Breast cancer is the leading cause of cancer deaths in Malaysian and Singaporean women. A study done to compare the epidemiology of the disease, as well as to compare the rate of conservative surgery between Malaysian and Singaporean women was carried out. The results show that the median age at presentation was the same in both countries, and the incidence was lower among the Malays. However, there was a significant difference in the stage at presentation and the tumour size; Singaporean women presented at earlier stages and with smaller tumours compared to Malaysian women. This led to a lower rate of conservation surgery in Malaysian women.
An eighteen month old phenotypically and genotypically normal male child was admitted with a left inguinal hernia and a right undescended testis. At operation, he was found to have a uterus, bilateral fallopian tubes, and a vagina in the left hernial sac. Bilateral orchidopexies and excision of the persistent Mullerian duct structures were carried out. This rare case of persistent Mullerian duct syndrome is due to a defect in Mullerian regression, which is in turn controlled by the Mullerian inhibiting substance (MIS). Orchidopexy with excision of the persistent Mullerian duct structures is usually not possible without damage to the vas deferens which is closely adherent to the wall of the uterus. The alternative of leaving the persistent Mullerian duct structures alone and performing a staged or primary orchidopexy has been suggested.
Four hundred and nineteen articles related to breast cancer were found in a search through a database dedicated to indexing all original data relevant to medicine published in Malaysia between the years 2000-2013. One hundred and fifty four articles were selected and reviewed on the basis of clinical relevance and future research implications. Overall, Malaysian women have poor survival from breast cancer and it is estimated that half of the deaths due to breast cancer could be prevented. Five-year survival in Malaysia was low and varies among different institutions even within the same disease stage, suggesting an inequity of access to optimal treatment or a lack of compliance to optimal treatment. Malaysian women have poor knowledge of the risk factors, symptoms and methods for early detection of breast cancer, leading to late presentation. Moreover, Malaysian women experience cancer fatalism, belief in alternative medicine, and lack of autonomy in decision making resulting in delays in seeking or avoidance of evidence-based medicine. There are ethnic differences in estrogen receptor status, HER2 overexpression and incidence of triple negative breast cancer which warrant further investigation. Malay women present with larger tumours and at later stages, and even after adjustment for these and other prognostic factors (stage, pathology and treatment), Malay women have a poorer survival. Although the factors responsible for these ethnic differences have not been elucidated, it is thought that pharmacogenomics, lifestyle factors (such as weight-gain, diet and exercise), and psychosocial factors (such as acceptance of 2nd or 3rd line chemotherapy) may be responsible for the difference in survival. Notably, survivorship studies show self-management programmes and exercise improve quality of life, highlighting the need to evaluate the psychosocial impact of breast cancer on Malaysian women, and to design culturally-, religiously- and linguistically-appropriate psycho-education programmes to help women cope with the disease and improve their quality of life. Research done in the Caucasian populations may not necessarily apply to local settings and it is important to embark on local studies particularly prevention, screening, diagnostic, prognostic, therapeutic and psychosocial research.
INTRODUCTION: Advanced presentation of breast cancer and the problem of late diagnosis is well documented. Patient delay beyond three months has been shown to reduce survival. This paper aims to explore the experience of Malaysian women presenting with advanced breast cancer with regards to their interpretation of breast symptoms.
METHOD: Purposive sampling of 19 breast cancer patients presenting with delayed treatment and/ or advanced cancer diagnosed within two years at the University Malaya Medical Centre, Kuala Lumpur were carried out. In-depth interviews were conducted using a self-devised interview guide. The interview guide covered the journey of the patient from discovering of symptoms to their present state. The audiotaped interviews were transcribed verbatim. NVivo 8 qualitative software was utilised for data management. Grounded theory with thematic analysis was utilised.
RESULTS: Nine women delayed seeking diagnosis although recognizing the symptom, five did not recognize symptom, three delayed treatment and two did not delay health attention. Themes that emerged with regards to triggering help seeking behavior were: a) poor symptom knowledge and recognition; b) importance of knowledge of the disease and its' outcomes; c) role of coping mechanisms and affect; and lastly d) role of significant others in appraising a breast symptom.
CONCLUSION: Symptom recognition remains an important public health issue in Malaysia. Educating women, their significant others and primary health and primary care providers in detecting early staged breast cancer are needed. Supporting and sanctioning women with breast symptoms are important. The psycho-social-cultural model of symptom appraisal may serve as an important addition to the fight against cancer in countries that do not have the resources for population based screening mammogram programmes.
