Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Case Study:
Infiltrating Ductal Carcinoma
Rachel LeSage
Argosy University Twin Cities
Julie Yasgar

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Case Study
Oncology Consult
Mr. Doe* is a 58 year old African American male who has been diagnosed with
pT2 N2b M0 grade 2 infiltrating ductal carcinoma of the left periareolar breast. He
reports having developed what he thought was a non tender nodular mole on the medial
aspect of the left areola that eventually engulfed the left nipple and included a deep
nodular component.
A biopsy in early September of 2014 portrayed a ruptured epidermal inclusion
cyst. Later that month Mr. Doe underwent an excisional biopsy that recovered a 2.3 cm
grade 2 infiltrating ductal carcinoma with invasion of the epidermis with positive deep,
superior, and inferior surgical margins. Angiolymphatic and perineural invasion were
both observed. Tumor was ER 99%, PR 15%, and HER-2 1+, fish negative. MyRisk
genetic testing was negative including BRCA 1 and 2.
Two months later year Mr. Doe underwent a modified radical mastectomy that
recovered both residual invasive and in situ disease. Margins were negative. 4 of 10
lymph nodes contained disease with extra capsular excision. He also underwent
chemotherapy receiving 4 cycles of AC (Adriamycin and Cyclophosphamide) and 12
cycles of Taxol. His last cycle was on 4/19/2015. Mr. Doe reports undergoing surgery and
Chemotherapy without complication and is to receive radiation as the next course of
action.
His pas medical history is unremarkable in relation to his cancer. He suffers from
diabetes mellitus, hypertension, and sleep apnea. Past surgery includes the left
mastectomy as described before and left knee surgery at the age of 18. Family History

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

includes a paternal uncle developing prostate cancer and a paternal grandfather

developing throat cancer.
Pre-radiation physical assessment showed that Mr. Doe was alert and oriented x4
with no acute distress. He sat at a healthy weight for his height, a normal pulse, and a
slightly elevated blood pressure. All extra ocular muscles and cranial nerves were intact.
He had no cervical or supraclavicular adenopathy. Cardiovascular functions had a regular
rate and rhythm without murmur or gallop. His breathing was clear to auscultation
bilaterally. A breast exam revealed surgical absence of the left breast including the nipple
areolar complex with no worrisome skin change and a well healed incision site with no
palpable abnormality and a negative axilla. breast was normal without any palpable
abnormality and a negative axilla. Abdomen was non tender and non distended with
positive bowel sounds and no hepatomegaly. He has good range of motion in both
shoulders with no gross lymphedema.
Mr. Doe had a lengthy discussion with his Radiation Oncologist regarding the role
of radiation in improving regional control rates and survival in patients with male breast
cancer with multiple positive lymph nodes. Acute and chronic side effects were also
discussed. Mr. Doe voiced an understanding and a desire to proceed with treatment.
Informed written consent was signed.

Simulation
Mr. Doe underwent CT Simulation on 6/3/15 for immobilization in the supine
position using a vac loc bag on a tilt board with a tilt of 1 with his left arm over his head
and his right arm at his side with his chin lifted and turned to the right. He was given a

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

knee sponge for his comfort. He was scanned and given marks at about midplane and
midline, centered in the thoracic area. The doctor and the dosimetry team took the scan
and generated a plan to treat Mr. Doe using a 4 field set up to treat the supraclavicular
nodes, a posterior axillary boost, and two opposing breast tangents. 3-D planning using
MLC leaves and wedges were used to ensure complete and even coverage of the affected
chest wall and involved lymphatics, while still saving critical structures such as the heart,
lung, other breast, mandible. And airway. He was prescribed 50 Gy in 25 fractions to all
four fields at 2 Gy a day, and also received a 10 Gy en face electron boost to the
mastectomy scar region. Both 6 and 15MV energies were used to ensure no hot or cold
spots along with .5 cm of bolus used on both tangents.

