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.

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.