1) The report describes two cases of male breast cancer patients who underwent sentinel lymph node biopsy (SLNB). 2) Both patients were in their 70s and presented with mammary masses. Clinical diagnoses for both were T1N0. 3) Mastectomies with SLNB were performed, identifying the sentinel lymph nodes using dye injection. 4) Postoperatively, both patients were hormone receptor-positive and are being treated with oral tamoxifen.

1. Surg Today (2011) 41:837–840
DOI 10.1007/s00595-010-4366-1
Case Report
Sentinel Lymph Node Biopsy in Patients with Male Breast Carcinoma:
Report of Two Cases
MASAHIRO KITADA, KEISUKE OZAWA, KAZUHIRO SATO, SATOSHI HAYASHI, and TADAHIRO SASAJIMA
Department of Surgery, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Hokkaido 078-8510, Japan
Abstract gies similar to those used for female breast cancer typi-
The incidence of male breast cancer is low, and treat- cally provide successful effects and similar toxicity to
ment strategies similar to those used for female breast that observed in women. In addition, lymph node dis-
cancer patients are frequently used for male patients. section and SLNB have been reported in some preop-
However, the safety and utility of sentinel lymph node erative N0 patients. In our hospital, among the 1230
biopsies (SLNBs) for male breast cancer have not been surgeries performed for breast cancer between January
proven. Among the five cases of male breast cancer who 2000 and December 2009, five (0.41%) were male breast
received surgery at our hospital, mastectomy with SLNB cancer patients. This paper reviews the surgical proce-
was performed in two of the cases. The first patient was dure selected for these five patients, as well as their
77 years old and the second was 74 years old, and both breast tumor tissue type and their histopathological
presented as outpatients with chief complaints of a diagnosis. We also report the details for two patients
mammary mass. Clinical diagnoses were T1N0 in both who received SLNB, both of whom were found to
cases, and mastectomies with SLNB were performed. be lymph node negative during the preoperative
The sentinel lymph node was identified using the dye diagnosis.
method. Postoperatively, the patients were hormone
receptor-positive, and they are now being followed
while continuing to take oral tamoxifen.
Case Reports
Key words Male breast cancer · Sentinel lymph node
biopsy Male Breast Cancer Surgical Cases
The mean age of male breast cancer patients was higher
(74.1 years) than for females (51.4 years) with breast
cancer. One patient showed intracystic papillary carci-
Introduction noma. In all cases, masses were palpable and identified
on ultrasonography. The cytology was class 3 in the
Recently the number of cases of breast cancer has patient with intracystic papillary carcinoma and class 5
increased, but clinical advances in the treatment of in the other four patients. In the patient with class 3
breast cancer have also been made, including improved disease, an excisional biopsy of the mass was performed
breast conservation rates and increased use of sentinel for definitive diagnosis. All five patients underwent a
lymph node biopsy (SLNB), molecular targeted therapy, mastectomy, and SLNB was performed in two cases
and preoperative chemotherapy (primary systemic (cases 3 and 4).
therapy). Conversely, male breast cancer is a rare disor- The tissue type was found to be intracystic papillary
der, accounting for <1% of all breast cancers, making it carcinoma in one patient, papillotubular carcinoma
difficult to conduct large-scale clinical trials or establish in one patient, and solid-tubular carcinoma in three
an optimal standard of care. However, treatment strate- patients. Patient 1 (who had intracystic papillary carci-
noma) had stage TisN0 disease, Patient 2 was classified
as having T4bN1, patient 5 as having T2N1, and patients
Reprint requests to: M. Kitada 3 and 4 were classified as having T1N0 disease. Patients
Received: April 5, 2010 / Accepted: June 30, 2010 3 and 4 underwent SLNB. All five patients were hormone

