Scarless Thyroid Surgery

@#Traditionally, treatment for thyroid diseases is associated with very high mortality and morbidity. Various techniques been performed in the past including finger dissection and the use of finger nails to remove the thyroid tissues. The earliest reported thyroidectomy was probably by Abu al-Qasim al-Zahrawi or Albucasis. It was mentioned that, he performed an enucleation of a thyroid nodule in the 11th century in Spain. This was followed by Salerno in the twelfth centuries, using different technique, including setons, hot irons and caustic powders. The first documented partial thyroidectomy was performed by Pierre Joseph Desault in 1791. But at that time, thyroidectomy was considered as a barbaric surgery with high mortality. The poor result and high mortality had lead to the imprisonment of surgeons and total ban of the operation by the French Academy of Medicine in 1850. The advancement of thyroid surgery was most obvious in the second half of the nineteenth century when Theodor Billroth managed to reduce the mortality dramatically, thanks to the establishment of antisepsis, arterial ligation and precise capsular dissection which was introduced at the same time. There was further improvement on the mortality of the thyroid surgeries to almost zero, but the basic principles remain the same: identification of the recurrent laryngeal nerves and preservation of the parathyroid glands. What becoming a more important issue is the surgery now been performed for smaller thyroid for cosmetic reason, with the need to avoid visible scar in the neck

Relationship Between Patient Factors And Specific Learning Needs Of Women On Breast Cancer

The type of specific learning needs of women with breast cancer using the Information Needs Questionnaire (INQ) had been identified prior to developing a breast cancer education package. It is also important to determine the types of patient factors such as demographic and clinical factors that influence women’s specific learning needs on breast cancer. This study thus reports the findings on what type of patient factors influence women’s specific learning needs related to the types of INQ. A total of 140 women with breast cancer who sought treatment at Universiti Kebangsaan Malaysia Medical Centre participated in this cross sectional study. Age showed a significant relationship with specific learning needs on sexual attractiveness (p=0.001) and self-care (p=0.048). Duration of illness was related to information on spread of breast cancer (p=0.040) and self-care (p=0.047). Education level showed a significant relationship with cure (p=0.001), sexual attractiveness (p=0.007) and spread of breast cancer (p=0.003). Occupation showed a significant relationship with specific learning needs on sexual attractiveness (p=0.005), chemotherapy (p=0.043), radiotherapy (p=0.039) and hormonal therapy (p=0.043). On treatment received, a significant relationship was noted with sexual attractiveness (p=0.009), radiotherapy (p=0.029), hormonal therapy (p=0.038) and targeted therapy (p=0.047). Ethnicity and Marital status showed no significant relationship with all the specific learning needs. Findings of this study concluded that certain patient factors had significant relationship with certain specific learning needs. All the patient factors studied and their influence on the specific learning needs were taken into consideration prior to developing the breast cancer education package.

Parathyroid Hormone Secreting Metaplastic Breast Carcinoma: A Case Report of Paraneoplastic Syndrome

Paraneoplastic syndrome (PNS) is a distant neurological manifestation of an underlying tumour. Humoral hypercalcaemia of malignancy is a form of paraneoplastic syndrome where there is an increased in calcium levels. In this article we report a 48 year old lady, with no known medical illness and presented with symptomatic hypercalcaemia. She presented to our institution complaining of a fungating and ulcerating mass over the right breast, measuring 11 X 15 cm and associated with gradual paraxial body weakness. Further investigations revealed the lesion to be an invasive breast carcinoma with metaplastic features. Computed tomography (CT) scan showed a locally advanced breast carcinoma with right axillary node metastasis, without evidence of distant metastasis. Serum calcium, i-PTH together with SPECT has confirmed the patient to have a humoral hypercalcaemia malignancy with elevated ectopic parathyroid hormone level. Bone scan did not reveal any evidence of metastasis. High volume intake and loop diuretics were employed in the management of hypercalcaemia, which was eventually resolved following mastectomy with axillary clearance of the ipsilateral side. Currently she’s she is under oncologist’s follow up for further management.

Surgeons’ Experience In Breast Conserving Surgery: Does It Influence Surgical Margin?

