Need for Staging Investigations in Newly Diagnosed Breast Cancer: Establishing Local Guidelines for Radiological Staging in Bahrain.

Objective: Staging workup and detection of distant metastases is important in newly diagnosed breast cancer in order to make treatment decisions and establish the prognosis. There is wide variation in current recommendations for staging investigations in breast cancer. Routine staging is performed for all patients in Bahrain because of lack of consistent guidelines. Optimization of the criteria for staging is important for identification of metastases, while minimizing harm and costs. The aim of this study was to evaluate factors associated with distant metastases in newly diagnosed patients with breast cancer, in order to establish local guidelines for proper selection of patients for systemic staging. Materials and Methods: Patients with newly diagnosed breast cancer at Salmaniya Medical Complex in Bahrain who underwent staging investigations between January 2016 and December 2022 were identified from a pathology database. Patients with previous history of cancer, synchronous tumors, bilateral breast cancer and ductal carcinoma in situ were excluded. Clinical, radiological and pathological data were retrospectively analyzed. Results: A total of 593 patients underwent staging computed tomography and bone scans or a PET scan. Distant metastases were identified in 20.7% of cases. M1 disease was significantly associated with multifocality/multicentricity, high grade tumors, hormone receptor-negative cancers, high Ki67 index, advanced tumor stage, node-positive disease, triple-negative breast cancer, use of PET scans and those who underwent neoadjuvant chemotherapy. Age was not associated with identification of distant metastases. Conclusion: The prevalence of distant metastases in this population of newly diagnosed patients with breast cancer was higher than previously reported. Routine staging of all patients at presentation was not indicated, especially for asymptomatic patients with early breast cancer. This study identified certain groups of patients with a higher risk of distant metastasis, in whom metastatic workup should be performed. These findings may allow for the development of a local guideline that addresses the question of which breast cancer patients need staging investigations for distant metastases.

Bizarre Parosteal Osteochondromatous Proliferation (Nora's Lesion) Of the Second Proximal Phalanx Encasing the Flexor Tendon of the Foot: A Case Report.

Introduction: Bizarre Parosteal Osteochondromatous Proliferation (BPOP) is a rare benign lesion commonly referred to as Nora's lesion. It typically affects adults in their 20s-30s. Due to its aggressive local invasion, it can be confused with some malignant tumors, including chondrosarcoma. Nora's lesion can be diagnosed radiographically, and its diagnosis is confirmed with an excisional biopsy. Case Report: A 40-year-old Bahraini male complained of swelling over the metatarsal head of the second digit, increasing in size over a year. He also complained of a reduced range of motion of the second toe and a pins-and-needles sensation affecting the entire toe. Plain X-ray, computed tomography, and magnetic resonance imaging were done, showing findings suggestive of bizarre parosteal osteochondromatous. The lesion was encasing the flexor tendon of the second digit. He was treated with surgical excision, and histopathology confirmed the diagnosis of BPOP. Conclusion: We report on a rare presentation of BPOP in the second proximal phalanx of a male in his 40 s. The patient underwent a wide local excision, and the diagnosis was confirmed with histopathology.

Risk Factors Associated With Sentinel Lymph Node Metastasis in Clinically Node-Negative Breast Cancer.

Objective: Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in clinically node negative breast cancer. If predictive factors for sentinel lymph node (SLN) metastasis could be identified, it would allow selection of candidates for SLNB and omit axillary surgery in those with the lowest risk of axillary lymph node involvement. The aim of this study was to determine risk factors associated with SLN metastasis in breast cancer patients in Bahrain. Materials and Methods: Patients with clinically node-negative breast cancer who underwent SLNB at a single institution between 2016 and 2022 were identified from the pathology database. Patients who had failure of localization of SLN, those with bilateral cancers and those treated for a local recurrence were excluded. Results: A total of 160 breast cancer patients were retrospectively analyzed. Of these, 64.4% had a negative SLNB and 21.9% of all cases underwent axillary dissection. The following parameters emerged as predictors of SLN metastasis in univariate analysis: age; tumour grade; ER status; presence of lymphovascular invasion (LVI) and tumor size. On multivariate analysis, age was not independently associated with the incidence of SLN metastasis. Conclusion: This study showed that high tumour grades, presence of LVI and large tumour size were all risk factors related to axillary metastasis after SLNB in breast cancer. In the elderly, the incidence of SLN metastasis appeared to be relatively low, providing an opportunity to de-escalate axillary surgery in these patients. These findings may allow for the development of a nomogram to estimate the risk of SLN metastasis.

Hashimoto Thyroiditis beyond Cytology: A Correlation between Cytological, Hormonal, Serological, and Radiological Findings.

