How is breast cancer in men diagnosed?
Signs and symptoms
Men need to know that breast cancer is not limited to only women. Possible signs of breast cancer to watch for include:
- A lump or swelling, which is usually (but not always) painless
- Skin dimpling or puckering
- Nipple retraction (turning inward)
- Redness or scaling of the nipple or breast skin
- Discharge from the nipple
Sometimes a breast cancer can spread to lymph nodes under the arm or around the collar bone and cause a lump or swelling there, even before the original tumor in the breast tissue is large enough to be felt.
These changes aren't always caused by cancer. For example, most breast lumps in men are caused by gynecomastia (a harmless enlargement of breast tissue). Still, if you notice any breast changes, you should see your health care professional as soon as possible.
Medical history and physical exam
If there is a chance you have breast cancer, your doctor will want to get a complete personal and family medical history. This may give some clues about the cause of any symptoms you are having and if you might be at increased risk for breast cancer.
A thorough clinical breast exam will be done to locate any lumps or suspicious areas and to feel their texture, size, and relationship to the skin and muscle tissue. The doctor may also examine the rest of your body to look for any evidence of possible spread, such as enlarged lymph nodes (especially under the arm) or an enlarged liver. Your general physical condition may also be evaluated.
Tests used to evaluate breast disease
If the history and physical exam suggest breast cancer may be possible, several types of tests may be done.
A mammogram is an x-ray exam of the breast. It is called a diagnostic mammogram when it is done because problems are present.
For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. This procedure produces a black and white image of the breast tissue either on a large sheet of film or as a digital computer image that is read, or interpreted, by a radiologist (a doctor trained to interpret images from x-rays and other imaging tests). In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.
A digital mammogram (also known as a full-field digital mammogram, or FFDM) is like a standard mammogram in that x-rays are used to produce an image of your breast. The differences are in the way the image is recorded, viewed by the doctor, and stored. Standard mammograms are recorded on large sheets of photographic film. Digital mammograms are recorded and stored on a computer. After the exam, the doctor can look at them on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital images can also be sent electronically to another site for a remote consultation with breast specialists. Not all centers offer the digital option, but it is becoming more widely available.
The results of this test might suggest that a biopsy is needed to tell if the abnormal area is cancer. Mammography is often more accurate in men than women, since men do not have dense breasts or other common breast changes that might interfere with the test.
Ultrasound, also known as sonography, uses high-frequency sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is first lubricated with gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image on a computer screen. This test is painless and does not expose you to radiation.
Breast ultrasound is sometimes used to evaluate breast abnormalities that are found during mammography or a physical exam. It can be useful to see if a breast lump or mass is a cyst or a tumor. A cyst is a non-cancerous, fluid-filled sac that can feel the same as a tumor on a physical exam. A mass that is not a simple cyst will often need to be biopsied.
Magnetic resonance imaging (MRI) of the breast
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a very detailed image of parts of the body. For breast MRI to look for cancer, a contrast liquid called gadolinium is injected into a vein before or during the scan to show details better.
MRI scans can take a long time — often up to an hour. You have to lie inside a narrow tube, face down on a platform specially designed for the procedure. The platform has openings for each breast that allow them to be imaged without compression. The platform contains the sensors needed to capture the MRI image. It is important to remain very still throughout the exam. Lying in the tube can feel confining and might upset people with claustrophobia (a fear of enclosed spaces). The machine also makes loud buzzing and clicking noises that you may find disturbing. Some places will give you headphones with music to block this noise out. MRIs are also expensive, although insurance plans generally pay for them in some situations, such as once cancer is diagnosed.
MRI machines are quite common, but they need to be specially adapted to look at the breast. It's important that MRI scans of the breast be done on one of these specially adapted machines and that the MRI facility can also do a MRI-guided biopsy if it is needed.
MRI can be used to better examine suspicious areas found by a mammogram. MRI is also used in someone who has been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast.
Nipple discharge exam
Fluid leaking from the nipple is called nipple discharge. If you have a nipple discharge, you should have it checked by your doctor. If there is blood in this fluid, you might need more tests. One test collects some of the fluid to look at under a microscope to see if cancer cells are present. This test is often not helpful, since a breast cancer can still be there even when no cancer cells are found in the nipple discharge. Other tests may be more helpful, such as a mammogram or breast ultrasound. If you have a breast mass, you will probably need a biopsy (even if the nipple discharge does not contain cancer cells or blood).
