David Atallah

Bilateral ovary adrenal rest tumor in a congenital adrenal hyperplasia following adrenalectomy.

OBJECTIVEnIn contrast to the high incidence of testicular adrenal rest tumors in adult male patients with congenital adrenal hyperplasia (CAH), ovarian adrenal rest tumors (OARTs) in female CAH patients are rare. In this case report, we describe a case of bilateral OART in a female patient with CAH due to 21-hydroxylase deficiency.nnnMETHODSnWe present a detailed case report with the clinical, imaging, and laboratory findings of the patient. The pertinent literature is also reviewed.nnnRESULTSnA 17-year-old patient was known to have CAH due to 21-hydroxylase deficiency. Since the second month of her gestational age, her mother was treated with cortisone-replacement therapy. The patient was treated with hydrocortisone and fludrocortisone since the neonatal period. Her pertinent history included a bilateral adrenalectomy at the age of 13 years in 2006, and for 3 years she led a normal puberty life with no complaint with hormonal replacement therapy. Nevertheless, in 2009, she developed a virilizing syndrome. Subsequently, she underwent surgery in December 2009 for right adnexectomy. However, the regression of the masculinizing mass was not complete and worsened several months after the surgery. A new pelvic magnetic resonance image showed the activation of a contralateral ovarian mass, necessitating a left adnexectomy in August 2010.nnnCONCLUSIONnThis case demonstrates some interesting features of OART that pose challenges to its management. If an OART is detected early enough and glucocorticoid therapy is received, it is possible that the OART will decrease in size following suppression of adrenocorticotropic hormone levels.

Extraovarian cystadenomas: ultrasound and MR findings in 7 cases.

Objective: To describe the ultrasound and MR appearance of paraovarian cystadenomas. Methods: We reviewed retrospectively the radiologic findings in 7 patients with surgically proven paraovarian cystic neoplasms, including 6 serous cystadenomas and 1 borderline seromucinous cystadenoma. All had ultrasound and 4 had MR preoperatively. Results: On ultrasound, the ipsilateral ovary was visualized in six cases, in contact with the cyst in five and separate from it in one. On MR, the ovary and the cyst were visible in four cases, in contact in three and separate in one. Internal papillary excrescences, present at pathology in all cysts, were seen in five on ultrasound and in four on MR. Conclusion: Although the extraovarian location of these neoplasms is difficult to determine preoperatively by ultrasound and MR, these imaging modalities are more reliable in predicting the histology of these rare lesions and differentiating them from simple paraovarian cysts.

Mycobacterial infection of breast prosthesis – a conservative treatment: a case report

BackgroundBacterial infection is a well-known risk of breast implant surgery. It is typically caused by bacterial skin flora, specifically Staphylococcus aureus and the coagulase negative staphylococci. There have been infrequent reports of breast implant infection caused by the atypical mycobacteria, of which Mycobacterium canariasense not yet reported in the literature.Case presentationThis report summarizes the case of a female patient who underwent mastectomy followed by bilateral breast augmentation and presented approximately three years later with clinical evidence of infected breast prosthesis by Mycobacterium canariasense. One year after thoroughly follow-up, appropriate antibiotherapy and the change of the infected prosthesis, the patient presented no signs of reinfection.ConclusionOur case demonstrates that Mycobacterium canariasense should be considered as a new potential cause of infected breast prosthesis.

Next-generation sequencing in familial breast cancer patients from Lebanon

BackgroundFamilial breast cancer (BC) represents 5 to 10% of all BC cases. Mutations in two high susceptibility BRCA1 and BRCA2 genes explain 16–40% of familial BC, while other high, moderate and low susceptibility genes explain up to 20% more of BC families. The Lebanese reported prevalence of BRCA1 and BRCA2 deleterious mutations (5.6% and 12.5%) were lower than those reported in the literature.MethodsIn the presented study, 45 Lebanese patients with a reported family history of BC were tested using Whole Exome Sequencing (WES) technique followed by Sanger sequencing validation.ResultsNineteen pathogenic mutations were identified in this study. These 19 mutations were found in 13 different genes such as: ABCC12, APC, ATM, BRCA1, BRCA2, CDH1, ERCC6, MSH2, POLH, PRF1, SLX4, STK11 and TP53.ConclusionsIn this first application of WES on BC in Lebanon, we detected six BRCA1 and BRCA2 deleterious mutations in seven patients, with a total prevalence of 15.5%, a figure that is lower than those reported in the Western literature. The p.C44F mutation in the BRCA1 gene appeared twice in this study, suggesting a founder effect. Importantly, the overall mutation prevalence was equal to 40%, justifying the urgent need to deploy WES for the identification of genetic variants responsible for familial BC in the Lebanese population.

