What Are the Uses of Tamoxifen for Men?

(I) Causes of Onset

Painless lump in the breast of elderly men

The occurrence of painless lumps in the breasts of elderly men is one of the clinical diagnosis of male breast cancer. Male breast cancer (malemammarycancer) is a rare malignant tumor that accounts for 0.2% to 1.5% of all cancers in men and about 1% of breast cancer.

Affected area

Reproductive site

Related diseases

Breast hyperplasia breast liposarcoma male breast breast liposarcoma sweat gland cancer elderly breast cancer chromosomal abnormalities

Affiliated Department

General surgery

Related symptoms

Nodular ulcer in elderly male breast painless mass skin adhesion skin redness itching eczema

(I) Causes of Onset

The cause of breast cancer in men is not very clear, and it is currently believed to be related to the following factors.

1. Familial In domestic and foreign reports of male breast cancer, there are a considerable proportion of cases in the family, or a family history of female breast cancer, or the existence of other tumor cases in the family. It is suggested that the occurrence of breast cancer in men is familial.

2. Endogenous estrogen increase Compared with female breast cancer, male breasts have no physiological activity and lack of over-stimulation of ovarian hormones. But most of the patients have male breast development, endocrine abnormalities and liver damage. Lacassegne confirmed (1932) that repeated injections of estrogen in male mice can induce breast cancer. When the liver is damaged, the liver's inactivation of estrogen is reduced, which leads to a relatively excessive amount of estrogen in the body and an increase in male mammary glandular development. Some people believe that male mammary glandular development is a precancerous disease, which easily leads to breast cancer.

3. Sex chromosomal abnormalities. Other studies have shown that some testes have small testicles, seminiferous fibrosis, and hyaline degeneration. Increased pituitary gonadotropin and abnormal chromosomes in the urine are called Klinefelter syndrome. In this case, the incidence of breast cancer is 20 times higher than that of normal men.

4. Exposure to other radioactive materials, local breast damage, and estrogen in clinical treatment can also induce breast cancer.

(Two) pathogenesis

1. Male breast cancer occurs in the central part of the mammary glands below the nipple and areola. It is mainly unilateral, with the left side being slightly more common than the right side.

2. Pathological morphology

(1) General morphology: The lumps are deep on the naked eye, the border is unclear, hard and painless, and the average diameter is 3.1cm. As the lump progresses, it can adhere to the skin, often showing nodular bulges, forming ulcers, and it can spread to the deep and fixate with pectoral muscle adhesion.

(2) Tissue morphology: The pathological type of male breast cancer under optical microscope is basically the same as that of female breast cancer. Non-specific invasive cancer is more common, accounting for 82% to 86.5%; invasive cancer can be divided into adenocarcinoma and hard cancer. , Simple cancer, medullary cancer, papillary cancer, mucinous cancer, sweating adenocarcinoma, etc. (Figure 1). Many people believe that normal male breast cancer lacks lobular tissue, so lobular cancer does not occur, but lobular cancer has been reported in the literature in recent years.

The cellular origin of male breast cancer is still under debate. It is worth mentioning that the detection of estrogen receptor (ER) and carcinoembryonic antigen (CEA) in cancer tissues by immunoenzyme technology is of great significance to guide the treatment and monitor the recurrence of breast cancer. Male breast cancer can be divided into hormone-dependent and non-hormone-dependent as well as female breast cancer. Some people have found that when men treat certain diseases with estrogen, the breast can form true leaflets, the structure of which is the same as that of sexually mature women's breasts.

1. Late visits Due to the physiological anatomic characteristics of male breasts, and most of them are painless breasts, they are usually late. Sun Yan et al. Reported 88 cases with a pre-diagnosis course of 31.2 months and growing female breast cancer for more than 1 year.

2. Breast lump is a common complaint when patients with spontaneous symptoms see a doctor as a painless lump under the areola, which is easy to invade the skin and nipples, and ulcers can appear. Generally unilateral, the left and right disease equally, rarely bilateral, paramilitary can also occur. Small and unclear painless masses initially appear in the nipples and under the nipples. About half of patients may experience skin redness, itching, nipple retraction, and nipple eczema. As the disease progresses, the mass can adhere to and fix the skin, and satellite nodules appear.