Treatment & Follow-Up

For treatment, Mr. Doe was positioned exactly as the CT sim and dosimetric
parameters prescribed. Before each treatment he was leveled and straightened according
to the marks on his body. On his first day of treatment isocenter was determined by
taking x rays from all of the treatment angles and compared to the digitally reconstructed
radiograph that was made on the day of simulation. From there forward, films were taken
ever 5 treatments to ensure that our marks still accurately depicted isocenter.
As treatment progressed, Mr. Doe began to experience tenderness and erythema
of the skin in the affected area. He was given Aquaphor at first, and was then given
Domeboro astringent solution when he began to experience moist desquamation. Mr. Doe
also reported increased fatigue throughout his treatment. Those two things being said, Mr.
Doe tolerated treatment fairly well and had no further complaints. Weekly assessments

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

showed that he maintained weight and his hypertension remained the same. No concern
was noted.
Mr. Doe came back for a 6 month follow up and was in great condition. His left
chest showed to have darker pigment than the right, but had no tenderness and was
without adenopathy. He denies any back pain or extremity pain. MRI brain scan came
back negative for any brain metastasis. It was truly exciting to see how much better his
skin looked compared to how it did the last day of his treatment. He has begun taking
hormone therapy in the form of Tamoxifen. Mr. Doe has an appointment to come back to
the clinic for a one-year follow up.
Description of Male Breast Cancer
Epidemiology and Etiology
Breast cancer is second most common cancer among American women, but is
about 100 times less common in men. According to the American Cancer Society, the
approximate lifetime risk of men getting breast cancer is 1 in 1,000. (American Cancer
Society, 2015).
While the cause of breast cancer in men is ultimately unknown, many factors are
related to sex hormone levels in the body, just like in women. Men with a defect in the
BRCA2 gene have an increased risk of breast cancer. Age holds an important role as a
risk factor being as the risk goes up as men age. On average, men are about 68 years old
when they are diagnosed with breast cancer. Family history is also a component. About
1 in 5 men with breast cancer have a close male or female relative with the same
disease. Previous radiation exposure, alcohol abuse, liver disease, estrogen treatments,

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

obesity, and undescended testicles or having one or both testicles removed are other
factors that could aid in the onset of male breast cancer (American Cancer Society, 2015).
Pathology and Staging
The most common breast cancers in men are ductal carcinomas. Ductal describes
the origin of the cancer, which was in the milk ducts of the breast. It is not uncommon for
ductal carcinomas to be invasive. Non invasive ductal carcinomas, DCIS (ductal
carcinoma in situ), are uncommon in men. It is also rare for males to be diagnosed with
lobular carcinoma of the breast. This is due to the fact that lobules are not fully formed in
the male breast tissue (What kind of breast cancer is it?, 2016).
The stage of male breast cancer is found using the TNM system. A pathology
report will give insight on the size of the tumor, lymph node involvement, or if there is
any distant metastasis of the cancer. Stage 0 describes non-invasive breast cancer. Stage I
describes an invasive cancer that has no lymph node involvement and no metastatic
spread. Stage II describes an invasive cancer with axillary lymph node involvement and
no metastatic spread. Stage III breast cancer describes invasive carcinoma that has
involved IM nodal and axillary involvement, and/or Supraclavicular nodal involvement
without metastatic spread. Stage 4 describes an invasive breast cancer that has spread
beyond the breast and any lymph nodes and has a metastatic presence.
Mr. Doe was given a stage II diagnosis, meaning that his tumor was larger than 2
cm, but smaller than 5 cm and has spread to the axillary lymph nodes.
Methods of diagnosis include an ultrasound, blood work, CT scan, MRI scan, and
a bone scan. Not every tool is always used for every patient when determining stage of
cancer if metastatic spread isnt a concern (What is the stage of breast cancer?, 2016.)