Characteristics of incident female breast cancer in Lebanon, 1990–2013: Descriptive study of 612 cases from a hospital tumor registry

Despite the fact that breast cancer is a major health issue, very few studies describe its characteristics in the Arab world or the Middle East, particularly in Lebanon. We report in this article a retrospective pilot study of the characteristics of breast cancer in Lebanon. The pathological characteristics of 624 patients diagnosed between 1990 and 2013 randomly chosen from the archives of an oncology clinic affiliated to Hotel Dieu de France Hospital are analyzed. The mean age at diagnosis is 54.6±13.4 years with 43% diagnosed before the age of 50 years. The infiltrative ductal carcinoma represents the major pathological subtype. One third of the tumors had a size of more than 2 cm at diagnosis. Estrogen-receptors are positive in more than 50% of our patients and Her2-neu is overexpresssed in 30%. Luminal A represents 45.5% and the triple negative subgroup constitutes only 8.3%. Breast cancer in Lebanon is evolving to a more indolent disease. Therefore, public awareness and institution of screening programs are required. These programs should be based on national epidemiological data and necessitate the activation of the national cancer registry.

Cutaneous metastasis in endometrial cancer: once in a blue moon - case report.

BackgroundCutaneous metastases from internal malignancies are uncommon. Moreover, endometrial carcinoma rarely metastasizes to the skin, with a reported prevalence of 0.8%. Here, we report the case of a 62-year-old woman who developed cutaneous metastases from an endometrial carcinoma.Case presentationWhen admitted to our department, the patient underwent a biopsy that showed the presence of cutaneous metastasis in relation to her initial endometrial cancer, diagnosed 3 years earlier. Thereafter, she was treated with a bilateral uterine artery embolization and chemotherapy. The patient had complications and survived 5 months after the diagnosis of the cutaneous metastasis. She died from sepsis.ConclusionCutaneous metastases of the endometrial carcinoma are usually incurable and suggest an unfortunate prognosis where palliation is the mainstay of patient management.

Simultaneous early ovarian and endometrial cancer treated conservatively with spontaneous pregnancy

IntroductionYoung cancer patients increasingly request fertility sparing alternatives to their cancer treatments, which they should be offered when allowed so by the risk-benefit balance and after obtaining informed consent.Case presentationHere, we report the case of a 25xa0year-old nulliparous patient who presented with a synchronous endometrioid ovarian and endometrial carcinoma. She was able to conduct a full-term spontaneous pregnancy after conservative surgical treatment followed by adjuvant chemotherapy and hormonal treatment. Fertility sparing treatment is feasible in selected cases of synchronous ovarian and endometrial cancers. Thorough follow-up remains mandatory.ConclusionThis case demonstrates some interesting and unique features of synchronous ovarian and endometrial cancers since it resulted in a spontaneous pregnancy and normal delivery.

Placenta accreta and beyond: Aesop's fables

will; in fact, an earlier Danish nationwide cohort study (10) referenced in our article, did include register-based data on induced abortions from 1973 onwards, but not, in contrast to our study, illegally induced abortions. We agree with Mr. Carroll that the inclusion of in situ carcinomas would have increased the number of cases. We were, however, reluctant to do this, because reporting of this type of cancer is probably incomplete. Therefore, the inclusion of in situ carcinomas might have introduced selection bias in our study. We agree with Mr. Carroll that it would be interesting to compare the incidence in our data with data from the national population. However, the incidence rate of breast cancer does not necessarily affect the hazard ratio. This will only be the case if the association between induced abortion and breast cancer differs between, for example, Copenhagen and other areas.

Placenta accreta and beyond: Aesop is not Zeus.

