Postoperative Patient Pain Severity and Its Association With Anxiety, Depression, and Sleep Quality.

Introduction The experience of pain is a complex phenomenon. A patient in the acute postsurgical pain setting may feel a constant bombardment of nociceptive input from the surgical site; this in turn influences psychological factors that determine the overall emotional experience of pain, which is significant. The aim of our study was to investigate the severity of pain in postsurgical patients three days after surgery using the 100 mm visual analog scale (VAS). Methods This was a cross-sectional assessment of postoperative pain. Participants were patients between 18 and 64 years of age who had undergone a surgical procedure (laparoscopic or open surgery), three days prior to the data collection and who were admitted or discharged postoperatively at the Al Salmaniya Complex, Manama, Bahrain. Participants were asked demographic questions about whether they had laparoscopic or open surgeries and completed self-reporting scales. Patient Health Questionnaire-9 (PHQ-9) was utilized to screen for both the presence and severity of depression; Generalized Anxiety Disorder 7-item (GAD-7) was administered to screen for anxiety; the Insomnia Severity Index (ISI) was used to evaluate insomnia; and the VAS was used to evaluate pain.  Results Sixty-seven patients were recruited, with a mean age of 61.53 years (SD = 7.37). Twenty-nine (43%) were females, 38 (57%) were males, 36 (54%) underwent elective surgery, 31 (46%) underwent emergency surgery, 31 (46%) underwent laparoscopic surgery, and 36 (54%) underwent open surgery. The average score on the Brief Pain Inventory Short Form (BPISF) was 8.12 (SD = 1.16), indicating a moderate level of pain. Twenty-six (43%) patients had moderate-severe insomnia, 21 participants (31%) had no insomnia, 17 participants (25%) had subthreshold insomnia, 28 (42%) had moderate depression, five (7%) had moderate-severe depression, and 34 (51%) had severe depression. Eighteen participants (27%) had mild anxiety, 46 (69%) had moderate anxiety, and 3 (4%) had severe anxiety. Six of the participants (9%) reported moderate pain, while 61 participants (91%) reported severe pain.

Programmed Death-Ligand 1 Expression in Breast Cancer Patients: Clinicopathological Associations from a Single-Institution Study.

PURPOSE: Tumor expression of programmed death-ligand 1 (PD-L1) is associated with evasion of immune response in several types of malignancies and such expression may render patients eligible for PD-L1 inhibitors. The use of immune checkpoint blockade therapy has been recently approved for the treatment of breast cancer. However, PD-L1 expression data are lacking among Jordanian breast cancer patients. In this study, the tumor PD-L1 expression was characterized in breast cancer patients to assess their eligibility for immune checkpoint blockade therapy. The study also aimed to explore the association between tumoral PD-L1 expression and the clinicopathologic characteristics and the prognostic factors in patients with breast cancer. PATIENTS AND METHODS: Tissue samples were available from 153 female patients with primary invasive breast cancer. Immunohistochemistry was performed on paraffin-embedded tumor sections that were stained with a PD-L1 antibody. Expression of tumor PD-L1 was correlated with demographics, clinicopathologic characteristics, and prognosis. RESULTS: The mean age at diagnosis was 54.2±12.8 years (median 52, interquartile range 45-65). The percentage of PD-L1-positive tumors was 26.1%. PD-L1 expression on tumor cells significantly and positively correlated with tumor size (rho=0.174, p=0.032). PD-L1 positivity was significantly associated with the grade of carcinoma (p=0.001), HER2-positivity (p=0.015), and lymphovascular invasion (p=0.036). PD-L1 intensity was significantly associated with tumor stage (p=0.046). No significant associations were observed for the PD-L1 expression status or intensity with patient menopausal status, hormone receptor expression, and molecular subtypes. PD-L1 expression significantly correlated with a worse prognosis of breast cancer patients at the time of diagnosis (rho=0.230, p=0.005). CONCLUSION: Tumor PD-L1 expression was associated with advanced clinicopathologic features and worse prognosis in this cohort of Jordanian breast cancer patients. Future studies are needed to better understand the impact of PD-L1 blockade therapy on treatment outcomes in eligible breast cancer patients in Jordan.

