1

CE Information
In order to receive CE credit, you must first complete the activity content. When completed, go
to the Take CE Test! link to access the post-test.

Submit the completed answers to determine if you have passed the post-test assessment. You
must obtain a score of 75% to receive the CE credit. You will have no more than 3 attempts to
successfully complete the post-test.

Participants successfully completing the activity content and passing the post-test will receive
1.0 ARRT Category A credits.

Approved by the American Society of Radiologic Technologists for ARRT Category A credit.

This activity may be available in multiple formats or from different sponsors. ARRT does not
allow CE activities such as Internet courses, home study programs, or directed readings to be
repeated for CE credit in the same or any subsequent biennium.

2
Course Description
Male breast cancer (MBC) is a rare disease that has become more prevalent over the past
decade. Because MBC is so rare, most of the published information regarding the disease is
extrapolated from female breast cancer (FBC) data. It appears that males do not benefit from
the advancements leading to earlier breast cancer diagnosis and improved cancer care in the
same way females have in the last 10 years. Furthermore, males are often misdiagnosed at
initial presentation or imaging results are inconclusive.The two patients considered in this study
were informed that their presenting symptoms were not caused by cancer upon initial
consultations and workups. However, after a lumpectomy in one patient, the specimen was
found to be ductal carcinoma in situ (DCIS). The second patient was found to have breast
cancer during workup years after initial consultation. Both patients underwent radiation
therapy (RT) treatments following surgery; either whole breast or chest wall irradiation. Clinical
trials have shown that irradiation after breast surgery can reduce the probability of cancer
recurrence and may contribute to increased 15-year overall survival rates. Radiation Therapy is
delivered to the breast after surgery, resulting in a boost to the surgical scar to sterilize the
area.Composite doses of 6040 cGy were delivered to each patient. Although mammograms and
ultrasounds (US) are the standard for initial breast examination in both men in women, it may
be possible that an alternative form of imaging such as magnetic resonance imaging (MRI)
could be more effective at diagnosing breast cancer in males in earlier stages. Since males have
not benefited the same from the advancements in breast cancer compared to women, perhaps
MRI studies in conjunction with another diagnostic study should be considered for males at the
time of initial examination for breast cancer.

Learning Objectives
After reading this article, the participant should be able to:

Discuss the epidemiology and etiology of MBC.

Describe the role of radiation therapy for breast cancer patients in the postoperative
setting

Understand the difference and significance of ER/PR positive and negative tumors

Explain the difference between diagnostic and simulation CT scans

4
CE Article

Challenges of Diagnosing and Treating Male Breast Cancer: A Case Study

Lee Culp, RT(T), Andy Kressin, NisheleLenards, MS, CMD, RT(R)(T), FAAMD, Anne Marie Vann,
MEd,CMD, RT(R)(T), FAAMD
Medical Dosimetry Program at the University of Wisconsin - La Crosse, WI

ABSTRACT
Male breast cancer (MBC) is a rare disease that has become more prevalent over the past
decade. Because MBC is so rare, most of the published information regarding the disease is
extrapolated from female breast cancer (FBC) data. It appears that males do not benefit from
the advancements leading to earlier breast cancer diagnosis and improved cancer care in the
same way females have in the last 10 years. Furthermore, males are often misdiagnosed at
initial presentation or imaging results are inconclusive.The two patients considered in this study
were informed that their presenting symptoms were not caused by cancer upon initial
consultations and workups. However, after a lumpectomy in one patient, the specimen was
found to be ductal carcinoma in situ (DCIS). The second patient was found to have breast
cancer during workup years after initial consultation. Both patients underwent radiation
therapy (RT) treatments following surgery; either whole breast or chest wall irradiation. Clinical
trials have shown that irradiation after breast surgery can reduce the probability of cancer
recurrence and may contribute to increased 15-year overall survival rates. Radiation Therapy is
delivered to the breast after surgery, resulting in a boost to the surgical scar to sterilize the
area. Composite doses of 6040 cGy were delivered to each patient. Although mammograms
and ultrasounds (US) are the standard for initial breast examination in both men in women, it
may be possible that an alternative form of imaging such as magnetic resonance imaging (MRI)
could be more effective at diagnosing breast cancer in males in earlier stages. Since males have
not benefited the same from the advancements in breast cancer compared to women, perhaps

5
MRI studies in conjunction with another diagnostic study should be considered for males at the
time of initial examination for breast cancer.
Key Words: Male Breast Cancer (MBC), early detection, Magnetic Resonance Imaging (MRI),
Mammography

Introduction
Epidemiology
Male breast cancer (MBC)is a rare disease, accounting for only 1% of total breast cancers
worldwide; however, the incidence of MBC has increased in the past 10 years.1-4 More
specifically, there has been a 45% increase seen in the United States, with the average age for
MBC diagnosis at 60 years.3It is expected that more than 2300 men will be diagnosed in 2014
with breast cancer, including a death toll between 400 and 500.5Because of the rarity of the
disease, most of the published information regarding MBC is based on small, single institutional
data or extrapolated from data on female breast cancer (FBC). Traditional imaging and
treatments for FBC are the current standards of care for MBC patients as a result of the lack of
data.

