Ductal carcinoma in situ and invasive carcinoma originating in a Fibroadenoma with concurrent benign phyllodes tumor: A case report.

INTRODUCTION AND IMPORTANCE: This case report presents a rare occurrence of multiple bilateral breast fibroadenomas, one evolving into ductal carcinoma in situ (DCIS) and invasive carcinoma, occurring simultaneously with a benign phyllodes tumor in the same breast. The importance of this case lies in emphasizing the crucial need for surveillance in patients with a long history of fibroadenomas and the necessity to investigate any rapid change in the size of fibroadenoma. CASE PRESENTATION: A 35-year-old multiparous female with a 17 year history of bilateral multiple breast lumps presented with recent onset of right breast pain and yellowish nipple discharge. Two lumps in her right breast had demonstrated an increase in size. Examination revealed a significant mass in the retroareolar region of the right breast and another at the 2 o'clock position. Histopathological examination of the biopsy specimens revealed fibroadenoma and benign phyllodes tumor. The patient underwent a bilateral breast lumpectomy. Further histopathological examination revealed ductal carcinoma in situ and invasive carcinoma within a complex fibroadenoma in the right breast and benign phyllodes tumor. Sentinel lymph node biopsy was negative. She had adjuvant radiations and trastuzumab. Regular follow-ups show no recurrence. CLINICAL DISCUSSION: Fibroadenomas are usually benign but rarely undergo malignant change. Quick response to size changes and early detection greatly enhance patient results. CONCLUSION: Ductal carcinoma in situ and invasive breast cancer, a rare malignancy found within a fibroadenoma, necessitates histopathological specimens and immunohistochemical results for accurate diagnosis. Survival rates are significantly enhanced through a multidisciplinary approach.

Cecal volvulus with acute appendicitis in a 33-year-old male managed by manual detorsion, cecopexy, and appendectomy: A case report.

INTRODUCTION: A volvulus is a serious surgical emergency caused by torsion or hyper-flexion of the bowel loop and its mesentery on a fixed point. Cecal volvulus is an uncommon cause of intestinal obstruction, accounting for just 1-1.5 % of all cases of bowel obstruction. CASE PRESENTATION: A 33-year-old intellectually disabled male presented to the emergency department with complaints of generalized abdominal pain, absolute constipation, and non-projectile vomiting. He had a grossly distended and rigid abdomen with generalized tenderness and guarding. The abdomen was hyper-resonant. Bowel sounds were hypoactive. Digital rectal examination revealed an empty and collapsed rectum with no stool staining of the finger. Laboratory reports showed leukocytosis and neutrophilia. Radiographic imaging was consistent with acute intestinal obstruction. Laparotomy was performed, and cecal volvulus with viable bowel and acute appendicitis was diagnosed intra-operatively. Manual detorsion, cecopexy, and appendectomy were performed. The patient had an uneventful postoperative course. The patient is still on follow-up since June 2023, and no complication has occurred. CLINICAL DISCUSSION: Cecal volvulus is an uncommon cause of intestinal obstruction with multiple etiologies. The annual incidence of cecal volvulus is estimated to be between 2.8 and 7.1 cases per million. Cecal volvulus may lead to life-threatening complications such as bowel ischemia and perforation. CONCLUSION: Diagnosis of cecal volvulus must be made promptly to prevent bowel gangrene and perforation. In this case, manual detorsion and cecopexy were performed as the bowel was viable per-operatively due to early surgical intervention.

Does sentinel lymph node biopsy for screening high-grade ductal carcinoma in situ of the breast cause more harm than good?

PURPOSE: Ductal carcinoma in situ (DCIS) of the breast does not metastasize to axillary lymph nodes. Yet high-grade DCIS (HgDCIS) is often subjected to Sentinel Lymph Node Biopsy (SLNB) concomitant with definitive surgery. This is to avoid further axillary surgery in the event of upstaging to invasive carcinoma, which often entails Axillary Lymph Node Dissection (ALND). We wished to examine the validity of this approach. METHODS: This study includes a retrospective analysis of consecutive pre-operatively diagnosed HgDCIS patients from a single screening unit between December/2014 and August/2016. The main outcomes were the overall incidence of upstaging and the independent predictors of upstaging on multivariable analysis. The rates of various complications of SLNB vs ALND in four RCTs were used to calculate the upstaging rate below which SLNB could be safely omitted. RESULTS: There were 224 eligible patients of whom 26 (11.6%) were upstaged. Axillary metastasis (pN1) occurred in two patients (0.9%). On Univariable analysis, upstaged patients were significantly younger (median (IQR) = 56.0 (51.0-63) vs 60.0 (54.0-65.0); p = 0.019). Radiological size, pathological size, type of biopsy, type of operation, and comedo-necrosis were not significant (p > 0.05). On multivariable analysis, age as a continuous variable (OR 0.93; p = 0.031) and core biopsy (OR 2.62; p = 0.036) were the only independent predictors of upstaging. Chi-square test showed that patients < 55 years whose pre-operative diagnosis was made on core biopsy were at significantly higher risk of upstaging than the others (31.8% vs 9.4%; p = 0.002). CONCLUSION: Upstaging of HgDCIS is infrequent. According to the known rates of complications of SLNB relative to ALND, routine SLNB concomitant with surgery seems to be more harmful than its routine omission. A selective approach based on age and type of biopsy could be considered.

Effect of Flap Fixation Technique in Modified Radical Mastectomy on Incidence of Postoperative Seroma Formation.

OBJECTIVE: To determine the efficacy of flap fixation technique on formation of postoperative seroma after modified radical mastectomy. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: General Surgery Department, PIMS Hospital, Islamabad, from August 2014 to February 2015. METHODOLOGY: This study included 70 female patients, aged 16 to 70 years, undergoing modified radical mastectomy, randomly divided into two groups of 35 each, Group A (flap fixation) and Group B (non-flap fixation). Flap fixation was done by suturing flaps by absorbable, fine suture to underlying pectoralis fascia to obliterate the dead space. Two closed suction drains were used in both groups. Patients were discharged on the second postoperative day. Patients and their attendants were thoroughly educated about record of drain output. Patients followed in OPD after one week. Drains were removed when fluid output was less than 50 ml/day. After removal of drains, patient were again called for weekly follow-ups in surgical OPD. Formation of seroma was diagnosed clinically as collection of fluid under the mastectomy flaps and axilla seen as fluctuant, non-tender swelling. Data was collected on proforma designed for the study and analysed by SPSS version 20.0. RESULTS: Flap fixation group had 2 (5.7%) cases of seroma formation while control group had 3 (8.6%) cases of seroma formation. The difference between both groups statistically was insignificant (p=0.643). CONCLUSION: Flap fixation technique has no statistically significant effect on reducing frequency of seroma formation in patients undergoing modified radical mastectomy.

Peritoneal encapsulation presenting as small bowel obstruction in a 16 year old girl.

Peritoneal encapsulation is a rare congenital anomaly characterized by a thin membrane of peritoneum encasing the small bowel to form an accessory peritoneal sac. Cases usually present with small bowel obstruction or can be an incidental finding during laparotomy. We report a case of peritoneal encapsulation presenting as a small bowel obstruction in a 16 year old girl. The sac was easily excised and surgery was otherwise uneventful. A discussion of the case and review of literature is presented.