Sir I thank Professor Matsubara for his reply (1). First of all, I would like to insist that the pathology we are dealing with might be more frequent in countries where the cesarean section rate is very high as compared with Japan, where abnormal placentation seems to be a relatively rarer event (1,2). On the other hand, I agree with him that few persons in the same department or in other departments are able to reproduce the procedure as we previously described it. The difficulty in operating placenta accreta or percreta originates in the pathology itself rather than in the surgical technique; the variable aspects of the pathology and its presenting mode require a standardized technique as well as a great surgical versatility on the part of the operator. In our opinion, an anterior classical hysterectomy technique instead of a posterior retroperitoneal approach exposes the surgeon to a much greater risk of massive hemorrhage. Placenta percreta almost never invades posteriorly, unless the patient has previously had posterior hysterotomies, but we have seen it repeatedly invading laterally and anteriorly far beyond the usual surgical landmarks of the classical anterior hysterectomy. The ascending branch of the uterine artery for instance, which is habitually clamped to perform a classical hysterectomy, is almost always involved inside the placental mass. Posterior incision in the avascular plane of the pouch of Douglas in between the utero-sacral ligaments guarantees minimum or no bleeding; the pouch of Douglas is almost always free, unless there is a superimposed pathology such as endometriosis. Similarly, the retroperitoneum is very rarely involved, leaving a safety margin for the surgeon. This is exactly the same approach that we regularly use for ovarian cancer debulking and posterior exenterations. Posterior retroperitoneal incision is a standardized pathway (3). I am not reinventing the wheel. Nonetheless, the procedure should not be performed by everyone. A surgeon who will only be encountering the pathology once in a lifetime, as Professor Matsubara puts it, will have to pass the operation on to others who have the appropriate expertise in pelvic surgery; in an emergency situation, these cases should be addressed to specific centers and trained surgeons and not be operated on in sub-optimal conditions by persons who will simply apply “extrapolated” or “democratized” techniques. It is worth noting here that the cases must be diagnosed early in gestation and planned ahead of time. Allowing untrained, insufficiently trained or inexperienced gynecologists to perform such a procedure is clearly compromising patient security. We have witnessed cases of cataclysmic hemorrhage that barely allowed us enough time to drape the patient and start the operation in a rush to extract the baby and perform the hysterectomy. Ureteral stents could not have been placed in such a situation. I am somehow astonished that surgeons in Professor Matsubara’s team who could easily place ureteral stents in an emergency case, could not also perform incision of the pouch of Douglas and retroperitoneal dissection. The type of procedure we are describing is quite similar to oncologic surgery operations and therefore such a specialist could readily manage it.

Clinical research ethics review process in Lebanon: efficiency and functions of research ethics committees – results from a descriptive questionnaire-based study

BackgroundClinical trials conducted in Lebanon are increasing. However, little is known about the performance of research ethics committees (RECs) in charge of reviewing the research protocols. This study aimed to assess the level of adherence to the ethics surrounding the conduct of clinical trials and perceptions of team members regarding roles of the RECs during the conduct of clinical trials in Lebanon. The research question was: Are RECs adherent to the ethics surrounding the conduct of clinical trials (chapters II and IV in ‘Standards and Operational Guidance for Ethics Review of Health-related Research with Human Participants’ in Lebanon?’MethodsThis was a quantitative and descriptive questionnaire-based study conducted among RECs of university hospitals in Lebanon. The questionnaire had to be completed online and included general questions in addition to items reflecting the different aspects of a REC performance and effectiveness. All the questionnaire was assigned a total score of 175 points. General information and questions assigned point values/scores were analysed using descriptive statistics: frequency and percentage, mean scoreu2009±u2009standard deviation.ResultsTen RECs participated in the study (52 persons: four chairs, one vice-president, 47 ordinary members). Forty-seven (90.4%) had previous experience with clinical research and 30 (57.7%) had a diploma or had done a training in research ethics. Forty-one percent confirmed that they were required to have a training in research ethics. All RECs had a policy for disclosing and managing potential conflicts of interest for its members, but 71.8% of participants reported the existence of such a policy for researchers. Thirty-three point three percent reported that the RECs had an anti-bribery policy. The questionnaire mean score was 129.6u2009±u200922.3/175 points reflecting thus an excellent adherence to international standards.ConclusionInadequate training of REC members and the lack of anti-bribery policies should be resolved to improve their performance.