Introduction: Hashimoto thyroiditis is the most common cause of chronic inflammation of the thyroid gland. Ultrasound is the modality for detection, while fine needle aspiration is the gold standard method for diagnosis. Serologic markers, such as antithyroidal peroxidase antibody (TPO) and antithyroglobulin antibody (TG), are usually elevated. Aim: The main objective is to appraise the incidence of neoplasms on a background of Hashimoto thyroiditis. Our second objective is to recognize the different sonographic appearances of Hashimoto thyroiditis, to focus on its nodular and focal patterns, and to measure the sensitivity of the ACR TIRAD system (2017) when interpreted on patients with Hashimoto thyroiditis. Methods: A single-center retrospective cross-sectional study. We studied 137 cases diagnosed cytologically as Hashimoto thyroiditis from January 2013-December 2019. The data collected were analyzed using SPSS (26th edition), and ultrasounds were reviewed by a single board-certified radiologist. The ACR thyroid imaging and Data System 2017 (ACR TI-RADs 2017) and the Bethesda System for reporting thyroid cytology 2017 (BSRTC 2017) were used for reporting ultrasound and cytology, respectively. Results: The mean age was 44.66 years and the female : male was 9 : 1. Serologically, anti-Tg was high in 22 cases (38%), while anti-TPO was positive in all of the 60 cases studied. Histologically, 11 cases were diagnosed with papillary thyroid carcinoma (8%) and a single case with follicular adenoma (0.7%). Ultrasonographically, 50% of the cases showed diffuse pattern, in which 13% of them showed micronodules. 32.2% were macronodular, and 17.7% were a focal nodular pattern. 45 nodules were interpreted with the ACR TIRAD system (2017), in which 22.2% were TR2, 26.6% were TR3, 17.7% were TR4, and 33.3% were TR5. Conclusion: Hashimoto thyroiditis is a risk factor for developing thyroid neoplasms, which necessitate a proper assessment of the cytological material studied and a correlation with the clinical and radiological features. Recognizing the different types of Hashimoto thyroiditis and its variable appearances is significantly important in performing and interpreting thyroid ultrasound imaging. Microcalcification is the most sensitive parameter to discriminate between PTC and nodular type of Hashimoto thyroiditis. The TIRAD system (2017) is a useful tool for risk stratification; however, it might create unnecessary FNA studies in the setting of Hashimoto thyroiditis because of its variable appearances on ultrasound. A modified TIRAD system for patients with Hashimoto thyroiditis is important to alleviate this confusion. Finally, anti-TPO is a sensitive marker for detecting Hashimoto thyroiditis, which could be used for future referencing of newly diagnosed cases.

Deceptive Triple-Negative Breast Cancer of Intermediate Grade: A Case of Rare Microglandular Adenosis-Associated Carcinoma.

Breast cancer is the most common cancer among women and the leading cause of cancer-related deaths globally. Ductal carcinoma of no special type is the most prevalent, followed by lobular carcinoma. Finding a triple-negative breast cancer of intermediate grade on core biopsies should raise the possibility of dealing with one of the rare subtypes such as microglandular adenosis (MGA)-associated carcinoma. Here, we present a case of a 40-year-old female, who presented with bilateral breast masses, in which one of them was a high-grade carcinoma and the other turned out to be an MGA-associated carcinoma, which was misdiagnosed initially on the core biopsy as a grade II triple-negative ductal carcinoma of no special type. Such diagnosis is challenging to pathologists, especially on small biopsies where the full morphological spectrum is not evident.

Safety and efficacy of COVID-19 prime-boost vaccinations: Homologous BBIBP-CorV versus heterologous BNT162b2 boosters in BBIBP-CorV-primed individuals.

