Clinical Presentation and Management of Severe Bilateral Duct Ectasia: A Case Report Mammary duct ectasia is frequently asymptomatic and found incidentally during routine screening but its presentation is varied. In this case report, we highlight a case of bilateral duct ectasia with extensive inflammatory changes in a parous, obese and diabetic middle aged woman. Her condition had been recurrent over several years, despite multiple courses of antibiotics and was increasing in severity. It was successfully treated with bilateral total ductal excision.

The Rotated Bipedicled Tram Flap: Maximising Breast Projection but Minimising Donor Morbidity - A Case Report Autologous breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap remains a cornerstone of breast reconstructive surgery. However, with the classical TRAM flap, it is challenging to close a large post mastectomy defect in nulliparous and/or slim women. The resultant reconstructed breast also lacks projection. This case reported a novel modified TRAM flap technique performed in a nullipara. She had previously undergone a hysterectomy and oophorectomy for endometrial carcinoma via a pfannenstiel incision. She presented with a large left breast invasive micropapillary carcinoma (ER/PR negative HER2 3+) with only marginal response to neoadjuvant chemotherapy. She underwent a left mastectomy with axillary dissection and immediate breast reconstruction. The rotated bipedicled TRAM Flap was used to close the large defect, maximising breast projection while minimising donor site morbidity.

The Submammary-Evert (Sub-E) Technique for Excision of Benign Breast Lumps in Underdeveloped and Developing Countries - A Case Series The Submammary-Evert (Sub-E) technique is a novel technique for the excision of one or multiple benign breast lumps. It may be performed by surgical trainees and general surgeons. It is best suited for deep seated, medium to large breast lumps. It enables the lump or lumps to be excised through one hidden inframammary scar. As the approach is through the avascular submammary plane, blood loss is minimised. Unlike the endoscopic or percutaneous vacuum assisted biopsy, this procedure is easy to learn with no additional instruments required; thus minimising cost. This makes it feasible to be performed in underdeveloped and developing countries. We describe a series of ten women (age 18-35 years old) with one or multiple breast lumps (1-5 breast lumps) who underwent this procedure. The size of the lumps measured 1-13 cm. All lumps measuring a minimum of 3 cm were located at the upper half or retroareolar region. The duration of surgery for excision of a lump was 50-100 minutes. The surgery to remove 5 lumps took the longest time of 125 minutes. There were no intra or post-operative complications.

Hypercalcaemic Paraneoplastic Syndrome in a Young Woman with Malignant Phyllodes of the Breast: A Case Report Paraneoplastic syndromes, though uncommon, present systemic effects secondary to primary malignancies or metastases. We presented a case of a 25-year-old nullipara with a left breast malignant phyllodes. Pre-operative investigations revealed hypercalcaemia. Her staging computed tomography scan did not demonstrate any enlarged parathyroid gland. Her serum intact parathyroid hormone level was not raised. After correction with saline hydration, she underwent a left mastectomy, axillary dissection and a supercharged bipedicle TRAM flap. The following day, due to flap congestion, she underwent flap exploration but unfortunately, the flap necrosed. She required temporary coverage with a split-skin graft to allow her post operative sepsis to resolve. She underwent a delayed extended latissimus dorsi myocutaneous pedicled flap for chest wall closure. The cause of hypercalcemia was attributed to be a paraneoplastic syndrome which has not been reported previously in a malignant phyllodes tumor. The hypercalcaemia is postulated to have caused the thrombosis leading to flap failure