The Role of Establishing a Multidisciplinary Team for Idiopathic Granulomatous Mastitis in Improving Patient Outcomes and Spreading Awareness about Recent Disease Trends.

BACKGROUND: Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002. RESULTS: Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence (χ 2 = 5.598; p = 0.018). Chi-square analysis showed no significant association between BMI and recurrence (χ 2 = 0.776; p = 0.678). CONCLUSION: The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating.

Impact of Obesity on Clinicopathologic Characteristics and Disease Prognosis in Pre- and Postmenopausal Breast Cancer Patients: A Retrospective Institutional Study.

Purpose: To investigate the association between obesity and breast cancer clinicopathologic characteristics at presentation along with prognostic impact among Jordanian breast cancer patients. Such data are lacking in Arabian countries. Methods: In this retrospective study, 348 breast cancer patients were included. Analyses were conducted for associations between body mass index (BMI) and age at diagnosis, tumor clinicopathologic characteristics, and molecular subtypes. Eight prognostic factors were considered, and total prognostic scores were calculated. The analysis was stratified by menopausal status. Multivariate logistic stepwise regression analysis was conducted to identify predictors for breast cancer recurrence and death. Results: Mean age at diagnosis was 50.98 ± 10.96 years. Mean BMI at diagnosis was 29.52 ± 5.32 kg/m2. Mean age at diagnosis was significantly higher for overweight and obese patients compared to underweight/normal patients (P < 0.001). A significant positive correlation was observed between patient age and BMI at diagnosis (r = 0.251, P < 0.001). Grade of carcinoma was significantly correlated with BMI in the whole population examined (P=0.003). Obese breast cancer patients had significantly higher prognostic scores compared to nonobese cases, indicating worse prognostic features at presentation (P=0.034). Stratification of data analysis based on menopausal status revealed significant associations between obesity and each of tumor stage and grade among postmenopausal but not premenopausal patients (P=0.019 and P=0.031, respectively). Similarly, postmenopausal obese patients had significantly higher prognostic scores compared to nonobese counterparts (P=0.007), indicating worse prognosis, a finding which was also absent among premenopausal breast cancer patients. No significant association between BMI with expression status of hormone receptors, HER2, lymphovascular invasion, and molecular subtypes was found among patients. BMI was a significant predictor for disease recurrence in which obese breast cancer patients had greater odds (2-fold) to develop locoregional and distant recurrence compared to nonobese cases (P=0.011). Conclusions: Obesity was associated with advanced stage and grade of breast carcinoma at diagnosis. The impact of BMI on clinicopathologic characteristics and prognosis was confined to postmenopausal cases. Jordanian obese breast cancer patients are at greater risk of breast cancer recurrence and reduced survival compared to their nonobese counterparts.

Immunotherapy for HER2-positive breast cancer: recent advances and combination therapeutic approaches.

Cancer immunotherapy has evolved dramatically with improved understanding of immune microenvironment and immunosurveillance. The immunogenicity of breast cancer is rather heterogeneous. Specific subtypes of breast cancer such as estrogen receptor (ER)-negative, human EGF receptor 2 (HER2)-positive, and triple-negative breast cancer (TNBC) have shown evidence of immunogenicity based on tumor-immune interactions. Several preclinical and clinical studies have explored the potential for immunotherapy to improve the clinical outcomes for different subtypes of breast cancer. This review describes the immune microenvironment of HER2-positive breast cancer and summarizes recent clinical advances of immunotherapeutic treatments in this breast cancer subtype. The review provides rationale and ongoing clinical evidence to the use of immune checkpoint inhibitors, therapeutic vaccines, and adoptive T cell immunotherapy in breast cancer. In addition, the present paper describes the most relevant clinical progress of strategies for the combination of immunotherapy with standard treatment modalities in HER2-positive breast cancer including chemotherapy, targeted therapy, and radiotherapy.

Evaluation of Plasma Growth Factors (VEGF, PDGF, EGF, ANG1, and ANG2) in Patients with Varicose Veins Before and After Treatment with Endovenous Laser Ablation.

