Skin Cancer or Locally Advanced Mammary Carcinoma: A Discussion of Cutaneous Pathology on the Male Chest

© 2024 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Wounds or HMP Global, their employees, and affiliates.

The physiological and pathological processes arising from the male breast and chest wall have varying clinical presentations and can be difficult to evaluate.¹ Examinations of the male chest are routine as part of regular whole-body skin examinations. Between 1998 and 2008 the percentage of men presenting with breast concerns at a single diagnostic imaging center increased from 0.8% to 2.4%.² Knowledge of the characteristics of pathologic lesions and a thoughtful diagnostic work-up are critical to developing a treatment plan. Benign conditions broadly include gynecomastia and pseudogynecomastia, lipomas, vascular anomalies, cysts, nevi, seborrheic keratoses, and other common skin findings. Malignant processes include primary breast cancer, extramammary metastases to the breasts, nonmelanoma and melanoma skin cancer, and other soft tissue tumors. Malignant lesions of the male breast are uncommon and tend to present at more advanced stages, requiring aggressive treatment. A thorough physical examination and careful assessment involving clinical context, imaging, and tissue sampling are key to making the correct diagnosis and avoiding treatment delays.

To illustrate challenges of diagnosis in the male breast, the case of an 82-year-old male who was referred to a dermatologist with a 6-month history of an ulcerated and erythematous plaque on the left chest involving the NAC is presented (Figure 1). The patient’s other medical problems included hypertension, coronary artery disease, and multiple prior basal cell carcinomas of the skin that were treated with Mohs micrographic surgery. The patient first described the lesion to his dermatologist as painless and crusted over. Wound care instructions were provided, but over the next several weeks the lesion began to ulcerate. He returned to the dermatologist, who performed a shave biopsy in June 2022 that returned a pathological diagnosis of basal cell carcinoma.

Given the location of the lesion and substantial underlying soft tissue, the patient was referred to a plastic surgeon for further management. On clinical examination, the patient had hypertrophy of the breast with a feminine appearance, skin excess, formation of a submammary fold, and ptosis. The patient had an ulcerated central mass involving the NAC, with no recorded evidence of lymphadenopathy (Figure 2). He underwent wide local excision of the presumed basal cell carcinoma in September 2022. The pathology report indicated a diagnosis of invasive mammary carcinoma measuring 32 mm with associated dermal invasion, skin ulceration, and lymphovascular invasion. Given the skin involvement, the cancer was upstaged to at least TNM stage T4b. The patient was then referred to a breast surgical oncologist, and on ultrasound examination he was also found to have lymphadenopathy. He underwent staging scanning and ultimately required modified radical mastectomy. Pathology demonstrated stage III (T4bN2) invasive mammary carcinoma.

Several aspects of the patient’s history and presentation were concerning for malignancy, including the patient’s age and history of nonmelanoma skin cancer, as well as characteristics of the lesion, such as progressive ulceration, the absence of cutaneous pain, and involvement of the NAC. The differential diagnosis for pathologic cutaneous lesions of the male chest should include melanoma, nonmelanoma skin cancers, and breast cancer and its associated conditions (eg, Paget disease). Importantly, in the patient in the current case report, early diagnostic mammography likely would have aided in his treatment. Although a shave biopsy demonstrated basal cell carcinoma, it is important to consider clinical context and the need for imaging. From the perspective of the treating physician, there may be systemic barriers in pathology processing that affect diagnosis and clinical decision-making. The convenience of communicating with pathologists responsible for reading specimens can depend on institutional contracts and policies. For these reasons, the authors of the current report recommend that health care providers who perform cutaneous biopsies of the male chest insist that multiple pathologists offer their interpretation of the pathology.

Nonmelanoma skin cancer involving the NAC is quite rare. As of 2016, 55 patients with basal cell carcinoma of the nipple and areola had been reported in the world literature, with most occurring in males (63.6%).³ Some pathologists contend that either simple or modified radical mastectomy should be the standard of care for malignant cutaneous lesions involving the NAC, considering the aggressive nature of both locally advanced breast cancer and basal cell carcinoma in this area.⁴

Male breast cancer accounts for less than 1% of diagnosed breast cancer, with rates rising in the last decade.⁵ Compared with females, males are more likely to present at advanced stages. It is estimated that in 2019, 2670 new cases of male breast cancer would be diagnosed in the United States, with 18% mortality.^5,6 With breast cancer high on the differential diagnosis, a complete work-up should include pre-biopsy mammography or ultrasound. Studies show that mammography (specificity, 94.8%; sensitivity, 94.7%; negative predictive value, 99.7%) and ultrasound (specificity, 95.3%; sensitivity, 88.9%; negative predictive value, 99.4%) have high sensitivity and specificity for breast malignancy in males.⁷ Imaging in the case reported in this manuscript likely would have been abnormal and led to the discovery of invasive mammary carcinoma, obviating the need for wide local excision and prompting earlier referral to a surgical oncologist.

The study limitations include the small sample size, which may affect generalizability, and a paucity of available evidence regarding the difficulties of pathological analysis of cutaneous samples from the nipple. Because this case report focuses on 1 individual, the findings may not be reflective of broader trends and epidemiology.

Knowledge of the natural history, clinical characteristics, and management of cutaneous pathology on the male chest is essential for surgeons who may encounter these patients at various stages of diagnosis. The experience of the authors of the current report with this case highlights the importance of a multidisciplinary approach with consideration of breast imaging and a thoughtful surgical plan that weighs radical and conservative management of cutaneous lesions of the male chest involving the NAC.

Authors: Rishub Karan Das, MD¹; Wesley Paul Thayer, MD, PhD¹; and Raeshell Sharawn Sweeting, MD²

Affiliations: ¹Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN; ²Department of Surgical Oncology, Vanderbilt University Medical Center, Nashville, TN

Disclosure: The authors disclose no financial or other conflicts of interest.

Ethics: Written and verbal informed consent was provided by the patient to use images and pertinent medical information for the purposes of this manuscript.

Correspondence: Rishub Karan Das, MD; 1161 21st Avenue South, 1019, Nashville, TN 37232; rishub.das@vanderbilt.edu

Manuscript Accepted: June 3, 2024