A surgeon’s experience plays an important role in breast conserving surgery (BCS). The common conception is that, the more junior is the operating surgeon, the surgical margin will be wider or closer to the tumour edge. Thus the aim of this study is to look into the adequacy of surgical margin performed by different level of surgeons’ experience in patients whom underwent wide local excision (WLE) and hook-wire localization (HWL) in our surgical unit. The surgical experience of the operating surgeon and their surgical margins will be analyzed. This is a retrospective study from January 2000 to December 2012. Eighty-eight patients with early breast cancer underwent WLE and HWL by 3 different groups of surgeons (breast surgeons, junior surgeons and surgical registrars) were included. The surgical margins were analyzed for involved-margin, closed-margin or excessed-margin.The incidence of involved-margin, closed-margin and excessed-margin is the lowest among breast surgeons compared to other groups. However, the results were not statistically significant. The incidence of involved surgical margin is significantly higher within junior surgeons for HWL compared to the breast surgeons. The incidence of involved, closed or excessed surgical margin were lowest when performed by breast surgeon but not significantly different between the three groups. However, for HWL the breast surgeons significantly better compared to the other groups.

Male ductal carcinoma in situ (DCIS): treatment strategies in this rare entity.

Ductal carcinoma in situ (DCIS) in females is a recognized premalignant disease. However, its occurrence in males is rare. Articles describing this disease are scarce with documented occurrence is less than 7% worldwide. We report a case of 52 year-old gentleman presented with 6 months history of left breast lump. It was painless with no nipple discharge. Despite an inconclusive biopsy, lumpectomy was performed in view of the suspicion of malignant disease. Histopathology confirms DCIS. He underwent mastectomy and sentinel lymph nodes. Most treatment strategies are based on evidence on female breast malignancy and modifications are needed due to the different pathological pathway in male.

Radiation Induced Sarcoma: A Risk that is Almost Forgotten

Radiotherapy has been widely use as an adjuvant therapy in the breast cancer management. The usage has increased the incidence of radiation induce sarcoma. We here present a case of radiation induce sarcoma of the axilla following mastectomy and axillary lymph node dissection for infiltrating ductal carcinoma.

Diagnostic Dilemma in Metaplastic Chondroid Breast Carcinoma

Metaplastic breast cancer is a rare form of primary breast cancer. It contains a mixture of adenocarcinoma with metaplastic elements. It is important to differentiate with primary sarcoma of the breast which carries different treatment strategies and prognosis. A 55-year-old lady previously diagnosed to have a left breast cancer in the year 2000 and carcinoma of the endometrium in 2009, presented with a right breast lump. A trucut biopsy reported as an infiltrating ductal carcinoma with background of chondromyxoid and cartilagenous matrix, most probably metaplastic carcinoma. A wide local excision with sentinel lymph node biopsy was performed, and the final histology was consistent with metaplastic chondroid carcinoma of the breast with no evidence of metastsis. The surgery was followed by adjuvant radiotherapy and currently free from any recurrence. The diagnostic dilemma on this very rare condition is reviewed.

Ultracision versus electrocautery in performing modified radical mastectomy and axillary lymph node dissection for breast cancer: a prospective randomized control trial.

BACKGROUND: Treatment for breast cancer has improved dramatically over the decades. Nevertheless, modified radical mastectomy with axillary dissection remains the standard treatment for most patients, especially those with big tumours. The conventional technology is to use diathermy to cut and coagulate blood vessels. The Ultracision dissector has been widely used in laparoscopic surgery and is documented to be safe and fast for cutting and coagulating tissue. The aim of this study is to compare ultracision to electrocautery, looking in terms of amount of post operative drainage, duration of drain days, seroma formation and other complications. METHODOLOGY: This study was a prospective randomized control trial of modified radical mastectomy performed for breast cancer in Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM) between 1st June 2007 to 31st December 2008. Patients were randomized in two groups: group A (n = 20) underwent modified radical mastectomy using ultracision (UC) and group B (n = 20) with the conventional electrocautery (EC) method. Main outcome measures were amount of drainage and duration of drain days. An unpaired 2-tailed Student's t test and the χ2 test to compare the groups. RESULTS: A total of 40 patients were involved in this study. The majority of patients were Malay (55%) followed by Chinese (35%), Indian (5%) and others (5%). The mean volume of drainage from the axilla in the EC group was significantly higher than UC group [489.5 versus 188.1 mls (p < 0.001)]. The mean volume of drainage from the breast and the total drainage from both the breast and axilla was also significantly higher in the EC group compared to UC [169.3 versus 58.8 mls (p = 0.004) and 663.7 versus 247.0 mls (p < 0.002) respectively]. The drainage consequently showed significant reduction in terms of drain days in the axilla [6 days versus 3 days (p < 0.002)] and the breast [3 days versus 2 days (p < 0.002)] in the UC compared to the EC. There was no significant complication in both arms. In conclusion, the use of ultracision able to reduce the amount of drainage and the number of drain days after performing modified radical mastectomy. In doing so, the use of this technology enable us to discharge patients earlier without significant morbidities.

