The value of 18F-fluorodeoxyglucose PET (18F-FDG PET) and MRI spectroscopy in underpinning suspicious breast cancer

The aim of this study was to evaluate the value of MRI spectroscopy and association with the altered glucose metabolism on 18-FDG PET/CT in patients with suspicious breast cancer. Eight selected breast cancer patients with BIRADS 4 or 5 on mammogram were recruited and patients underwent 18F-FDG PET/CT MRI (spectroscopy). The standardise uptake value (SUVmax) was analysed to determine the degree of the altered glucose metabolism on the PET. The metabolites of tumor lesions were measured using in vivo proton MR spectroscopy (MRS) of the breast. There were eight females with a mean age of 55.3±12.2 years with a biopsy result of invasive ductal carcinoma (2), lobular carcinoma (1) and benign lesion (5). There was a significant difference between the mean of the malignant tumour (SUVmax 4.28±3.74 g/ml) and the mean of the benign tumour (SUVmax: 2.33±0.9 g/ml). On the per-lesional basis of the MRS correlate with SUVmax, the suspicious breast tissue exhibited raised creatinine metabolites (mean: 3.39±0.54u) with significant correlation SUVmax mean 3.06±2.34 as compared to N-acetyl Aspartate (NAA), (mean: 2.84±0.99u) and choline (mean: 2.46± 0.70 u). This study showed that high SUVmax was associated with malignant cancer and the high creatinine metabolite that correlated with the SUVmax could potentially be utilised as a surrogate marker in detecting breast cancer

The accuracy of surgeon-performed preoperative parathyroid ultrasound localization for Renal Hyperparathyroidism patient

INTRODUCTION: Parathyroid surgery for renal hyperparathyroidism (RHPT) is indicated when patients have a progressive disease despite optimal medical therapy. The success of total parathyroidectomy in RHPT lies in accurate localization and excision of all PTGs. Recently, surgeon-performed ultrasound (SPU) has been increasingly used for the preoperative localization of PTGs in the intent of focused approach and reduce morbidity. Thus, we conducted a prospective observational single-center study to determine the accuracy of SPU for PTG localization in RHPT and the factors affecting its accuracy. MATERIALS AND METHODS: This is a prospective, observational, single-center study conducted in University Kebangsaan Malaysia Medical Centre between March 2018 and March 2019. The patients’ preoperative demography, clinical data, and relevant blood laboratory results, including calcium, phosphate, alkaline phosphatase, and intact parathyroid hormone, were recorded. Preoperative USG and surgery were performed by the same endocrine surgery consultant. RESULTS: SPU localization had an overall accuracy of 78.1%, sensitivity of 81.0%, and specificity of 30.0% with a positive predictive value of 94.8% and a negative predictive value of 10.5%. The SPU gland localization rate was significantly higher in patients without goiter (median=0.88, IQR=0.63–1.00) than in those with goiter (median=0.50, IQR=0.25–0.75) (p=0.028). CONCLUSIONS: SPU localization of the PTG in RHPT had an accuracy comparable with that in previous literature with the additional advantage of identifying concurrent unknown thyroid nodules. Considering the high prevalence of concomitant nodular thyroid disease in our RHPT population, we advocate the routine use of preoperative neck ultrasound for RHPT patients undergoing parathyroid surgery

Enoxaparin-associated spontaneous breast haematoma in elderly with chronic kidney disease: a case report

Thomboembolic events are relatively common among elderly with restricted mobility. These adversities include deep vein thrombosis and pulmonary embolism that require anticoagulants as the mainstay of treatment. The elderly are not only at higher risk of thromboembolism, but also have a higher haemorrhagic complication especially among chronic kidney disease. Physicians should be cautious of haematoma formation if they present with sudden onset of painful breast swelling. We describe a rare case of an elderly with underlying chronic kidney disease who developed spontaneous right breast haematoma after taking low molecular weight heparin for her recently diagnosed pulmonary embolism

ORIGINAL ARTICLE Ultracision Versus Electrocautery In Performing Modified Radical Mastectomy And Axillary Lymph Node Dissection For Breast Cancer: A Prospective Randomized Control

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 Kebangsaa

Immunohistophenotyping and 18F-FDG PET-CT in characterizing malignant breast tumors: preliminary results