Dual Pathology Breast Carcinoma: A Report of Two Cases Dual pathology breast carcinoma, whether unifocal, multifocal or multicentric may significantly impact patient prognosis. Certain histological combinations are associated with favourable outcomes, while others may indicate a more aggressive disease. We presented a report of two women with different pathological combinations. The first case had multicentric cancers of the left breast. She underwent neoadjuvant chemotherapy, then nipple-sparing mastectomy with axillary dissection and immediate transverse rectus abdominis myocutaneous (TRAM) breast reconstruction. Histopathological assessment revealed a combination of metaplastic carcinoma and invasive micropapillary carcinoma; both aggressive subtypes. Post adjuvant radiotherapy, she remained disease-free for five years. The second case had a unifocal right breast cancer managed with breast-conserving surgery and sentinel lymph node biopsy. Histopathology revealed a combination of invasive carcinoma of no special type (NST) and invasive papillary carcinoma. These subtypes are associated with a more favourable prognosis. Post radiotherapy and on endocrine therapy, this patient remains well at 2 years follow-up. These cases demonstrate the prognostic variability in dual histopathology breast cancers and highlights the importance of individualised treatment. Both patients remain disease free despite having dual pathology breast carcinoma which seem to suggest a more aggressive disease behaviour.

Prior to COVID-19, dengue was an important public health problem in Malaysia. Due to the movement control order imposed by the Malaysian government to curb the COVID-19 transmission, a study predicted that mosquito-borne diseases would increase during lockdown and partial lockdown seasons. Thus, this study aims to determine the current situation of dengue incidence during the pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020 and 2021). We compared the number of laboratory-confirmed cases in the pre-COVID19 year (2019) and during the COVID-19 pandemic (2020 and 2021). In addition to that, we characterized the clinical manifestation, dengue serotype and viremia levels of dengue patients that were admitted to the Hospital Cancelor Tuanku Muhriz. We found a significant decrease in the number of laboratory-confirmed cases between COVID-19 pandemic and the pre-covid period (p2020=0.064; p2021<0.001). In this study, we found DENV 4 serotype was the most common serotype in dengue patients admitted to our hospital. There was no significant correlation between DENV serotype/viremia level with clinical manifestation of dengue fever and dengue with warning signs. However, patients infected with DENV4 had the highest viral load compared to patients infected with other serotypes. We also found high viremia levels were significantly associated with the febrile phase.

Breast Conserving Surgery Post Neo-Adjuvant Chemotherapy for Locally Advanced Breast Carcinoma in a Developing Country: Is It Safe? Breast conserving surgery (BCS) is the standard treatment for early breast cancer and has similar survival with mastectomy. The role of BCS in locally advanced breast cancer (LABC), post neoadjuvant chemotherapy (NACT), is controversial. Surgeons, especially in developing countries, fear higher margin involvement and local recurrence (LR) in BCS. The aim of this study was to determine the LR in BCS compared to mastectomy in LABC post NACT and to ascertain the percentage of involved surgical margins following both methods of surgery. This was a retrospective study of breast cancer patients seen in Universiti Kebangsaan Malaysia Medical Centre (UKMMC). All patients had NACT followed by either mastectomy or BCS. The patients with Her2 enriched carcinomas did not have access to targeted therapy (Trastuzumab or Pertuzumab). The patients with ill-defined tumours underwent ultrasound assessment in the surgical clinics. All had post-operative radiotherapy. All with ER or PR positive cancers were given Tamoxifen for a minimum of 5 years. This study demonstrated that BCS post NACT was safe to be performed in selected patients with LABC in a developing country.

Introduction: Infant hepatitis B vaccination was introduced into the Expanded Programme on Immunisation (EPI) in Malaysia in 1989. This study aimed to investigate seroprevalence of hepatitis B among UKM pre-clinical medical students, born between 1991 and 1995, and had their infant vaccination more than 20 years ago. Materials and Methods: A prospective, cross-sectional study involving 352 students, comprising 109 (31.0%) males and 243 (69.0%) females. Blood specimens were tested for anti-HBs, where levels of ≥10 mIU/mL was considered reactive and protective. Students with non-reactive levels were given a 20 µg HBV vaccine booster. Anti-HBs levels were tested six weeks after the first booster dose. Those with anti-HBs <10 mIU/mL were then given another two booster doses, at least one month apart. Anti-HBs levels were tested six weeks after the third dose. Results: Ninety-seven students (27.6%) had anti-HBs ranging from 10 to >1000 mIU/ mL while 255 (72.4%) had anti-HBs <10 mIU/mL. After one booster dose, 208 (59.1%) mounted anti-HBs ≥10 mIU/mL. Among the remaining 47 (13.3%), all except two students (0.6%) responded following completion of three vaccination doses. They were negative for HBsAg and anti-HBcore antibody, thus regarded as non-responders. Conclusions: Anti-HBs levels waned after 20 years post-vaccination, where more than 70% were within non-reactive levels. For healthcare workers, a booster dose followed by documenting anti-HBs levels of ≥10 mIU/mL may be recommended, to guide the management of post-exposure prophylaxis. Pre-booster anti-HBs testing may not be indicated. Serological surveillance is important in long-term assessment of HBV vaccination programs. No HBV carrier was detected.
serological surveillance ; healthcare workers

