A Dual-Surgeon Approach to Breast Cancer Surgery in a Transmale

Abstract

With increasing numbers of gender-affirming chest surgery, new questions regarding breast cancer management and surgical practice arise. Guided by our case report, we present a comprehensive review of breast cancer surgery in a transman to educate both plastic and breast surgeons on various factors to consider when caring for these patients. Our case involves a 31-year-old transmale patient who presented for plastic surgery consultation for gender-affirming mastectomy but was subsequently found to have a right breast mass. This is the first case in the literature of a transmale on hormone therapy with breast cancer interested in gender-affirming surgery, thus requiring a dual-surgeon approach for oncologic and gender-affirming mastectomy. With a multidisciplinary patient-centered approach involving breast surgery, plastic surgery, medical oncology, and radiology, we devised a surgical plan to safely remove his breast tissue with consideration for his gender-affirming goals. He underwent a right skin-sparing mastectomy with sentinel node biopsy and left prophylactic skin-sparing mastectomy through skin markings by the plastic surgeon, with bilateral free nipple grafts. Final pathology confirmed estrogen and progesterone receptor–positive and androgen receptor–positive invasive ductal carcinoma with clear margins and negative sentinel node. The patient did not require adjuvant chemotherapy or radiation but was started on adjuvant hormone therapy targeting his hormone receptor positive cancer. He elected to stay on low-dose masculinizing hormone therapy with continued surveillance examinations. We follow our case with a review of the current literature involving breast cancer in transmales to explore current screening practices, surgical recommendations, adjuvant therapies, continuation of masculinizing hormone therapy, and postoperative surveillance guidelines in the hopes of informing plastic surgeons in having these discussions with their transmale patients and thus improving informed cancer care for this population.

A case report of gender-affirming mastectomy in a transgender individual with breast cancer

“…Described above is one of only several cases in which a transmale underwent GAM following breast cancer diagnosis (12,13). Further, this is the first documented case report of an individual also discovering BRCA2 positivity as a result of pre-operative screening.…”

The Impact of Exogenous Testosterone on Breast Cancer Risk in Transmasculine Individuals

“…10,13,15,17,18,23,26,27,30,31,33 Eight cases reported a negative BRCA status, and the rest did not report a BRCA status. 10,15,21,24,26,29,30 Body mass index and race were not reported in these studies despite being known risk factors for BCa incidence. Brown and Jones, 11 Katayama et al, 23 and Fundytus et al 18 each describe one case of BCa in patients who had undergone a prior hysterectomy and bilateral oophorectomy.…”

“…31 One study showed increased rates of atypia in cisgender women (3.2%) compared with transmasculine individuals (0.8%), but this finding was not significant. 50 Cohorts of transmasculine individuals examined in these studies had mean ages ranging from 25.0 to 31.5, 22,29,31,35,36,38,39,[47][48][49] with one study reporting a median age of 24. 50 Many of these histological studies contained significant experimental limitations.…”

“…Estrogen receptor status was positive in 21 and negative in 6. [10][11][12][13][14][15][16][17][18][19][20][21][24][25][26][27][29][30][31][32][33] Progesterone receptor status was positive in 13 and negative in 8. [10][11][12][13][14][15][16][18][19][20][21][23][24][25][26][27]29,30,32,33 Androgen receptor status was positive in 8 and negative in 2.…”

“…[10][11][12][13][14][15][16][17][18][19][20][21][24][25][26][27][29][30][31][32][33] Progesterone receptor status was positive in 13 and negative in 8. [10][11][12][13][14][15][16][18][19][20][21][23][24][25][26][27]29,30,32,33 Androgen receptor status was positive in 8 and negative in 2. 10,16,18,21,23,24,27,29,30 HER2 receptor status was reported in 18 cases and was positive in 10.…”