Objective: Malignant breast tumors are associated with a poor prognosis. Accurate tumor localization and characterization of the disease phenotype may avert inappropriate futile surgery and toxic treatment. This study evaluated the roles of standardized uptake value (SUVmax) and flurodeoxygenase (FDG) and immunohistochemical markers in assessing malignant breast tumors. Patients and Methods: This was a prospective study of 21 consecutive patients who underwent 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) prior to treatment. Tissue biopsies were sought from patients with BIRADS 4/5 score on mammogram. Tumor SUVmax 18F-FDG PET-CT was assessed for potential correlation with the histological and immunohistochemical categories. Results: We investigated 21 patients (18 malignant, 3 benign) with a mean age of 54.48 ± 12.1 years. In the immunohistochemical categorization, tumors were HER positive (42.86%), HER negative (42.86%) and benign (14.29%). The sensitivity, specificity (on a per patient and per lesion basis), positive predictive value and negative predictive value for the primary lesion by CT and 18F-FDG PET-CT were 82.3%, 20%, 77.8%, 25% (on per patient basis); 88.2%, 25%, 88.3%, 66.7% (on per lesion basis); and 100%, 100%, 100%, 100% (on per patient basis); 100%, 75%, 94.1%, 100%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for CT and 18F-FDG PET-CT were 15.4%, 50%, 66.7%, 8.33% and 100%, 50%, 92%, 100%, respectively. There was no significant difference in the mean SUV max between HER positive and HER negative immunohistochemical phenotypes, but these values were significantly higher in single hormone receptor (HR), HER negative or HER positive tumors than in benign entities (p<0.05). Conclusions: 18F-FDG PET-CT and Immunohistophenotyping are potentially important surrogate markers for characterizing malignant breast disease and axillary lymph node metastasis

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

Papillary Thyroid Carcinoma with Spindle Cell Metaplasia: A Rare Encounter

A myriad of histological variants of papillary thyroid carcinoma (PTC) have been described, some of which can be diagnostically challenging due to their rarity and overlapping histomorphology with other entities. One of the scarce and poorly characterised variants is PTC with spindle cell metaplasia, of which fewer than 20 cases have been reported in the literature hitherto. Our patient was a 51-year-old woman with a four-month history of painless, gradually enlarging neck swelling. Physical examination revealed a solitary left thyroid nodule. Thyroid ultrasonography demonstrated a hypoechoic nodule with irregular borders and speckles of microcalcification at the periphery. Total thyroidectomy with central and lateral lymph node dissection was performed. Grossly, there was a poorly circumscribed mass occupying the entire left thyroid lobe measuring 30 mm in the largest dimension. Histopathological examination revealed features of a classical PTC. Incidentally, a well-circumscribed 9 mm nodule was identified within the tumour mass. The nodule comprised of spindle cells arranged in loose fascicles, displaying uniform bland looking nuclei. No mitosis, necrosis or nuclear atypia was observed. Immunohistochemically, the spindle cells were immunopositive to TTF-1 and thyroglobulin, indicating thyroid follicular cell lineage. p53 and BRAF V600E mutant protein immunoexpression were focally noted. They were negative for calcitonin, S100, and desmin. Loss of E-cadherin and CK19 were also demonstrated. A diagnosis of PTC with spindle cell metaplasia was rendered. The nature of spindle cell in PTC needs to be meticulously defined. Careful histomorphology examination and judicious use of immunohistochemistry stains are helpful in arriving at an accurate diagnosis

Breast Carcinoma Occurring from Chronic Granulomatous Mastitis

Chronic granulomatous mastitis is known as a benign and relatively rare disorder that is often difficult to differentiate from breast carcinoma. We highlight the case of a 34-year-old woman who had recurrent episodes of right breast swelling and abscess for 8 years. These were proven to be chronic granulomatous mastitis by tissue biopsies on 3 different occasions. Her condition improved on similar courses of antibiotics and high-dose prednisolone. However, she subsequently developed progressive loss of vision due to an orbital tumour. She then underwent a craniotomy and left orbital decompression with excision of the tumour, which proved to be a metastatic carcinoma. A trucut biopsy of the right breast was then done and showed features consistent with an infiltrating ductal carcinoma. This case illustrates the possibility that chronic granulomatous mastitis could be a precursor for malignancy and the difficulty in differentiating one from the other. The possible mechanisms of development and the implications for future management are also discussed

Integrated microRNA, gene expression and transcription factors signature in papillary thyroid cancer with lymph node metastasis