OBJECTIVE: To measure pre- and postoperative plasma concentrations of growth factors (VEGF, PDGF, EGF, ANG1, and ANG2) in patients with primary lower limb varicose veins (VVs) treated with endovenous laser ablation (EVLA). BACKGROUND: Many studies have explored the potential relationship between primary VVs and growth factors. No previous studies were done for patients treated with EVLA. MATERIALS AND METHODS: Blood samples were obtained from 30 patients with primary VVs undergoing treatment with EVLA before and 1 week after treatment. Similar samples were obtained from 20 healthy matched adults as a control. Plasma concentrations of growth factor derivatives (VEGF, PDGF, EGF, ANG1, and ANG2) were measured through commercially available enzyme-linked immunosorbent assay. RESULTS: There was statistically significant reduction in median plasma growth factor (VEGF, PDGF, EGF, and ANG1) levels in the preoperative group (p = 0.001) when compared with the control group except for ANG2, which showed increased plasma level (p = 0.001). However, values of plasma concentration of those growth factors after treatment with EVLA were nearly equal to the control group, especially in EGF and VEGF (p = 0.564, 0.515, respectively). CONCLUSIONS: The altered plasma concentrations of growth factors VEGF, PDGF, EGF, ANG1, and ANG2 among patients with VVs normalized 1 week after treatment with EVLA compared with the control group. This may support the role of these factors in the pathogenesis of the disease. Future studies may evaluate if these changes can play a prognostic and/or predictive value regarding the adequacy of treatment and the possibility of recurrence.

Effectiveness of 18F-FDG-PET/CT vs Bone Scintigraphy in Treatment Response Assessment of Bone Metastases in Breast Cancer.

The aim of the study was to examine the effectiveness of fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) versus bone scintigraphy (BS) in treatment response assessment of bone metastases in breast cancer.The medical records of breast cancer patients with metastatic bone disease were reviewed retrospectively in our hospital from the period of January 2003 until April 2014. We included in our study patients evaluated by BS and/or 18F-FDG-PET/CT. Group 1 included patients who underwent pre- and post-treatment BS. Group 2 included patients who underwent pre- and post-treatment 18F-FDG-PET/CT scans. Group 3 included patients who underwent pretreatment BS and post-treatment both modalities. Functional and structural bone changes were monitored on pre- and post-treatment scans.Group 1 included 71 patients, average age of 49.5 y (range 28-73 y). Post-treatment results were as follows: 34% stable disease, 43% progressed disease, 19% improved disease, 3% resolved disease, and 2% relapsed disease. Group 2 included 32 patients, average age 53.2 y (ranges between 37 and 78 y). Post-treatment results were as follows: 3% stable disease, 15% progressed disease, 15% improved disease, 53% resolved disease, and 14% relapsed disease. After treatment, the total symptomatic/imaging concordance rate was 51% in BS and 83% in 18F-FDG-PET/CT. Structurally, most patients with newly diagnosed metastatic bone disease had predominantly osteolytic lesions, which became mixed or osteoblastic after treatment as noted on CT images of responders. Group 3 included 8 patients, average age 48.9 y (ranges 32-64 y). Five patients had stable disease according to BS. 18F-FDG-PET/CT was concordant in 3/5 patients and discordant in 2/5 patients. Three patients had progressed disease on BS with concordant findings on 18F-FDG-PET/CT.18F-FDG-PET/CT was found a powerful tool in treatment response assessment of bone metastases in breast cancer and consistent with clinical status of the patients as it reflects tumor activity. BS is insufficient for response assessment of bone metastases as it reflects osteoblastic reaction of the bone against metastatic disease which increases as the disease responds to treatment.

Clinical relevance of 18F-FDG-negative osteoblastic metastatic bone lesions noted on PET/CT in breast cancer patients.

