FFinalistSouthampton · 2027
Endocrine
AKT · Endocrine/Breastlow yield

Male breast cancer

Breast carcinoma in men (often ER-positive; BRCA2-associated)

Overview

Rare breast carcinoma in men, presenting as a hard, often retroareolar (subareolar) painless lump with nipple changes. Usually ER-positive; strongly associated with BRCA2, Klinefelter syndrome and oestrogen excess. The key is to distinguish a firm fixed eccentric mass from symmetrical, soft, central gynaecomastia.

Recognise

  • Hard, usually retroareolar/eccentric, fixed, PAINLESS lump in an older man, often with nipple retraction/discharge/ulceration
  • Risk factors: BRCA2, Klinefelter syndrome, family history, oestrogen excess (cirrhosis, obesity), radiation
  • Contrasts with gynaecomastia (soft, symmetrical, central, often bilateral, mobile)

Red flags

  • A firm, fixed, eccentric breast mass with nipple change in a man → suspected-cancer pathway (not 'just gynaecomastia')
  • BRCA2/Klinefelter associations → genetics

Differentials & how to tell them apart

Gynaecomastiasoft, mobile, symmetrical, central (subareolar) disc, often bilateral and tender — benign breast tissue, not a hard fixed mass
Lipomasoft, mobile, no nipple change
Pseudogynaecomastiafatty enlargement without glandular tissue (obesity)

Investigations

Triple assessment (mammography/ultrasound + core biopsy, ER/PR/HER2); BRCA testing.

Management

Triple assessment → mastectomy + adjuvant therapy (tamoxifen if ER-positive)

  1. 1Refer a firm, fixed, eccentric breast mass with nipple change on the suspected-cancer pathway; triple assessment. Treatment is usually mastectomy + sentinel node, with adjuvant endocrine therapy for ER-positive disease.Gate: Distinguish from GYNAECOMASTIA (soft, symmetrical, central, mobile) — a hard, fixed, eccentric mass with nipple change is cancer until proven otherwise; offer BRCA testing
  2. 2Adjuvant tamoxifen (ER-positive)/chemotherapy/radiotherapy per risk; genetic counselling.
Surgery (usually mastectomy) + sentinel node — primary treatment
Tamoxifen (ER-positive) — adjuvant endocrine therapy

Key points

Hard, fixed, eccentric, painless retroareolar lump + nipple change in a man = male breast cancer (BRCA2/Klinefelter). Gynaecomastia is soft, symmetrical and central — the discriminator.

Monitor & prognosis

Surveillance; endocrine therapy.

Stage-dependent; often presents later.

Source: NICE NG101