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

Medial pectoral pedicle is a reliable landmark for axillary lymph node dissection

Background The anatomical orientation of structures in the axilla has not been well studied, although it is essential for a neat and safe dissection. The objective of this study was to determine the relations between neurovascular structures in the axilla as they were encountered during axillary lymph node dissection (ALND) for breast cancer. Methods This was a prospective study of 29 consecutive ALNDs accompanying either mastectomy or wide local excision. The dissections were conducted in a stepwise manner and the orientation of the structures was determined as the dissections advanced from superficial to deeper planes. Results The medial pectoral pedicle was the most superficial neurovascular structure encountered during the dissections and was curled around the lateral border of the pectoralis minor muscle in most cases. The intercostobrachial nerve lay 1-2 cm behind and below, and the axillary vein was located 2-3 cm behind and above the pedicle. The long thoracic nerve was constantly found 2-3 cm behind the intercostobrachial nerve. The thoracodorsal nerve was always accompanied by a posterior tributary of the axillary vein. Conclusion Relations between neurovascular structures in the axilla are predictable. The medial pectoral pedicle, which is consistently found and superficially located, could be used as a landmark for ALN

Unilateral adrenal hyperplasia: a rare cause of primary aldosteronism

A 73-year-old gentleman with a background history of long-standing hypertension and hyperlipidaemia presented with one-year history of persistent asymptomatic hypokalaemia associated with metabolic alkalosis. Within a few months, the hypertension worsened, needing increasing dose of anti-hypertensive agents. Biochemical test showed an elevated aldosterone-renin ratio but the computerized tomography (CT) scan of adrenal did not show any adrenal mass. Arterial stimulation venous sampling (ASVS) lateralized the lesion to the left side. A left retroperitoneal adrenalectomy was performed with immediate reversal of hypokalaemia and improvement of blood pressure control to only single anti-hypertensive agent

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

Potential biomarkers through genome-wide expression analysis of breast cancer samples from Malaysian patients

Breast cancer is a serious health concern and still a leading cause of death among women in the world. To explore the complexity of this cancer, we performed microarray analysis on highly selective cancer and normal breast tissues. The aim of this study was to identify differentially expressed genes between both tissues and to elucidate further molecular pathways involved in breast cancer carcinogenesis. Genome-wide expression profiling was performed on fifteen cancer and five normal breast tissues using the Affymetrix GeneChip® Human Gene 1.0 ST array. Supervised hierarchical cluster analysis using filtering parameters of -1.5 to 1.5 fold-change and p-value with False Discovery Rate < 0.05 revealed 404 up-regulated and 463 down-regulated genes. Pathway analysis revealed the significant genes were involved in cell cycle regulation, DNA repair, Hedgehog pathway, histone phosphorylation, TRRAP/Tip60 chromatin remodelling and apoptosis regulation. Among the top 10 significantly overexpressed genes were CENPF, DTL and MK167 and these were related to cell cycle regulation. Among the top 10 significant down-regulated genes, HOXA5 and NRG1 were found to be associated with Wnt signalling pathway and ErbB signalling pathway respectively. Aberrations in these genes are likely to promote breast cancer carcinogenesis. Our current findings highlighted the importance of differentially expressed genes in breast cancer and their molecular pathways that linked these genes. Further studies are required to validate our findings using larger sample size

Ko-pengekspresan reseptor estrogen beta (ERβ) dan aktin otot licin pada tumor filodes di payudara: suatu kajian tisu mikroarai