PURPOSE: Our study aims to assess the clinical relevance of fluorine-18 fluorodeoxyglucose (F-FDG) negative osteoblastic metastatic bone lesions noted on PET/computed tomography (CT) in breast cancer patients. PATIENTS AND METHODS: The medical records of breast cancer patients were reviewed retrospectively from January 2012 until April 2015. We included the patients who had metastatic bone disease evaluated by F-FDG-PET/CT. Group 1 included patients with newly diagnosed metastatic bone disease at the time of imaging and group 2 included patients with a history of treated metastatic bone disease at the time of imaging. Functional and structural bone abnormality was monitored on F-FDG-PET/CT scans. RESULTS: Fifty-three patients, median age 47.1 years (range 27-80 years), were included. Group 1 included 35 patients. Of those, 88% had predominantly F-FDG-avid osteolytic and mixed lesions (destructive pattern). Complete response was noted in 65% of the patients after treatment, evidenced by disappearance of bony focal activity with partial or total ossification of most osteolytic lesions converting into mixed and 'secondary' osteoblastic lesions. In addition, more ossified lesions were noted in some patients whose lesions were left untreated for long time (aged lesions). The remaining 12% of group 1 patients had pure 'primary' osteoblastic lesions (nondestructive pattern), which started small and expanded with time and tend to be F-FDG-negative. Group 2 included 18 patients who had predominantly mixed and 'secondary' osteoblastic lesions. CONCLUSION: We described two types of osteoblastic metastatic bone lesions in breast cancer patients: 'primary' and 'secondary'. 'Secondary' lesions (88%) are totally ossified (healed) osteolytic lesions and are almost always F-FDG-negative on PET/CT. These lesions are of no clinical importance. Healing is potentially seen after treatment or if the lesions are left untreated for a long time (aged lesions). 'Primary' lesions (12%) are seen without previous bone destruction and tend to be F-FDG-negative, although they contain tumor cells. Hence, sequential CT is more helpful than sequential FDG-PET in following 'primary' lesions.

Value of baseline and follow-up whole-body bone scans in detecting bone metastasis in high-risk breast cancer patients.

OBJECTIVE: The aim of the study was to test the value of routine baseline and follow-up bone scans in societies with a prevalence of high-risk breast cancer features. PATIENTS AND METHODS: The medical records of 261 Jordanian breast cancer patients were reviewed. Patients who had (a) breast cancer proven by pathology, (b) had undergone a baseline bone scan, and (c) had undergone follow-up bone scan(s) for at least 12 months were included in the study. The patients were divided into three groups. Group 1 included 171 patients who had negative bone scans; group 2 included 52 patients who had negative baseline bone scans but developed bone metastasis on follow-up; and group 3 included 38 patients who had bone metastasis at presentation. RESULTS: Patients' ages ranged between 21 and 85 years with mean ± SD of 49.7 (± 11.3) years. About 55% of our patients were younger than 50 years. Clinicopathological stages were as follows: 14% of patients were in stage I, 42% were in stage II, 30% were in stage III, and 14% were in stage IV. A significant proportion of our patients have high-risk features. Fourteen percent of the patients already had bone metastasis at diagnosis and 20% developed bone metastasis on follow-up. Sixty percent of group 2 patients developed bone metastasis within 2 years after diagnosis and the rest (40%) developed bone metastasis 2 years after diagnosis (≤ 13 years). CONCLUSION: Within the limitations of this retrospective study, in a country like Jordan with greater prevalence of high-risk breast cancer features, a routine baseline whole-body bone scan might be justifiable. Follow-up whole-body bone scans might result in better quality of life and lower skeletal-related morbidity. Further prospective work is suggested.

Postcatheterization femoral artery pseudoaneurysms: therapeutic options. A case-controlled study.

