Case Presentation: A 62-year-old male with past medical history including tobacco use and hypertension presented to the ED with fatigue, generalized weakness, and ankle pain of two-week duration. His clinical course started with upper respiratory symptoms following contact with family members who were positive for COVID-19. The presenting symptoms resolved without confirmatory testing and were followed by persistent fatigue and ankle pain. Given his atraumatic acute onset of symptoms, he had a lower extremity duplex that revealed acute DVT in bilateral lower extremities. Follow-up CT pulmonary artery imaging in the setting of previous shortness of breath demonstrated multiple lucent-appearing lesions in the cervical spine, thoracic spine, scapulae, and ribs without evidence of pulmonary embolism. No prior CT imaging was available for comparison. Oncology was consulted for further recommendations. A CT scan of the chest, abdomen, and pelvis did not suggest a primary origin of possibly bony metastasis aside from mild prostatic enlargement. Multiple myeloma labs were negative. PSA screen was within normal range. CEA and Ca-19-9 were mildly elevated. Biopsy was performed on the right iliac bone lesion suggesting metastatic carcinoma of unknown origin with nonspecific immunophenotype. He was discharged home and scheduled to follow up with oncology as an outpatient. At his follow-up appointment, physical examination revealed a small scab over the left nipple with a palpable mass beneath the skin. A diagnostic mammogram was performed that revealed an irregular marginated mass highly suspicious for malignancy. Biopsy was performed and diagnostic for invasive ductal carcinoma, confirmed to be the primary origin of his metastatic bone disease.
Discussion: Breast cancer in males is quite rare, accounting for less than 1% of all breast cancers worldwide and less than 1% of all cancers in men (3). Because of this, men are often diagnosed with breast cancer at more advanced stages given its infrequency as well as lack of screening tests (2). Risk factors include family history of breast or ovarian cancer, age, race, history of cirrhosis, obesity and radiation exposure (3). BRCA2 is the most commonly associated gene mutation (3). The majority of breast tumors in males are invasive ductal carcinoma followed by ductal carcinoma in situ (3). Male breast tumors are commonly in the areolar region and can often be palpated or have associated ultrasound findings (3). Breast cancer should always be on the differential for males with a palpable breast mass and should be considered in cases of metastasis with unknown etiology.
Conclusions: This case highlights the importance of physical exam in diagnosis of disease. Breast cancer is the most common form of cancer amongst women and is the second leading cause of cancer-related death in women (1). Although less common, it is always important to keep breast cancer in the differential when working up a male for malignancy.