The risk of recurrence in breast cancer patients treated with tamoxifen: polymorphisms of CYP2D6 and ABCB1.

CYP2D6 plays a major role in the metabolism of tamoxifen, and polymorphism of P-glycoprotein has been associated with resistance of many drug therapies. This study investigates the clinical impact of genetic variants of CYP2D6 and ABCB1 in breast cancer patients treated with tamoxifen. Blood samples from 95 breast cancer patients treated with tamoxifen were collected and genotyped for CYP2D6 and ABCB1 variants using allele-specific PCR method. Recurrence risks were calculated using Kaplan-Meier analysis and compared using the log-rank test. Patients carrying CYP2D6*10/*10 and heterozygous null allele (IM) showed higher risks of developing recurrence and metastasis (OR 13.14; 95% CI 1.57-109.94; P = 0.004) than patients with CYP2D6*1/*1 and *1/*10 genotypes. Patients with homozygous CC genotypes of ABCB1 C3435T showed a shorter time to recurrence. Patients who were CYP2D6 IM and homozygous CC genotype of C3435T have statistically significant higher risks of recurrence (P = 0.002). Similarly, median time to recurrence in these patients was only 12 months (95% CI = 0.79-23.2) compared to those without this combination which was 48 months (95% CI = 14.7-81.2). Patients with CYP2D6 IM and homozygous CC genotype of ABCB1 C3435T have shorter times to recurrence. The results confirmed the findings of previous studies and support FDA recommendation to perform pre-genotyping in patients before the choice of therapy is determined in breast cancer patients.

3p25 Aneusomy in Follicular Thyroid Neoplasms: A Report of Three Cases with Review of Literature

Aneusomy is an early genetic event and a characteristic feature of many solid tumors. It is often associated with poor prognosis in cancer patients. The involvement of PAX8-PPARγ rearrangement in tumorigenesis of follicular thyroid lesions has been widely assessed. However, there were few reports on aneusomy of the PPARγ gene at the 3p25 locus in follicular thyroid lesions. It remains undetermined whether these abnormalities can be translated into improved diagnosis, classification, or outcome prediction. Herein, we report three cases of follicular thyroid neoplasms [two follicular thyroid carcinomas (FTCs) and one Hurthle cell adenoma (HCA)] with 3p25 aneusomy detected by fluorescence in situ hybridization (FISH). 3p25 trisomy was observed in one FTC and one HCA while 3p25 tetrasomy was observed in one FTC. Furthermore, all three lesions did not show overexpression of PPARγ protein. Hurthle cell neoplasms (HCN) are distinct clinically and histologically from other follicular thyroid neoplasms (FTN). However, the presence of the aneusomy in HCA and FTC indicates that there could be a biological continuum between the two and chromosomal gains might play an important role in the pathogenesis of these two types of neoplasms. Despite their differences, HCN and FTN may share the same early genetic event in tumour development.

The contribution of reproductive factors and family history towards premenopausal breast cancer risk in Kuala Lumpur, Malaysia.

Breast cancer is the most common cancer among Malaysian women. This study aimed to determine the reproductive for premenopausal breast cancer risk in Kuala Lumpur, Malaysia. A case-control study was conducted in 216 histopathologically confirmed cases of premenopausal breast cancer and 216 community-based controls that were matched by age within a 5-year period and ethnicity. The results of this study showed that premenopausal breast cancer risks were strongly related to parity, number of live births and family history of breast cancer. Premenopausal women with these known reproductive and family history risk factors should take extra measures to undergo appropriate screening method for early detection of breast cancer.

Isolated late chest wall recurrence after mastectomy for breast cancer.

