Bilateral Metachronous Invasive Lobular Breast Cancer with Pulmonary Metastasis in an Elderly Male: The First Case in Saudi Arabia

Abstract Introduction: The occurrence of bilateral metachronous invasive lobular breast cancer in men is infrequent, considering that male breast cancer itself is found in less than 1% of all breast cancer cases, and bilateral cases are even less common. To our knowledge, this is the first case reported in Saudi Arabia. Case presentation: This is a 62-year-old male who presented to the general surgery clinic complaining of a left breast lump for 4 years, and an inverted nipple 2 years ago, respectively. The patient underwent breast ultrasound, revealing a Left breast lesion classified as (BIRAD4 b). The mammography was not done because he had a flat chest. Tru-cut biopsy indicated left invasive breast cancer, ER&PR positive, and HER2 negative. The patient underwent a left breast mastectomy on August 8, 2024. Unfortunately, the patient missed several appointments, and a few weeks later, then presented with a lump, felt retroareolar. The subsequent evaluation through the breast Ultrasound showed a right breast lesion classified as (BIRAD4) and highly suspicious right axillary lymphadenopathy. Then the patient underwent a right breast mastectomy and Sentinel lymph node biopsy (SLNB) on January 1st, 2025. Discussion: Gynecomastia is a common benign condition resulting in expansion of glandular breast tissue in men, usually because of increased estrogen and reduction in androgen activity. It can usually be thought of clinically as a palpable, firm subareolar mass, which can be unilateral or bilateral. Gynecomastia can be physiological, when it happens most frequently, for example, during neonatal life or puberty, and because of aging. Gynecomastia may also be secondary to pathological condition. Physiological causes include endocrine disorders, systemic disorders (e.g. liver cirrhosis, renal failure), medication (e.g., antiandrogens, spironolactone, antipsychotics), and malignancy. In general, gynecomastia is a benign condition, however, a detailed evaluation is required to exclude male breast cancer, even though the prevalence of cancer in men with gynecomastia is rare. Thus, further evaluation is warranted, particularly in older men or men with other risk factors. An understanding of the underlying etiological factors and clinical context is critical to definitive diagnosis and treatment. Although gynecomastia itself is common and generally non-malignant, A large epidemiological study found no direct evidence that gynecomastia increases the risk of developing MBC. Conclusion: In this case, the Compliance involves follow-up with History and physical examination every 6 months for 5 years, then annually, and genetic counseling and hormonal therapy with radiation management are significantly stressful to the patient. Keywords: Male; Bilateral; Breast cancer; Invasive lobular carcinoma; Metachronous