3. Regional lymph node metastasis early Due to the small size of male breasts and the anatomical features of short lymphatic vessels, 54% to 80% of patients have lymph node metastasis earlier. In particular, the areola area in men is closer to the lymph nodes in the inner breast area, and the lymph nodes in the inner breast area are easily involved. This is also one of the reasons why the prognosis of male adenocarcinoma is worse than that of female breast cancer.

4. High ER-positive rate The ER-positive rate of breast cancer in men is 64% to 76%, and has a good response to endocrine therapy. Tamoxifen can be commonly used, and advanced testicular resection is feasible.

People with the following conditions may be considered as male breast cancer.

1. Elderly men have painless lump in the breast.

2. Examination of masses invades the skin and nipples, and ulcers may appear.

3. Needle aspiration cytology to find severe hyperplasia, suspicious cancer cells, and even cancer cells.

4. Frozen before diagnosis.

Differential diagnosis of painless mass in breasts of elderly men:

Should be distinguished from male breast development. Male breast cancer patients are mostly elderly, unilateral masses, eccentric masses, hard and painless; cancer cells are found by needle aspiration. And male breast development is more common in adolescents and liver disease patients, mostly bilateral discs, with tenderness; needle aspiration cytology is one of the important identification methods. 1. Late visits Due to the physiological anatomic characteristics of male breasts, and most of them are painless breasts, they are usually late. Sun Yan et al. Reported 88 cases with a pre-diagnosis course of 31.2 months and growing female breast cancer for more than 1 year.

2. Breast lump is a common complaint when patients with spontaneous symptoms see a doctor as a painless lump under the areola, which is easy to invade the skin and nipples, and ulcers can appear. Generally unilateral, the left and right disease equally, rarely bilateral, paramilitary can also occur. Small and unclear painless masses initially appear in the nipples and under the nipples. About half of patients may experience skin redness, itching, nipple retraction, and nipple eczema. As the disease progresses, the mass can adhere to and fix the skin, and satellite nodules appear.

3. Regional lymph node metastasis early Due to the small size of male breasts and the anatomical features of short lymphatic vessels, 54% to 80% of patients have lymph node metastasis earlier. In particular, the areola area in men is closer to the lymph nodes in the inner breast area, and the lymph nodes in the inner breast area are easily involved. This is also one of the reasons why the prognosis of male adenocarcinoma is worse than that of female breast cancer.

4. High ER-positive rate The ER-positive rate of breast cancer in men is 64% to 76%, and has a good response to endocrine therapy. Tamoxifen can be commonly used, and advanced testicular resection is feasible.

People with the following conditions may be considered as male breast cancer.

1. Elderly men have painless lump in the breast.

2. Examination of masses invades the skin and nipples, and ulcers may appear.

3. Needle aspiration cytology to find severe hyperplasia, suspicious cancer cells, and even cancer cells.

4. Frozen before diagnosis.

(A) treatment

Treatment of breast cancer in men is the same as in women.

Surgical treatment

(1) For patients who do not invade the pectoral muscle, modified radical mastectomy should be preferred. There are reports that classic radical surgery has large injuries, many complications, and the same prognosis as patients with modified radical surgery, and should not be preferred.

(2) For patients with pectoral muscle invasion, the main surgical method is radical surgery or expanded radical surgery. Because tumors located in the areola area can easily metastasize to the internal breast area and axillary lymph nodes; therefore, if there is no radiotherapy equipment and there are contraindications to radiotherapy, there is a greater indication for expanded radical mastectomy. If you have the above equipment, you can consider radical surgery and additional radiotherapy after surgery, but carefully choose modified radical mastectomy for breast cancer; it is more inappropriate to choose a surgical procedure that is smaller than simple mastectomy.

2. Radiation therapy

Male breast cancer has a rich lymphatic network under the nipples and areolas, and its small masses cause lymph node metastasis in the inner breast area or under the armpits. Therefore, postoperative radiotherapy of the internal breast area, underarms, supraclavicular and chest wall is necessary to reduce recurrence. Radiotherapy treatment can be divided into:

(1) Postoperative radiotherapy: It is commonly used in patients with axillary lymph node metastasis after radical or modified radical surgery, and irradiates lymph nodes in the supraclavicular and internal breast areas. If the tumor is located outside the breast and there is no axillary lymph node metastasis, surgery is generally not required After radiation therapy. The radiation equipment can use 60Co or linear accelerator. The irradiation area must be accurate. The general dose is 50 Gy (5000 rad) / week, and most reports suggest that it can reduce local and regional lymph node recurrence. Whether the patient's survival rate can be changed is inconclusive.

