Early post-operative outcome of pre-pectoral implant-based immediate total breast reconstruction with Polyglactin 910 (Vicryl™) mesh - low cost solution for a low-middle income country.

BACKGROUND: The incidence of breast cancer in Pakistan has been rising with approximately one third of these patients requiring mastectomy. Among breast reconstruction treatment options, the use of Acellular Dermal Matrix (ADM) for pre-pectoral breast implant surgery has proven effective with improved cosmetic outcome. However, due to high cost it cannot be regularly implemented in a developing country like Pakistan. An alternative to ADM, Polyglactin 910 (Vicryl™, Ethicon) mesh has been introduced in pre-pectoral breast reconstructive surgery which has shown to be almost 10 times lower in cost. We set out to determine the frequency of early postoperative complications when using Polyglactin 910 mesh for pre-pectoral implant-based breast reconstruction surgery. METHODS: A single centre, retrospective, chart review was conducted, and a total 28 women were included in the study. Thirty-two pre-pectoral implant-based mastectomies with Polyglactin 910 mesh were performed. Early post-operative outcomes (within 12 months of procedure) including duration of antibiotic use, post-operative infection, implant displacement, flap necrosis, seroma formation, wound dehiscence, hematoma formation, capsular contracture and reconstruction failure, were recorded. RESULTS: Only 4 (12.5%) women experienced early post-operative morbidity. One patient developed a wound dehiscence, which eventually led to reconstruction failure and removal of the implant. Another patient had seroma formation and flap necrosis. None of the patients developed postoperative implant displacement, hematoma formation or capsular contracture in the early post-operative period. CONCLUSION: This study reveals that early post-operative outcomes with Polyglactin 910 mesh in breast reconstructive surgery are few, thus making it a cost effective, reliable, and safe treatment option, especially in developing countries like Pakistan.

A rare case of a recurrent atypical adenomyoepithelial tumor of the breast: Case report.

INTRODUCTION: Adenomyoepithelial tumors of the breast are very rare tumors comprising of - fibroepithelial and myoepithelial components PRESENTATION OF THE CASE: We present the case of a 66 years old lady who presented with a right breast lump 5 cm in size, diagnosed as an atypical adenomyoepithelioma who underwent successful excision and returned two and half years later with a recurrence DISCUSSION: These tumors present a diagnostic dilemma needing histopathology for definitive diagnosis. Recurrence is not uncommon CONCLUSION: Adenomyoepitheliomas demand regular surveillance for early detection of any recurrence.

Breast adenoid cystic carcinoma: An uncommon neoplasm- Case report.

INTRODUCTION: Adenoid cystic carcinoma is a neoplasm that is commonly of salivary gland origin. It could infrequently arise from other tissues such as breast in which case it behaves favorably despite belonging to triple-negative breast cancer subgroup. CASE PRESENTATION: We report a case of a 49-year-old female patient, who presented with right breast pain and upon work-up, was diagnosed with early-stage adenoid cystic carcinoma of the breast. She underwent breast conservation successfully and was advised to get evaluated for adjuvant radiotherapy. The work has been reported in line with the SCARE criteria (Agha et al., 2020). CLINICAL DISCUSSION: Breast adenoid cystic carcinoma (BACC) is a rare distinct salivary gland-like carcinoma of the breast with similar morphological features to those seen in salivary gland adenoid cystic carcinoma. Surgical resection is the standard mode of treatment in BACC. The role of adjuvant chemotherapy has not proven beneficial in the management of BACC, owing to the similar survival rates seen in patients with and without chemotherapy. CONCLUSION: Localized breast adenoid cystic carcinoma (BACC) is an indolent disease having optimal response to surgical resection alone and thus can omit adjuvant radiotherapy and chemotherapy when completely excised. Our case is unique as BACC is a rare clinical variant of breast cancer with a very low incidence rate.

Skin reducing nipple sparing mastectomy with immediate breast reconstruction for huge borderline phyllodes tumor of the breast: Case report.

INTRODUCTION: Borderline phyllodes tumors are very infrequent breast tumors encountered by surgeons. CASE PRESENTATION: We present a case of a young woman with a very large borderline phyllodes tumor measuring 20 cm × 20 cm, involving almost all of the breast, causing gross asymmetry of the breasts. DISCUSSION: The patient wished to maintain symmetry following the surgery as a result of which a simple mastectomy followed by implant based Immediate breast reconstruction was planned. The patient had an uneventful recovery postoperatively with equal breast size bilaterally. CONCLUSION: Implant based immediate breast reconstruction thus provides a comprehensive solution and excellent cosmesis for women with very large borderline phyllodes requiring mastectomy.

Comprehensive targeted treatment options available for Breast cancer stem cells; A literature review of the last 10 years' developments.

