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CE Information
In order to receive CE credit, you must first complete the activity content. When completed, go
to the Take CE Test! link to access the post-test.

Submit the completed answers to determine if you have passed the post-test assessment. You
must obtain a score of 75% to receive the CE credit. You will have no more than 3 attempts to
successfully complete the post-test.

Participants successfully completing the activity content and passing the post-test will receive
1.0 ARRT Category A credits.

Approved by the American Society of Radiologic Technologists for ARRT Category A credit.

This activity may be available in multiple formats or from different sponsors. ARRT does not
allow CE activities such as Internet courses, home study programs, or directed readings to be
repeated for CE credit in the same or any subsequent biennium.

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Course Description
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.

Learning Objectives
After reading this article, the participant should be able to:

Discuss the epidemiology and etiology of MBC.

Describe the role of radiation therapy for breast cancer patients in the postoperative
setting.

Assess the difference and significance of estrogen and progesterone receptor positive
and negative tumors.

Explain the difference between diagnostic and simulation computed tomography scans.

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CE Article

Challenges of Diagnosing and Treating Male Breast Cancer: Breast Imaging and Radiation
Therapy Case Studies

Lee Culp, RT(T), Andy Kressin, Nishele Lenards, MS, CMD, RT(R)(T), FAAMD
Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI

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, 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 500.5 Because of the rarity of the

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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 stageseither 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

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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 Xrays, 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

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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

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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 Imaging-Reporting
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

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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.14 Estrogen 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 ERpositive 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 DFs
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 longterm side effects may include fibrosis of the irradiated tissue and arm lymphedema. These longterm side effects can severely affect the patients 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 4-mm 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 oclock 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

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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 HER-2 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

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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. Postsurgery RT can decrease local recurrence in patients with high-risk breast cancer and improve
the overall survival rate.20 The radiation oncologist reviewed the patients 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.

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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 DFs

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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 PPs 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.22 Conventional 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 oncologists 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

14
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 30o wedge 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 PPs case, the radiation oncologists 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

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.

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.

16
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). The radiation oncologist 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 PPs 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

17
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

18
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.

References
1. Anderson WF, Jatoi I, Tse J, et al. Male breast cancer: a population-based comparison with
female breast cancer. J Clin Oncol. 2010;28:232-239. Available at:
http://dx.doi.org/10.1200/JCO.2009.23.8162. Accessed November 2, 2014.
2. Andrykowski MA. Physical and mental health status and health behaviors in male breast
cancer survivors: a national, population-based, case-control study. Psycho-Oncol. 2012;21:927934. Available at: http://dx.doi.org/10.1002/pon.2001. Accessed November 2, 2014.
3. Reis LO, Dias FGF, Castro MA, et al. Male breast cancer. The Aging Male. 2011;14:99- 109.
Available at: http://dx.doi.org/10.3109/13685538.2010.535048. Accessed November 2, 2014.
4. Shah S, Bhattacharyya S, Gupta A, et al. Male breast cancer: a clinicopathologic study of 42
patients in Eastern India. Indian J Surg Oncol. 2012;3:245-249. Available at:
http://dx.doi.org/10.1007/s13193-012-0163-1. Accessed November 2, 2014.
5. American Cancer Society. Breast Cancer Facts & Figures 2013-2014. Available at:
http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc042151.pdf. Accessed May 9, 2014.
6. Rudlowski C. Male breast cancer. Breast Care. 2008;3:183-189. Available at:
http://dx.doi.org/10.1159/000136825. Accessed November 2, 2014.
7. Leibowitz S, Fox E, Loda M, et al. Male patients with diagnoses of both breast cancer and
prostate cancer. Breast J. 2003:9:208-212.

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8. Wang W, Chen L, Ouyang X. Misdiagnosed male breast cancer with an unknown primary
tumor: a case report. OncolLett.2014;8:190-192. Available at:
http://dx.doi.org/10.3892/ol.2014.2111. Accessed November 2, 2014.
9. Drew Y, Calvert H. The potential or PARP inhibitors in genetic breast and ovarian cancers. Ann
NY Acad Sci. 2008;1138:136-145. Available at: http://dx.doi.org/10.1196/annals.1414.020.
Accessed November 2, 2014.
10. American Cancer Society. Magnetic resonance imaging. Available at:
http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearly
detection/breast-cancer-early-detection-a-c-s-recs-m-r-i. Accessed October 17, 2014.
11. Susan G. Komen. Fine needle aspiration (fine needle biopsy). Available at:
http://ww5.komen.org/BreastCancer/FineNeedleBiopsy.html. Accessed October 17, 2014.
12. Charlot M, Beatrix O, Dubuisson J, et al. Pathologies of the male breast. Diagn Interv Radiol.
2013;94:26-36.
13. Eberl M, Fox C, Edge S, et al. BI-RADS classification for management of abnormal
mammograms. J Am Board Fam Med. 2006;19:161-164. Available at:
http:dx.doi.org/doi:10.3122/jabfm.19.2.161. Accessed November 2, 2014.
14. Breast Cancer.org. IDC Type: Cribriform Carcinoma of the Breast.
http://www.breastcancer.org/symptoms/types/cribriform. Accessed June 2, 2014.
15. Hammond E, Hayes D, Dowsett M, et al. American Society of Clinical Oncology/College of
American Pathologists guideline recommendations for immunohistochemical testing of
estrogen and progesterone receptors in breast cancer. J Clin Oncol. 2010;28:2784-2795.
16. Ashworth A, Kong W, Whelan T, et al. A population-based study of the fractionation of
postlumpectomy breast radiation therapy. Int J Radiat Oncol Bio Phys. 2013;86:51-57. Available
at: http://dx.doi.org/10.1016/j.ijrobp.2012.12.015. Accessed November 2, 2014.
17. Mayer EL, Gropper AB, Harris L, et al. Long-term follow-up after preoperative trastuzumab
and chemotherapy for HER2-overexpressing breast cancer. Clin Breast Cancer. In press.
Available at: http://dx.doi.org/10.1016/j.clbc.2014.07.010. Accessed November 2, 2014.