BACKGROUND: Booster vaccine doses against SARS-CoV-2 have been advocated to address evidence of waning immunity, breakthrough infection, and the emergence of immune-evasive variants. A heterologous prime-boost vaccine strategy may offer advantages over a homologous approach, but the safety and efficacy of this approach with the mRNA vaccine BNT162b2 (BNT: Pfizer) and inactivated BBIBP-CorV (BBIBT: Sinopharm) vaccines have not been studied. METHODS: We conducted a non-randomized, non-blinded phase II observational community trial acrossBahrain, investigating the reactogenic and immunogenic responseof participants who had previously received two doses of BBIBP, followed by a third booster dose of either BBIBP (homologous booster) or BNT (heterologous booster). Immunogenicity through serological statuswas determined at baseline and on the following 8thweek. Reactogenicity data (safety and adverse events) were collected throughout study period, in addition to participant-led electronic journaling. RESULTS: 305 participants (152 BBIBP and 153 BNT booster) were enrolled in the study,with 246 (127 BBIBP and 119 BNT booster) included in the final analysis. There was a significant increase in anti-SARS-CoV-2 antibody levels post booster administration in both groups; however, the heterologous BNT arm demonstrated a significantly larger mean increase in the level of spike (S) antigen-specific antibodies (32.7-fold increase versus 2.6, p < 0.0001) and sVNT neutralising antibodies (3.4-fold increase versus 1.8, p < 0.0001), whereas the homologous arm demonstrated a significant increase in the levels of nucleocapsid (N) antigen-specific antibodies (3.8-fold increase versus none). Non-serious adverse events (injection site pain, fever, and fatigue) were more commonly reported in the heterologous arm, but no serious adverse events occurred. CONCLUSION: Heterologous prime-boost vaccination with the mRNA BNT162b2 (Pfizer) vaccine in those who had received two doses of inactivated virus BBIBP-CorV (Sinopharm) vaccine demonstrated a more robust immune response against SARS-CoV-2 than the homologous BBIBP booster and appears safe and well tolerated. Clinical Trial Registry Number (ClinicalTrials.gov): NCT04993560.

Gastrointestinal Stromal Tumor Recurrence Presenting as a Small Bowel Obstruction: A Case Report.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the alimentary tract in adults. The most common site is the stomach, followed by the small intestine. The clinical presentation varies from an incidental finding in asymptomatic patients to a large palpable mass causing complications such as bowel obstruction or viscus perforation. The best imaging modality is a CT scan of the abdomen. Treatment is determined by the size and location of the GISTs. Surgical intervention is considered for resectable tumors, while tyrosine kinase inhibitor therapy is considered for irresectable, metastatic, or recurrent GISTs. In this case report, we present a 30-year-old female who is a known case of gastric GIST and liver metastases. She presented to the emergency department with intestinal obstruction secondary to a recurrent GIST abdominal mass and underwent emergency laparotomy for mass resection. Following surgery, the patient developed aspiration pneumonia, which was treated with proper antibiotics. She was discharged in stable clinical condition with a recommendation to start alternative tyrosine kinase therapy. GISTs are difficult to diagnose preoperatively, as most patients are asymptomatic, and they may present with complications, as in our case, a small bowel obstruction. A proper imaging modality will guide the physician toward the diagnosis, but the final diagnosis will be achieved by biopsy. The diagnosis may be challenging, as small bowel obstruction has many causes, although GISTs should be kept in mind as one of the deferential diagnoses.

SARS-CoV-2 in peritoneal swabs from asymptomatic patients undergoing emergency abdominal surgery.

This is a case series of five patients with acute abdomen requiring surgery who tested positive for coronavirus disease 2019 (COVID-19) and were asymptomatic, with the purpose of detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in peritoneal fluid. Nasopharyngeal swab was done as a prerequisite for admission or prior to admission as part of random testing. Two methods of viral testing were employed: Xpert® Xpress SARS-CoV-2 (rapid test) and real-time reverse transcription polymerase chain reaction (RT-PCR). Either or both tests were done, with the former performed for patients requiring surgery immediately. Surgery was performed within 24-36 h from admission. Peritoneal fluid swabs were obtained for the detection of SARS-CoV-2 using RT-PCR test. Swabs were immediately placed in viral transfer media and delivered to the public health laboratory in an ice bag. SARS-CoV-2 was not detected in peritoneal swabs. Due to the limited number of patients, further studies are required; yet, protective measures should still be taken by surgeons when dealing with COVID-19 cases.

Seasonal Variation in Cases of Acute Appendicitis.

OBJECTIVES: To investigate whether the incidence of acute appendicitis increases in summer and whether complicated cases present more in summer. METHODS: A single-center cross-sectional, retrospective study on 697 cases of appendicitis admitted in the year 2018. Inclusion criteria: patients admitted with acute appendicitis who underwent appendectomy of all ages. Exclusion criteria: conservative management. Analysis was performed using Microsoft Excel. Pearson correlation coefficient was calculated to assess the correlation between monthly incidence of appendicitis and mean temperature in that month. RESULTS: Fifty-one patients who were managed conservatively were excluded. Accordingly, 646 patients were included. Ages ranged from three to 77 years. Males comprised the majority (500, 77.4%). Gangrenous, perforated, and purulent appendices were regarded as complicated appendicitis. The highest number of cases were admitted in summer (234), comprising 36.2% of cases. Complicated cases were equal to 65, of which 23 (35.4%) were admitted in summer and 30 (46.2%) in winter. The highest number of cases was during the month of July (68), while the lowest (40) was during February. This corresponded to the highest recorded mean temperature (36.2°C) and second lowest (19.8°C), respectively. Moderate positive correlation (Pearson's R 0.5183) between the monthly incidence of appendicitis and the mean temperature is noted. CONCLUSION: More cases of appendicitis were noted during summer. Monthly incidence correlated positively with the temperature. Larger numbers over several years are needed to draw better conclusions and reach the possible causes behind such variation.

