Human breast cancer is a rare malignant tumor that accounts for less than 0.2% of all human cancers and less than 1% of breast cancers [
We report the results of a retrospective and descriptive study on cases of breast cancer in humans diagnosed histologically at the Pathological Anatomy and Imaging Laboratory of the Sylvanus Olympio University Hospital in Lomé, from January 1, 1995 to December 31, 2019, a period of 25 years. Togo is a small country of 56,600 km2, with an estimated population of 7,200,000, located between Ghana in the west and Benin in the east. These cases were collected from the registers of the said laboratory. The study material consisted of biopsies and operating pieces fixed in 10% buffered formalin and came from various health structures in the country. The parameters studied were epidemiological (frequency, age, location, family history, and circumstances of discovery) and pathological (nature of the sample, histological group, histological type, histoprognostic grade, pTNM stage (AJCC, 2017), molecular profile, and existence of mutations in the BRCA2 and BRCA1 genes). The imaging aspects observed during ultrasound and mammography in patients with an imaging record were taken into account. The size, American College of Radiology (ACR) classification, and axillary lymphadenopathy were studied.
Clinical, therapeutic, and prognostic data were collected from the patient’s medical records.
The histologic analysis has been performed on paraffin-embedded and formalin-fixed specimens stained by hematoxylin-eosin-saffron. The immunohistochemical analysis has also been performed on paraffin-embedded and formalin-fixed tissues.
Immunostaining was done for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and Ki-67 count using a Ventana Benchmark immunostainer using the manufacturer’s supplied antibodies. Positive status for ER and PR was defined as having nuclear staining in at least 10% of invasive tumors cells. HER2 was scored based on a 0 to 3 scale according to the criteria set by ASCO (American Society of Clinical Oncology). In the final analysis, a score of 3+ was considered overexpressed or positive and a score ≤2 as negative. Fluorescence in situ hybridization for HER2 amplification was not performed.
Breast cancer subtypes were defined according to the IHC expression of ER/PR/HER2 and Ki-67 count as follows: luminal A (ER+/PR+, HER2-,
Table
Sociodemographic characteristics of patients.
Value | |
---|---|
Annual frequency | 3.28 |
Age (year) | |
(i) Average age | |
(ii) Range | 27-63 |
(iii) <40 | 38/82 |
(iv) 40-60 | 32/82 |
(v) >60 | 12/82 |
Location | |
(i) Left breast | 41/82 |
(ii) Right breast | 40/82 |
(iii) Bilateral | 01/80 |
Family histories | 47/82 |
(i) Breast cancer | 27/82 |
(ii) Ovarian cancer | 15/82 |
(iii) Breast and ovarian cancer | 05/82 |
The circumstances of discovery consisted of palpable mass in 68 cases (82.93%). It was an isolated palpable mass in 50 cases, associated with changes in the skin covering in 14 cases and lymphadenopathy in 4 cases. These skin changes were represented by an “orange peel” thickening in 11 cases and by a skin ulceration in 3 cases. The rest of the circumstances of discovery consisted of an isolated modification of the skin covering in 6 cases (5 cases of thickening with an “orange peel” appearance and 1 case of skin ulceration), a fortuitous discovery in 4 cases, and discharge bloody nipple in 2 cases.
Eighteen medical imaging records were found, with at least one ultrasound performed on all 18 patients. A mammogram was coupled with ultrasound in 10 patients (55.6%). No other imaging modality was found. Eleven (61.1%) had had an ultrasound-guided microbiopsy. The lesions were classified ACR 5 in 61.5% (11/18), ACR 4 in 33.3% (6/18), and ACR 3 in 5.6% (1/18). The lesions had an average size of
The diagnosis of breast cancer was made on 14 biopsy fragments and 68 surgical pieces including 64 pieces of nodulectomy and 4 pieces of mastectomy with axillary dissection. The nodulectomy pieces were between 2 and 5 cm in size, ill-defined, firm in consistency, and showing foci of hemorrhagic changes. The mastectomy pieces all presented foci of necrotic and hemorrhagic changes with a tumor size varying from 3 to 6 cm. The examination of the axillary dissections found more than 3 lymph nodes in 75% of the cases. We found 80 cases (97.56%) of breast carcinomas and 2 cases (2.44%) of breast angiosarcoma were diagnosed by CD31 markers and factor VIII immunohistochemistry. Invasive carcinoma of the nonspecific type represented 87.5% (70 cases) of all carcinomas, followed by carcinoma in situ of the ductal type with 8 cases (10%) and 2 cases (2.5%) of papillary carcinomas. The diagnosis of invasive carcinoma of a nonspecific type was made on 60 surgical pieces including the 4 pieces of mastectomy and 10 biopsy fragments. By the Nottingham histoprognostic classification, 53 cases (75.71%) of these invasive carcinomas corresponded to grade II and 7 cases (10%) to grade III. Fifty-six (56) cases or 80% of these invasive carcinomas corresponded to the T2NxMx grade, 4.28% (3 cases) to the T2N2Mx grade, and 1 case (1.43%) to the T2N1Mx grade. The diagnosis of the 2 cases of mammary sarcoma was made on parts of nodulectomy. They both corresponded to grade 2 of the FNCLCC classification. Regarding molecular classification, 66 cases (82.5%) of these carcinomas expressed hormone receptors. Thirty-one cases (38.75%) had a luminal B profile; 13 cases (16.25%) had an enriched HER2 profile. The luminal A profile was seen 12 cases (15%), and 10 cases (12.5%) were triple negative. The search for mutations in the BRCA2 and BRCA1 genes was carried out in 12 patients. There were mutations in the BRCA2 gene in 9 cases (10.97%) and in the BRCA1 gene in 3 cases (3.66%). The histopathological characteristics are summarized in Table
Histopathological characteristics of patients.
