Metaplastic breast carcinoma with osteogenic component

Metaplastic breast carcinomas [MBC] are rare primary breast malignancies characterized by the co-existence of carcinoma with non-epithelial cellular elements. They can be classified as monophasic spindle cell [sarcomatoid] carcinoma, biphasic carcinosarcoma, adenocarcinoma with divergent stromal differentiation [osseous, chondroid and rarely rhabdoid] as well as adenosquamous and pure squamous cell carcinomas. Nearly all reports portrait women in their forties or older, yet younger affected females in their twenties have been reported. The usual presentation included firm painless breast mass ranging between 1.4 and 14 cm in diameter, with no evidence of loco-regional or distal metastasis. Mammary osteosarcomas are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Metastatic disease expected to develop at a mean of 10.5 and 14.5 months from the initial diagnosis and demise followed within 20 months of the onset of metastasis. MBC remains a rare entity with poor response to both chemo-radiotherapy, histological diagnosis is challenging yet it is the main stay in outlining the management. The surgical option remains the only successful current treatment in the form of simple Mastectomy to achieve negative margins sparing the patients axillary node dissection

Breast cancer management delay - time for improvement: a reflection from the eastern province of Saudi Arabia

Breast cancer is the commonest international malignancy among women. Its increased prevalence over recent years in our part of the world has prompted women to randomly seek medical advice. Many patients are delayed for weeks to months prior to receiving medical treatment. This review explores the causes of delay and proposes possible solutions. This review was undertaken at King Fahd Hospital of the University, a tertiary care center with the capacity of 420 beds. It accommodates a large number of referrals from the Eastern Province, other regions of the Kingdom, in addition to many walk-in patients. Most of the patients referred with breast cancer are directed to the breast clinic for treatment. There was random re-tracing of patients' steps from the discovery of the suspicious breast mass to the delivery of care. The total number of diagnosed breast cancer cases at this center between 1997-2007 was 303, with a total number of 975 registered visits. Random retracing of these patients' records identified three points of delay: community related, primary heath care and tertiary care. It was found that the patients spent 6-15 weeks and around 32-38 hand offs before receiving the final care. This unnecessary delay creates anxiety and mistrust of the operating health system leading patients to seek alternative medicine or treatment abroad. A multidisciplinary one-stop breast oncology clinic may be the solution to the above problem. It may allow the fast tracking of breast cancer patients through a highly specialized and well-trained multidisciplinary team that offers the highest quality of care, thereby optimizing the chances of cure with the least delay and possible morbidity

Can saline be an alternative to aesthetic surgery in extended breast quadrantectomy?

To explore other simpler options sparing the patients the morbidity and cost in extended breast quadrantectomy. This prospective study was undertaken at King Fahd Hospital of the University, Al-Khobar, Eastern Province of Saudi Arabia between 1999-2005. Factors considered for patients undergoing breast-conserving surgery were based on age, tumor size, pathological characteristics, and patient's preference. Frozen section was adopted in all procedures to insure negative margins. After extended quadrantectomy, 200-400 cc was injected into the cavity to retain breast contour. Magnetic resonance imaging was used for postoperative assessment. Twenty-four patients were included, aged 28-43 years and tumor size 3-5 cms. All margins were negative on frozen section. The contour of the breast was restored with saline, MRI was employed for follow up at the immediate post operative period and at 4-6 months, it demonstrated restored breast contour and the saline filled cavity replaced by lipo-fibrous tissue. Follow up after 4-24 months showed that all patients noticed some degree of asymmetry, yet were satisfied with the result, none required or requested additional surgery. In large tissue excisions injecting saline into cavities temporarily prevents the caving in of the redundant skin, which has the tendency to permanently adhere to the fascia thereby preventing gross deformities. It has proven effective, contour storing and scored high satisfaction among patients. It certainly does not replace cosmetic breast surgery, however, it should be considered in centers were onco-plastic surgery is not readily available