Due to the lack of public awareness, as well as the rarity of disease,MBC is usually diagnosed in
late stageseither stages III or IV. Perhaps feelings of humiliation in males presenting with
breast cancer symptoms also plays a role and leads to refusing to seek medical attention
immediately upon presentation of symptoms. As a result, MBC generally has a worse prognosis
than FBC.2,6As with FBC, survival is correlated with tumor size and nodal status, and men with
negative lymph nodes have an excellent prognosis.7As is diagnostically customary in the initial
workup for women, men who present with possible breast cancer typically receive
mammograms, ultrasound (US), magnetic resonance imaging (MRI), fine-needle aspiration
(FNA), or some combination thereof. However, current statistics and evidence show that males
do not benefit from the advancements leading to earlier breast cancer diagnosis and improved
cancer care in the same way females have in the past decade.3This may be due to greater
awareness and preventive screening programs currently in place for women, in addition to the

6
rarity of MBC.Some studies have shown that MBC diagnoses are delayed 6 to 10 months on
average.8This leads to a late-stage diagnosis and poorer outcomes for patients with
MBC.Perhaps,alternativeimaging and diagnostic approachesshould be taken when male
patients present in the clinic.

Etiology
Currently, there are no definitive etiological risk factors known to be solely responsible for the
onset of MBC, although certain criteria have been known to be linked. The strongest link for
MBC is the breast cancer 2 (BRCA2) gene mutation. The BRCA2 gene is a gene that produces
tumor suppressing proteins. These proteins aid in repairing damaged DNA in the nucleus of
each cell. When these genes are mutated, the damaged DNA may not be repaired accurately,
resulting in uncontrolled cell growth.9 BRCA2 increases the overall risk of breast cancer for both
men and women. Nonetheless, women statistically present more often with BRCA1,
whereasmale BRCA1 mutations are uncommon. Perhaps genetic differences between male and
female breast cancers suggest different diagnostic approaches should be utilized when males
present with breast cancer symptoms.

Imaging Modalities
A mammogram of the breast is an actual X-ray examination of the breast. The breast is
compressed between 2plates to allow for the X-ray to penetrate the whole breast tissue.
During a mammogram, the patient is exposed to a dose of radiation. However, this dose of
radiation is very low, and much lower than mammograms in the past. Mammograms are useful
for detection and evaluation of possible breast cancer, in that they provide alook inside the
breast and skin. There are 2types of mammograms: screening anddiagnostic. Screening
mammogramsare completed yearly for a patient and are done proactively. The patient has no
signs of breast cancer, but these studies are completed to look for possible early stages and
signs. Diagnostic mammograms are done for patients in which an abnormal finding has
occurred. A diagnostic mammogram can take more images than a screening mammogram, and

7
can also magnify problematic areas for further detail and evaluation. Mammograms are known
to have limitations, especially in regard to larger breasted women.

Oftentimes, for women at high risk of breast cancer, an MRI is completed at the same time as
the yearly mammogram. A MRI scan has the ability to better examine a suspicious area in a
mammogram, as well as a secondary imaging modality in someone already diagnosed with
breast cancer. MRIs use very large magnets, as well as radio waves, to produce the detailed
images instead of x-rays; therefore minimizing the ionizing radiation dose to the patient. The
most useful MRI exams for breast imaging use a contrast material (called gadolinium) that is
injected into a catheter in a vein (IV) in the arm before or during the exam. This improves the
ability of the MRI to clearly show breast tissue details.10

An ultrasound is a diagnostic imaging modality that uses sound waves to look inside the body. A
transducer is placed on the skin and emits sound waves. The sound waves are reflected back to
the receiver as they recoil off body tissues. The reflected sound waves, or echoes, are then
transformed to images in black and white and displayed on a computer screen for visual
observation. Due to the nature of the procedure, ultrasound is considered noninvasive and less
expensive than most other diagnostic modalities. For breast cancer, ultrasounds are used to
evaluate a mass and determine whether it is a fluid-filled cyst without having to use a needle
for biopsy. Ultrasounds are also useful for physicians when performing image-guided biopsies
of breast tissue.

After a lump in the breast is discovered, a FNA biopsy may be performed. The FNA biopsy is
used to assess whether the tissues within the lump are cancerous or not. A fine, small needle is
placed within the lump to take a sample. The sample is then looked at under a microscope to
assess the differentiation of the cells within the sample. The FNA is very accurate when
performed by an experienced professional, and results in less bruising than other types of
biopsies. However, there can be some drawbacks to the FNA, especially if not enough of the

8
tissue sample is obtained during the procedure. So, if a FNA does not find cancer, it may need
to be followed up with different imaging modalities.11

Case Description
Patient Selection
This case study compares 2 patients with MBC who are receiving radiation therapy (RT)in
2different locations across the United States. Patient DF was treated in New York, whereas the
other patient (patient PP) was treated in Wisconsin. Both patients presented with abnormalities
in their breasts and both were initially told that their symptoms were non-cancerous. However,
after later follow-up visits regarding their concerns, as well as numerous imaging studies and
procedures, both men were diagnosed with MBC.

Patient DF
Patient DF is a 57-year-old male who presented in December of 2013 with a sudden onset of
moderate pain in his left breast. At the time of his initial consult, the pain had been present for
2months;he describedit as shooting and sore to the touch but not radiating. The patient also
denied any associated mass, nipple discharge, axillary lump, axillary swelling, or skin changes.
He believed the pain was due to a change in activity or exercise because the pain was alleviated
by medication and rest. During initial consultation, a breast examination was performed while
DF was standing, in the supine position, and in a sitting position. The breasts were found to be
normal on inspection, with no skin changes. However, the left breast was found to be tender,
with no dominant mass noted. At the time of initial consult, a bilateral mammogramwas
completed with findings of a focal density on the left side in the retroareolar region and 25-mm
adjacent lymph nodes at the lateral aspect of the left breast(Figure 1). Following the
mammogram study, an ultrasound was completedwhich demonstrateda 2.2-cm ill-defined
retroareolar area, likely a focal mastitis, with no definite lump or erythema (Figure 2).

