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Breast Cancer Stem Cells (BCSCs), unlike normal breast cells, exhibit the potential for self-regeneration and tumour formation and express unique markers. Studies have highlighted their role in tumour progression, recurrence, and treatment resistance. BCSCs can be one of the reasons that resistance is encountered despite recent advances in the treatment of breast cancer (BC). This review underlines the clinical implications at the molecular level of different cellular pathways, cellular level interactions in Tumour Micro Environment (TME), and types of markers and receptors involved in tumorigenesis. It accentuates the importance of comprehensive targeted treatment options available for BCSCs so that targeted modalities can be introduced to deal with treatment resistance. Stem cells (SCs) are a developing field, and limited data is available from our country to use stem cell-targeted treatment plans as a therapeutic option. Therefore, this literature review will provide insight for future research in this domain. Continued...

Various oncoplastic techniques have emerged over the years to preserve breast cosmesis and symmetry without compromising the principles of tumor excision. One of the newer techniques for breast volume replacement to achieve symmetry and cosmesis is the use of fasciocutaneous pedicled chest wall perforator flaps or local perforator flaps (LPF). The objectives of this study were to document the details of the surgical procedure as well as patient-reported satisfaction and well-being following the procedure using a validated BREAST-Q tool among Pakistani women.This cross-sectional study was conducted from March 2019 to February 2021 enrolling 25 female patients who underwent breast conservative surgery using LPF for breast tumors at The Aga Khan University Hospital, Karachi. Data related to the procedure was collected on a pre-designed proforma. Cosmetic outcomes and patient satisfaction were evaluated using 2 scales from BREAST-Q BCT domain version 2.0. The questionnaire was self-administered by the patients during their routine follow-up in the clinic. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 23. Mean (SD)/median (IQR) were computed for quantitative variables and frequency and percentages were calculated for qualitative variables. 2 sample25 patients underwent LPF with a mean age of 47 ± 13.1 years. 8 LICAP, 7 AICAP, and 10 LTAP flaps were performed. Two postoperative complications of wound site erythema were encountered. 23 women were eligible for the BREAST-Q survey. Median (IQR) postoperative satisfaction with breasts and physical well-being chest (equivalent Rasch transformed score) was 100 (41) and 76 [18] respectively. We found high satisfaction with breasts and comparable physical well-being among Pakistani women after LPF surgeries.Local perforator flaps in oncoplastic breast-conserving surgery are a good option showing high satisfaction with breasts and physical well-being in Pakistani women.

Ductal carcinoma in situ (DCIS) is the earliest and most curable form of breast cancer. Patients who harbour this disease for quite some time usually have micro invasion by virtue of high-grade disease or big size. Herein, we report a case of 56-year-old postmenopausal woman presenting with a one-year history of blood-stained nipple discharge from right breast. She was a known case of depression receiving oral anti-depressants containing lithium for 20 years. Her mammogram was performed followed by ultrasound breast. Mammogram identified suspicious clusters of micro calcifications hence subjected to stereotactic core biopsy which revealed two separate foci of high-grade DCIS. Therefore, based on her clinical, radiological, and pathological findings she was subjected to mastectomy and sentinel node biopsy. Final histopathology showed big DCIS (10×8×3 cm in size) with immunohistochemical stains confirmed no invasive focus on extensive sampling. Therefore, we postulated that it might be correlated to the use of Lithium which has anti-cancer properties.

Highlights • Diagnosis and management of giant juvenile fibroadenoma can be challenging. • Maintaining symmetry after complete excision is tougher in developing breasts. • Periareolar approach for subareolar fibroadenomas provides good cosmetic results. • Benign tumor to breast size ratio up to 70% provides excellent cosmetic outcome., Introduction Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5–2% of all fibroadenomas. Presentation of case In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan. Discussion Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases. Conclusion The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility.

