Rami Jalal Yaghan

Breast-related herniation (BRH) is a vague term for many clinicians. The absence of a universal nomenclature and the different nature of the herniation process involved, being true or false, contribute to this vagueness. BRH includes a spectrum of disorders ranging from a few congenital breast disorders to commoner herniation processes related to acquired breast diseases. We aim to raise multidisciplinary awareness about BRH by reviewing the related literature and reviewing our experience with BRH. We will also propose a classification for BRH. PubMed and Scopus databases were searched for any herniation disorders that are related to the breast in any clinical or pathological aspect. The literature review revealed 12 various groups of BRHs that we could classify into two anatomical categories: pectoral (mammary) BRH, in which the herniations occur at the pectoral site of the chest wall, and extra-pectoral BRH, in which the herniations occur at an extra mammary site but are related to breast pathologies. Pectoral BRH was further divided into clinicopathological subcategories, including congenital BRH, pulmonary BRH complicating breast cancer and breast infections, factitious BRH, and iatrogenic BRH. Extra-pectoral BRH was further divided into clinicopathological subcategories, including abdominal wall hernias following autologous breast reconstruction (ABR) and herniated siliconomas. Our study group included 19 patients with BRHs, among which congenital BRHs and pulmonary BRHs were the most common. Congenital BRHs are rare and are of main interest to plastic surgeons. However, abdominal wall hernias following ABR, pulmonary BRH, and factitious BRHs are relatively common complications of breast cancer treatment. This calls for a multidisciplinary approach to ameliorate the morbidity of BRHs. Further studies are needed to refine our proposed classification.

Conclusion: High BRAF mRNA expression as well as the gain and high-level amplification copy numbers were associated with advanced tumor characteristics and unfavorable prognostic factors in breast cancer. BRAF could be an appealing target for the treatment of premenopausal patients with hormone receptornegative breast cancer.

Background: Laterality in breast cancer means an increased frequency of left-sided breast cancers compared to right-sided breast cancers ranging between 1.05 and 1.26. It was first described in 1935 by Fellenberg, Sweden. The explanation of this phenomenon is not clear, but the association with other factors was found. This study aimed to explore the laterality of breast cancer in Bahrain as a model for Arabian countries. The association of laterality with the clinicopathological characteristics of the tumor was also analyzed to explore any applied clinical value. Methods: This is a cross-sectional, retrospective review of a particular ethnic population to study laterality of breast cancer versus a number of clinicopathological factors, as well as prognosis. The study analyzed 228 breast cancer patients treated in Arabian Gulf University facilities in Bahrain between 1999 and 2020. Three bilateral breast cancer and two malignant phyllodes patients were excluded. The following variables were analyzed: laterality ratio (Lt/Rt) and the association between laterality and clinicopathological characteristics (age at diagnosis, family history of malignancy, size of the tumor, tumor grade, histological type, hormonal receptors and HER2, axillary lymph node status, tumor stage, five-year survival rate, nulliparity, and multifocality). Results: The laterality ratio (Lt/Rt) was 1.06 and was 0.97 for patients below 50 years of age, and 1.19 for patients 50 years of age and above. Analysis of our data showed a statistically significant association between laterality and tumor stage (p. value =0.025) at presentation, and laterality and family history of malignancy (p. value =0.052). Right-sided breast cancer was associated with a higher positive family history of malignancy and an increased ratio of locally advanced and metastatic disease, and a reduced 5-year survival in relation to size and stage. Left-sided breast cancer was associated with higher early tumor stage. Conclusion: This is the first study exploring the issue of breast cancer laterality in a defined Arabian population. The laterality ratio in this study was 1.06, which is consistent with the globally published range (1.05 to 1.26) and is increasing with increasing age. The association between breast cancer laterality, and the hormonal and HER2 is still not widely addressed in the available literature, although other clinicopathological characteristics were extensively analyzed.

Purpose: Tumor expression of programmed death-ligand 1 (PD-L1) is associated with evasion of immune response in several types of malignancies and such expression may render patients eligible for PD-L1 inhibitors. The use of immune checkpoint blockade therapy has been recently approved for the treatment of breast cancer. However, PD-L1 expression data are lacking among Jordanian breast cancer patients. In this study, the tumor PD-L1 expression was characterized in breast cancer patients to assess their eligibility for immune checkpoint blockade therapy. The study also aimed to explore the association between tumoral PD-L1 expression and the clinicopathologic characteristics and the prognostic factors in patients with breast cancer. Patients and Methods: Tissue samples were available from 153 female patients with primary invasive breast cancer. Immunohistochemistry was performed on paraffin-embedded tumor sections that were stained with a PD-L1 antibody. Expression of tumor PD-L1 was correlated with demographics, clinicopathologic characteristics, and prognosis. Results: The mean age at diagnosis was 54.2± 12.8 years (median 52, interquartile range 45– 65). The percentage of PD-L1-positive tumors was 26.1%. PD-L1 expression on tumor cells significantly and positively correlated with tumor size (rho=0.174, p=0.032). PD-L1 positivity was significantly associated with the grade of carcinoma (p=0.001), HER2-positivity (p=0.015), and lymphovascular invasion (p=0.036). PD-L1 intensity was significantly associated with tumor stage (p=0.046). No significant associations were observed for the PD-L1 expression status or intensity with patient menopausal status, hormone receptor expression, and molecular subtypes. PD-L1 expression significantly correlated with a worse prognosis of breast cancer patients at the time of diagnosis (rho=0.230, p=0.005). Conclusion: Tumor PD-L1 expression was associated with advanced clinicopathologic features and worse prognosis in this cohort of Jordanian breast cancer patients. Future studies are needed to better understand the impact of PD-L1 blockade therapy on treatment outcomes in eligible breast cancer patients in Jordan.

