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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
These changes aren't always caused by cancer. For example,
most breast lumps in men are due to 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 may 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.
Diagnostic mammography
A diagnostic mammogram is an x-ray exam of the breast that is
done when problems are present. In some cases, special images known as cone views with magnification
are used to make a small area of abnormal breast tissue easier to
evaluate. The results of this test may suggest that a biopsy is needed
to tell whether 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.
Breast ultrasound
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 often 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 physical exam. A mass that is not a cyst will often need to be
biopsied.
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 any
cancer cells are present. This test is often not helpful, since a
breast cancer can still be present even when no cancer cells are found
in a nipple discharge. Other tests may be more helpful, such as a
mammogram or breast ultrasound. If you have a breast mass, a biopsy
will likely be needed (even if the nipple discharge does not contain
cancer cells or blood).
Biopsy
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 individual 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 may actually be more uncomfortable than the biopsy itself.
When the samples of most breast abnormalities are looked at
under a microscope, they show if they are benign or cancerous.
Sometimes,though, the results of the FNA are not clear, and another
type of biopsy is needed.
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
felt by the doctor 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 may still miss some cancers.
Surgical (open)
biopsy: Sometimes, surgery is needed to remove all or
part of the lump for microscopic examination. Usually this is an excisional biopsy,
where the surgeon removes the entire mass or abnormal area, as well as
a surrounding margin of normal-appearing breast tissue. If the mass is
very large, an incisional
biopsy, where only part of the mass is removed, may be
done instead. In rare cases, this type of biopsy can be done in the
doctor's office, but it is more commonly done in the hospital's
outpatient department under a local anesthesia (you are awake, but the
area around the breast is numb). You may also be given medicine to make
you drowsy.
This type of biopsy is more complicated than an FNA biopsy or
a core needle biopsy, but it is more likely to give an accurate
diagnosis and, in some cases, may be the only surgery that is needed if
the cancer is not invasive. It typically needs several stitches and may
leave a scar.
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 in the section, "How
is breast cancer treated?"
Lab tests of breast cancer biopsy samples
Once breast tissue samples have been obtained from a biopsy,
they are looked at in the lab to determine whether breast cancer is
present and if so, what type it is. 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, there should be time for you 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 may want to get a second opinion before
deciding on what treatment is best for you.
The tissue removed during the biopsy (or during surgery) is
first looked at under a microscope to see if cancer is present. The
biopsy is also used to determine the cancer's type. Most breast cancers
in men are invasive ductal carcinomas.
Grading
A pathologist (a doctor who specializes in diagnosing disease
in tissue samples) also assigns a
histologic grade to the cancer, which is based on how
closely the cancer in the biopsy sample looks like normal breast
tissue. 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.
The grade is based on the arrangement of the cells in relation
to each other, as well as features of individual cells.
- 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 are formed by cells that
appear very abnormal, grow rapidly, and rarely form tubules.
This system of grading is used for invasive cancers but not
for in situ cancers.
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.
About 9 out of 10 male breast cancers are ER-positive,
PR-positive, or are positive for both types of receptor. These cancers
tend to have a better prognosis than cancers without these receptors
and are much more likely to respond to hormonal therapy (see the
section, "How
is breast cancer in men treated?").
HER2/neu status
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). The HER2/neu gene instructs cells to make this
protein. Tumors with increased levels of HER2/neu are referred to as HER2-positive.
HER2-positive breast cancers have too many copies of the
HER2/neu gene (known as gene amplification). This results in greater
than normal amounts of the HER2/neu protein on the cancer cells. These
cancers 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, "How is breast cancer in men treated?" for more
information on these drugs.
Testing of the biopsy or surgery sample is usually done 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 (like
trastuzumab). If the test comes back 3+, the cancer is HER2-positive.
Patients with HER2-positive tumors may be treated with drugs like
trastuzumab. When the result is 2+, the HER2 status of the tumor is not
clear. This often leads to having the tumor tested with FISH. Newer
test methods are now becoming available as well (see the section,
"What's
new in breast cancer research and treatment?").
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 the course of 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 additional (adjuvant) treatment
such as chemotherapy might be helpful after surgery. Two such tests
(Oncotype DX® and MammaPrint®),
which look at different
sets of genes, are now available.
Although some doctors are using these tests (along with other
information) to help make decisions about offering chemotherapy, others
are waiting for more research to prove they are 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 if they would
be as useful in breast cancers in men. Still, men may want to discuss
whether or not these tests might be appropriate with their doctors.
Last Medical Review: 01/14/2010 Last Revised: 01/14/2010
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