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.

Johari et al Brunei International Medical Journal 2025;21:133-136 Brunei International Medical Journal Life Threatening Diverticular Bleeding in an Elderly: Not Always from Colonic Diverticula Nur Farehah JOHARI1,2, Andee Dzulkarnaen ZAKARIA1,2, Rosnelifaizur RAMELY1,2, Firdaus HAYATI3*

Traumatic gallbladder perforation is an unusual but potentially life-threatening injury that can occur following blunt or penetrating abdominal trauma. A 46-year-old male presented to the emergency department following a motor vehicle accident (MVA). He complained of severe abdominal pain and sustained ecchymosis with localized tenderness over the right upper quadrant. Despite a positive focused assessment with sonography in trauma scan, initial computed tomography of the abdomen revealed grade 1 liver and splenic injury but was unable to identify gallbladder perforation. He was initially managed conservatively until he developed secondary signs of sepsis after 24 hours. An exploratory laparotomy revealed a perforated gallbladder. A subtotal cholecystectomy was done. A retrospective review revealed a missed gallbladder perforation from an earlier CT scan assessment. We report a case of missed gallbladder perforation following MVA which was only diagnosed intraoperatively after failing non-operative management, following which the patient underwent laparotomy and subtotal cholecystectomy.

Higher education institutions face major challenges in managing the impact of the COVID-19 pandemic. The risk of exposure from the community poses a threat to campus staff and students. This study describes epidemiological characteristics of suspected COVID-19 cases among a public university’s students and staff. This is a retrospective review on data collected from the institute’s COVID-19 Preparedness and Respond Centre, located at the main campus in Kota Kinabalu, the capital city of Sabah from mid-January to April 2020. Incidence rate was calculated, and epidemiological information retrieved from interviews and relevant documents. The majority of suspected COVID-19 cases were staff (57.1%) with incidence rates higher among males (IR=40.2/1,000 population) and those working in the frontline (IR=39.6/1,000 population). Suspected COVID-19 cases were mostly related to occupation (37.3%) and social contacts (27.3%). Student cases were largely related to household (38.1%) and during travel (33.3%). One positive COVID-19 case was reported of out of the 161 suspected cases (0.6%) in the institution. An operational team must be set up to conduct situational analysis and integrate management with other departments. Suspected COVID-19 cases must be quarantined and monitored on a daily basis. A high index of suspicion and effective containment of suspected cases will prevent spread of the virus among students and staff.

Wandering spleen is renowned as a surgical enigma due to its diverse presentations. Due to lack of its attaching ligaments which would usually place it at the left hypochondrium region, the spleen ‘wanders’ and may be located anywhere within the abdominal cavity. This condition has been associated with many complications such as splenic torsion, pancreatitis and portal hypertension. We report a case of a wandering spleen presenting as acute appendicitis in an 18-year-old young active sportsman. The patient developed post-operative ileus and later intestinal obstruction which necessitated exploratory laparatomy onto which the final diagnosis of splenic and small bowel infarct due to splenic torsion with small bowel volvulus was made. Splenectomy, small bowel resection and primary anastomosis were performed and the patient made a full recovery.

Necrotizing fasciitis (NF) is a deadly soft tissue infection causing a significant morbidity and mortality. Abdominal and chest wall NF are unusual. We describe a 49-year-old male with anterior abdominal wall NF secondary to perforated gastric ulcer (PGU). He was admitted in septic shock presenting an abdominal wall NF with severe metabolic acidosis requiring dialysis and admission to the intensive care unit. There was a patch of gangrene with surrounding skin discoloration at lower quadrant of the abdominal wall. Local debridement was done without a preoperative computed tomography that was performed after surgery. Adequate source control was not achieved after the second surgery and the patient had worsened resulting to death. We describe this rare presentation of NF and discuss the issues learnt from this unfortunate event.

Penetrating injury to the abdominal viscera is not uncommon unless when it is caused by marine life. We present a 39-year-old fisherman from a tropical country who had sustained a penetrating injury from a stab wound to the abdomen due to needlefish impalement. He sustained a small perforation of the sigmoid colon during exploratory laparotomy and primary repair was done. Although this incident is rare, there are cases involving seawater activities either for leisure, sport or diving for fishing. We highlight this rare incident and discuss the management plan.

Colorectal cancer is ranked as the most common cancer for men and the second most common cancer for women according to the Malaysian National Cancer Registry Report (MNCR) 2007-2011. However, delay in the diagnosis of colorectal cancer is still common partly attributable due to late presentation and incorrect diagnosis by the general practitioners. The aim of this study is to determine the relationship between presenting symptoms of colorectal cancer to the location of the tumour in order to prevent delay in diagnosis of colorectal cancer. Between 1996 until 2009, a total of 212 patient data from Hospital Universiti Sains Malaysia were retrospectively analyzed. The demographic and surgical data were obtained. We studied the relationship of the presenting symptoms of colorectal cancer to the location of the tumour. The age of candidate included in this study range from 16 to 93 years old with mean age was 56 and male predominance. In this study, there is a strong relationship between presenting symptoms and the location of the colorectal cancer but no significant relationship between age and sex to the anatomical location of the tumour. The study showed the presenting symptoms of rectal bleeding, change in bowel habit and tenesmus were significantly associated with rectal tumor, intestinal obstruction with left sided tumors and anemia and abdominal mass with right sided tumors (p-value <0.05). However abdominal pain does not follow this role as it is mostly associated with other presenting symptoms and it has no significant relation to the anatomical location of the tumor.