Background. Papillary thyroid carcinoma (PTC) is the commonest thyroid malignancy originating from the follicle cells in the thyroid. Despite a good overall prognosis, certain high-risk cases as in those with lymph node metastasis (LNM) have progressive disease and poorer prognosis. MicroRNAs are a class of non-protein-coding, 19–24 nucleotides single-stranded RNAs which regulate gene expression and these molecules have been shown to play a role in LNM. The integrated analysis of miRNAs and gene expression profiles together with transcription factors (TFs) has been shown to improve the identification of functional miRNA-target gene-TF relationships, providing a more complete view of molecular events underlying metastasis process. Objectives. We reanalyzed The Cancer Genome Atlas (TCGA) datasets on PTC to identify differentially expressed miRNAs/genes in PTC patients with LNM-positive (LNM-P) versus lymph node negative (LNN) PTC patients and to investigate the miRNA-gene-TF regulatory circuit that regulate LNM in PTC. Results. PTC patients with LNM (PTC LNM-P) have a significantly shorter disease-free survival rate compared to PTC patients without LNM (PTC LNN) (Log-rank Mantel Cox test, p = 0.0049). We identified 181 significantly differentially expressed miRNAs in PTC LNM-P versus PTC LNN; 110 were upregulated and 71 were downregulated. The five topmost deregulated miRNAs were hsa-miR-146b, hsa-miR-375, hsa-miR-31, hsa-miR-7-2 and hsa-miR-204. In addition, 395 miRNAs were differentially expressed between PTC LNM-P and normal thyroid while 400 miRNAs were differentially expressed between PTC LNN and normal thyroid. We found four significant enrichment pathways potentially involved in metastasis to the lymph nodes, namely oxidative phosphorylation (OxPhos), cell adhesion molecules (CAMs), leukocyte transendothelial migration and cytokine–cytokine receptor interaction. OxPhos was the most significantly perturbed pathway (p = 4.70E−06) involving downregulation of 90 OxPhos-related genes. Significant interaction of hsa-miR-301b with HLF, HIF and REL/NFkB transcription factors were identified exclusively in PTC LNM-P versus PTC LNN. Conclusion. We found evidence of five miRNAs differentially expressed in PTC LNM-P. Alteration in OxPhos pathway could be the central event in metastasis to the lymph node in PTC. We postulate that hsa-miR-301b might be involved in regulating LNM in PTC via interactions with HLF, HIF and REL/NFkB. To the best of our knowledge, the roles of these TFs have been studied in PTC but the precise role of this miRNA with these TFs in LNM in PTC has not been investigated

Integrated Characterization of MicroRNA and mRNA Transcriptome in Papillary Thyroid Carcinoma

The incidence rate of papillary thyroid carcinoma (PTC) has rapidly increased in the recent decades, and the microRNA (miRNA) is one of the potential biomarkers in this cancer. Despite good prognosis, certain features such as lymph node metastasis (LNM) and BRAF V600E mutation are associated with a poor outcome. More than 50% of PTC patients present with LNM and BRAF V600E is the most common mutation identified in this cancer. The molecular mechanisms underlying these features are yet to be elucidated. This study aims to elucidate miRNA–genes interaction networks in PTC with or without LNM and to determine the association of BRAF V600E mutation with miRNAs and genes expression profiles. Next generation sequencing was performed to characterize miRNA and gene expression profiles in 20 fresh frozen tumor and the normal adjacent tissues of PTC with LNM positive (PTC LNM-P) and PTC without LNM (PTC LNN). BRAF V600E was genotyped using Sanger sequencing. Bioinformatics integration and pathway analysis were performed to determine the regulatory networks involved. Based on network analysis, we then investigated the association between miRNA and gene biomarkers, and pathway enrichment analysis was performed to study the role of candidate biomarkers. We identified 138 and 43 significantly deregulated miRNAs (adjusted p value &lt; 0.05; log2 fold change ≤ −1.0 or ≥1.0) in PTC LNM-P and PTC LNN compared to adjacent normal tissues, respectively. Ninety-six miRNAs had significant expression ratios of 3p-to-5p in PTC LNM-P as compared to PTC LNN. In addition, ribosomal RNA-reduced RNA sequencing analysis revealed 699 significantly deregulated genes in PTC LNM-P versus normal adjacent tissues, 1,362 genes in PTC LNN versus normal adjacent tissue, and 1,576 genes in PTC LNM-P versus PTC LNN. We provide the evidence of miRNA and gene interactions, which are involved in LNM of papillary thyroid cancer. These findings may lead to better understanding of carcinogenesis and metastasis processes. This study also complements the existing knowledge about deregulated miRNAs in papillary thyroid carcinoma development