Adil Aljarrah

Idiopathic Granulomatous Mastitis: Diagnostic strategy and therapeutic implications in Omani patients

OBJECTIVES Idiopathic granulomatous mastitis (IGM) is a rare benign disorder of the breast whose aetiology is controversial, and is often misdiagnosed clinically and radiologically as mammary malignancy; as a result, it may be incorrectly treated. Although no standard treatment is available for this chronic disease, surgery with or without corticosteroids has been tried with controversial results. This study discusses the clinical presentation, diagnosis, management, recurrence, and follow-up data of IGM with a review of relevant literature. METHODS From 2009-2012, the Breast Unit at Sultan Qaboos University Hospital, Oman, conducted a clinical study on 20 patients with breast lumps. Their clinical and radiological examinations were indeterminate, and a diagnosis of granulomatous mastitis was established only by histopathology. RESULTS The majority of the patients were cases of unknown aetiology, who presented with a unilateral breast mass. A few patients had a mass with an abscess, along with axillary lymphadenopathy. A total of 4 patients were suspected of malignancy using radiology. In all patients, sterilised pus was sent for culture and sensitivity. Microscopy showed the characteristic pattern of granulomatous inflammation. All patients were treated with antibiotics for 6 weeks, and the mean follow-up period was 15 months (11-33 months). All patients had complete remission with no further recurrence. CONCLUSION This single largest study of cases of IGM in Oman highlights the pitfalls in diagnosing this non-neoplastic disease of unknown aetiology and uncertain pathogenesis. It emphasises IGMs excellent response to antibiotics, which is crucial, as IGM is a disease which is notoriously difficult and controversial to treat.

Trends in the distribution of breast cancer over time in the southeast of Scotland and review of the literature

Introduction Breast cancer is the most common form of malignancy in Scottish women, and its incidence appears to be increasing with time. It is therefore important to identify factors associated with risk and outcome. Whilst breast cancer occurs equally in the right and left breasts, tumours most commonly affect the upper outer quadrant (UOQ) of the breast. However, there is only limited information as to whether the incidence has changed over time. Materials and patients We investigated two cohorts of women diagnosed with breast cancer in the south-east of Scotland between either 1957–1959 or 1997–1999 (i.e., 40 years apart). The earlier cohorts represent 1158 of 1207 women referred to radiation oncologists in the region and the latter group comprised 1477 of about 1600 women referred to the Edinburgh Breast Unit. Results Whilst the mean age, menopausal status, and laterality of the patients were similar in both groups, the tumour size and tumour location within the breast were significantly different in the two groups. Thus, there was significant reduction in T stage with year of diagnosis (p < 0.0001), the incidence of T1, T2, and T3/4 being 15.6%, 51.9%, and 25.6% in the earlier cohort compared with 49.3%, 36.8%, and 13.7% in the later cohort. The overall distribution within the breast was significantly different by chi-squared analysis ( p < 0.0001). In terms of individual quadrants 469 of 1158 (40.5%) tumours were located in the UOQ, whereas in the more recent cohort it was 788 of 1477 (53.4%), this increase in proportion being statistically significant ( p < 0.0001). Occurrence in the lower outer quadrant also significantly increased (p < 0.028) but was significantly reduced in the upper inner quadrant and centrally (both p < 0.0001). Conclusion Analysing data on location for each T stage separately showed that the increased incidence in the UOQ with time was apparent for each subgroup. The increased incidence in UOQ tumours over time is therefore not a simple reflection of decreased size between the two time groups. The underlying reason(s) for this change in distribution with time requires further study.

A case report on radiation-induced angiosarcoma of breast post skin-sparing mastectomy and reconstruction with transverse rectus abdominal muscle

Radiation-induced angiosarcomas (RIA) are rare tumours that can affect breast cancer patients following treatment with breast conservative surgery and radiotherapy. Their diagnosis is often delayed because of their benign appearance and the difficulty in differentiation from radiation-induced skin changes. We report here a case of RIA which occurred seven years after radiotherapy to highlight awareness of the disease and the role of careful histological evaluation of these tumours.

Mucinous Breast Cancer with Solitary Metastasis to Humeral Head: A Case Report

Breast cancer is the most common cause of metastatic deposits in the skeleton, and bone is the most common site of recurrence of breast cancer. Breast cancer metastasis most commonly affects the spine, ribs, pelvis, and proximal long bones; however, only 3.5% of breast cancer patients develop long-bone metastases. The humerus is the most common upper-extremity site for bony metastasis, and pathologic fractures can result. The patient in the current study presented with breast cancer and discovered to have humeral head metastasis during initial workup. The dilemma was in investigation the modality to confirm humeral head metastasis as there are many differential diagnoses with similar findings. After staging workup, the patient was treated with neoadjuvant chemotherapy followed by modified radical mastectomy and radiotherapy of the chest wall and the shoulder. The lesion in humerus was well healed.

Diagnostic dilemmas in Intraductal papillomas of the breast - Experience at Sultan Qaboos University Hospital in the Sultanate of Oman

Objectives: The aim of this retrospective study was to correlate the significance and accuracy of the colour of nipple discharge and breast ultrasound imaging in the diagnosis of intraductal papilloma. Methods: This is a retrospective study of 34 patients who underwent 36 microdochectomies in Sultan Qaboos University Hospital (SQUH) in the Sultanate of Oman, over a 4 year period of January 2009 till December 2012. The confounders considered were patient age, physical examination findings, nipple discharge cytology result, ultrasound results and biopsy report following microdochectomy. Comparisons analysis, charts and graphs were made using the SPSS software (version 20). Results: The mean age of the patients was 44(27-73) years old. Twenty-seven out 36 (75%) patients had presented with nipple discharge, 14 out 27 (52%) had blood stained nipple discharge and 13(48%) with coloured discharge (yellow, brown and green), 9 patients had no discharge. The final histopathology showed intraductal papilloma 13 (36%), duct ectasia 18(50%), DCIS 1 (2.7%), fibrocystic disease 3(8.3%) and LCIS 1(2.7%). Thirteen out of 36 had intraductal papilloma on final histopathology. The correlation between blood stained discharge and final histopathology of intraductal papilloma was insignificant (p=0.44). Conclusion: Nipple discharge is irrelevant to the diagnosis of intraductal papilloma. Spontaneous nipple discharge regardless of color is to be referred to breast surgeon and to be assessed with triple assessment. Surgery remains the mainstay of treatment.

Metastatic Invasive Lobular Carcinoma of the Breast Masquerading as a Primary Renal Malignancy = ورم الكلية قد يكون مؤشرا لإنتشار سرطان الثدي الحويصلي

Breast cancer is known to metastasise to different organs in the body, but an initial presentation of breast cancer with loin pain secondary to a metastatic renal mass is extremely rare. We report a 58-year-old woman who presented with recurrent left loin pain due to a metastatic deposit of invasive lobular carcinoma of the breast. The detection of a renal mass on computed tomography led to the assumption of a renal pelvic malignancy. The diagnostic dilemma posed by the detection of a breast mass during staging and the usefulness of immunohistochemistry in the confirmation of diagnosis are discussed.