The main objective of this paper is to examine the psychometric properties of the Malay Version of the Hospital Anxiety and Depression Scale (HADS), tested on 67 husbands of the women who were diagnosed with breast cancer. The eligible husbands were retrieved from the Clinical Oncology Clinic at three hospitals in Kuala Lumpur, Malaysia. Data was collected at three weeks and ten weeks following surgery for breast cancer of their wives. The psychometric properties of the HADS were reported based on Cronbach' alpha, Intraclass Correlation Coefficients (ICC), Effect Size Index (ESI), sensitivity and discriminity of the scale. Internal consistency of the scale is excellent, with Cronbach's alpha of 0.88 for Anxiety subscale and 0.79 for Depression subscale. Test-retest Intraclass Correlation Coefficient (ICC) is 0.35 and 0.42 for Anxiety and Depression Subscale, respectively. Small mean differences were observed at test-retest measurement with ESI of 0.21 for Anxiety and 0.19 for Depression. Non-significant result was revealed for the discriminant validity (mastectomy vs lumpectomy). The Malay Version of the HADS is appropriate to measure the anxiety and depression among the husbands of the women with breast cancer in Malaysia.
Study site: Oncology clinic, University of Malaya Medical Centre (UMMC), Hospital Kuala Lumpur, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
This paper validates the Brief COPE Scale in Malaysian women with breast cancer. Test-retest evaluation was undertaken at two/three weeks and ten weeks following surgery. Internal consistencies ranged from 0.25 to 1.00. Meanwhile, the Intraclass Correlation Coefficient (ICC) ranged from 0.05 to 1.00. Sensitivity of the scale was indicated by the mean differences as observed in most of the domains with Effect Size Index (ESI) ranged from 0 to 0.53. Significant differences between mastectomy and lumpectomy were observed for Active coping, Planning and Acceptance. Brief COPE Scale showed fairly good reliability and validity.
BACKGROUND: Breast cancer is the commonest cancer amongst Malaysian women but local survival data are scarce. The present study was therefore conducted to assess overall survival and prognostic factors in Malaysian breast cancer patients.
METHODS: The research sample was a prospective cohort of 413 patients diagnosed with breast cancer in the University of Malaya Medical Centre between 1993 to 1997. Survival data were obtained from the National Registry of Birth and Deaths in December 2000. The clinico-pathological variables studied were age, ethnic group, stage, tumour size, lymph node status, oestrogen receptor status and grade. The data were analysed utilizing Splus statistical software. The important prognostic factors were identified by fitting the Cox's proportional hazard model to the data set. Survival probabilities were estimated using the Kaplan-Meier method and differences were compared by the log-rank test.
RESULTS: The overall 5-year survival was 59.1%. The Cox's proportional hazard model identified stage, lymph node status, size and grade as factors that correlated with prognosis. Age was not a significant prognostic factor. The Cox regression model by stepwise selection showed stage, nodal status and grade of tumour to be independent prognostic factors, whereas ethnicity, age and ER status were not.
INTERPRETATION: The overall survival in our centre was low. Recognizing factors that affect prognosis of breast cancer patients in Malaysia may improve delivery of health care to at-risk groups by strategizing interventions as survival depends on early detection and effective treatment.
The HER2 codon Ile655Val and Cyclin D1 (CCND1) G870A polymorphisms were analyzed in a hospital-based Malaysian population using PCR-RFLP method. Peripheral blood samples were collected from 230 breast cancer patients, and 200 normal and healthy women who had no history of breast disease or breast cancer. We evaluated the association between HER2 or CCND1 polymorphisms and breast cancer risk, and clinico-pathological parameters in the population. The genotype and allele frequencies of HER2 (P=0.163 vs P=0.0622) and CCND1 (P=0.377 vs P=0.284) polymorphisms were not significantly different between the breast cancer cases and normal subjects, respectively. Women who were Ile/Val heterozygotes (OR=1.48; 95% CI, 0.91-2.43), Val/Val homozygotes (OR=1.93; 95% CI, 0.51-7.77) and carriers of Val allele genotype (OR=1.53; 95% CI, 0.95-2.45) were not significantly associated with increased breast cancer risk. Similarly, women who were homozygous (OR=1.34; 95% CI, 0.77-2.34) or heterozygous (OR=0.98; 95% CI, 0.60-1.60) for A allele, or carriers of A allele genotype (OR=1.10; 95% CI, 0.70-1.73) were not associated with breast cancer risk. Analysis on clinico-pathological parameters showed that Val allele genotype was significantly correlated with nodal metastases but A allele genotype was not associated with any of the variables. Our findings suggest that the polymorphic alleles of HER2 and CCND1 may not play an important role as genetic markers for breast cancer risk, but presence of Val allele may be useful for tumor prognosis.