Lung Cancer in Bahrain: Histological and Molecular Features.

OBJECTIVES: To define the histological types of primary lung cancer in Bahrain and to determine prevalence of EGFR and ALK mutation in patients with non-small cell lung carcinoma. METHODS: Data regarding Bahraini patients diagnosed with primary lung cancer between January 2013 and December 2018 were collected from the lab information system in Salmaniya medical complex, Manama, Bahrain. RESULTS: One hundred and forty-three Bahraini patients were diagnosed with lung cancer in the study period. 67.1% of the patients were male. The mean age at diagnosis was 68 years. The most common histological type was adenocarcinoma (58%), followed by squamous cell carcinoma (19%). EGFR mutation was found in 21.5% of non-small cell lung cancer cases with predominance of exon 19 deletions (29%) and exon 21 nucleic acid changes (21%). ALK mutation was found in 10.5% of EGFR negative patients. CONCLUSION: Adenocarcinoma is the most common primary lung cancer in Bahrain. Genetic mutations of EGFR and ALK genes were found in 21.5% and 10.5% of adenocarcinoma cases, respectively.

Evaluation of thyroid nodules classified as Bethesda category III on cytology and their malignancy rate: An institutional experience.

BACKGROUND: Thyroid gland nodules are common and fine-needle aspiration (FNA) is the gold standard for screening those nodules. The Bethesda system for reporting thyroid cytolopathology standardized reporting thyroid nodules aspirations, but atypia of undetermined significance or follicular lesion of undetermined significance (Bethesda category III) was the most controversial category. The aim of our study is to review our institutional experience and analyze the clinical implications of making a diagnosis of AUS/FLUS (Bethesda category III). METHODS: This is a retrospective study of an 889 thyroid FNAs from 825 patients in Salmaniya Medical Complex, during (January 2013-December 2017). RESULTS: The most common cause for designating cases as AUS/FLUS (Bethesda category III) was the presence of features suggestive of papillary thyroid carcinoma, but not quite fulfilling the criteria for such diagnosis. Ninety-six cases were diagnosed as AUS/FLUS (10.7%), in which 26 (27%) patients underwent surgery without repeating the FNA, 25 (26%) underwent a second FNA and 43 (44.7%) patients were followed up by ultrasound. On repeating the FNA, 1 (4%) was unsatisfactory, 13 (52%) were benign, 10 (40%) were AUS/FLUS, and only 1 (4%) was categorized as malignant. Thirty cases were surgically excised, in which 4 (13.3%) were diagnosed as follicular adenoma, 2 (6.6%) as Hurthle cell adenoma, 9 (30%) as multinodular goiter, 5 (16.6%) as multinodular goiter with Hashimoto thyroiditis, 1 (3.3%) as colloid nodule with Hashimoto thyroiditis, and 9 (30%) as papillary thyroid carcinoma. Among all the cases diagnosed initially as AUS/FLUS (Bethesda category III), 9 (9.3%) cases were diagnosed as papillary thyroid carcinoma. CONCLUSION: Diagnostically, we almost meet the international standards of designating cases with AUS/FLUS (Bethesda category III) and approximate the risk of malignancy. However, the clinical management's guidelines should be followed to decrease the risk of unnecessary surgeries and their complications. There is a statistically significant correlation between the age and gender with the final histopathology report, respectively.

Plasmacytoma as a Mimicker of Colonic Carcinoma in an Elderly Man.

Multiple myeloma is a neoplastic proliferation of monoclonal plasma cells. Although it is usually restricted to the bone marrow, extraskeletal spread in the form of localised extramedullary collections of malignant plasma cells (plasmacytomas) can occur. However, gastrointestinal tract involvement in multiple myeloma is rare and overt gastrointestinal bleeding from plasmacytoma is uncommon. We report a case of colonic plasmacytoma which presented with bleeding per rectum and was initially misdiagnosed as colonic neuroendocrine carcinoma. Later the patient presented with recurrence of the colonic mass along with multiple lytic bone lesions. The diagnosis of colonic plasmacytoma with progression into multiple myeloma was given. We also discuss here the diagnostic difficulty of plasma cell neoplasms in small biopsies of the colon.