OBJECTIVES: Postcatheterization femoral artery pseudoaneurysm is a troublesome complication following percutaneous canulations of the femoral artery. Both diagnostic and therapeutic options in the management of these pseudoaneurysms have changed dramatically, with surgery being required only rarely. We aimed to perform a comprehensive review of our experience, techniques and results in treating postcatheterization femoral artery pseudoaneurysms. METHODS: A retrospective study of all patients presenting with local complications following invasive percutaneous femoral artery canulations over a five-year period was performed. Physical examination with color Doppler ultrasound analysis identified 29 femoral artery pseudoaneurysms. Surgery, duplex-guided compression, and thrombin injection were the main therapeutic options. RESULTS: Fourteen cases of femoral artery pseudoaneurysms were treated by duplex-guided compression obliteration with a 78.5% success rate. Four patients had spontaneous thrombosis of their pseudoaneurysms. Five patients underwent percutaneous thrombin injection. Six patients had conventional surgery. Three cases failed duplex-guided compression: one closed with thrombin injection, and two were repaired surgically. Follow-up US showed no recurrent pseudoaneurysms for patients who underwent successful duplex-guided compression. CONCLUSION: Despite the voluminous data in the literature of treating postcatheterization femoral artery pseudoaneurysms by thrombin guided injection, as a quick and effective method of therapy, with infrequent failures and complications, our study confirms the clinical usefulness of duplex-guided compression in the management of these pseudoaneurysms. The possibility of spontaneous thrombosis of small pseudoaneurysms is emphasized.

Herniation of part of the breast through a congenital defect of the superficial fascia of the anterior thoracic wall.

This report describes the management of a 28-year-old female patient who had herniation of part of her left breast through a defect in the superficial fascia of the anterior thoracic wall. Closure of the defect was associated with correction of the deformity. To the best of our knowledge, this is the first report describing such a lesion.

Retained surgical sponges (gossypiboma).

OBJECTIVE: Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid unnecessary morbidity. We present our experience with this entity and review the related literature. METHODS: The medical records of 11 patients who were diagnosed as having retained surgical sponges from 1990 to 2003 were reviewed. RESULTS: The incidence was 1:5,027 inpatient operations. There were four males and seven females with a median age of 45 years. The original operations were gynaecological (n=4), general (n=4), urological (n=2) and laminectomy (n=1). In seven cases, the original operation was performed on an emergency basis. Five patients were obese. A presumed correct sponge count was documented in eight cases. The median time between the original procedure and diagnosis of retained sponges was 12 months. The tentative diagnosis was intestinal obstruction (4 patients), urinary tract infection (1 patient), Crohn's disease (1 patient) and tumour recurrence (1 patient). The correct diagnosis was suggested in the remaining four patients. Surgical removal of the retained sponges was carried out in all cases except one, in which the patient passed the sponge spontaneously through the rectum. CONCLUSION: Retained sponges are more common in obese patients and after emergency surgery. A high degree of suspicion is important for preoperative diagnosis. Despite the use of radio-opaque sponges and thorough sponge counting, this moribund mishap still occurs. Although human errors cannot be completely abolished, continuous medical training and strict adherence to regulations should reduce the incidence to a minimum.

The magnetic resonance image findings of idiopathic granulomatous mastitis.

Idiopathic granulomatous mastitis is a rare disease of the breast. Clinically and radiologically it may mimic breast carcinoma. We report a case of a 34-year-old female patient with this diagnosis, concentrating on magnetic resonance image MRI findings and its clinical application. There have been other reports on MRI findings in this entity in the radiological literature, but in our case report, clinical, cytological, pathological, and radiological correlations are also provided.

Gastric malignancies in Northern Jordan with special emphasis on descriptive epidemiology.

AIM: To study the epidemiology of gastric malignancies in Jordan as a model for Middle East countries where such data is scarce. METHODS: Pertinent epidemiological and clinicopathological data for 201 patients with gastric malignancy in north of Jordan between 1991 and 2001 were analyzed. RESULTS: Male: female ratio was 1.8:1. The mean age was 61.2 years, and 8.5% of the patients were younger than 40 years of age. The overall age-adjusted incidence was 5.82/100 000 population/year. The age specific incidence for males raised from 1.48 in those aged 30-39 years to 72.4 in those aged 70-79 years. Adenocarcinomas, gastric lymphomas, malignant stromal tumors, and carcinoids were found in 87.5%, 8%, 2.5%, and 2% respectively. There was an average of 10.1-month delay between the initial symptoms and the diagnosis. Only 82 patients underwent curative gastrectomy. Among adenocarcinoma groups, Lauren intestinal type was the commonest (72.2%) and the distal third was the most common localization (48.9%). The mean follow up for patients with gastric adenocarcinoma was 25.1 mo (range 1-132 mo). The 5-year survival rates for stages I (n=15), II (n=41), III (n=59), and IV (n=53) were 67.3%, 41.3%, 5.7%, and 0% respectively (P=0.0001). The overall 5 year survival was 21.1%. CONCLUSION: Despite low incidence, some epidemiological features of gastric cancer in Jordan mimic those of high-risk areas. Patients are detected and treated after a relatively long delay. No justification in favor of a possible gastric cancer screening effort in Jordan is supported by our study; rather, the need of an earlier diagnosis and subsequent better care.