A biopsy removes a body tissue sample to be looked at under a microscope. A biopsy is the only way to tell if a breast abnormality is cancerous. Unless the doctor is sure the lump is not cancer, this should always be done. There are several types of biopsies. Your doctor will choose the type of biopsy based on your situation.
Fine needle aspiration biopsy: Fine needle aspiration (FNA) biopsy is the easiest and quickest biopsy technique. The doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area. The doctor can guide the needle into the area of the breast abnormality while feeling the lump. A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic might actually be more uncomfortable than the biopsy itself.
An FNA biopsy is the easiest type of biopsy to have, but it has some disadvantages. It can sometimes miss a cancer if the needle is not placed among the cancer cells. And even if cancer cells are found, it is usually not possible to determine if the cancer is invasive. In some cases there may not be enough cells to perform some of the other lab tests that are routinely done on breast cancer specimens. If the FNA biopsy does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.
Core needle biopsy: For a core biopsy, the doctor removes a small cylinder of tissue from a breast abnormality to be looked at under a microscope. The needle used in this technique is larger than that used for FNA. The biopsy is done with local anesthesia in the doctor's office.
A core biopsy uses a larger needle to sample breast changes the doctor felt or pinpointed by ultrasound or a mammogram. (When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.) In some centers, the biopsy can be guided by an MRI scan.
Because it removes larger pieces of tissue, a core needle biopsy is more likely than an FNA to provide a clear diagnosis, although it might still miss some cancers.
Surgical (open) biopsy: Most breast cancer can be diagnosed with a needle biopsy. Rarely, though, surgery is needed to remove all or part of the lump to know for certain if cancer is present. Most often, the surgeon removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue. This is called an excisional biopsy. If the mass is too large to be removed easily, only part of it may be removed. This is called an incisional biopsy.
In rare cases, a surgical biopsy can be done in the doctor's office, but it is more commonly done in the hospital's outpatient department under local anesthesia (you are awake, but the area around the breast is numb), often with intravenous sedation (medicine given into a vein to make you drowsy).
A surgical biopsy is more involved than an FNA biopsy or a core needle biopsy, and it often requires several stitches and may leave a scar. Sometimes, though, this type of biopsy is needed to get an accurate diagnosis.
All biopsies can cause bleeding and can lead to swelling. This can make it seem like the breast (or the lump in the breast) is larger after the biopsy. This is generally nothing to worry about and the bleeding and bruising go away quickly in most cases.
Lymph node biopsy: Cancer in the breast can spead to lymph nodes under the arm and around the collar bone (clavicle). If any of these lymph nodes are enlarged, they may be biopsied at the same time as the breast tumor is. Most often, a needle biopsy is done.
Lymph node dissection and sentinel lymph node biopsy: These procedures are done specifically to look for cancer in the lymph nodes. They are described in more detail under "Types of breast surgery" in the “Surgery for breast cancer in men” section.
Lab tests of breast cancer biopsy samples
Breast tissue samples from a biopsy are looked at in the lab to determine whether cancer is present. If there is enough tissue, the pathologist can usually determine if the cancer is in situ (not invasive) or invasive. The biopsy is also used to determine the cancer's type, such as invasive ductal carcinoma or invasive lobular carcinoma. Most breast cancers in men are invasive ductal carcinomas. Relatively few cells are removed with an FNA biopsy and they frequently become separated from the underlying breast tissue, so it is often only possible to say that cancer cells are present without being able to say if the cancer is in situ or invasive. Other lab tests can help determine how quickly a cancer is likely to grow and (to some extent) what treatments are likely to be effective.
If a benign condition is diagnosed, no further treatment is needed. If the diagnosis is cancer, you should have time to learn about the disease and to discuss treatment options with your cancer care team, friends, and family. It is usually not necessary to rush into treatment. You might want to get a second opinion before deciding which treatment will be best for you.
A pathologist (a doctor who specializes in diagnosing disease in tissue samples) also assigns a histologic grade to the cancer (known as grading). The grade is a measure of how closely the cancer in the biopsy sample looks like normal breast tissue and how fast the cancer cells are dividing. It is based on the arrangement of the cells in relation to each other, as well as features of individual cells. The grade helps predict the patient's prognosis (outlook). In general, a lower grade number indicates a slower-growing cancer that is less likely to spread, while a higher number indicates a faster-growing cancer that is more likely to spread.
- Grade 1 (well differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.
- Grade 2 (moderately differentiated) cancers have features between grades 1 and 3.