(2) Preoperative radiotherapy: It is mainly used in patients over stage III. The lesion is large and ulcers. The tumor shrinks after irradiation, which is conducive to palliative resection. Generally, the tangent field on both sides of the breast is used, and the irradiation dose is 40Gy (4000rad) / 4 weeks. Operate within 2 to 4 weeks after the irradiation. (3) Radiotherapy for tumor recurrence: For recurring nodules or supraclavicular lymph node metastases in the surgical field, radiotherapy can often achieve better results. Localized bone metastases also have good radiotherapy effects.

3. Chemotherapy for breast cancer in men before surgery and additional chemotherapy based on lymph node metastasis-positive and ER-negative patients are expected to improve survival.

Commonly used chemotherapy drugs are: cyclophosphamide, fluorouracil, methotrexate, doxorubicin (adriamycin) and mitomycin. Chemotherapy combined with comprehensive treatment before, during, after and after surgery can play a significant role in inhibiting the growth and doubling of cancer. According to the theory of cytology, postoperative chemotherapy should be started early, generally not more than 1 month after surgery. When the situation allows, adhere to chemotherapy within 1 year after surgery. Long-term application does not improve its curative effect, and at the same time it has a certain damage to the human immune function.

4. Endocrine therapy is mainly used in male patients with advanced or relapsed breast cancer.

(1) Drug treatment: Morgan et al. First applied tamoxifen to the treatment of advanced male breast cancer in 1978, and achieved good results. In the future, there have been reports that tamoxifen (tamoxifen) has no obvious side effects and is suitable for patients of any age. And the effective rate for advanced male breast cancer is 48%, and for the elderly frail and advanced male breast cancer patients, tamoxifen can achieve a response rate of 66%. Ribeim et al. Added tamoxifen for 10 years after surgery and radiotherapy to operable stage and cases, and the 5-year survival rate was 55%. Therefore, tamoxifen is a conventional drug for male breast cancer ER receptor positive, and is the drug of choice for endocrine therapy.

Aminoglutamate (AG) is a biological process that inhibits peripheral sex hormones produced in the body and inhibits estrogen conversion by aromatase. Harris et al. Have achieved good results in the treatment of male patients with advanced breast cancer by treating with ammonia ruminide (AG); at the same time, they found that the combination of ammonia ruminide (AG) and hydrocortisone will produce an additive effect; Lumit (AG) plus hydrocortisone is a second-line treatment for patients with advanced male breast cancer.

(2) Surgical treatment:

Bilateral orchiectomy: In 1942, Farrout et al. Reported for the first time that bilateral orchiectomy for advanced male breast cancer patients had achieved significant results. Since then, many reports have shown that the effectiveness of bilateral orchiectomy is 50% to 60%. However, Willian et al. Found that there seems to be no significant relationship between estrogen receptor levels and symptom relief rates after orchiectomy, so ER receptor status cannot be used as an indicator of orchiectomy.

Bilateral adrenalectomy: In 1952, Huggins and Bergenstal et al. Applied adrenalectomy to patients with advanced breast cancer for the first time and achieved significant results. Since then, many scholars have reported this one after another, and this method has been popularized and applied, and its efficacy has been recognized. Patel underwent bilateral adrenalectomy plus orchiectomy in 1984, with a remission rate of 80% and a remission period of 4 to 30 months. Investigating its principle, it is believed that bilateral adrenalectomy plus testectomy can eliminate the production of adrenal androgens and cut off the main peripheral sources of androgens and estrogen in the body. Therefore, adrenalectomy can be used as a second-line endocrine therapy for treatment failure after orchiectomy.

Pituitary resection: In 1955, Luft first applied pituitary resection to the treatment of advanced male breast cancer and achieved a certain effect. However, due to the difficulty of the operation and the large side effects, and because the surgery could not completely remove the pituitary or pituitary-like tissue Treatment often fails, so surgery is rarely used.

(B) the prognosis

Male breast cancer patients are older, have a longer course, and have a worse prognosis. However, if detected early and treated promptly, the prognosis of treatment tends to be the same as that of women. The factors that affect the prognosis of breast cancer in men are mainly the pathological type, staging, treatment methods, and presence or absence of lymph node metastasis at the time of consultation. Most reports suggest that the overall 5-year survival rate after treatment is slightly lower for men than for women. Therefore, to improve the prognosis of male breast cancer lies in early detection, early diagnosis and early treatment.