9
A mammogram usually shows a dense mass without calcifications. For males, the mass is
usually situated in the retroareolar region, as MBC often originates in the central ducts. A
peripheral mass is highly suspicious for malignancy because it cannot be
gynecomastia.12Gynecomastia is a common condition in patients with MBC, in which hormonal
changes cause the male breast tissue to enlarge.

Final assessment from the initial mammogram and ultrasound was Breast Imaging-Reporting
andData System (BI-RADS) category 3,probably benign. The BI-RADS was developed by
radiologists for reporting mammogram results using a common language.A BI-RADS category 3
means that the mammogram is probably normal, but a repeat mammogram should be
completed in 6 months. The chance of breast cancer is approximately 2% in this category. 13A
chest X-ray was also completedat this time showing no invasion into the chest.

One month later, in January 2014, DF had a follow-up ultrasoundof the left breast because of
continued associated pain. This ultrasound study revealed the previously noted changes in the
left retroareolar region once again, but they appeared less prominent. This time the density
was found to measure 1.6 cm. The previously mentionedlymph nodesremained the same, at 5
mm again. In February 2014, the patient had another consultation regarding the pain that still
resided in his left breast. Pathology at this appointment was found to show gynecomastia and
focal atypia with no evidence for malignancy. Another series of breast examinations was
performed with no dominant masses noted. An MRI was ordered for further evaluation which
showed no evidence of active disease. At this point, excision was recommended to DF, along
with a partial mastectomy. The patient declined partial mastectomy and elected to have a
lumpectomy in late February 2014.

A post-lumpectomy pathology report was completed on the mass, and it was determined to be
ductal carcinoma in situ (DCIS) with a nuclear grade of 1 to 2, measuring 4.7 mm. No lymph
nodes were taken for sampling. Necrosis was not detected in the sample, and margins were
negative. The architectural pattern of the DCIS was that of cribriform. With cribriform

10
carcinoma, the cancer cells invade the stroma (connective tissues of the breast) in nest-like
formations between the ducts and lobules. Within the tumor, there are distinctive holes in
between the cancer cells. Cribriform carcinoma is usually low grade, meaning that the cells look
and behave somewhat like normal, healthy breast cells.14 Estrogen and progesterone receptor
(ER/PR) assays were performed, and both receptors were found to be positive.The ER/PR assays
are immunohistochemical levels that grow in response to the endocrine system. The ERpositive tumors grow in response to the hormone estrogen, and the PR-positive tumors grow in
response to the hormone progesterone. These levels can estimate and help determine a
potential survival rate for a patient with breast cancer. Overall survival, disease-free survival,
recurrence-/relapse-free survival, 5-year survival, and response to endocrine therapy are all
positively associated with ER levels.Overall survival, time-to-treatment failure/progression, and
time to recurrence are positively related to PR levels.15It is believed thatpatients with breast
cancerwho have higher hormone receptor levels (ER/PR) will have a higher probability of
positive outcomes and survival. If a tumor is ER/PR positive, it will likely to respond to hormonal
therapies whichare to be administered at the completion of chemotherapy, surgery, and RT.

Patient DF was informed of his treatment options, which included mastectomy or lumpectomy
followed by postoperative radiation. The patient refused a mastectomy due to chest deformity
concerns and his rather young age. In March 2014, patient DF was referred to radiation
oncology for post-lumpectomy RT of the left breast. Breast conservation therapy, involving
lumpectomy and postoperative RT, is currently the treatment of choice for many women with
early breast cancer.Post-lumpectomy RT reduces the risk of local recurrence and the need for
salvage mastectomy, as well as long-term breast cancer mortality.16After review of patient DFs
records, the radiation oncologist had a long discussion with DF about his diagnosis and various
treatment options, including post-lumpectomy irradiation of the whole breast, with the
addition of an electron boost to the tumor bed. Because MBC treatment is similar to that of
FBC, post-lumpectomy RT was recommended to DF.The radiation oncologist discussed the
benefits, as well as the acuteand chronicside effects of whole breast irradiation. Some of the
acute side effects can include skin erythema and fatigue, while long-term side effects may

11
include fibrosis of the irradiated tissue and arm lymphedema. These long-term side effects can
severely affect the patients quality of life in the future. Patient DF elected to proceed with the
post-lumpectomy RT treatments.

Patient PP
Patient PP is a 73-year-old male who presented at an outside institutionin August 2009 with left
nipple discharge but no palpable lump. In August 2009, PP underwent a mammogram and
anultrasound of the left breast. The mammogram showed a 4-mm indeterminate density, while
the ultrasound showed no sonographic evidence of malignancy. Patient PP was noted to have
gynecomastia in both breasts. In March 2010, PP was seen for follow-up and was found to have
a new 1.5 x 1 cm lump in the 4 oclock position of the left breast.The patient underwent an
additional mammogram and ultrasound. The mammogram showed no abnormality in the left
breast corresponding to the palpable lump. Ultrasound on the same day also showed no
sonographic abnormalities in the left breast. The patient returned for follow-up in June 2010,
and was found to have no more bloody discharge and no palpable abnormalities. In March
2014, the patient presentedwith a self-identified lump in the left breast that had been
problematic. A diagnostic bilateral mammogram was completed in March 2014 (Figure 3). The
mammogram showed a 4-cm density in the upper inner quadrant of the left breast. In the same
month, the patient underwent a left breast ultrasound demonstrating a hypoechoic mass
corresponding to the location of the palpable lump (Figure 4). Some margins demonstrated
nodularity with small nodules not connected to the larger mass. Therefore, the possibility of
additional disease further away from the palpable mass could not be ruled out.