Aim: This study aimed to determine findings of axillary view mammogram (MMG) and ultrasound (USG) of the ipsilateral side in post-mastectomy patients and to document difficulty level in performing the axillary view and patients’ pain level during the procedure. Methods: Post-mastectomy patients who had MMG and USG on follow-up during an 18-months period were included. The MMG and USG findings of 183 patients were reviewed and histology results were recorded when available. Radiographers’ difficulty and patients’ pain level during the axillary view MMG were charted. Results: On MMG, 172 cases were normal, eight cases were benign (Category 2) and three cases indeterminate (Category 3). On USG, 175 cases were normal, three cases were benign (Category 2) and five cases indeterminate (Category 3). Malignant lesions detected in two out of 183 patients (1%) were metastatic carcinoma in bilateral axillary lymph nodes and leiomyosarcoma at the mastectomy site. These two cases were Category 3 on USG with negative MMG findings. In majority of cases (79%), the radiographer had no difficulty performing the axillary view compared with contralateral MMG. Majority of patients (80%) experienced similar pain during axillary view compared to contralateral MMG. Conclusion: Follow-up imaging of post-mastectomy patients should include (i) USG of the mastectomy site, both axillary regions, and the contralateral breast, and (ii) MMG of the contralateral side. Ipsilateral axillary view MMG is not necessary.

Aim: This study was performed to: (i) determine the association of breast cancer with dense breasts, and (ii) determine the breast cancer association with early onset of menarche, nulliparity, late age at first childbirth, not breast-feeding, and family history of breast cancer. Methods: This was a retrospective hospital-based case-control study. The 231 cases were women diagnosed with breast cancer on histology during the study period from July 1998 to April 2005. The 231 controls were age-matched and randomly selected women who did not have breast cancer but had mammography performed during the same time interval. Tabar classification was used to classify the mammographic parenchymal pattern of the 462 samples. The same radiologist analysed the parenchymal pattern based on the craniocaudal and mediolateral oblique views. Statistical analysis was done using the SPSS package. Results: Majority of women with breast cancer (55%) had dense breasts (29% Type IB, 19% Type IC, 4% Type IV, 3% Type V). Majority of controls (58%) had dense breasts (22% Type IB, 26% Type IC, 6% Type IV, 4% Type V). The majority of women with breast cancer had menarche at 12 years or older (93%), were parous (89%), had the first childbirth before 35 years old (91%), had breast-fed (67%), and did not have family history of breast cancer (84%). For controls, the majority had menarche at 12 years or older (88%) were parous (87%), had the first childbirth before 35 years old (98%), had breast-fed (66%), and did not have family history of breast cancer (85%). All factors explored, including breast density, were not significantly associated with breast cancer. The odds ratio for breast cancer among those with dense breast compared to those with non-dense breast is 0.8 (95% CI=0.6, 1.2). Conclusion: This study found no association between breast cancer and dense breasts (p=0.398). There was also no association between breast cancer with early onset of menarche (p=0.174), nulliparity (p=0.448), older age at first childbirth (p=0.065), not breast-feeding (p=0.716) and family history of breast cancer (p=0.665).