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Case History

image A 35 year transgender man was referred to the triple assessment breast clinic after the finding of a breast mass on examination prior to bilateral mastectomy and male chest reconstruction.

He was unsure how long the lump had been present as he experienced dysphoria related to his chest and so was unable to self-examine. He had experienced no skin changes or other symptoms. He had a history of depression and anxiety in his teens and early 20s but this was much improved since his transition. He was taking testosterone propionate 250 mg intramuscularly every 4 weeks which was started 2 years ago. He stated that his mother was diagnosed with ovarian cancer in her late 60s and that he thinks his grandmother may have also had cancer.

On examination he had a 2 cm firm mass in the upper outer quadrant of his right breast with no axillary lymphadenopathy. Biopsy of the mass confirmed a grade 3 invasive ductal carcinoma ER 7/8 PR 6/8 and HER2 negative. Given his greater than 10% chance of familial breast cancer, he underwent BRCA mutation testing which confirmed a mutation in BRCA2 gene.

He was informed that he would require surgery, followed by chemotherapy, hormonal therapy and possibly radiotherapy in addition.

What additional histopathological testing is required on his tumour?

What are his surgical options at this stage?

How should his testosterone dosing be managed during cancer treatment?

What are his options regarding his future fertility?

What other challenges might a breast cancer diagnosis bring for a transgender male patient and how can the healthcare team help to minimize these?

What additional screening is important to enquire about in this patient?

What additional histopathological testing is required on his tumour?

This patient was taking exogenous testosterone for masculinization. It was therefore important to test his tumour for androgen receptor (AR) positivity to ensure that testosterone was not directly promoting tumour growth. There are reports in the literature of AR positive breast tumours in both transgender (trans) men and cisgender (cis) women, although it is less common in the presence of ER positivity.1–4

What are his surgical options at this stage?

This patient had been scheduled for a bilateral mastectomy and male chest reconstruction, sometimes called ‘top surgery’. This surgery is opted for by most trans men and associated in general with a dramatic lowering of dysphoria.5 It leaves a limited amount of breast tissue remaining to give the cosmetic appearance of a male chest, but the volume is so low that if monitoring is necessary, this can be done only by ultrasound or MRI and not by mammography.

The most recent literature estimates the risk of breast cancer in trans men is approximately 5 times lower than cis women but this is also affected by duration of exposure to oestrogen prior ...

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