The clinical and epidemiological features of hydatid disease in Northern Jordan.

OBJECTIVE: To elaborate on the epidemiology of hydatid disease in Jordan as a model for the Middle East, and highlight the obstacles that face disease control in the region. METHODS: The clinical and epidemiological data for 65 patients with the diagnosis of hydatid cyst (who were treated in the Department of Surgery, Jordan University of Science and Technology, Irbid and its affiliated hospitals, between January 1994 through to September 2003) were analyzed. Fifty-five patients were interviewed for details of life style. RESULTS: Forty-six percent of patients were below 40- years of age. Fifty-seven percent were females. All interviewed patients gave history of contact with dogs and history of ingestion of raw vegetable food. The latter in addition to a high zoonotic infection rate and uncontrolled animal movement were factors contributing to the high prevalence. CONCLUSION: Optimization of control programs in the Middle East requires the establishment of a regional center. Wide traveling has made it essential for physicians practicing in non-endemic areas to be aware of the diverse presentations of this disease when dealing with immigrants from endemic areas.

Idiopathic granulomatous mastitis: time to avoid unnecessary mastectomies.

Idiopathic granulomatous mastitis is a rare disease of the breast. Clinically and radiologically it may mimic breast carcinoma. Awareness of surgeons, pathologists, and radiologists is essential to avoid unnecessary mastectomies. Data regarding 24 patients with histologically confirmed idiopathic granulomatous mastitis treated at our center over 8 years were analyzed. The mean age of patients was 34.3 years. Breast lump was the most common presentation. The right breast was affected in 16 cases. Four patients were pregnant at the time of presentation. Lactation within 6 months of presentation was documented in four patients. Two patients used contraceptives pills. A clinical suspicion of malignancy was present in 17 cases. Mammography was performed in 16 patients and showed focal asymmetrical dense lesions in 9, well-circumscribed opacity in 4, spiculated lesion in 1, and was normal in 2. Fine-needle aspiration was performed in 17 patients, of which 2 were reported as malignant. Wide local excision was the mainstay of treatment. One patient underwent mastectomy upon clinical, mammographic, and repeated cytologic findings consistent with malignancy, and the final histology confirmed idiopathic granulomatous mastitis with no evidence of malignancy. Four patients developed recurrence after a mean follow-up of 31.2 months. A greater awareness of the rare entity of idiopathic granulomatous mastitis is mandatory to avoid unnecessary mastectomies. Clinical, radiologic, and even cytologic findings are sometimes confused with malignancy. To the best of our knowledge, our patient who developed the disease at the age of 11 years is the youngest reported case.

Male breast disorders in Jordan. Disease patterns and management problems.

OBJECTIVE: To highlight the features and management problems of male breast disorders in an eastern country such as Jordan. METHODS: Data regarding 33 male patients who underwent surgery for breast diseases in the Department of Surgery at Jordan University of Science and Technology, Irbid, Jordan, between the year 1996 and 2002 were analyzed. RESULTS: Gynecomastia (45.5%), ductal carcinoma (18.2%), and lipoma (12.1%) were the most frequent lesions. Endocrine testing when the clinical diagnosis was physiologic gynecomastia was not yielding. Many features of male breast carcinoma in Jordan (symptomatology, male to female ratio, high education rate, age, diagnostic yield of fine-needle aspiration, histological type, and estrogen receptor status) did not depart from the experience of others. Delayed presentation is evident from the fact that 57% of tumors were stage III. Loco-regional control was achieved by modified radical mastectomy. Tamoxifen was used in 5 patients, and chemotherapy in 4 patients. The patient with stage I is still disease free 6 years after the diagnosis. The 5-year survival rate for stages II and III was zero. Rare lesions (cystic hygroma, cystic mastopathy, fibroadenoma, duct papilloma, tuberculosis, periductal mastitis, and the previously unreported primary primitive neuroectodermal tumor of the breast) accounted for the rest of the group. The patient with primary primitive neuroectodermal tumor of right breast was treated by mastectomy and adjuvant chemotherapy. He remains disease free 31 months after the diagnosis. CONCLUSION: Unawareness and the fact that male breast enlargement is considered a social stigmata are responsible for the delayed presentation. The value of fine needle aspiration cytology and mammography is not widely appreciated. The wide spectrum of potential pathologies calls for referring all patients to specialized breast units.