Mycobacterium abscessus is a rapidly growing non-tuberculous, multi-drug resistant mycobacterium (NTM). Its common clinical presentation includes pulmonary infection followed by wide spectrum of skin and soft tissue infections. Chronic breast conditions, such as peri-ductal mastitis are rarely caused by NTM. Due to an intrinsic and acquired drug resistance to conventional antibiotics and anti-tuberculous therapy, it is often managed with a combination of antibiotics with or without surgical adjuncts. It is important to consider NTM in patients with chronic mastitis who show suboptimal response to initial broad-spectrum antibiotics, and especially when symptoms recur after complete resolution. This case report describes peri-ductal mastitis caused by mycobacterium abscessus in a 32-year female presenting with a history of painful breast lump and blood stained discharge. With initial diagnosis of nonspecific abscess, she received antibiotic therapy for 4 days at community healthcare setting without promising response. Subsequently, she was diagnosed as a case of peri-ductal mastitis for which quadrantectomy was performed; and surprisingly mycobacterium abscessus was identified on AFB culture. Full recovery was obtained with combination of antibiotics for prolonged period due to frequent relapses. Key Words: Mastitis, Mycobacterium abscessus, Non-tuberculous mycobacteria.

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan. There is a need to establish dedicated oncoplastic breast surgery training centres, fellowship programmes, workshops, and webinars to incorporate such techniques in the practice of breast surgeons.

Objective: To determine the accuracy and false negative rate of axillary ultrasound compared to sentinel nodebiopsy.Method: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, from February 1 toMarch 31, 2021, and comprised data of breast cancer patients who had undergone neo-adjuvant chemotherapyfollowed by axillary lymph node dissection or axillary disease diagnosed using lymph node biopsy or sentinel lymphnode biopsy between January 1, 2016, and December 30, 2020. After receiving neoadjuvant chemotherapy, axillaryultrasound findings were compared with histopathology of lymph nodes. Data was analysed using SPSS 22.Results: Of the 155 patients evaluated, 104(67.1%) were diagnosed with negative axillary lymph nodes and51(32.9%) were diagnosed with positive axillary lymph nodes post-chemotherapy. The overall mean age was51.13±1.3 years. When histopathology results were compared with those of axillary ultrasound, 36 cases turned outto be true positive, while 23(%) were false negative, yielding a positive predictive value of 75% and negativepredictive value of 65%. Axillary ultrasound had 75% accuracy, false negative rate 30%, sensitivity 61% andspecificity 84.4%.Conclusion: Axillary ultrasound was found to be fairly useful, but not completely reliable, in identifying positivelymph nodes, Continuous...

Aim We sought to compare breast conservation therapy & mastectomy as treatment of occult breast cancer in terms of recurrence. Methods It is a retrospective cross sectional study conducted on patients diagnosed to have occult breast cancer and going for either breast conservation therapy or mastectomy at The Aga Khan University Hospital Karachi between January 200o to December 2018, patients will be divided into two groups, first group will be consisting of patients who underwent breast conservation therapy and 2nd one will be of patients who had mastectomy. Patients will be included by consecutive sampling technique. Hospital database will be used to identify patients and data collected on a self designed tool using files and electronic patient records. Patients in both groups will be followed to see local recurrence from date of diagnosis to 2 years post operatively in hospital data base and their files, and then their data will be compared with the reference studies reported in this article. Results Awaited as the study is ongoing. Conclusions Awaited as study is ongoing.