An isolated late chest wall recurrence after mastectomy for breast cancer is rare. We present a case of a lady with a T2N1M0 right breast cancer who developed an isolated local recurrence on the chest wall 11 years after mastectomy. Staging investigations excluded distant metastases. She underwent an excisional biopsy and was started on an aromatase inhibitor. Radiotherapy was given to the chest wall followed by a boost to the site of excision. Although most chest wall recurrences fare poorly, a favourable subgroup can be identified and should be treated aggressively in a multidisciplinary approach.

Identification of different subtypes of breast cancer using tissue microarray.

Breast cancer may be classified into luminal A, luminal B, HER2+/ER-, basal-like and normal-like subtypes based on gene expression profiling or immunohistochemical (IHC) characteristics. The main aim of the present study was to classify breast cancer into molecular subtypes based on immunohistochemistry findings and correlate the subtypes with clinicopathological factors. Two hundred and seventeen primary breast carcinomas tumor tissues were immunostained for ER, PR, HER2, CK5/6, EGFR, CK8/18, p53 and Ki67 using tissue microarray technique. All subtypes were significantly associated with Malay ethnic background (p=0.035) compared to other racial origins. The most common subtypes of breast cancers were luminal A and was significantly associated with low histological grade (p<0.000) and p53 negativity (p=0.003) compared to HER2+/ER-, basal-like and normal-like subtypes with high histological grade (p<0.000) and p53 positivity (p=0.003). Luminal B subtype had the smallest mean tumor size (p=0.009) and also the highest mean number of lymph nodes positive (p=0.032) compared to other subtypes. All markers except EGFR and Ki67 were significantly associated with the subtypes. The most common histological type was infiltrating ductal carcinoma, NOS. Majority of basal-like subtype showed comedo-type necrosis (68.8%) and infiltrative margin (81.3%). Our studies suggest that IHC can be used to identify the different subtypes of breast cancer and all subtypes were significantly associated with race, mean tumor size, mean number of lymph node positive, histological grade and all immunohistochemical markers except EGFR and Ki67.

Elevated Expression of CD151 Gene in Estrogen Receptor and Progesterone Receptor Positive Breast Carcinoma

The tetraspanin gene, CD151 is involved in various tumour cell progression and metastasis. Its expression is increased in high grade, estrogen receptor negative and c-erbB-2 positive breast cancer. However, the biological function and expression phenotype among different tumour status, estrogen receptor (ER) status, progesterone receptor (PR) status and c-erbB-2 expression in multi-ethnic Malaysian breast cancer patients has not been well investigated. We used quantitative real-time reverse transcriptase polymerase chain reaction (qRT-PCR) to measure the CD151 gene expression in 45 breast cancers. Our preliminary results revealed that CD151 expression is significantly higher in ER positive and PR positive breast cancers at 95% and 99% confidence intervals, respectively. In contrast, there is no significant correlation between CD151 expression and tumour grades or c-erbB-2 status at 95% confidence interval level. Our preliminary findings suggested that CD151 may be involved in the estrogen responsive pathways. CD151 could be a potential prognostic marker and therapeutic target in the treatment of estrogen dependent breast cancer patients.

Pigmented ‘black’ adenoma: a rare cause of conn’s syndrome

Presence of a hypofunctioning pigmented adenoma are commonly asymptomatic and is usually only found during an autopsy. In contrast, hyperfunctioning pigmented adenoma is a rare clinical entity and in the majority of cases results in Cushing‟s syndrome. In this case study, we report a 66-year-old male who presented instead with the clinical and biochemical features of Conn‟s syndrome. On laparoscopic adrenalectomy, it was found that the tumour had a functioning black adenoma which does not usually present with Conn‟s syndrome but rather to that of a Cushing‟s. The intraoperative changes and histopathological findings are discussed.

Carcinosarcoma of the thyroid: a case report.

Thyroid carcinosarcoma (TC) is a very rare, aggressive thyroid malignancy with a clinical course similar to anaplastic carcinoma. A thorough search of the literature reveals limited information regarding its behavior and treatment modalities. TC has a high mortality rate despite the multi-modal approach. A 54-year-old Chinese gentleman with a long history of a nodule in the right lobe of the thyroid presented with recent history of hemoptysis and shortness of breath. Cytology was suggestive of follicular neoplasm. However, histopathological examination of the total thyroidectomy specimen confirmed TC. This case reports discusses the clinical course and management of TC, which can cause a diagnostic dilemma.

