REPORT: A 10 year old girl with end stage renal failure dialysing through a left brachiocephalic fistula presented with left upper limb and facial swelling. She had previously exhausted the option of ambulatory peritoneal dialysis for recurrent peritonitis. A central venogram showed occlusion at the left subclavian vein, which was not amenable for angioplasty through either an upper limb or femoral approach. Given the precious fistula with concomitant worsening venous hypertension, an ipsilateral axillary vein to external iliac vein bypass was performed. Subsequently, her venous hypertension was significantly resolved. This report is the first in English literature on this surgical bypass in a child with central venous occlusion.

CASE DESCRIPTIONS: We report three women managed at a single Malaysian tertiary center. Case 1 (56 years old; metachronous interval of approximately 4 years) had an ER-positive, HER2 3+ (immunohistochemistry [IHC]) carcinoma of no special type that presented as a circumferential Siewert III gastroesophageal junction (GOJ) tumor with gastric satellites; the metastasis retained E-cadherin and was HER2 2+ with a non-amplified in situ hybridization (ISH) result, a discordance from the HER2 3+ primary. Case 2 (47 years old; synchronous) presented with a linitis plastica-like pattern and gastric outlet obstruction (GOO) from an ER-positive, HER2-negative carcinoma; the primary showed patchy E-cadherin and the metastasis showed focal E-cadherin, consistent with a mixed ductal-lobular phenotype; PR expression was lost between the primary (strong, >90%) and the metastasis (negative). Case 3 (91 years old; effectively synchronous, approximately 6-year course) had a lobular carcinoma with E-cadherin loss and a decline in PR expression (from focal weak positivity in the primary to negative in the metastasis), with a protracted course dominated by recurrent feeding-tube complications. In each case, the diagnosis rested on morphology, a breast-oriented IHC panel, and comparison with the known breast primary rather than on any single marker.

MATERIAL AND METHODS: An interventional study was carried out among oesophageal and gastric cancer patients who had undergone surgery at the National Cancer Institute of Malaysia. The prehabilitation process took a maximum of two weeks, depending on the patient's optimisation before surgery. The prehabilitation is based on functional capacity (ECOG performance status), muscle function (handgrip strength), cardio-respiratory function (peak flow meter) and nutritional status (calorie and protein). Postoperative outcomes are measured based on the length of hospital stay, complications, and Clavien-Dindo Classification.

RESULTS: Thirty-one patients were recruited to undergo a prehabilitation intervention prior to gastrectomy (n=21) and esophagectomy (n=10). Demographically, most of the cancer patients were males (67.7%) with an ideal mean of BMI (23.5±6.0). Physically, the majority of them had physical class (ASA grade) Grade 2 (67.7%), ECOG performance status of 1 (61.3%) and SGA grade B (51.6%). The functional capacity and nutritional status showed a significant improvement after one week of prehabilitation interventions: peak expiratory flow meter (p<0.001), handgrip (p<0.001), ECOG performance (p<0.001), walking distance (p<0.001), incentive spirometry (p<0.001), total body calorie (p<0.001) and total body protein (p=0.004). However, those patients who required two weeks of prehabilitation for optimization showed only significant improvement in peak expiratory flow meter (p<0.001), handgrip (p<0.001), and incentive spirometry (p<0.001). Prehabilitation is significantly associated postoperatively with the length of hospital stay (p=0.028), complications (p=0.011) and Clavien-Dindo Classification (p=0.029).