Male breast cancer: An often forgotten diagnosis.

Sir,

A 50-year-old gentleman presented with a progressively enlarging lump over left mammary area for 6 months. He was taking anti-tuberculosis treatment for left axillary tubercular lymphadenitis with discharging sinus for 4 months. Tubercular axillary lymphadenitis was diagnosed in another hospital; the cytological examination of the pus from the axillary sinus suggested tuberculosis and the radiometric liquid culture system (BACTEC®, Becton Dickinson, USA) for Mycobacterium tuberculosis was also positive. Serological tests for HIV I and II were negative. He also had a lump over the left mammary area for 6 months. Both the patient and the treating physician did not give much attention to the lump, and no further investigations were carried out. He was prescribed four drug anti-tuberculosis treatment including rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months followed by rifampicin and isoniazid alone for four additional months. The anti-tuberculosis treatment led to subsidence of discharge from the sinus with reduction in the size of the lymph nodes. However, the lump over the left mammary area continued to increase in size. When he presented to us, there was a 3 cm × 2 cm lump over the left mammary area on physical examination. The lump was nontender, mobile, and hard in consistency. There was a healed sinus in the left axilla [Figure 1]. There were also multiple hard and matted lymph nodes palpable in the left axilla. The contralateral breast and axilla were unremarkable. Cytological examination of the fine needle aspirate form the lump revealed ductal carcinoma while fine needle aspirate from the axillary lymph node showed epithelioid cells, a few multinucleated giant cells and granular eosinophilic material (caseation) suggestive of tuberculosis; stain for acid-fast bacilli was negative. Chest X-ray was unremarkable. Metastatic work up did not reveal distant metastasis. He underwent left modified radical mastectomy. Histopathological examination of the mastectomy specimen revealed invasive ductal carcinoma. There were twelve lymph nodes identified in the axillary specimen. Although all the lymph nodes were free of metastasis, they showed epithelioid granulomas with caseating necrosis. Subsequent Ziehl–Neelsen staining for acid-fast bacilli was negative. However, positive polymerase chain reaction for M. tuberculosis confirmed the tubercular etiology. The anti-tuberculosis treatment was continued. The patient was advised adjuvant chemotherapy in view of pT2N0M0 stage.

Figure 1

Clinical photograph showing left mammary mass (black arrow) and healed left axillary sinus (white arrow)

A few cases of coexisting breast cancer and axillary tubercular lymphadenitis have been reported in the literature.[12] The possibility of coexistence of malignancy and tuberculosis seems likely in developing countries where tuberculosis is endemic. This does not seem to be a major problem in female patients where a treating clinician always has a high index of suspicion for breast cancer. The same index of suspicion may not be maintained by the treating clinicians while encountering a male patient who has similar coexistence of tuberculosis and breast malignancy as was the case in our patient. We conclude that breast cancer should always be kept in the differential diagnosis of a mammary lump in male patients so as to avoid the delay in the diagnosis and subsequently appropriate treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.