An ultrasound-guided biopsy took place in March 2014 and revealed intermediate-grade

infiltrating mammary carcinoma of no special type. The ER/PRassays were positive and human
epidermal growth factor receptor (HER-2) was negative. When HER-2 is found to be positive in
a specimen, endocrine therapy agents targeting this receptor may be an additional treatment
option to RT.17The HER-2 receptor has been found to be positive in up to 20% of all breast

12
cancersand generally leads to a worse prognosis compared to HER-2 negative cancers.The
patient underwent total left breast mastectomy along with left axillary sentinel lymph node
biopsy in late March 2014. The sentinel lymph node was positive, leading to complete axillary
dissection.

Sentinel lymph node biopsies have become the standard of care for patients with breast cancer
in order to determine the status of nearby lymph nodes.18 This type of biopsy plays an
important role in accurately staging breast cancers. There has been some controversy about
whether or not disease-free survival and overall survival are affected by the presence or
absence of micrometastasis revealed via sentinel lymph node biopsies.19 Some studies have
shown that women with micrometastasis have similar 8-year disease-free survival and overall
survival compared to women with no micrometastasis present. On the other hand, additional
studies have shown that there is a reduction in disease-free survival and overall survival with
the presence of micrometastasis.19

A small piece of the superficial layer of the pectoralis muscle was also removed in order to
ensure an adequate deep margin. Pathology revealed grade 2 invasive ductal carcinoma that
was 3.8 cm in dimension. All margins were negative and the final deep margin was benign
skeletal muscle. Malignant cells were present in the lymph nodes with 1 macrometastasis and 1
micrometastasis. The largest metastatic focus was 15 mm. A total of 44 lymph nodes were
evaluated, 2 of which were positive. Extranodal extension was present. The patient was
diagnosed with pathologic T2N1a disease. Patient PP underwent genetics evaluation and was
advised to have genetic testing. Genetic tests were negative for BRCA1 and BRCA2 mutations.

Patient PP was informed of his many treatment options including mastectomy or lumpectomy
followed by postoperative RT and opted to undergo a mastectomy. In March 2014, the patient
was referred to radiation oncology for postoperative treatment of the left chest wall. Postsurgery RTcan decrease local recurrence in patients with high-risk breast cancer and improve
the overall survival rate.20 The radiation oncologist reviewed the patients records and

13
discussed various treatment regimens with PP. RT to the left chest wall and regional lymph
nodes was recommended to the patient. The radiation oncologist further recommended to PP
that an electron boost plan treating the mastectomy scar be added after the chest wall and
lymph node irradiation.The radiation oncologist discussed the benefits and side effects of chest
wall and lymph node irradiation. The patient elected to proceed with the chest wall and lymph
nodeRT treatments.

Patient Setup/Immobilization for RT

Both patients underwent a computed tomography (CT) simulation scan for RT treatment
planning. The patients were placed in the supine position on the CT simulation couch on a
breast or wing board and VacLoc with arms above their heads. A triangle sponge was placed
under the knees for added support and comfort. In both cases the radiation oncologist marked
the superior, inferior, medial, and lateral field borders with wire.

The goal of the simulation process is to imitate the setup that will be used during treatment and
also utilize a setup that will be reproducible from day to day on the treatment machine. If the
patient is setup differently during simulation or is setup in a manner that is difficult to
reproduce, a geometrical miss of the intended target may occur when the treatment plan is
delivered. This could result in under-dosing the target, possibly leading to recurrence of disease
or unnecessarily treating surrounding tissues which may lead to destruction of those tissues.

Target Delineation
The CT data set was electronically transferred to the radiation treatment planning system to
begin the treatment planning process. The purpose of the CT data set is to allow for the
treatment planning team to contour/delineate organs and structures that may be affected by
the radiation treatment. The radiation oncologist has the duty of contouring the tumor volumes
and planning target volumes (PTVs). Fusions of the treatment planning CT with MRI, diagnostic
CT, or positron emission tomography scans may assist the radiation oncologist in delineating
target volumes. The medical dosimetrist is typically the one to contour critical structures and

14
organs at risk. Contouring structures allows for tracking of radiation doses received by those
structures in the treatment planning system (TPS). Because certain organs and structures have
specific thresholds for which severe side effects or death can take place, they often become
limiting factors in the type of treatment plan that can be designed and delivered. CT scans also
provide CT numbers (Hounsfield unit, HU) to account for attenuation through different body
tissues and structures for heterogeneity correction in dose calculations utilized in treatment
planning.21

Computed tomography scans for the purposes of radiation treatment differ in setup from
diagnostic CT scans. One of the main differences between the 2 scans is the physical couch
structure. A simulation CT scanner couch is not concave like a diagnostic CT couch. It is flat in
order to imitate the architecture of the linear accelerator treatment couch. Another major
difference is that during simulation the patient must be scanned in the position in which they
will be treated on the linear accelerators. This means the patient must be scanned with the
immobilization or setup devices that will be used during the course of treatment. Patient DFs
CT data set was transferred to the TPS. The medical dosimetrist contoured the organs at
risk,which included the heart, spinal cord, right lung, left lung, total lung, and ipsilateral ribs.
The carina was also contoured by the medical dosimetrist to assist the radiation therapists in
daily setup on the treatment machine.