Value | |
---|---|
Nature of the sample | |
(i) Biopsy | 14/82 |
(ii) Operating sample | 68/82 |
Histological groups and types | |
(i) Carcinoma | 80/82 |
(i1) Invasive ductal carcinoma, NOS | 70/82 |
(i2) Ductal intraepithelial neoplasia | 08/82 |
(i3) Invasive papillary carcinoma | 02/82 |
(ii) Angiosarcoma | 02/82 |
Elston and Ellis classification (Nottingham) | 60/82 |
Grade III | 07/82 |
Grade II | 53/82 |
pTNM classification | 60/82 |
(i) pT2NxMx | 56/82 |
(ii) pT2N2Mx | 03/82 |
(iii) pT2N1Mx | 01/82 |
Molecular classification | 66/82 |
(i) Luminal A | 12/82 |
(ii) Luminal B | 31/82 |
(iii) HER2 enriched | 13/82 |
(iv) Triple negative | 10/82 |
BRCA mutations | 12/82 |
BRCA2 | 09/82 |
BRCA1 | 03/82 |
Four (4.87%) patients underwent a mastectomy with lymph node dissection. Radiotherapy was delivered in 15 patients (18.3%), with a dose of 50 Gy on the wall. Acute toxicity from radiation therapy like radiodermatitis was found in 20% of cases. Sequential chemotherapy was administered as a neoadjuvant in 3 patients (3.66%), as an adjuvant in 12 patients (14.63%). Nausea-vomiting was the main side effect of chemotherapy (85% of cases). Hormone therapy such as tamoxifen was prescribed in all luminal patients (43 patients). Togo did not have treatment with trastuzumab before 2015; only 5 patients out of 13 in the enriched HER2 category were able to benefit from this treatment. After a median follow-up of 36 months, evolution was characterized by complete remission in 27 patients (32.93%), local relapse in 18 patients (21.95%), metastatic relapse in 9 patients (10.97%), and death in 7 patients (8.54%); 21 patients were lost to follow-up (25.61%). The bone was the main metastatic site with 55.56% of cases (5/9), followed by the lung with 22.22% of cases (2/9) and liver and skin with 11.11% each (1/9). The overall 5-year and 10-year survivals were 59% and 47%, respectively.
We found an annual frequency of 3.28 cases of breast cancer in men, significantly lower than that of breast cancer in women in our country [
The circumstances of discovery were mainly represented by a palpable breast mass with 82.93% of all cases. It was isolated or associated with changes in the skin covering, with lymphadenopathy. In a review of the literature on male breast cancer case reports, Senger et al. note that the majority of patients had a palpable mass clinically [
Several imaging methods can be used in the male subject for breast exploration, but ultrasound is the basic examination. Due to the low abundance of breast tissue, mammography can be difficult to perform in the male subject [
We observed a predominance of nonspecific invasive carcinoma with 87.5% of all carcinomas. Invasive nonspecific carcinoma is the main histological type of breast cancer in men [
In general, the prognosis for men with breast cancer is similar to that for women [
Breast cancer in men is a rare condition, often diagnosed late and with a poor prognosis. Male breast cancer linked to a mutation in the BRCA2 gene occurs earlier and has a poorer prognosis. When matched for age, tumor size, grade, and axillary lymph node status, the prognosis is similar for men and women concerted efforts should be made to educate the public and healthcare professionals, in order to make diagnoses earlier and thus improve the prognosis.
All data generated or analyzed during this study are included in this published article.
This case report was approved by the Department of Pathology of CHU of Lomé, University of Lomé. This study was approved by the head of the Laboratory Department of the Sylvanus Olympio University Hospital (Ref. No. 012/2020/LAP/CHUSO/UL).
The authors declare that they have no competing interests.
TD was responsible for the conception of the study, participated in the study design, performed the laboratory analysis and interpretation, and wrote the paper. MT, TDj, PS, AKA, BN, AA, MB, BS, and KA were involved in the treatment and follow-up of the patient; they have reviewed the paper. GNK was responsible for the overall scientific management of the study and the preparation of the final paper. All the authors have read and approved the final paper to be submitted for publication.