Breast Cancer Stem Cells (BCSCs), unlike normal breast cells, exhibit the potential for self-regeneration and tumour formation and express unique markers. Studies have highlighted their role in tumour progression, recurrence, and treatment resistance. BCSCs can be one of the reasons that resistance is encountered despite recent advances in the treatment of breast cancer (BC). This review underlines the clinical implications at the molecular level of different cellular pathways, cellular level interactions in Tumour Micro Environment (TME), and types of markers and receptors involved in tumorigenesis. It accentuates the importance of comprehensive targeted treatment options available for BCSCs so that targeted modalities can be introduced to deal with treatment resistance. Stem cells (SCs) are a developing field, and limited data is available from our country to use stem cell-targeted treatment plans as a therapeutic option. Therefore, this literature review will provide insight for future research in this domain.

A single centre experience of local perforator flaps in oncoplastic breast surgery; a cross-sectional study.

Background & objectives: Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women. Materials & methods: This cross-sectional study was conducted from March 2019 to February 2021 enrolling 25 female patients who underwent breast conservative surgery using LPF for breast tumors at The Aga Khan University Hospital, Karachi. Data related to the procedure was collected on a pre-designed proforma. Cosmetic outcomes and patient satisfaction were evaluated using 2 scales from BREAST-Q BCT domain version 2.0. The questionnaire was self-administered by the patients during their routine follow-up in the clinic. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Mean (SD)/median (IQR) were computed for quantitative variables and frequency and percentages were calculated for qualitative variables. 2 sample t-test was applied. P-value ≤0.05 was considered significant. Results: 25 patients underwent LPF with a mean age of 47 ± 13.1 years. 8 LICAP, 7 AICAP, and 10 LTAP flaps were performed. Two postoperative complications of wound site erythema were encountered. 23 women were eligible for the BREAST-Q survey. Median (IQR) postoperative satisfaction with breasts and physical well-being chest (equivalent Rasch transformed score) was 100 (41) and 76 [18] respectively. We found high satisfaction with breasts and comparable physical well-being among Pakistani women after LPF surgeries. Conclusion: Local perforator flaps in oncoplastic breast-conserving surgery are a good option showing high satisfaction with breasts and physical well-being in Pakistani women.

An Unusual Large Size Ductal Carcinoma In Situ In A Patient On Lithium Therapy: A Case Report With Literature Review.

Background: Ductal carcinoma in situ (DCIS) is the earliest and most curable form of breast cancer. Patients who harbour this disease for quite some time usually have micro invasion by virtue of high-grade disease or big size. Herein, we report a case of 56-year-old postmenopausal woman presenting with a one-year history of blood-stained nipple discharge from right breast. She was a known case of depression receiving oral anti-depressants containing lithium for 20 years. Her mammogram was performed followed by ultrasound breast. Mammogram identified suspicious clusters of micro calcifications hence subjected to stereotactic core biopsy which revealed two separate foci of high-grade DCIS. Therefore, based on her clinical, radiological, and pathological findings she was subjected to mastectomy and sentinel node biopsy. Final histopathology showed big DCIS (10×8×3 cm in size) with immunohistochemical stains confirmed no invasive focus on extensive sampling. Therefore, we postulated that it might be correlated to the use of Lithium which has anti-cancer properties.

Case report: Axilla fibroadenoma - An atypical presentation.

Introduction: Fibroadenoma is the most common benign breast tumor among women between 15 and 35 years, however, a fibroadenoma arising from accessory breast tissue is a rare occurrence. Case presentation: We encountered this uncommon presentation in a 37 years old female with a gradually increasing left axillary lump associated with discomfort. On ultrasound it was a 17.3 mm × 10.6 mm x 17.5 mm well defined solid nodule with internal vascularity, BiRADS IVa lesion. Core biopsy revealed fibroepithelial lesion and the patient electively underwent excisional biopsy. Histopathology confirmed the diagnosis of fibroadenoma, which was completely excised. Clinical discussion: Approximately half of all breast lumps in women are diagnosed as fibroadenomas, making it the most common benign breast mass. Nonetheless, an axillary mass has several differentials such as lymphadenopathy, lipoma or sebaceous cyst, while a fibroadenoma developed from ectopic breast tissue in the axilla is an unusual condition. Masses in axilla like ectopic breast tissue are clinically significant as they undergo physiological changes like the normal breast tissue like pain and discomfort during pregnancy, lactation and menstruation. This tissue may also undergo pathological changes and may pose a diagnostic challenge. Conclusion: Axillary lumps pose a diagnostic dilemma and accessory breast tissue related pathologies should be considered.

Diagnostic accuracy of axillary nodal ultrasound after neoadjuvant chemotherapy in node-positive breast cancer patients: A validation study.