- Grade 3 (poorly differentiated) cancers have cells that appear very abnormal, grow rapidly, and rarely form tubules.
This system of grading is used for invasive cancers. Ductal carcinoma in situ is also graded, but the grade is based only on the features of the cancer cells.
Estrogen receptor (ER) and progesterone receptor (PR) status
Receptors are cell proteins that can attach to certain substances, such as hormones, that circulate in the blood. Normal breast cells and some breast cancer cells have receptors that attach to estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells.
An important step in evaluating a breast cancer is to test a portion of the cancer removed during the biopsy (or surgery) for the presence of estrogen and progesterone receptors. Cancer cells may contain neither, one, or both of these receptors. Breast cancers that contain estrogen receptors are often referred to as ER-positive cancers, while those containing progesterone receptors are called PR-positive cancers. If either type of receptor is present, the cancer is said to be hormone receptor-positive.
About 9 out of 10 male breast cancers are hormone receptor-positive. These cancers tend to grow more slowly than cancers without these receptors and are much more likely to respond to hormonal therapy (see the section, "Hormone therapy for breast cancer in men").
In a small number of breast cancers in men, the cells have too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). Tumors with increased levels of HER2/neu are referred to as HER2-positive.
The HER2/neu gene instructs cells to make this protein, and cells can become HER2-positive breast cancers by having too many copies of the HER2/neu gene (known as gene amplification). Cancer cells with greater than normal amounts of the HER2/neu protein tend to grow and spread more aggressively than other breast cancers.
All newly diagnosed breast cancers should be tested for HER2/neu because HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin®) and lapatinib (Tykerb®). See the section, "Targeted therapy for breast cancer in men" for more information on drugs that target this protein.
The biopsy or surgery sample is usually tested in 1 of 2 ways:
Immunohistochemistry (IHC): In this test, special antibodies that identify the HER2/neu protein are applied to the sample, which cause it to change color if abnormally high levels are present. The test results are reported as 0, 1+, 2+, or 3+.
Fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.
Many breast cancer specialists think the FISH test gives more accurate results than IHC, but it is more expensive and takes longer to get the results. Often the IHC test is used first. If the results are 1+ (or 0), the cancer is considered HER2-negative. People with HER2-negative tumors are not treated with drugs that target HER2.
If the test comes back 3+, the cancer is HER2-positive. Patients with HER2-positive tumors may be treated with drugs that target HER2.
When the result is 2+, the HER2 status of the tumor is not clear and the tumor is then tested with FISH. Some institutions also use FISH to confirm HER2 status that is 3+ by IHC and some perform only FISH.
A newer type of test, known as chromogenic in situ hybridization (CISH), works similarly to FISH, by using small DNA probes to count the number of HER2 genes in breast cancer cells. But this test doesn't require a special microscope and looks for color changes (not fluorescence) which may make it less expensive. Right now, it is not being used as much as IHC or FISH.
Tests of ploidy and cell proliferation rate
The ploidy of cancer cells refers to the amount of DNA they contain. If there's a normal amount of DNA in the cells, they are said to be diploid. If the amount is abnormal, then the cells are described as aneuploid. Although these tests may help determine prognosis, they rarely change treatment and are considered optional. They are not usually recommended as part of a routine breast cancer work-up. Different methods can be used to measure ploidy:
- Flow cytometry uses lasers and computers to measure the amount of DNA in cancer cells suspended in liquid as they flow past the laser beam.
- Image cytometry uses computers to analyze digital images of the cells from a microscope slide.
Flow cytometry can also measure the S-phase fraction, which is the percentage of cells in a sample that are replicating (copying) their DNA. DNA replication means that the cell is getting ready to divide into 2 new cells. The rate of cancer cell division can also be estimated by a Ki-67 test, which identifies cells in the S-phase, as well as cells getting ready to replicate DNA, cells that have just completed DNA replication, and cells in the process of dividing. A high S-phase fraction or Ki-67 labeling index means that the cancer cells are dividing more rapidly, which indicates a more aggressive cancer.
Tests of gene patterns
Researchers have found that looking at the patterns of a number of specific genes at the same time (sometimes referred to as gene expression profiling) can help predict whether or not an early stage breast cancer is likely to come back after initial treatment. This can help when deciding whether to use additional (adjuvant) treatment such as chemotherapy after surgery. Two such tests (Oncotype DX® and MammaPrint®) look at different sets of genes.