Patient PPs CT data set was transferred to the TPS. The medical dosimetrist contoured the right
lung, left lung, total lung, esophagus, spinal cord, carina, and heart. The physician contoured
the left chest wall, axillary vessels, larynx, and the level 1, 2, and 3 lymph nodes.

Treatment Planning
Both men received conventional fractionation for whole breast or chest wall irradiation.
Randomized clinical trials in patients with earlystage breast cancer have demonstrated that
following breast-conserving surgery, adjuvant whole breast irradiation lowers the relative risk
of ipsilateral breast tumor recurrence by approximately 70% at 5 years and produces a 5%

15
absolute improvement in 15-year overall survival.22 Conventional fractionation for whole breast
or chest wall irradiation consists of 180 cGy per day for 28 days for a total of 5040 cGy, followed
by a successive radiation boost to the surgical scar or tumor bed. Both patients received
electron boosts of 1000 cGy at 200 cGy per day for 5 fractions. Both men received the same
radiation dose composite prescriptions delivered to their post-surgical areas. The composite
doses for both locations, including electron boosts to the postoperative scars, were 6040 cGy in
33 fractions.

For patient DF, the radiation oncologists plan was to use hybrid intensity-modulated radiation
therapy (IMRT) due to better coverage of the PTV, increased skin dose, and reduced toxicity to
the heart. The medical dosimetrist placed an isocenter for DF corresponding to approximately
the middle of the left breast(Figure 5).During the simulation procedure, the radiation oncologist
marked the edges of the field to assist the medical dosimetrist in finding mid-field. Four fields
from a linear accelerator were used: 2 medial left breast fields utilizing 6 and 16 megavoltage
(MV) energies with IMRT and 2 lateral left breast fields utilizing 6 and 16 MV energies with
IMRT. The use of the 16MV energy photon beams were used to penetrate deep into the tissue,
while the 6MV energy photons were used to obtain superficial coverage near the skin surface. A
30o wedge was used on the 16 MV medial fields, while a 45o wedge was used on the 16 MV
lateral left breast fields. Multileaf collimators (MLC) were used on the 2 fluence IMRT fields to
blockareas determined by the medical dosimetrist with the intention of reducing dose to the
heart and ipsilateral lung. The radiation oncologist made final adjustments to the MLC leaves in
order to begin radiation treatment planning. The medical dosimetrist determined field sizes of
each beam in relation to the upper and lower limits set by the radiation oncologists during the
simulation, as well as to meet the goals of the desired dose distribution throughout the breast.

The radiation oncologistoutlined for DF the desired dose prescription and objectives for the
hybrid IMRT treatment plan. The intention was to irradiate the breast tissue with an
appropriate prescription coverage of the post-lumpectomy breast without destroying normal
tissues and organs at risk, which the radiation oncologist reviewed along with the dose volume

16
histogram (DVH; Figure 6). The prescription dose was prescribed to a point at mid-breast, and
gantry angles of 303o for the medial fields and 128o for the lateral fields were used. Each beam
was weighted differently and delivered different percentages of the daily prescription dose. The
16 MV medial left breast beam delivered 55MU per day, while the IMRT medial left breast field
delivered 141 MU per day. The 16 MV lateral left breast beam delivered 51MU per day and the
IMRT lateral left breast field delivered 89MU per day. A total of 336 MU was delivered daily.
The patient received a total of 180cGy per day to the 96% isodose line for 28 fractions.

In PPs case, the radiation oncologists recommendation was a 3-dimensional (3D) plan utilizing
conventional medial and lateral tangential beams for the primary chest wall and lymph node
treatment.The medical dosimetrist placed an isocenter in the medial left lung approximately 1.3
cm from the chest wall. The right anterior oblique (RAO) and the left posterior oblique (LPO)
chest wall fields had gantry angles of 315o and 134.5o,respectively. The RAO and LPO
supraclavicular fields had gantry angles of 345o and 169o,respectively. All 4 fields utilized 15MV
beams from a linear accelerator. There were no collimator or couch rotations for any of the
fields. The field size apertures for the left chest wall fields were defined by the radiation
oncologist and designed to include the entire post-mastectomy chest wall region with an
additional margin added for flash. The supraclavicular field size apertures were also defined by
the radiation oncologist.

The radiation oncologist outlined for PP the dose prescription along with the objective for the
3D conformal treatment. The objective was to use parallel opposed supraclavicular fields in
conjunction with conventional tangential chest wall fields to maintain an adequate and
homogeneous dose distribution throughout the left chest wall tissue and left neck nodes, while
reducing toxicity to the heart and left lung (Figure 7). The radiation oncologist also requested
that the maximum dose to the axillary vessels be kept below 5292 cGy. The prescription dose
for the conventional tangential chest wall fields was prescribed to a calculation point placed by
the medical dosimetrist within the left chest wall tissue. The prescription dose for the parallel
opposed supraclavicular fields was prescribed to a different calculation point placed by the

17
medical dosimetrist in the upper axilla region. The patient received 180 cGy per day to both the
left chest wall and left supraclavicular regions for 28 fractions.

Plan Analysis and Evaluation

For patient DF, the medical dosimetrist presented a tangential 4-field arrangement, as well as
the hybrid IMRT plan for the radiation oncologist to review. The radiation oncologist chose the
hybrid IMRT plan due to the fact that there was better coverage of the skin with the
prescription dose and more homogeneous dose coverage of the whole breast. The clinic where
DF was treated requires the distance between the skin and dose coverage be less than 5mm,
and that the maximum dose be less than 5544 cGy after normalization. Hybrid IMRT is chosen
for the left breast often due to the fact that the heart dose can be reduced, as well as the
maximum dose, and skin coverage can be increased without decreasing the conformity of the
isodose lines.