Proliferasi tumor filodes tertumpu terutama pada bahagian stroma yang dianggap sebagai komponen neoplastik bagi tumor filodes. Reseptor Estrogen (ER) yang memainkan peranan dalam payudara neoplastik juga terlibat dalam perkembangan tumor filodes. ERβ adalah satu jenis klon ER yang dilaporkan hadir pada stroma tumor payudara manakala pengekspresan aktin otot licin (SMA) di stroma dapat membandingkan gred histologi tumor filodes. Kami membandingkan pengekspresan ERβ dengan SMA pada komponen stroma tumor filodes menggunakan teknik tisu mikroarai (TMA). TMA dibentuk ke atas 77 kes tumor filodes (46 benigna, 17 pinggiran dan 14 malignan) menggunakan jarum berdiameter 0.6 mm (Alphelys Plaisir, Perancis) dan pewarnaan imunohistokimia dijalankan menggunakan penanda molekul ERβ dan SMA. Tumor filodes kerap hadir pada wanita berusia lebih daripada 40 tahun dengan tumor filodes benigna menunjukkan median umur pesakit paling rendah (p=0.017). Ekspresi ERβ dalam komponen stroma meningkat dengan gred histologi tumor. Sementara SMA menunjukkan ekspresi pada 62.8, 41.2 dan 57.1%, masing-masing bagi tumor filodes benigna, pinggiran dan malignan. Kedua-dua ERβ (p=0.024) dan SMA lebih cenderung hadir pada wanita ≥40 tahun. Kajian menunjukkan hubungan signifikan antara ko-pengekspresan ERβ dan SMA (p=0.047) dan 65.5% daripadanya adalah wanita berumur lebih daripada 40 tahun. Ekspresi SMA yang tinggi pada stroma tumor filodes benigna mungkin menunjukkan potensi proliferasi tumor ini untuk menjadi malignan. Ekspresi tinggi ERβ dengan tumor filodes malignan dan hubungannya dengan SMA mencadangkan ko-pengekspresan kedua-dua penanda molekul ini mungkin berperanan dalam tumorigenesis stroma tumor filodes

Medial pectoral pedicle is a reliable landmark for axillary lymph node dissection

Background: The anatomical orientation of structures in the axilla has not been well studied, although it is essential for a neat and safe dissection. The objective of this study was to determine the relations between neurovascular structures in the axilla as they were encountered during axillary lymph node dissection (ALND) for breast cancer. Methods: This was a prospective study of 29 consecutive ALNDs accompanying either mastectomy or wide local excision. The dissections were conducted in a stepwise manner and the orientation of the structures was determined as the dissections advanced from superficial to deeper planes. Results: The medial pectoral pedicle was the most superficial neurovascular structure encountered during the dissections and was curled around the lateral border of the pectoralis minor muscle in most cases. The intercostobrachial nerve lay 1–2 cm behind and below, and the axillary vein was located 2–3 cm behind and above the pedicle. The long thoracic nerve was constantly found 2–3 cm behind the intercostobrachial nerve. The thoracodorsal nerve was always accompanied by a posterior tributary of the axillary vein. Conclusion: Relations between neurovascular structures in the axilla are predictable. The medial pectoral pedicle, which is consistently found and superficially located, could be used as a landmark for ALND

Prospective Study Comparing Scrape Cytology with Frozen Section in the Intraoperative Identification of Parathyroid Tissue

Intraoperative identification of parathyroid tissue is crucial during parathyroid surgery. Frozen section is the most common tool, but is time-consuming and expensive. Scrape cytology is a modification of imprint cytology that provides rapid and cheap intraoperative identification of parathyroid tissue, but its reliability remains controversial. We assessed the sensitivity and specificity of scrape cytology in the intraoperative identification of parathyroid tissue. Methods: Scrape cytology samples from parathyroid tissue (n = 29), adipose tissue (n = 3) and thyroid tissue (n = 2) were prepared intraoperatively using May-Grünwald-Giemsa and Papanicolaou staining and subsequently sent for routine frozen section and standard paraffin section. A single pathologist reading the scrape cytology was blinded to the results of the frozen and standard paraffin sections. Results: Scrape cytology identified 25 of 29 parathyroid tissues, all three adipose tissues and one of two thyroid tissues. The remaining samples, four parathyroid tissues and one thyroid tissue, were not identified due to insufficient sample for diagnosis. The result translated to give a diagnostic accuracy of 88.2%, sensitivity of 86%, and specificity of 100%. All tissues were accurately identified by frozen section. Conclusion: Scrape cytology is a rapid, economical test with acceptable sensitivity and high specificity. It can be used as an adjunct to frozen section and may be used as a tool in helping surgeons to identify parathyroid tissue

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

Encapsulated Papillary Carcinoma: A Rare Case Report and Its Imaging Features

Papillary lesions in the breasts are uncommon and have a wide range of pathologies. Due to diverse non-specific findings radiologically and histologically, papillary neoplasms are always a challenge to radiologists. Encapsulated papillary carcinomas (EPCs) of the breast, also known as intracystic papillary carcinomas, are a subgroup of intraductal papillary lesions of the breast. We present a case of a painless right breast lump with the aim to describe a rare encapsulated papillary carcinoma and its imaging features