20
18. Jaffer S, Bleiweiss IJ, Nayak A. Are cytokeratin positive cells in sentinel lymph nodes of
patients with invasive breast carcinomas up to 5 mm usually significant? Histopathol. In press.
Available at: http://dx.doi.org/10.1111/his.12504. Accessed November 2, 2014.
19. Zervoudis S, Iatrakis G, Tomara E, et al. Main controversies in breast cancer. World J Clin
Oncol. 2014;5:359-373.
20. Yang B, Wei X, Zhao, et al. Dosimetric evaluation of integrated IMRT treatment of the chest
wall and supraclavicular region for breast cancer after modified radical mastectomy. Med
Dosim. 2014;39:185-189. Available at: http://dx.doi.org/10.1016/j.meddos.2013.12.008.
Accessed November 2, 2014.
21. Wu V, Podgorsak M, Tran TA, et al. Dosimetric impact of image artifact from a wide-bore CT
scanner in radiotherapy treatment planning. Med Phys. 2011;38:4451-4463. Available at:
http://dx.doi.org/10.1118/1.3604150. Accessed November 2, 2014.
22. Smith B, Bentzen S, Correa C, et al. Fractionation for whole breast irradiation: an American
Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys.
2011;81:59-68. Available at: http://dx.doi.org/10.1016/j.ijrobp.2010.04.042. Accessed
November 2, 2014.
23. Adibelli Z, Oztekin O, Postaci H, et al. The diagnostic accuracy of mammogram and
ultrasound in the evaluation of male breast disease: a new algorithm. Basel. 2009;4:255- 259.
24. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic
resonance imaging for surveillance of women at familial risk for breast cancer. J Clin Oncol.
2005;3:8469-8476. Available at: http://dx.doi.org/10.1200/JCO.2004.00.4960. Accessed
November 2, 2014.
25. Ng A, Dissanayake D, Metcalf C, et al. Clinical and imaging features of male breast disease,
with pathology correlation: a pictorial essay. J Med Imag Radiat Oncol. 2013;58:189-198.
Available at: http://dx.doi.org/10.1111/1754-9485.12073. Accessed November 2, 2014.

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Figure 1. Patient DFs Initial Bilateral Mammogram

Image shows a focal density on the left side in the retroareolar region and 2 5-mm adjacent
lymph nodes at the lateral aspect of the left breast.

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Figure 2. Patient DFs Initial Ultrasound

Image demonstrating a 2.2-cm ill-defined retroareolar area in the left breast.

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Figure 3. Patient PPs Diagnostic Bilateral Mammogram

Shows a 4-cm density in the upper inner quadrant of the left breast.

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Figure 4. Patient PPs Initial Ultrasound

Demonstrates a hypoechoic mass of the left breast corresponding to the location of the
palpable lump.

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Figure 5. Patient DF: Axial View of Isocenter Placement and Isodose Coverage of the Left
Breast

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Figure 6. Patient DFs Dose Volume Histogram

Shows a maximum total dose of less than 5544 cGy, a total lung V20 of 2.2%, and a heart V30 of
0%.
Magenta = heart; Purple = total lung; Green = spinal canal; Blue = right lung; Light Blue = left
lung; Yellow = ipsilateral ribs.

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Figure 7. Patient PP Isodose Distribution of the Inferior Left Chest Wall

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Figure 8. Patient PPs Dose Volume Histogram

Showing a maximum dose to the axillary vessels of less than 5292 cGy along with low toxicities
to the heart and lungs.
Magenta = heart; Blue = total lungs; Green = axillary vessels; Brown = esophagus; Light Brown =
larynx; Yellow = level 1 lymph nodes; Orange = level 2 lymph nodes; Teal = Level 3 lymph nodes.

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