OBJECTIVE: To determine the accuracy and false negative rate of axillary ultrasound compared to sentinel node biopsy. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, from February 1 to March 31, 2021, and comprised data of breast cancer patients who had undergone neo-adjuvant chemotherapy followed by axillary lymph node dissection or axillary disease diagnosed using lymph node biopsy or sentinel lymph node biopsy between January 1, 2016, and December 30, 2020. After receiving neoadjuvant chemotherapy, axillary ultrasound findings were compared with histopathology of lymph nodes. Data was analysed using SPSS 22. RESULTS: Of the 155 patients evaluated, 104(67.1%) were diagnosed with negative axillary lymph nodes and 51(32.9%) were diagnosed with positive axillary lymph nodes post-chemotherapy. The overall mean age was 51.13±1.3 years. When histopathology results were compared with those of axillary ultrasound, 36(23.2%) cases turned out to be true positive, while 23(14,8%) were false negative, yielding a positive predictive value of 75% and negative predictive value of 65%. Axillary ultrasound had 75% accuracy, false negative rate 30%, sensitivity 61% and specificity 84.4%. CONCLUSIONS: Axillary ultrasound was found to be fairly useful, but not completely reliable, in identifying positive lymph nodes.

Current perspectives of oncoplastic breast surgery in Pakistan.

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan. There is a need to establish dedicated oncoplastic breast surgery training centres, fellowship programmes, workshops, and webinars to incorporate such techniques in the practice of breast surgeons.

Primary synchronous malignancies of the breast and the kidney.

Synchronous primary malignancies are most frequently seen with cancers of the stomach and oesophagus, mainly attributed to the similar genetic mutations. Most of these multiple malignancies turn out to be metastatic or metachronous lesions. Multiple synchronous malignancies are rarer than metachronous ones. Primary synchronous breast and renal cancer is even rare. These patients require extensive workup to exclude all possible metastases. The nature of the primary tumours must also be confirmed, prior to any treatment strategy. We report the case of a healthy, middle-aged woman who initially presented with a lesion suspicious for breast carcinoma, and further workup revealed the presence of an asymptomatic, synchronous primary renal cell cancer, which is a very rare presentation.

Giant Juvenile Fibroadenoma of the breast in a 13-year-old Pakistani girl with excellent cosmetic outcome after subareolar enucleation - A case report.

INTRODUCTION: Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5-2% of all fibroadenomas. PRESENTATION OF CASE: In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan. DISCUSSION: Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases. CONCLUSION: The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility.

Mycobacterium Abscessus: A Rare Cause of Peri-Ductal Mastitis in Endemic Regions.

Mycobacterium abscessus is a rapidly growing non-tuberculous, multi-drug resistant mycobacterium (NTM). Its common clinical presentation includes pulmonary infection followed by wide spectrum of skin and soft tissue infections. Chronic breast conditions, such as peri-ductal mastitis are rarely caused by NTM. Due to an intrinsic and acquired drug resistance to conventional antibiotics and anti-tuberculous therapy, it is often managed with a combination of antibiotics with or without surgical adjuncts. It is important to consider NTM in patients with chronic mastitis who show suboptimal response to initial broad-spectrum antibiotics, and especially when symptoms recur after complete resolution. This case report describes peri-ductal mastitis caused by mycobacterium abscessus in a 32-year female presenting with a history of painful breast lump and blood stained discharge. With initial diagnosis of nonspecific abscess, she received antibiotic therapy for 4 days at community healthcare setting without promising response. Subsequently, she was diagnosed as a case of peri-ductal mastitis for which quadrantectomy was performed; and surprisingly mycobacterium abscessus was identified on AFB culture. Full recovery was obtained with combination of antibiotics for prolonged period due to frequent relapses. Key Words: Mastitis, Mycobacterium abscessus, Non-tuberculous mycobacteria.

INTRA OPERATIVE FROZEN EXAMINATION OF SENTINEL LYMPH NODE IN BREAST CANCER.

BACKGROUND: Sentinel node (SN) biopsy is the standard of care for the assessment of axilla in early breast cancer patients with clinically node negative disease. Confirmed absence of tumour deposit in node on intra operative frozen section (FS) examination saves the patient from complete axillary dissection. However controversies arise when inconsistencies occur in results of frozen and permanent section. Reported sensitivity of frozen examination of sentinel node in literature ranges from 70-95%.The purpose of this study was to determine the sensitivity of frozen examination of sentinel node in breast cancer. The frozen section examination of sentinel node is not a reliable technique for accurate pathological assessment of node. METHODS: Data was collected prospectively on patients with sentinel node procedure from May to December 2013. All SNs removed at surgery were submitted for frozen section and the results were compared with permanent sections. RESULTS: Of 50 patients 16 were true positive while 32 were true negative. Two patients reported negative on FS were confirmed to be positive on permanent section. The accuracy of frozen section was 96%, with sensitivity of 89%. In false negative cases the size of nodal metastasis was significantly smaller than that of true positive, i.e., 1-2 mm. The false negative cases were further classified for assessment into technical and interpretative error. CONCLUSION: The intra operative frozen section examination is a reliable technique for the assessment of Sentinel node with a high accuracy rate to detect metastasis size of >2 mm. It spares the patient from complete axillary dissection and its subsequent morbidity of lymphedema and shoulder pain.