Giant juvenile fibroadenoma: experience from a university hospital

Fibroadenoma is one of the commonest benign breast lesions in our outpatient clinics. Giant Juvenile fibroadenoma [GJF] characterized with their alarming rapid growth and gross disfigurement is less frequently identified. A 14-year review [1990-2004] of all fibroadenomas presented to the Outpatient Department was undertaken. Demographic data, duration of symptoms, size at presentation, the use of radiological, cytological and histo-pathological modalities, surgical excision and follow up were all noted. Eight-Hundred-Sixty-Four cases were diagnosed as fibroadenoma by both clinical and radiological examinations and confirmed by FNAC. Patients with fibroadenomas <2 cm in size were followed up regularly in the out patients department, while those >2 cm underwent surgical excision. GJF were defined as those with >5 cm in diameter. The total number of excised fibroadenomas was 202 [23%], while the remaining662 [77%] fell into the follow up category. GJF were diagnosed in 9 patients accounting for 4.5% of all excised fibroadenomas. Age ranged between 14-23 years. However benign these lesions may appear, in view of the history of a sudden rapid breast enlargement as demonstrated in nearly all the clinical presentations, surgical excision remains the mainstay of treatment of such lesions in order to allow the previously compressed normal surrounding breast tissue to expand and retain its normal function and cosmetic appearance. The use of radiological modalities such as ultrasound and MRI may aid the diagnosis, limiting mammography to the older age group

Breast infections in non-lactating women

Breast infection in lactating mothers is a common entity which in the majority of cases can be explained by ascending infections. However, it has been noticed that the number of non- lactating women presenting with breast abscesses is rising. This study attempts to explore the sensitivity pattern of organisms and underlying cause of breast infections in non-lactating women. Materials and Methods: This review was undertaken at King Fahd of the University, Alkhobar, Saudi Arabia between 1991-2003. All patients presenting with breast infections were included. Medical records, operative notes, cultures, histopathology reports and outcome were reviewed. Results: The number of patients presenting with breast infections accounted for 179[3.5%] out of the total number of patients 6314 with variable breast complaints. Infection occurred in 136[76%] lactating women [Group I] ,while Non lactating [Group II] breast infections accounted for 43[24%]. Age ranged from 24 years to 52 years. Underlying clinical conditions were found in 26 patients[60%] in Group II namely granulomatous mastitis13[50%], duct ectasia4 [15.3%], pregnancy3[11.5%], fat necrosis1[3.8%], diabetes3 [11.5%] and breast cancer 2[7.6%]. The pattern of culture results was different in the two groups, from differing causative organisms namely staphylococcus aureus as the commonest organism in both groups, in comparison to such uncommon organisms as Klebsiella pneumonae, Peptococcus magnus, Streptococcus group B, Entro-bacter cloacae, Methicillin resistant staphylococcus aureus [MRSA] and Mycobacterium tuberculosis occurring in group II only. Fortunately, all organisms were sensitive to antimicrobial therapy. Breast infection in non-lactating women is an infrequent but recognized clinical entity that deserves special attention. An underlying clinical condition should always be sought and treated. Indeed, in addition to cultures, radiological modalities such as ultrasonographic imaging may provide specific diagnosis and aid the management

latrogenic endometrioma: case report and review of literature

This 38-year old multiparous female presented to the surgical clinic with a painful nodule on the left margin of the pfannenstiel incision noticed three months after Cesarian Section [CS] and associated with regular cyclical pain. The nodule increased in size progressively over the next 36 months. Differential diagnosis included: foreign body granuloma, incisional hernia, traumatic neuroma and irreducible inguinal hernia. CT-scan revealed that the mass was extra-abdominal and partially extra muscular. Excision revealed endometrial active tissue with no signs of malignancy. This type of iatrogenic complication may be avoided, if meticulous intra-operative wound care is applied

Blood conservation in elective surgery

Blood transfusion is often a life-saving measure for surgical patients. In the era of numerous blood-transmitted diseases and known documented complications, however, blood transfusion is limited to patients who re q u i re blood replacement therapy. In elective surgery, blood transfusion is quite uncommon and most of the cross-matched blood is not used. Time and effort spent in cross-matching for each patient undergoing a surgical procedure is considerable. This study was initiated to determine ways to reduce the unnecessary demands on our blood bank and to support a suggested blood transfusion policy in our institution. Materials and This review was carried out at King Fahd Hospital of the University, Eastern Province of Saudi Arabia. It covered a four year period, from January 1995 - December 1998. During this time, a proposed blood utilization policy was submitted to all major departments for review and approval. The department of surgery was one of the first departments to accept and attempt to implement the suggested policy. This study reviewed the pre- and post-policy blood utilization. The calculated cross-match transfusion [CT] ratio for the two years after implementing the policy was 2.1:1 as compared to 4.8:1 before implementation. This is a 50% reduction. Despite the drop in the CT ratio, the type and screen requests increased only by 10.2%. The implementation of our blood utilization policy is a very important method in saving hospital resources and manpower. This policy, if adopted nationwide, will lead to enormous grand total savings that can be directed towards improvement of blood bank and hospital services