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.

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.

Purpose: Triple-negative breast cancer (TNBC) is a subtype of breast cancer known for its poor prognosis and the absence of viable targets for standard receptor-based therapies.Several studies have suggested that targeting programmed death-ligand 1 (PD-L1) in tumors that express this biomarker, either on tumor cells and/or in the tumor inflammatory infiltrate, may be beneficial in some patients. This study aimed to assess the overall prevalence of PD-L1 positivity using the SP142 antibody clone in patients with advanced TNBC in Malaysia. Methods: This was a multicenter, cross-sectional prevalence study on PD-L1 positivity among patients with advanced-stage TNBC in Malaysia. Patients were identified using medical records and were enrolled in the study if they met the inclusion criteria. PD-L1 evaluation was performed using archived formalin-fixed paraffin-embedded tissue specimens. Demographic and clinical data were also obtained and summarized using descriptive statistics. The association of these parameters with PD-L1 positivity was assessed using chi-square and logistic regression analysis. Results: Three medical centers provided 138 complete cases for analysis. Of these 138 cases, 52 (37.7%; 95% confidence interval, 29.6%–46.3%) showed positive PD-L1 expression, defined as immune cell PD-L1 expression ≥ 1%. In a univariate analysis, stage III of the disease and tumor samples from resected specimens were significantly associated with a positive PD-L1 status. However, further assessment using a multivariate model revealed that only resected tumor samples remained significantly associated with PD-L1 positivity after controlling for disease staging. Conclusion The prevalence of PD-L1 positivity among patients with stage III or IV TNBC was 37.7%. A significant association was noted between PD-L1 positivity and the tumor tissue obtained from resected specimens. Although the mechanism and clinical significance of this association remain unclear, this finding indicates a possible disparity in the PD-L1 status of samples obtained using surgical resection or biopsy.

Purpose: Triple-negative breast cancer (TNBC) is a subtype of breast cancer known for its poor prognosis and the absence of viable targets for standard receptor-based therapies.Several studies have suggested that targeting programmed death-ligand 1 (PD-L1) in tumors that express this biomarker, either on tumor cells and/or in the tumor inflammatory infiltrate, may be beneficial in some patients. This study aimed to assess the overall prevalence of PD-L1 positivity using the SP142 antibody clone in patients with advanced TNBC in Malaysia. Methods: This was a multicenter, cross-sectional prevalence study on PD-L1 positivity among patients with advanced-stage TNBC in Malaysia. Patients were identified using medical records and were enrolled in the study if they met the inclusion criteria. PD-L1 evaluation was performed using archived formalin-fixed paraffin-embedded tissue specimens. Demographic and clinical data were also obtained and summarized using descriptive statistics. The association of these parameters with PD-L1 positivity was assessed using chi-square and logistic regression analysis. Results: Three medical centers provided 138 complete cases for analysis. Of these 138 cases, 52 (37.7%; 95% confidence interval, 29.6%–46.3%) showed positive PD-L1 expression, defined as immune cell PD-L1 expression ≥ 1%. In a univariate analysis, stage III of the disease and tumor samples from resected specimens were significantly associated with a positive PD-L1 status. However, further assessment using a multivariate model revealed that only resected tumor samples remained significantly associated with PD-L1 positivity after controlling for disease staging. Conclusion The prevalence of PD-L1 positivity among patients with stage III or IV TNBC was 37.7%. A significant association was noted between PD-L1 positivity and the tumor tissue obtained from resected specimens. Although the mechanism and clinical significance of this association remain unclear, this finding indicates a possible disparity in the PD-L1 status of samples obtained using surgical resection or biopsy.

Purpose: Triple-negative breast cancer (TNBC) is a subtype of breast cancer known for its poor prognosis and the absence of viable targets for standard receptor-based therapies.Several studies have suggested that targeting programmed death-ligand 1 (PD-L1) in tumors that express this biomarker, either on tumor cells and/or in the tumor inflammatory infiltrate, may be beneficial in some patients. This study aimed to assess the overall prevalence of PD-L1 positivity using the SP142 antibody clone in patients with advanced TNBC in Malaysia. Methods: This was a multicenter, cross-sectional prevalence study on PD-L1 positivity among patients with advanced-stage TNBC in Malaysia. Patients were identified using medical records and were enrolled in the study if they met the inclusion criteria. PD-L1 evaluation was performed using archived formalin-fixed paraffin-embedded tissue specimens. Demographic and clinical data were also obtained and summarized using descriptive statistics. The association of these parameters with PD-L1 positivity was assessed using chi-square and logistic regression analysis. Results: Three medical centers provided 138 complete cases for analysis. Of these 138 cases, 52 (37.7%; 95% confidence interval, 29.6%–46.3%) showed positive PD-L1 expression, defined as immune cell PD-L1 expression ≥ 1%. In a univariate analysis, stage III of the disease and tumor samples from resected specimens were significantly associated with a positive PD-L1 status. However, further assessment using a multivariate model revealed that only resected tumor samples remained significantly associated with PD-L1 positivity after controlling for disease staging. Conclusion The prevalence of PD-L1 positivity among patients with stage III or IV TNBC was 37.7%. A significant association was noted between PD-L1 positivity and the tumor tissue obtained from resected specimens. Although the mechanism and clinical significance of this association remain unclear, this finding indicates a possible disparity in the PD-L1 status of samples obtained using surgical resection or biopsy.