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Diagnosis and Treatment

After an abnormality is found, different tests are used to verify that the
abnormality is in fact cancer. A mammogram is an x-ray of the breast that has been
compressed between two glass plates. This helps a radiologist see if there are any
abnormalities in the tissue of the breast. An ultrasound is the best way to find out if an
abnormality is solid (usually cancerous) or fluid-filled (benign cyst). Ultrasounds cannot
determine if a solid lump is cancerous. A biopsy is essential in distinguishing normal
tissue from cancerous tissue and even further, to determine the pathology of the cancer
that is present. There are many different techniques to preform a biopsy such as a fine
needle biopsy, a stereotactic needle biopsy, incisional biopsy, and excisional biopsy
(Diagnosis of male breast cancer, 2016).
The most favorable course of treatment for men who are diagnosed with breast
cancer will depend on various factors, including the size and location of the tumor, the
stage of cancer, and pathology reports. Many times treatment will involve a combination
of two or more of the modalities of treatment.
Surgery is usually the first course of treatment when breast cancer is found. The
most common surgery for male breast cancer patients is a modified radical mastectomy,
which includes the resection of the nipple, areola, all breast tissue, and all lymph nodes.
Lumpectomys are not usually done due to the small size of mens breasts (Surgery for
male breast cancer, 2016).
The next course of action is usually chemotherapy when necessary.
Chemotherapy is generally recommended when the tumor is larger than a centimeter,
axillary lymph nodes are involved, or the cancer retains the potential to grow quickly.

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Side effects of chemotherapy may include nausea, vomiting and diarrhea, mouth sours,
hair loss, and changes in taste and smell. (Chemotherapy for male breast cancer, 2013).
Mr. Doe was prescribed common chemotherapy agents used to help treat male breast
cancer.
After the patients surgical site has healed is when they are generally clear to start
radiation therapy. Radiation is usually given 5 days a week for 5-7 weeks. The extent of
the treatment is determined on the extent of the disease. If there is no lymph node
involvement, usually a patient will only receive tangential treatments. When there is
lymph node involvement, like in Mr. Does case, radiation treatment will be prescribed to
the affected nodes accordingly. Side effects of radiotherapy treatment of the breast/chest
wall may include skin irritation, fatigue, and armpit discomfort. Patients should try to
avoid extreme temperatures to the treatment area, avoid harsh soaps or scents, and to
make sure skin is moisturized throughout the duration of treatment to reduce skin
irritation (Radiation therapy for male breast cancer (2013). Mr. Doe received radiation
treatment that coincided with what is considered normal treatment for his stage of cancer.
After a patient is finished with these forms of treatment and were considered to be
hormone- receptor-positive, they will generally take hormone treatment. Most breast
cancers in men are hormone-receptor-positive. Tamoxifen is an example of a hormone
therapy and the particular hormone therapy that Mr. Doe was prescribed. The duration in
which a patient takes hormone therapy is dependent on the extensiveness of their disease.
Side effects may include: loss of sexual desire, trouble having an erection, weight gain,
hot flashes, and mood swings (Hormonal therapy for male breast cancer, 2012).

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Conclusion
In conclusion, it seemed to me that male breast cancer is treated almost identically
to the way female breast cancer is treated. It was definitely interesting to see a male
patient seeing as the therapists had stated that this is the first case the clinic has seen in
over 50 years. He tolerated treatment just the same as any other patient receiving a fourfield chest wall treatment. It was a complete joy being able to participate in the treatment
of Mr. Doe and getting to know him and his family throughout his 5 weeks of treatment. I
will always have a deep respect anyone who fights cancer, and Mr. Doe fought with an
esteemed amount of grace that I will never forget.

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

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References
Chemotherapy for male breast cancers. (2013). Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/treatment/chemo
Diagnosis of male breast cancer. (2016). Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/diagnosis
Hormonal therapy for male breast cancer. (2012). Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/treatment/hormonal
Radiation therapy for male breast cancer. (2013). Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/treatment/radiation
Surgery for male breast cancer. (2016). Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/treatment/surgery
What are the key statistics about breast cancer in men?. (2015). American Cancer
Society. Retrieved from
http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-inmen-key-statistics
What are the risk factors for breast cancer in men?. (2015). American Cancer Society.
Retrieved from
http://www.cancer.org/cancer/breastcancerinmen/detailedguide/breast-cancer-inmen-risk-factors
What is the stage of breast cancer? Male breast cancer: the pathology report. (2016).
Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/pathreport
What kind of breast cancer is it? Male breast cancer: the pathology report. (2016).

*Patient name changed for privacy

Running Head: CASE STUDY: INFILTRATING DUCTAL CARCINOMA

Breastcancer.org. Retrieved from:
http://www.breastcancer.org/symptoms/types/male_bc/pathreport

*Patient name changed for privacy

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