has not improved the frequency of early
MBC diagnosis. With males failing to benefit from recent breast cancer
advancements and females being diagnosed more frequently in early stages, changes
in the standards of screening males with potential breast cancer need to be more
seriously considered for research.
An obvious limitation of this case study is that only 2 patients were considered.
Further research should include a larger population of patients to evaluate the
diagnostic workup for MBC diagnoses and earlier detection.
Conclusions
Although the current standard of care was given to both patients presented in these
case studies, initial workups and imaging studies proved to be inconclusive.
Advancements in breast cancer care have improved early diagnosis rates in women,
but the majority of men presenting with breast cancer symptoms continue to be
diagnosed with later stage disease. Prospective research studies that focus on
discerning the most effective imaging studies for males presenting with breast
cancer symptoms could lead to alternative standards of care for men compared to
women. These types of research studies may also contribute to improvement in
rates of early diagnoses of male breast cancer. Until then, the current standards of
care remain commonplace and continue to result in late stage diagnosis of breast
cancers in males.
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Published December 10, 2014 at www.eRADIMAGING.com.

Challenges of Diagnosing and Treating Male

*Graduate Student, Medical Dosimetry Program, University of Wisconsin - La Crosse,

Medical Dosimetry Program Director, University of Wisconsin - La Crosse, La Crosse,

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developed by radiologists for reporting mammogram results using a common

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prescribed to a different calculation point placed by the medical dosimetrist in the

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