Introduction: Evaluation of HER2 status in breast cancer using immunohistochemistry (IHC) and in-situ-hybridisation (ISH) study is important to establish prognosis and to select patient for targeted therapy. Objective: The study aims to determine the concordance between HER2 protein IHC score and its gene status by dual-colour dual-hapten in-situ-hybridization (DDISH) study. Materials and Methods: Retrospective study was performed on 767 referred breast cancer cases over a period of five years. The HER2 IHC score (the initial and repeat test score) and the results of HER2 gene status by DDISH were retrieved from the histopathological reports. The agreement between initial IHC score with repeat test score was measured using Cohen Kappa. Chi square test analyzed the association between HER2 IHC score with its gene status by DDISH. Results: The concordance of HER2 IHC score between the initial and repeat test were 52.7% and 89.4% for IHC score 2+ and 3+ respectively. There was moderate agreement of HER2 IHC score between the initial and repeat test score (κ = 0.526, p<0.001). A significant association noted between HER2 IHC score with its gene status by DDISH (p<0.001). Only 56 out of 207 cases (27.1%) with 2+ IHC score showed HER2 gene amplification while the majority of cases with 3+ IHC score were gene-amplified (446 out of 451, 98.9%). Conclusion: ISH study should be done in all IHC-equivocal cases (2+) to select patient for targeted therapy. Gene amplification must also be confirmed in IHC-positive cases (3+) to prevent from giving non-effective treatment with possible adverse effects to patient with nonamplified HER2 gene.
breast cancer

Solitary fibrous tumours of the head and neck region are extremely rare. The clinical diagnosis is often difficult to establish, and this lesion may be indistinguishable from other soft tissue neoplasms. An 18-year old Chinese gentleman presented with a painless right submandibular swelling which was increasing in size for eight months. A computed tomography scan showed a well-defined solid mass measuring about 2.0 x 2.96 cm in the submandibular region. The tumour was resected and was confined within its capsule. Immunohistochemical staining was strongly positive for CD34, CD 99, and vimentin and negative for desmin, smooth muscle actin (SMA), cytokeratin, S100 and CD68. The microscopic and immunohistochemical profile were compatible with solitary fibrous tumour. Distinguishing solitary fibrous tumours from various spindle neoplasms can be difficult. In view of the resemblance, immunohistochemical staining can help differentiate solitary fibrous tumour from spindle neoplasm.
Neoplasms, Tumors, Cancer

Hydatid cysts are not endemic in Malaysia and are rarely seen. We hereby report a case of hydatid cyst of the liver in a 55-year-old Chinese-Australian lady who presented with a calcified liver cyst and negative hydatid serology. A liver segmentectomy was performed and revealed a well-circumscribed, calcified liver cyst containing only creamy whitish material without the typical daughter cyst. A histological examination revealed different layers of the cyst wall and the presence of loose, calcified scolices without a daughter cyst. The case highlights the importance of considering hydatid cyst in the differential diagnosis of liver cyst even in non-endemic areas, as the ease of travelling and migration allows the condition to be seen outside the endemic region.

Objective: The aim of this study was to compare the use of semi-automated (Medax Velox 2; Poggio Rusco, Italy) and automated (Bard Magnum Biopsy Instrument; Covington, GA, USA) core biopsy needles, for ultrasound guided breast biopsy. Materials and Methods: A 14G semi-automatic spring loaded core biopsy needle with a 22-mm-throw (Medax Velox 2; Poggio Rusco, Italy) and 14-gauge automated needle device with a 22-mm-throw biopsy gun (Bard-Magnum Biopsy Instrument, Covington, GA, USA) were used for breast biopsies under ultrasound guidance on alternate months during the study period between July 2009 and May 2011. One hundred and sixty lesions were biopsied and specimens were sent for histological evaluation. Results: The automated needle obtained a higher number of histology reports at 84% (67/80) as compared with the semiautomated needle at 60% (48/80) (Fisher exact test, p value=0.023). Inadequate samples with the automated needle were much less at 9% (7/60) than with the semiautomated needle at 23% (18/60) (Fisher exact test, p value=0.028). The semi-automated needle showed slightly less fragmented samples. However, the number of fragmented samples with definitive diagnosis was slightly higher with the automated compared with the semiautomated needle, at 16% (13/80) and 13% (10/80) respectively. Compared with histology of 29 lesions that were excised, the semi-automated needle had higher sensitivity (100%) but lower specificity (75%) and accuracy (90%) compared with the automated needle (88% sensitivity, 100% specificity, 95% accuracy). Conclusion: Definitive diagnosis from the study samples slightly favours the use of automated core biopsy needle as compared to semi-automated core biopsy needle.

Sinonasal tract malignancies are usually slow growing tumours with non-specific unilateral symptoms (occasionally bilateral) normal to the site of origin. They comprise a wide spectrum of pathological features. We report the case of a low grade non-intestinal sinonasal adenocarcinoma (SNAC) in a 38-year-old man who presented with a-six month history of right sided nasal blockage that was associated with occasional purulent rhinorrhoea and a month history of epistaxis.