Angiosarcoma of the breast is an extremely rare condition. This case illustrates the use of embolisation as a modality of treatment for primary breast angiosarcoma. No other case has been reported on the use of embolisation for this disorder.
Data from the National Cancer Registry of Malaysia for 2004 provide an age-standardised incidence rate (ASR) of 46.2 per 100,000 women. This means that approximately 1 in 20 women in the country develop breast cancer in their lifetime. However, the rate differs between the three main races, the Malays, Chinese and Indians. The age standardized incidence in Chinese is the highest, with 59.7 per 100,000, followed by the Indians at 55.8 per 100,000. The Malays have the lowest incidence of 33.9 per 100,000. This translates into 1 in 16 Chinese, 1 in 16 Indian and 1 in 28 Malay women developing breast cancer at some stage in their lives. The commonest age at presentation is between 40-49 years, with just over 50% of the cases under the age of 50 years, 16.8% below 40, and 2% under 30. Some 55.7% of all cases were found to be ER positive. The commonest presenting symptom was a lump in the breast in over 90% of cases, generally felt by the woman herself. The mean size of the lump was 4.2 cm, and on average, the women waited 3 months before seeking medical attention. Over the 12-year period from 1993 to 2004, about 60-70% of women presented with early stage (Stages 1-2) while 30-40% presented with late breast cancer (Stages 3-4). Especially Malays present at later stages and with larger tumours. Consequently their survival is worse than with Chinese and Indian women. The challenge in Malaysia is to be able to provide a comprehensive service in the diagnosis and treatment of breast cancer, and this requires training of a team of health professionals dedicated to breast health, such as breast surgeons, radiologists specializing in breast imaging, breast pathologists, plastic surgeons specializing in breast reconstruction, medical and radiation oncologists, psycho-oncologists, counselors, and breast nurses. Advocacy can play a role here in galvanizing the political will to meet this challenge.
BACKGROUND: Leiomyosarcoma of the breast is a rare neoplasm. We present a case of primary leiomyosarcoma of the breast in a middle-aged female in whom fine needle aspiration cytologic features suggested sarcoma.
CASE: A 55-year-old female presented with a rapidly growing breast lump of 1 month's duration. On examination, an ulcerating, 12 x 10 cm tumor was seen involving the lower medial and lateral quadrants of the right breast. Fine needle aspiration cytology showed variably sized, dissociated and loosely clustered polygonal, plump and spindle cells with pale blue cytoplasm and vesicular nuclei that were round, oval or irregular. Occasional giant forms and nucleolated and mitotic cells were present. A single cluster of benign ductal cells was seen. The tumor cells did not express immunocytologic reactivity to estrogen receptor protein. A cytologic diagnosis of sarcoma was given with differential diagnoses of metaplastic carcinoma and malignant phyllodes tumor. Histologic study established the diagnosis of leiomyosarcoma. Leiomyosarcoma of the breast shows fine needle aspiration cytologic features of sarcoma, but specific tumor typing may not be possible, especially when the cytologic material is inadequate for ancillary staining required to distinguish leiomyosarcoma from metaplastic carcinoma and malignant phyllodes tumor.
BACKGROUND: Teratoma of the thyroid in adults is extremely rare, and most are malignant. Only nine cases have been adequately documented in the English-language literature, and there are no reports detailing the fine needle aspiration (FNA) cytologic characteristics.
CASE: A 32-year-old female presented with a left-sided nodular thyroid mass with left cervical lymphadenopathy. FNA cytology of the thyroid and lymph nodes was done. The cytologic and immunocytochemical features were that of a small round cell tumor with neuroepithelial (NE) differentiation, metastasizing to the cervical nodes. Microscopic study of the thyroidectomy specimen showed a tumor showing an NE pattern with occasional islands of squamous and cuboidal epithelium, leading to a diagnosis of malignant teratoma.
CONCLUSION: Knowledge of FNA cytologic features of rare but highly malignant lesions like thyroid teratomas allow early recognition so that suitable and possibly aggressive treatment protocols can be adopted in the hope of prolonging survival.
OBJECTIVE: To examine the fine needle aspiration cytologic features of invasive lobular carcinoma of breast and to discuss problems that may occur in cytodiagnosis.