Introduction Breast Conserving Surgery (BCS) with whole breast radiation is now standard of care as a safer alternative to Mastectomy in terms of loco-regional recurrence and long-term survival. Despite this, a frequent pitfall of conventional BCS is positive surgical margins and need for second surgery with a reported frequency of 12–59 % in literature. Oncoplastic Surgery can be a safer, more cost effective alternate to conventional BCS owing to its higher rate of negative surgical margins (4–6% vs 12–59 %) and better cosmetic results. We aim to prove utility of Oncoplastic surgery for Low-Middle income countries. Objective The aim of this study was to determine Oncoplastic Surgery as a more appropriate alternative to Conventional Breast Conserving Surgery for Low-Middle Income countries in terms of its lower positive margins and re-excision rates. Methodology A retrospective comparative single center study by reviewing patient's medical records from August 2016 to June 2020 was conducted. Rate of positive margins and re-excisions along with mean volume of resection specimen, mean tumor size and quadrant dealt by both surgical procedures were compared. Results Out of 421 patients 249 patients underwent oncoplastic surgery and were compared with 173 patients who had conventional breast conserving surgery. Positive margins were seen in 5 patients (2 %) in OPS group whereas in 31 (17.9 %) patients in BCS group (p value, Highlights • Oncoplastic surgery has proven to be oncologically safe when compared to conventional breast conserving surgery. • Oncoplastic procedures results in lower rate of positive surgical margins and re-excision rates. • Difficult anatomic quadrants, multi-focal and tumors not responding to neo-adjuvant therapy can be dealt with oncoplastic techniques. • These advanteges makes it a better alternative to conventional breast conserving procedure in resource limited countries. • The concept of oncoplastic breast surgery is still contemporary to developing world there is a need to bridge gap in training.

Background Neo-adjuvant chemotherapy (NAC) is frequently administered in breast carcinoma patients. The clinical response to NAC guides further treatment. The pathological response is not only an independent prognostic factor, but it also guides further treatment and prognosis. Objectives The aim of our study was to find the degree of concordance between clinical and pathological response assessments after NAC in Invasive lobular Carcinoma (ILC) cases by using World Health Organization (WHO) criteria and different pathological systems, respectively. We also tried to identify any useful parameter of clinical assessment that could better correlate with pathologic assessment and provide a better estimation of residual tumor. Methods This retrospective study was conducted on 26 ILC tumors diagnosed in 24 patients who were treated with NAC followed by surgical resection between January 2009 and December 2020. Medical records and microscopy glass slides were reviewed for clinical and pathological response assessments, respectively. Results The pre-treatment tumor area ranged from 1.8-255 cm2 and the mean±SD was 52.2±66.8 cm2. After NAC, complete clinical response was observed in four (15.3%) cases. The clinically assessed mean tumor area significantly reduced from 52.2±66.8 cm2 to 17.2±22.6 cm2 (p-value

Background Pakistan has the highest incidence of breast cancer among Asian Countries but there is insufficient representation of local data addressing breast cancer treatment and outcome. We sought to determine the role of post-mastectomy radiotherapy (PMRT) in T1- T2 breast cancer with 1–3 positive axillary lymph nodes. Methods Data was reviewed retrospectively of total 755 patients out of which 291 received PMRT and 464 did not from two large breast cancer centres. Results With a median follow up of 78 months, 4 (4.5%) patients developed loco regional recurrence (LRR) in the PMRT group while a substantial number 74 (24.4%) recurred in the non PMRT group (p = 0.000). Loco regional free survival rate (LRFS) and overall survival rate (OS) was significantly better for PMRT patients than non-PMRT patients (P =, Highlights • Disease recurrence is a significant concern in post mastectomy patients with T1-T2 N1 disease. • Post mastectomy radiotherapy (PMRT) has a substantial effect in reducing disease recurrence in this subset of patients. • PMRT improves disease free survival rate (DFS) and overall survival rate (OS).

Background: Pakistan has the highest incidence of breast cancer among Asian Countries but there is insufficient representation of local data addressing breast cancer treatment and outcome. We sought to determine the role of post-mastectomy radiotherapy (PMRT) in T1- T2 breast cancer with 1-3 positive axillary lymph nodes. Methods: Data was reviewed retrospectively of total 755 patients out of which 291 received PMRT and 464 did not from two large breast cancer centres.Results: With a median follow up of 78 months, 4 (4.5%) patients developed loco regional recurrence (LRR) in the PMRT group while a substantial number 74 (24.4%) recurred in the non PMRT group (p=0.000). Loco regional free survival rate (LRFS) and overall survival rate (OS) was significantly better for PMRT patients than non-PMRT patients (P =

