Another cm irregular and lobulated mass was found in the

Another 11 cm, irregular, and lobulated mass was found in the subareolar region of the left breast. The mass showed interior septation, with solid and fluid components, fluid-hyperdense fluid component level, and enhancement of the solid component after intravenous cyproheptadine hcl administration (Fig. 3); overlying skin showed involvement. Therefore, the left breast tumor was suspected to be a clinical stage IIIB tumor (cT4bN0MX) in accordance with the American Joint Committee on Cancer (AJCC) guidelines. On gross examination of the breast mass specimen, it was found to be 13 × 10 × 6 cm3. The cut surface was friable and grayish-white in color, and much yellowish fluid was observed in the mass. On hematoxylin and eosin (HE) staining, the tumor mass showed prominent trabecular structures and solid cell nests (Fig. 4). The immunohistochemical (IHC) studies revealed strong positive staining for estrogen receptor (ER) and progesterone receptor (PR), but showed negative results for human epidermal growth factor receptor 2 (HER2), AFP, HBsAg, and thyroid transcription factor 1 (TTF-1) staining. Therefore, infiltrating ductal carcinoma not otherwise specified, with predominantly cystic degeneration, was pathologically diagnosed. The pathological findings of the liver biopsy specimen revealed moderately differentiated HCC. The surgeon recommended a second operation of the left breast and dissection of left axillary lymph node (i.e., left modified radical mastectomy); however, the patient refused. The patient then underwent treatment with tamoxifen for the breast cancer and transarterial chemoembolization for the HCC after the operation. The condition of the patient remained stable at the time of the case report.
Discussion Male breast cancer is rare, accounting for approximately 1% of all breast cancers, and has an incidence of only 0.7 per 100,000 population. It constitutes only 0.2% of all cases of male cancers. Although the natural history of male breast cancer is similar to that of the female counterpart, the majority of male patients with breast cancer are about 10 years older than female patients with breast cancer, and male breast cancer shows a higher level of hormone receptor (ER and PR) expression than the female breast cancer. Positive family history is a predisposing factor for male breast cancer. Other risk factors for the development of breast cancer in male patients include genetic and hormonal etiologies. The genetic factors include Klinefelter syndrome and mutations of the BRCA1 and BRCA2 genes (which are associated with a high risk of breast and ovarian cancers). The hormonal factors for male breast cancer are found in sporadic cases, and consist of obesity, alcohol ingestion, gynecomastia, liver cirrhosis, and lack of exercise. Such sporadic breast cancer is related to high levels of circulating estrogens, which stimulate breast growth and play a role in carcinogenesis through the metabolites of estrogen. Although blood estrogen levels were not examined in the present case, the strong positive staining for ER on IHC may suggest that this case of male breast cancer is most likely a sporadic disease. Alcoholic liver cirrhosis shows an abnormality in the metabolism of sex hormones and leads to a decrease in the circulating androgen levels and a rise in the circulating estrogen levels. The resulting hyperestrogenism may be associated with gynecomastia and cholelithiasis, and may play a key role in the development of breast cancer in men. Upon chronic alcohol ingestion, ethanol decreases the plasma levels of testosterone by increasing levels of sex hormone-binding globulin, and enhances the metabolism of the estradiol to catechol estrogens, which may be related with the carcinogenesis of breast cancer in a male patient with alcoholic liver cirrhosis. Although gynecomastia was not found in the male patient in the present case, alcoholic liver cirrhosis may be a risk factor for the development of male breast cancer.