Background: The current study aimed to evaluate the previously unexplored correlation between undergraduate medical students’ attendance during their surgical clerkship and their academic performance. It also aimed to explore any difference in the attendance rate between male and female students and whether this difference, if present, affects the academic performance. Methods: A retrospective descriptive cross-sectional study has been conducted on 331 undergraduate medical students during their surgical clerkships at the College of Medicine and Medical Sciences (CMMS) at Arabian Gulf University (AGU), Bahrain from September 2018 to June 2020. Results: There was a positive statistically significant correlation between students’ attendance during surgical clerkship and academic performance (r = 0.360, P < 0.01). Mean attendance rate was greater in each increasing category of academic performance: 47.95% in the weak category (less than 65%, n = 42), 57.62% in the good performance category (65% to less than 75%, n = 108), 67.82% in the very good performance category (75% to less than 85%, n = 126), 83.16% in the excellent performance category (85% and above, n = 55). The mean attendance rate of male students was 59.76% (SD = 25.73), compared to 66.92% (SD = 24.30) in the female students. T-test indicated that the difference between the mean attendance of the two groups of the students (male, female) was statistically significant (t = 2.483, p < 0.05). On the other hand, the difference between the mean academic performance for the two groups of students, male & female, (t = 0.284, p = 0.777) was not statistically significant. Conclusions: Our study showed a significant relationship between undergraduate medical students’ attendance during their surgical clerkship and their academic performance. Further studies are needed to stratify this correlation according to clinical and theoretical teaching activities. No significant difference was observed in academic performance between female and male students.

Receptor Tyrosine Kinases (RTKs) represent a class of transmembrane receptors known to play an important role in cancer development and progression. In this study, the expression of insulin receptor (IR) and the hepatocyte growth factor receptor (c-MET) was examined in breast cancer patients. Immunohistochemistry for IR and c-MET was performed on 71 cases of invasive breast cancer and expression scores were correlated with clinicopathologic characteristics and molecular subtypes and further stratified based on a menopausal status. Expression of IR was significantly associated with the tumor grade (p = 0.017) and estrogen receptor (ER) expression (p = 0.015). There was a significant positive correlation between IR and c-MET expression scores (rho = 0.458, p < 0.001). Among premenopausal cases, IR scores were significantly higher in patients with grade I/II disease (p = 0.025), ER-positive (p = 0.030), and progesterone receptor (PR)-positive carcinoma (p = 0.015). c-MET expression scores were significantly higher among premenopausal patients with ER-positive (p = 0.007) and PR-positive carcinoma (p = 0.024). IR expression scores were significantly different among molecular subtypes for all patients (p = 0.006) and among premenopausal cases (p = 0.035). c-MET expression was statistically different among molecular subtypes for premenopausal patients (p = 0.019). Survival analysis revealed that the expression status of IR and c-MET was not associated with overall survival. Our findings support a favorable prognostic value for IR and c-MET expression in premenopausal breast cancer patients.

Background. Iidiopathic granulomatous mastitis (IGM) is stereotypically described as a mysterious entity that mimics breast carcinoma imposing management challenges. In 2002, we established a multidisciplinary team to treat patients with IGM. This study aimed to evaluate the role of this team in improving patient outcomes. Also, a review of literature is provided to highlight recent disease trends. Patients and Methods. Pertinent data for 44 patients treated for IGM from 2002 to 2018 were analyzed and compared to data prior to 2002. Results. Mean age at diagnosis was 37.9 years ± 6.4. The diagnosis of IGM was confirmed by True-cut biopsy (TCB), Frozen section (FS), and surgical biopsy in 70.5%, 25%, and 4.5% of patients, respectively. FS was used to assess the resection margins in three patients. Suspicion for malignancy was raised in one out of 39 ultrasound reports, and one out of 20 mammography reports. Wide local excision was the main treatment modality (95.5%). 19 patients (43.2%) received corticosteroids. Prior to 2002, IGM was only recognized after surgical resection with a 71% initial false impression of carcinoma. After 2002, the initial false clinical impression of carcinoma dropped to 29.5%. Recurrence rate was 31.82%. Younger age at diagnosis was significantly associated with recurrence (χ² = 5.598; ). Chi-square analysis showed no significant association between BMI and recurrence (χ² = 0.776; ). Conclusion. The establishment of a multidisciplinary team for IGM was associated with a reduced erroneous impression of breast cancer, and a reduced false positive radiological diagnosis of breast carcinoma. FS was a useful confirmatory procedure. Our series included the first case of a diffuse papular rash as a systemic manifestation of IGM. Recent literature indicates that IGM is changing its face. IGM is being reported in all age groups, and even in males. The clinical manifestations have markedly expanded. Diagnosis by TCB has replaced blind surgical excision. More data regarding predictors of recurrence is accumulating.