It has been known that radiation to the lungs can cause pneumonitis. In order to avoid this,
radiation oncologists try to measure the percentage of the lung volume receiving 20 Gy(V20).
For the heart, there is risk of toxicity. Therefore, radiation oncologists measure the percent of
the heart receiving at least 30 Gy (V30). The radiation oncologist reviewed the hybrid IMRT plan
and noted that the V20 dose to the total lung was 2.2%, and the V30 dose to the heart was 0%;
both within their respective constraints. The plan was thenapproved for treatment.

In patient PPs case, a traditional tangential left chest wall and supraclavicular treatment plan
was developed.Once adequate prescription coverage and a homogeneous dose distribution
were achieved to the left chest wall and neck nodal volumes, the medical dosimetrist reviewed
the axillary dose constraint, the isodose lines, and the DVH (Figure 8). The maximum dose to
the axillary vessels was 5288 cGy, which fell within the constraint the radiation oncologist set at
5292 cGy. The radiation oncologist also reviewed the plan and assigned a normalization of
100% to both the left chest wall and left supraclavicular prescriptions of the treatment plan
prior to approving the plan.

18

Discussion
Both patients had initial workups that included mammogram andultrasound studies, and both
were noted to have gynecomastia. Even when small densities were found in the initial workups,
they were considered non-malignant and the patients were instructed to closely monitor their
areas of concern for any changes. Mammograms and ultrasounds are the standard for initial
breast examination in both men and women. Mammography is used when ultrasound findings
are indeterminate. When ultrasound and mammography findings are suspicious, or if
mammography appears indeterminate for malignancy, tissue diagnosis is
recommended.23However, a study by Kuhlet al24 found that MRI used for female breast
examinations was far superior to mammography and ultrasoundin detecting cancers, which is a
less invasive next step. Patient DF underwent an MRI which also failed to show malignancy. One
possible explanation for the negative results of the 3diagnostic studies for patient DF is that the
density was in an undetectable precancerous stage at the time of the early workups. Unlike
patient DF, patient PP never underwent an MRI. After one diagnostic study for patient PP
showed an abnormal density and the second study returned negative, perhaps a third study in
the form of an MRI could have been of diagnostic benefit for PP.

Because MBC has been on the rise in the past decade, perhaps different imaging studies for
men need to be given more consideration in research studies.3Furthermore, imaging features
that would normally suggest a benign tumor in females (mammogram and ultrasound) are not
always reliable imaging findings in men; further investigation is needed to distinguish between
a benign and malignant diagnosis in men.25 Because males do not benefitthe same from the
advancements in breast cancer screening and treatment compared to women because of the
lack of understanding of MBC, maybe MRI studies in conjunction with another diagnostic study
should be considered for males at the time of initial examination for MBC.The answer may be
as simple as performing MRIs and mammograms instead of ultrasounds and mammograms. The

19
research fromKuhlet al24 found that all the breast cancers in their study were found if MRI was
used in conjunction with mammography. The cost of diagnostic studies should be considered.
But there may be different combinations of studies besides the traditional mammogram and
ultrasound arrangement that could provide for earlier detection of breast cancer in males.The
extrapolation from FBC data has not improved the frequency of early MBC diagnosis. With
males failing to benefit from recent breast cancer advancementsand females being diagnosed
more frequently in early stages, changes in the standards of screening males with potential
breast cancer need to be more seriously considered for research.

An obvious limitation of this case study is that only 2patients were considered. Further research
should include a larger population of patients to evaluate the diagnostic workup for MBC
diagnoses and earlier detection.

Conclusions
Although the current standard of care was given to both patients presented in this case study,
initial workups and imaging studies proved to be inconclusive. Advancements in breast cancer
care has improved early diagnosis rates in women, but the majority of men presenting with
breast cancer symptoms continue to be diagnosed with later stage disease. Prospective
research studies focused on discerning the most effective imaging studies for males presenting
with breast cancer symptoms could lead to alternative standards of care for men compared to
women. These types of research studies may also contribute to improvement in rates of early
diagnoses of male breast cancer. Until then, the current standards of care remain
commonplace and continue to result in late stage diagnosis of breast cancers in males.

20

References
1. Anderson WF, Jatoi I, Tse J, et al. Male breast cancer: a population-based comparison with
female breast cancer. J ClinOncol. 2010;28(2):232-239.
http://dx.doi.org/10.1200/JCO.2009.23.8162
2. Andrykowski MA. Physical and mental health status and health behaviors in male breast
cancer survivors: a national, population-based, case-control study. Psycho-Oncol.
2012;21:927-934. http://dx.doi.org/10.1002/pon.2001
3. Reis LO, Dias FGF, Castro MA, et al. Male breast cancer. The Aging Male. 2011;14(2):99109. http://dx.doi.org/10.3109/13685538.2010.535048
4. Shah S, Bhattacharyya S, Gupta A, et al. Male breast cancer: aclinicopathologic study of 42
patients in Eastern India. Indian J SurgOncol. 2012;3(3):245-249.
http://dx.doi.org/10.1007/s13193-012-0163-1
5. American Cancer Society. Breast Cancer Facts & Figures 2013-2014.
http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc042151.pdf. Accessed May 9, 2014.
6. Rudlowski, C. Male breast cancer. BreastCare. 2008;3(3):183-189.
http://dx.doi.org/10.1159/000136825
7.Leibowitz S, Fox E, Loda M, et al. Male patients with diagnoses of both breast cancer and
prostate cancer. Breast J. 2003:9(3):208-212. http://dx.doi/10.1046/j.15244741.2003.09312.x
8. Wang W, Chen L, Ouyang X. Misdiagnosed male breast cancer with an unknown primary
tumor: a case report. OncolLett.2014;8(1):190-192. http://dx.doi.org/10.3892/ol.2014.2111
9. Drew Y, Calvert H. The potential or PARP inhibitors in genetic breast and ovarian cancers.
Ann NY AcadSci. 2008;1138(1):136-145. http://dx.doi.org/10.1196/annals.1414.020
10. American Cancer Society. Magnetic resonance imaging.
http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearly

21
detection/breast-cancer-early-detection-a-c-s-recs-m-r-i. Accessed October 17, 2014.
11. Susan G. Komen. Fine needle aspiration (fine needle biopsy).
http://ww5.komen.org/BreastCancer/FineNeedleBiopsy.html. Accessed October 17, 2014.
12.Charlot M, Beatrix O, Dubuisson J, et al. Pathologies of the male breast. DiagnInterv
Radiol. 2013;94(1):26-36. http://dx.doi/10.1016/j.diii.2012.10.011
13. Eberl M, Fox C, Edge S, et al. BI-RADS classification for management of abnormal
mammograms. J Am Board Fam Med. 2006;19(2):161-164.
http:dx.doi.org/doi:10.3122/jabfm.19.2.161
14. Breast Cancer.org. IDC Type: Cribriform Carcinoma of the Breast.
http://www.breastcancer.org/symptoms/types/cribriform. Accessed June 2, 2014.
15. Hammond E, Hayes D, Dowsett M, et al. American Society of Clinical Oncology/College of
American Pathologists guideline recommendations for immunohistochemical testing of
estrogen and progesterone receptors in breast cancer. J ClinOncol. 2010;28(16):2784-2795.
http://dx.doi/10.1200/JCO.2009.25.6529
16. Ashworth A, Kong W, Whelan T, et al. A population-based study of the fractionation of
postlumpectomy breast radiation therapy. Int J RadiatOncol Bio Phys. 2013;86(1):51-57.
http://dx.doi.org/10.1016/j.ijrobp.2012.12.015
17. Mayer EL, Gropper AB, Harris L, et al. Long-term follow-up after preoperative Trastuzumab
and chemotherapy for HER2-overexpressing breast cancer. Clin Breast Cancer. In press.
http://dx.doi.org/10.1016/j.clbc.2014.07.010
18. Jaffer S, Bleiweiss IJ, Nayak A. Are cytokeratin positive cells in sentinel lymph nodes of
patients with invasive breast carcinomas up to 5 mm usually significant? Histopathol.In
press. http://dx.doi.org/10.1111/his.12504
19. Zervoudis S, Iatrakis G, Tomara E, Bothou A, Papadopoulos G, Tsakiris G. Main
controversies in breast cancer. World J ClinOncol. 2014;5(3):359-373.
20. Yang B, Wei X, Zhao, et al. Dosimetric evaluation of integrated IMRT treatment of the chest
wall and supraclavicular region for breast cancer after modified radical mastectomy. Med
Dosim. 2014;39(2):185-189.http://dx.doi.org/10.1016/j.meddos.2013.12.008
21. Wu V, Podgorsak M, Tran TA, et al. Dosimetric impact of image artifact from a wide-bore

22
CT scanner in radiotherapy treatment planning. Med Phys. 2011;38(7):44514463.http://dx.doi.org/10.1118/1.3604150
22. Smith B, Bentzen S, Correa C, et al. Fractionation for whole breast irradiation: an American
Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J RadiatOncolBiol
Phys. 2011;81(1):59-68. http://dx.doi.org/10.1016/j.ijrobp.2010.04.042
23. Adibelli Z, Oztekin O, Postaci H, et al. The diagnostic accuracy of mammogram and
ultrasound in the evaluation of male breast disease: a new algorithm. Basel. 2009;4(4):255259. http://dw.doi.org/10.1159/000226284
24. Kuhl CK, Schrading S, Leutner CC, et al. Mammography, breast ultrasound, and magnetic
resonance imaging for surveillance of women at familial risk for breast cancer. J ClinOncol.
2005;3(33):8469-8476. http://dx.doi.org/10.1200/JCO.2004.00.4960
25. Ng A, Dissanayake D, Metcalf C, et al. Clinical and imaging features of male breast disease,
with pathology correlation: a pictorial essay. J Med ImagRadiatOncol. 2013;58(2):189-198.
http://dx.doi.org/10.1111/1754-9485.12073

23
Figure 1. Patient DFs Initial Bilateral Mammogram

Image shows a focal density on the left side in the retroareolar region and 2 5-mm adjacent
lymph nodes at the lateral aspect of the left breast.

24
Figure 2. Patient DFs Initial Ultrasound

Image demonstrating a 2.2-cm ill-defined retroareolar area in the left breast.

25
Figure 3. Patient PPs Diagnostic Bilateral Mammogram

Shows a 4-cm density in the upper inner quadrant of the left breast.

26
Figure 4. Patient PPs Initial Ultrasound

Demonstrates a hypoechoic mass of the left breast corresponding to the location of the
palpable lump.