Immunohistochemical expression of vascular endothelial growth factor (VEGF) and p53 in breast lesions.

OBJECTIVE: Vascular endothelial growth factor (VEGF) is a leading factor for tumour angiogenesis and p53 protein is the product of a tumor suppressor gene. The main aim of the study was to assess the association of p53 protein with VEGF expression in breast carcinoma. MATERIALS AND METHODS: This was a retrospective study involving 66 invasive breast carcinomas, 66 normal breast tissues and 55 cases of usual ductal hyperplasia (UDH), obtained from the histopathology records. The paraffin blocks were cut and processed by immunohistochemical technique using a monoclonal VEGF and a monoclonal p53 antibody. RESULTS: VEGF positive staining was detected in 12 (18.2%) of the 66 cases of breast carcinoma and only 1 (1.8%) of UDH cases (p=0.004). Expression of p53 was positive in 33 (50%) of the 66 cases of carcinoma; whereas 8 cases of UDH (14.5%) were p53 protein positive (p<0.001). There was statistically significant associations between p53 expression and tumour size (p=0.018) and lymph node status (p=0.046). The VEGF and p53 expressions were negative in all normal breast tissues analyzed. Ten (83.3%) of 33 invasive carcinoma with p53 protein positive were VEGF positive, whereas 2 of 33 patients did not have p53 expression and were VEGF positive (p=0.011). CONCLUSION: The expression of p53 in invasive breast carcinoma had a significant correlation with the tumour size and lymph node metastasis. The evaluation of VEGF expression together with p53 protein may aid clinicians in effective management.

Recurrent multiple myeloma presenting as a breast plasmacytoma.

We describe a patient with multiple myeloma, who initially responded to chemotherapy and went into remission. She presented 10 months later with a right breast lump which was confirmed by core biopsy to be a plasmacytoma. Further treatment with radiotherapy, thalidomide and later second line chemotherapy appeared unsuccessful and she showed rapid disease progression with rising paraproteins and new extramedullary plasmacytoma lesions in the forehead, supraclavicular region, nasopharynx, liver, spleen, pancreas and paraaortic lymph nodes.

Serum sex hormone levels in pre- and postmenopausal breast cancer patients.

INTRODUCTION: This study was conducted to determine the association between serum sex hormone levels and breast cancer. METHODS: The study was conducted on newly-diagnosed breast cancer patients who had not received any treatment. Controls were women not known to have any breast disease or hormone-related tumours. Serum hormones were divided into quartiles. Logistic regression adjusting for age and race were done to calculate the odds ratio (OR) and 95 percent confidence interval (CI). RESULTS: A total of 207 subjects were recruited; 73 premenopausal (37 cases, 36 controls) and 134 postmenopausal (68 cases and 66 controls) women. In the premenopausal women, only serum testosterone was positively associated with breast cancer (OR 1.72, 95 percent CI 0.40-7.40), but this was not a significant finding (p-value is 0.468). In the postmenopausal women, oestradiol, progesterone and testosterone were positively associated with breast cancer with a highest to lowest quartile OR of 1.48, 2.35 and 4.23 (95 percent CI 0.59-3.69, 1.11-4.95 and 1.52-11.78, respectively). The OR was significant for both progesterone and testosterone (p-values of 0.025 and 0.006, respectively). CONCLUSION: There were no statistically significant findings among the premenopausal cases. In postmenopausal women, serum progesterone and testosterone levels were significantly associated positively with the odds of having breast cancer.

Male breast cancer: experience from a Malaysian tertiary centre.

INTRODUCTION: Breast cancer is a rare condition among men with a reported incidence of about one percent. Nevertheless, it is thought to behave similarly in both genders. Due to its rarity, male breast cancer is not widely reported, especially in the Asian population. METHODS: In a five-year review of our breast cancer surgery series, about 1.6 percent involved male patients. There was a substantial delay in presentation among those men, whose mean age at presentation was 64 years. RESULTS: The majority of patients presented with a painless lump. Histologically, all tumours were ductal in origin and all patients had lower than stage III malignancies. The majority of patients underwent mastectomy and axillary lymph node dissection. All male patients were commenced on adjuvant tamoxifen. The longest survival was 54 months with all patients remaining tumour-free. CONCLUSION: Malaysian men are at risk of breast cancer and seem to have a better prognosis.