Although many doctors use these tests (along with other information) to help make decisions about offering chemotherapy, others are waiting for more research to prove they are really helpful. Large clinical trials of these tests are now under way. These tests have been studied mainly in breast cancers in women, and it's not yet clear how helpful they are in breast cancers in men. Still, men may want to ask their doctors if these tests might be appropriate.
Imaging tests to look for breast cancer spread
Once breast cancer is diagnosed, one or more of the following tests may be done. These tests aren’t often done for early breast cancer. Which of these tests (if any) is done depends on how likely it is that the cancer has spread, the size of the tumor, the presence of lymph node spread, and any symptoms you are having.
This test may be done to see if the breast cancer has spread to the lungs.
If they haven't been done already, more extensive mammograms may be done to get more thorough views of both breasts.
A bone scan can help show if a cancer has metastasized (spread) to the bones. It can be more useful than standard x-rays because it can show all of the bones in the body at the same time and can find small areas of cancer spread not seen on plain x-rays.
For this test, a small amount of low-level radioactive material is injected into a vein (intravenously or IV). The substance settles in areas of bone changes throughout the entire skeleton over the course of a couple of hours. You then lie on a table for about 30 minutes while a special camera detects the radioactivity and creates a picture of your skeleton.
Bone changes show up as "hot spots" on your skeleton. They attract the radioactivity. These areas may suggest the presence of metastatic cancer, but arthritis or other bone diseases can also cause the same pattern. To distinguish between these conditions, your cancer care team may use other imaging tests such as simple x-rays or CT or MRI scans to get a better look at the areas that light up, or they may even take biopsy samples of the bone.
Computed tomography (CT) scan
The CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking a single picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied. In people with breast cancer, this test is most often used to look at the chest and/or abdomen to see if the cancer has spread to other organs, such as the lungs or liver.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected to better outline structures in your body.
The injection may cause some flushing (a feeling of warmth, especially in the face). Some people are allergic and get hives. Rarely, more serious reactions can occur like trouble breathing or low blood pressure. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans take longer than regular x-rays, but in general are very quick. You need to lie still on a table while they are being done. During the test, the table moves in and out of the scanner, a ring-shaped machine that completely surrounds the table. You might feel a bit confined by the ring while the pictures are being taken.
CT guided needle biopsy: If an abnormal area is seen on a CT scan, it may need to be biopsied to see if it is cancer. The biopsy can be done using the CT scans to precisely guide a biopsy needle into the area. For this procedure, you remain on the CT scanning table while a radiologist advances a biopsy needle through the skin and toward the location of the mass (abnormal area). CT scans are repeated until the doctors are sure that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is then removed and sent to be looked at under a microscope.
Magnetic resonance imaging (MRI) scan
This use of this test to look at the breast was discussed earlier in this section.
MRI scans are also used to look for cancer that has spread to various parts of the body, just like CT scans. MRI scans are particularly helpful in looking at the brain and spinal cord.
There are some differences between using this test to look at the breast and other areas of the body. Firstly, you will lie face up in the machine. Second, the contrast material called gadolinium is not always needed to look at other areas of the body. Also, you may have the option of having the scan in a less confining machine known as an open MRI machine. The images from an open machine are not always as good, though, so this is not always an option.
The use of this test to look at the breast was discussed earlier in this section. But ultrasound can also be used to look for cancer that has spread to some other parts of the body.
Abdominal ultrasound can be used to look for tumors in your liver or other abdominal organs. When you have an abdominal ultrasound exam, you simply lie on a table and a technician moves the transducer over the skin overlying the part of your body being examined. Usually, the skin is first lubricated with gel.
Positron emission tomography (PET) scan
For a PET scan, glucose (a form of sugar) that contains a radioactive atom is injected into the blood. Because cancer cells in the body are growing rapidly, they absorb large amounts of the radioactive sugar. After about an hour, a special camera is used to create a picture of areas of radioactivity in the body.
A PET scan is useful when your doctor thinks the cancer may have spread but doesn't know where. The picture is not as finely detailed as a CT or MRI scan, but it can provide helpful information about your whole body. Some machines can perform both a PET and CT scan at the same time (PET/CT scan). The radiologist can compare areas of higher radioactivity on the PET with the appearance of that area on the CT.
This test can be useful in looking for cancer that has spread to distant organs, but it is not as helpful in looking for small deposits of cancer cells in the lymph nodes under the arm (axillary lymph nodes). PET scans are most often ordered for patients with large tumors or when the doctor suspects the cancer has spread.
Last Medical Review: 09/21/2012
Last Revised: 02/26/2013