27
Figure 5. Patient DF: Axial View of Isocenter Placement and Isodose Coverage of the Left
Breast

28
Figure 6. Patient DFs Dose Volume Histogram

Shows a maximum total dose of less than 5544 cGy, a total lung V20 of 2.2%, and a heart V30 of
0%.
Magenta = heart; Purple = total lung; Green = spinal canal; Blue = right lung; Light Blue = left
lung; Yellow = ipsilateral ribs.

29
Figure 7. Patient PP Isodose Distribution of the Inferior Left Chest Wall

30
Figure 8. Patient PPs Dose Volume Histogram

Showing a maximum dose to the axillary vessels of less than 5292 cGy along with low toxicities
to the heart and lungs.
Magenta = heart; Blue = total lungs; Green = axillary vessels; Brown = esophagus; Light Brown =
larynx; Yellow = level 1 lymph nodes; Orange = level 2 lymph nodes; Teal = Level 3 lymph nodes.

31
CE Test
1. Male breast cancer accounts for what percent of total breast cancers?
A. 10%
B. 1%
C. 40%
D. 25%
Answer: B, Epidemiology para 1

2. Most of the published MBC data is derived from prospective clinical trials on male breast
cancer patients.
A. True
B. False
Answer: B, Epidemiology para 1

3. Breast cancer survival is correlated with:

A. Size of the tumor
B. Imaging modality used during workup
C. Status of lymph node involvement
D. A and C
Answer: D, Epidemiology para 2

4. What etiological factor is considered to be the strongest link for male breast cancer?
A. Breast cancer 2 gene mutation
B. Breast cancer 1 gene mutation
C. Poor diet
D. P53 gene mutation
Answer: A, Etiology para 1

5. What are the 2 types of mammograms?

A. Surgical mammogram
B. Screening mammogram

32
C. Diagnostic mammogram
D. B and C
Answer: D, Imaging Modalities para 1

6. How does a breast ultrasound work?

A. Shows uptake of a radioactive isotope in the breast in the form of bright spots on the image
B. Transmits and receives reflected sound waves within the body and displays the reflected
waves in the form of an image
C. Uses X-rays to penetrate the breast tissues
D. None of the above
Answer: B, Imaging Modalities para 2

7. In males, the most common location of tumor occurrence in the breast is:
A. Retroareolar region
B. Nipple
C. Tail of the breast
D. Mediastinum
Answer: A, Patient DF para 2

8. What is gynecomastia?
A. Enlargement of the breast tissue
B. Inflammation of lymph nodes
C. Weight loss
D. Surgical removal of breast tissue
Answer: A, Patient DF para 2

9. What does a BI-RADS category 3 mean?

A. The patient must undergo a lumpectomy
B. The tumor is most likely benign
C. The tumor has metastasized
D. The tumor is likely growing rapidly

33
Answer: B, Patient DF para 3

10. ER-positive tumors grow in response to what?

A. Progesterone hormones
B. Increased levels of testosterone
C. Estrogen hormones
D. Radiation
Answer: C, Patient DF para 5

11. What is a side effect of whole breast irradiation?

A. Skin erythema
B. Fibrosis of irradiated tissue
C. Lymphedema
D. All of the above
Answer: D, Patient DF para 6

12. If a specimen is found to be HER-2 positive, then endocrine therapy agents may be an
additional treatment option.
A. True
B. False
Answer: A, Patient PP para 1

13. Radiation therapy post-surgery can accomplish which of the following:

A. Decrease local recurrence
B. Decrease overall survival rate
C. Improve overall survival rate
D. A and C
Answer: D, Patient PP para 5

14. What is the most important aspect of the simulation process?

A. The simulation CT is taken after the diagnostic CT

34
B. Oral contrast is used to assist with the delineation of organs
C. The setup used during simulation is reproducible and imitates the patients treatment position
D. The simulation is done exactly 2 days prior to radiation treatments
Answer: C, Patient Setup/Immobilization for RT para 2

15. What is the purpose of the simulation CT data set?

A. Allow for calculation of the patients lung volume
B. Allow for delineation of organs and structures
C. Assist with disease diagnosis
D. None of the above
Answer: B, Target Delineation para 1

16. What is the radiation oncologist responsible for contouring?

A. Planning target volumes (PTVs)
B. Lungs
C. All organs at risk
D. Heart
Answer: A, Target Delineation para 1

17. What is one of the main differences between diagnostic and simulation CT scans?
A. A diagnostic CT couch is flat, whereas a simulation CT couch is concave.
B. A diagnostic CT couch has 360 degrees of rotation, whereas a simulation CT couch doesnt
rotate.
C. A simulation CT couch has 360 degrees of rotation, whereas a diagnostic CT couch doesnt
rotate.
D. A simulation CT couch is flat, whereas a diagnostic CT couch is concave.
Answer: D, Target Delineation para 2

18. Which of the following is an organ at risk that needs to be contoured for breast radiation
therapy treatments?
A. Lungs

35
B. Heart
C. Spinal cord
D. All of the above
Answer: D, Target Delineation para 2 and 3

19. What is the conventional fractionation scheme for whole breast and chest wall irradiation?
A. Initial treatment of 4500 cGy followed by a 1000 cGy boost
B. Initial treatment of 5040 cGy followed by a 1000 cGy boost
C. Single treatment of 5040 cGy
D. Single Treatment of 4500 cGy
Answer: B, Treatment Planning para 1

20. What does the term V20 mean?

A. percentage of organ volume receiving a dose of 20 Gy
B. 20 % of the specified organ receiving a certain dose
C. 20% the specified organ is receiving 20 Gy
D. 0% of the specified organ is receiving 20 Gy
Answer: A, Plan Analysis and Evaluation para 2