Colorectal cancer in young patients under 40 years of age. Comparison with old patients in a well defined Jordanian population.

OBJECTIVE: To determine the incidence of colorectal cancer (CRC) in young Jordanians and to compare the clinical and pathological characteristics with those in older patients and with those in high risk populations. METHODS: Clinical and pathological data of all the patients with CRC managed at Princess Basma Teaching Hospital, Irbid, Jordan over a 10 year period (January 1990 through December 1999) were recorded. The patients were divided according to age into group one (those <40 years) and group 2 (> 40 years). The 2 groups were compared regarding sex, predisposing conditions, tumor stage at presentation, tumor differentiation, mucin secretion, tumor invasion, presentation with complications and tumor location. The data were compared with those of "high risk" Western populations and with the few reports coming from "low risk" populations, mainly from Kingdom of Saudi Arabia and Egypt. RESULTS: Out of 202 patients evaluated, 4 were excluded. Group 1 constituted 20.2% of the patients, 17.5% of them have predisposing conditions. Comparison between group 1 and 2 revealed the following: female sex (65% versus 50.6%, p=0.104), advanced stages at presentation (65% versus 41%, p=0.005), rectal tumors (50% versus 39.2%) and right side tumors (15% versus 29.1%) (p=0.18). Mucinous and signet ring tumors (30% versus 15.8%, p=0.04), poor tumor differentiation (20% versus 18.3%, p=0.78) and presentation with complications (21% versus 22.2%, p=0.96). CONCLUSION: The incidence of CRC in young Jordanians was much higher than high risk populations. Half of the tumors were rectal. Young patients have more advanced stage and more mucin secreting tumors. The relative high frequency and frequency of predisposing conditions calls for family screening and surveillance in the presence of predisposing conditions.

Gallbladder cancer in northern Jordan.

BACKGROUND AND AIM: To highlight the epidemiological, clinical, and pathological features of gallbladder cancer in Jordan as a model for the Middle East. Only scattered reports are available from this region. METHODS: The histopathological reports and the hospital records for all cholecystectomies performed at Princess Basma Teaching Hospital between 1994-2000 were retrospectively reviewed to identify all patients with gallbladder carcinoma. All the histological slides for the cancer group were reviewed and reclassified by a single pathologist. RESULTS: Of 4502 cholecystectomies performed, 33 cases (0.73%) of gallbladder carcinoma were found. The mean age was 61.4 years (range 39-80 years). The male : female ratio was 1 : 3.7. Biliary colic and/or acute cholecystitis were the main presentations. Gallstones were present in 88% (29/33) of the patients. The spectrum of histological subtypes was similar to other series. Only three cases were diagnosed preoperatively, making the incidence of incidental gallbladder cancer 0.66% (30/4502). Simple cholecystectomy was performed for 13 patients. The remaining 20 patients underwent cholecystectomy and portal lymphadenectomy with (five cases) or without (15 cases) extrahepatic resection of the bile ducts. The mean follow up was 22 months (SD +/- 18.95 months; range 1-96 months). The 2-year survival rates for stages I, II, III, and IV were 100%, 42.9%, 10.8%, and 0%, respectively (P = 0.0013). CONCLUSIONS: The importance of a high index of suspicion when dealing with cholelithiasis in elderly patients, particularly with large sized stones, cannot be over-emphasized. Proper gross inspection in the theater should be a routine procedure performed by all surgeons. Routine ultrasound for suspected gallbladder stones should always be performed under the supervision of senior radiologists.