STUDY DESIGN: Fine needle aspiration cytologic smears from 21 cases of invasive lobular carcinoma (ILC) of breast were subjected to detailed cytomorphologic analysis. Features studied included pattern of cells, size of cells, nuclear placement, pleomorphism, presence of intracytoplasmic lumina (ICL) and signet ring cells.
RESULTS: Cellularity was generally moderate or high, and the pattern was predominantly or partly dissociated in 86% of cases. Rosettelike pattern was discerned in alveolar-type ILC. Cell size was usually small or intermediate, with nuclei placed eccentrically in most cases. ICLs with or without signet ring cells were present in 12 cases (57%).
CONCLUSION: A cytologic picture consisting of predominantly dissociated small or intermediate-sized tumor cells with eccentric nuclei, with some of the cells showing ICLs, is highly suggestive of ILC. Indian file pattern, another characteristic feature of ILC, is, however, focal and inconsistent. Variant patterns of ILC may show other cytologic features, such as rosettelike pattern (alveolar variant of ILC) or large cell pattern (pleomorphic variant of ILC) and may consequently be difficult to categorize on cytologic smears.
A total of 676 palpable breast lumps seen in the Breast Clinic, University Hospital, Kuala Lumpur from August 1993 to August 1994 were subjected to fine needle aspiration cytology. Fifty-four were reported as inadequate, 501 benign, 95 malignant and 26 suspicious. One hundred and eighty-seven aspirates had histological correlation, while 34 of the malignant aspirates had clinical correlation. The majority of the other 455 patients were followed up for a period of 60 to 72 months without any malignancies becoming apparent. For analysis, only the 221 cases with histological or clinical correlation were included, (the suspicious category was included into the positive group and the inadequate cases were excluded), giving a sensitivity of 91.7%, a specificity of 91.7% and a diagnostic accuracy of 91.7%. Breast cytology was an accurate and rapid method of diagnosis of breast diseases, and in a busy surgical unit with limited operating time, it allowed for the triage of patients with breast complaints in deciding which cases needed early open biopsy. A negative cytology does not exclude the possibility of cancer, as there was a false negative rate of 11%. However by utilising a diagnostic triad of clinical examination, radiological assessment and fine needle aspiration cytology, the risk of missing a malignancy is small.
780 breast cytology samples obtained over a one year period at the Breast Clinic of the University Hospital, Kuala Lumpur were reviewed. These included 745 fine needle aspirates (FNA's) and 35 nipple smears. The broad categories of cytodiagnoses were as follows: malignant: 95, suspicious or equivocal: 26, benign: 543, no proliferative lesion: 58 and inadequate: 58. The benign and malignant lesions were also subcategorized on cytological basis. The suspicious or equivocal lesions were subjected to biopsy and 17 of these proved to be malignant. 194 cases that were subjected to histological confirmation and 34 cases that were considered to be undisputably malignant (on the basis of clinical features, recurrences, metastases, etc.) were subjected to statistical analysis (total 228 cases). If the cytologically suspicious/equivocal category was considered as "test positive" the sensitivity of cytodiagnosis was 97.4% and the specificity 92%. The high degree of cytodiagnostic sensitivity and specificity make breast cytology a valuable adjunct in the evaluation of breast lesions.
A 39-year-old female presented with a mobile 1.5 cm nodule in the right breast. Fine needle aspiration cytology smears stained with May Grunwald Giemsa were highly cellular with a monotonous population of dissociated and clustered tumour cells that showed a bland cytological appearance with cytoplasmic vacuolation and occasional signet ring forms. Intracellular and extracellular mucus was present. Histological study of the excised breast mass showed a secretory carcinoma. This is a rare breast neoplasm in which cytological features are characteristic enough to permit a specific diagnosis on needle aspirates.
Plasma cell granuloma of the breast is an extremely rare condition. Only one other case has been reported in the literature. We report here the second case of plasma cell granuloma of the breast. After the initial excision, the lesion recurred in both breasts after 5 months.
The breast clinic in the university Hospital Kuala Lumpur was started in August 1993 to cater for the increasing number of women seeking treatment for breast complaints. A four-month survey carried out from January to April 1994 found that Chinese women are more "breast conscious" than Malay and Indian women. The majority of patients were in the reproductive age group. Benign breast diseases form the majority of cases of breast diseases seen. The pick-up rate for new cases of breast cancer was 3.1%. Fine needle aspiration biopsy had a 100% sensitivity during the four-month study, and was a quick method of obtaining a diagnosis.
Study site: Breast clinic, University Malaya Medical Centre (UMMC)