Synchronous primary malignancies are most frequently seen with cancers of the stomach and oesophagus, mainly attributed to the similar genetic mutations. Most of these multiple malignancies turn out to be metastatic or metachronous lesions. Multiple synchronous malignancies are rarer than metachronous ones. Primary synchronous breast and renal cancer is even rare. These patients require extensive workup to exclude all possible metastases. The nature of the primary tumours must also be confirmed, prior to any treatment strategy. We report the case of a healthy, middle-aged woman who initially presented with a lesion suspicious for breast carcinoma, and further workup revealed the presence of an asymptomatic, synchronous primary renal cell cancer, which is a very rare presentation.

Background COVID-19 outbreak has adversely affected care of breast cancer patients world-wide. There is paucity of available data on cancer management in lower-middle income countries during this pandemic, we sought to determine the institutional approach towards management of breast cancer patients and the outcomes during COVID-19 pandemic at our institution. Materials and methods Clinicopathological and treatment record of cancer patients who presented to the Breast Clinic from 15th March to 31st December 2020 was retrieved from the institutional database for this retrospective clinical observational study. Results A total of 292 patients were qualified for the analysis in which 206 patients (70.5%) underwent breast cancer surgeries. Only 10 of them (4.9%) were identified to be COVID-19 virus positive on routine pre-operative RT-PCR test before elective surgeries. All were asymptomatic, received home-based care via telecommunication and were operated at a later date when test turned out negative. None of them developed any complications post-operatively. Another group of 86 patients (29.5%) were referred for Neoadjuvant/Systemic chemotherapy in which COVID-19 infection was detected in only 4 patients (4.6%) while receiving cycles. Two patients shown symptoms of cough and fever hence hospitalised but were not candidates for Intensive Care Unit admission while other two patient were asymptomatic and isolated at home. All patients recovered well and chemotherapy was commenced again after negative RT-PCR test. No mortality was observed. Conclusion Despite of being a global crisis particularly for cancer patients we observed infectivity, complications and fatality much lower among breast cancer cases. Further research is needed in this regard including public and private sector hospitals for better understanding behavior of COVID-19 disease and achieve common goal to combat COVID-19 and cancer together.

Angiosarcoma of breast or chest wall is a rare recognized side effect in breast cancer survivors secondary to Adjuvant radiation. The treatment of angiosarcoma of the breast is carried out in number of ways. We would like to report the case of a 50-year old woman. She developed an angiosarcoma of the breast following adjuvant radiation to her conserved breast and was successfully treated with classical Cyclophosphamide, Methotrexate, and 5- fluorouracil (CMF) chemotherapy leading to a successful local surgical salvage.

Sentinel node (SN) biopsy is the standard of care for the assessment of axilla in early breast cancer patients with clinically node negative disease. Confirmed absence of tumour deposit in node on intra operative frozen section (FS) examination saves the patient from complete axillary dissection. However controversies arise when inconsistencies occur in results of frozen and permanent section. Reported sensitivity of frozen examination of sentinel node in literature ranges from 70-95%.The purpose of this study was to determine the sensitivity of frozen examination of sentinel node in breast cancer. The frozen section examination of sentinel node is not a reliable technique for accurate pathological assessment of node.Data was collected prospectively on patients with sentinel node procedure from May to December 2013. All SNs removed at surgery were submitted for frozen section and the results were compared with permanent sections.Of 50 patients 16 were true positive while 32 were true negative. Two patients reported negative on FS were confirmed to be positive on permanent section. The accuracy of frozen section was 96%, with sensitivity of 89%. In false negative cases the size of nodal metastasis was significantly smaller than that of true positive, i.e., 1-2 mm. The false negative cases were further classified for assessment into technical and interpretative error.The intra operative frozen section examination is a reliable technique for the assessment of Sentinel node with a high accuracy rate to detect metastasis size of2 mm. It spares the patient from complete axillary dissection and its subsequent morbidity of lymphedema and shoulder pain.