2. 838 M. Kitada et al.: SLNB in Patients with Male Breast Carcinoma
Table 1. Cases of male breast cancer
Case Age (years) Pathology Surgery Stage T N Grade ER PgR HER2
1 65 Papi-tub Bt+Ax 1 1 — 1 1+ 2+ 3+
2 81 Solid-tub Bt+Ax 3b 4b 1 3 2+ 1+ —
3 77 Papi-tub Bt+SN 1 1 — 1 2+ 3+ —
4 74 Solid-tub Bt+SN 1 1 — 2 3+ 2+ 2+
5 78 Solid-tub Bt+Ax 3b 4b 1 3 3+ — 2+
Papi-tub, papillotubular carcinoma; solid-tub, solid tubular carcinoma; Bt, breast resection; Ax, dissection of axillary lymph node; SN, sentinel
node sampling resection; ER, estrogen receptor; PgR, progesterone receptor; HER2, human epidermal growth factor receptor 2
receptor-positive, and all received oral tamoxifen as
postoperative chemotherapy. One patient died 4 years
3 months after surgery due to another disease. The
remaining patients have survived without recurrence
(Table 1).
Cases of Patients Who Underwent SLNB
Case 1: 77-Year-Old Man
In early June of 2009, the patient noticed a mammary
mass and was evaluated in the outpatient breast clinic.
Fine-needle aspiration cytology revealed class V disease.
The patient was being followed for Hunt’s syndrome. His
height was 174 cm and his weight 64 kg. Breast examina-
tion of the right E area showed a 1.5 × 1.8-cm elastic-hard, a
well-defined, somewhat poorly mobile mass. No axillary
lymph nodes were palpable. Ultrasonography showed a
lobulated solid mass in the right breast. The interior was
hypoechoic, the margins were partially irregular and
indistinct, posterior echoes were enhanced, halo(+), and
the patient was given a diagnosis of category 4 disease
(Fig. 1a). Computed tomography revealed a mass in the
right breast, but no enlargement of axillary or cervical
lymph nodes (Fig. 1b). In addition, no evidence of distant
metastasis was seen. The patient was diagnosed as having
stage T1N0M0 disease, and a mastectomy with SLNB
(using the dye method with measurement of indocyanine
green [ICG] fluorescence) was performed. On intraop-
erative rapid pathologic diagnosis, the sentinel node (SN) b
showed no metastases (2/0), and therefore we carried out
a sampling resection around the SN while an axillary Fig. 1. a Ultrasonography showed a solid mass in the right
lymph node dissection was omitted. The patient’s breast. b Chest computed tomography revealed a mass in the
right breast
histopathological diagnosis was p-stage (T1cN0(sentinel
node(0/2), level I (0/1)M0), papillotubular carcinoma,
Grade I, ly(−) v(−), 1.4 cm, n(−), ER(2+), PgR(3+),
HER2(−). Postoperatively, the patient has been treated
with oral tamoxifen. As of the time of writing, no signs of Fine-needle aspiration cytology revealed class V disease.
recurrence have been identified. During this same period, in February 2009, the patient
underwent a total gastrectomy for gastric cancer (p-stage
Case 2: 74-Year-Old Man I). The patient’s height was 165 cm and weight 72 kg.
Starting in February of 2009, the patient noticed a lump Breast examination of the BD area below the nipple
below the left nipple that gradually increased in size. showed a 2.5 × 3.0-cm elastic-hard, well-defined, poorly
He was evaluated at our hospital in June of 2009. mobile mass. No enlarged axillary lymph nodes were

3. M. Kitada et al.: SLNB in Patients with Male Breast Carcinoma 839
Discussion
The overall number of breast cancer cases is increasing,
but male breast cancer remains rare, accounting for
<1% of all breast cancers.1 In our case experience over
the last 10 years, the incidence has only been 0.41%.
Causes of male breast cancer include Klinefelter’s syn-
drome, gynecomastia, trauma, and effects of irradiation,
but no specific etiology was apparent in any of our
patients. In terms of past medical history, one patient
had multiple cancers of the stomach. All patients had
noticed the masses themselves and were diagnosed
within 6 months. With regard to diagnosis, the masses
were readily detectable on ultrasonography. Four
a patients had solid masses with class 5 cytology. One
patient with intracystic papillary carcinoma had class 3
cytology, so an excisional biopsy was performed.
In male breast cancer surgery, because males have
little breast tissue, breast-conservation surgery is of
little significance. A mastectomy is performed in
most cases, but few established reports have described
minimal axillary dissection. In early-stage N0 breast
cancer in women, SLNB is already used as standard care
in many medical centers. The safety and usefulness of
SLNB has also been reported for male patients.2–4 In
addition, although few data are available, the American
Society of Clinical Oncology guidelines recommend
that SLNB be performed the same as in female breast
cancer.5 We currently use dye injection of ICG with
subsequent measurement of fluorescence to differenti-
b
ate malignant from normal lymph nodes. For intraop-
erative rapid pathological diagnosis, the SNs are sliced
Fig. 2. a Ultrasonography showed a solid mass in the left at 2-mm intervals and stained with hematoxylin and
breast. b Chest computed tomography revealed a mass in the eosin. We performed the same procedure in our two
left breast male breast cancer patients. The SNs were identified,
and no false negatives were observed.
The postoperative course of treatment for male
evident. Ultrasonography showed an isoechoic mass patients is also the same as in female breast cancer.6
with a solid interior. The margins were generally well Hormone receptor positivity tends to be higher than in
defined, with some partial irregularity (Fig. 2a). Com- women, and tamoxifen is the mainstay of treatment.7
puted tomography revealed a mass in the left breast, but However, hormone-sensitivity patterns in male breast
no enlargement of axillary or cervical lymph nodes cancer are thought to be similar to postmenopausal
(Fig. 2b). No metastases to other organs were identified. breast cancer, and because aromatase activity in male
Stage T2N0M0 disease was diagnosed, and a mastec- breast cancer tissue is higher than in females, it is not
tomy with SLNB was performed. Intraoperative patho- surprising that aromatase inhibitors have been shown to
logical diagnosis showed no lymph node metastases, and be effective against male breast cancer.8,9 Although the
therefore we performed a sampling resection around number of cases seen at our institution was small, and no
the SN, and an axillary lymph node dissection was results have yet been achieved that will lead to standard-
omitted. The patient’s histopathological diagnosis was ized treatment, the use of SLNB should continue to be
stage I (T1cN0(sentinel node(0/2), level I (0/3))M0), investigated in the future, including for recurrent cases.
solid-tubular carcinoma, grade II, 1.7 cm, ly(+), v(−),
ER(3+), PgR(2+), HER2(2+), n0(0/2). His postopera- References
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