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In the present study, we investigated the effect of acrylamide (ACR) exposure during pregnancy on the ovary of female adult offspring of two subsequent generations. Sixty-day-old Wistar albino female rats were given different doses of ACR (2.5 and 10 mg/kg/day) from day 6 of pregnancy until giving birth. Females from the first generation (AF1) were fed ad libitum, and thereafter, a subgroup was euthanized at 8 weeks of age and ovary samples were obtained. The remaining females were maintained until they reached sexual maturity (50 days old) and then treated in the same way as the previous generation to obtain the second generation of females (AF2). The histopathological examination indicated a high frequency of corpora lutea along with an increased number of antral follicles that reached the selectable stage mainly at a dose of 2.5 mg/kg/day. Interestingly, ACR exposure significantly increased the mRNA levels of CYP19 gene and its corresponding CYP19 protein expression in AF1 females. The TUNEL assay showed a significantly high rate of apoptosis in stromal cells except for dose of 2.5 mg/kg/day. However, in AF2 females, ACR exposure significantly increased the number of degenerating follicles and cysts while the number of growing follicles was reduced. Moreover, in both ACR-treated groups, estradiol-producing enzyme CYP19A gene and its corresponding protein were significantly reduced, and an excessive apoptosis was produced. We concluded that the ovarian condition of AF1 females had considerable similarity to the typical early perimenopausal stage, whereas that of AF2 females was similar to the late perimenopausal stage in women.

BACKGROUND In the pediatric age group, middle ear tumors are rare. Rhabdomyosarcoma is considered the most common soft-tissue sarcoma in children. It comprises 5% of all pediatric malignant tumors. It is hypothesized to originate from embryonic mesenchymal cells of striated skeletal muscles. These malignant lesions display an aggressive behavior with local and distant metastasis and can be staged as per the Intergroup Rhabdomyosarcoma Study Group, depending on the organs involved, such as the orbit, head, neck, or genitourinary tract. CASE REPORT In this study, a 2-year-old boy with no medical ailments was presented with a history of ear pain and on/off bleeding from the right ear for 1 year. The patient's case was initially managed medically, for the clinical picture of an ear infection. However, clinical improvement was not seen. Therefore, radiological imaging was done. After further investigations, the diagnosis was confirmed, and a rare case of embryonal rhabdomyosarcoma of the temporal bone was reported. CONCLUSIONS Rhabdomyosarcoma is an uncommon tumor in which delayed diagnosis could cause a significant fatality rate in children. Physicians need a strong index of suspicion to make an early diagnosis. The presented case is of a 2-year-old boy with a clinical picture of a complicated ear infection who was found to have rhabdomyosarcoma of the temporal bone. Early detection and multimodal treatment are critical for a positive outcome.

Progesterone receptor (PR), estrogen receptor (ER), and human epidermal growth factor receptor 2 (HER2) significantly influence disease prognosis and therapeutic response in patients with breast cancer. Neoadjuvant chemotherapy (NACT) can change the receptor status, affecting the disease characteristics.A retrospective chart review was carried out at a single tertiary care hospital in Riyadh, Kingdom of Saudi Arabia, from December 2008 to December 2014, where 91 adult female patients diagnosed with locally advanced breast cancer planning to receive NACT were included. Original pathology and surgical histopathology reports were assessed, and patients were followed up to recurrence, death, or until December 2019. An expression for the ER, PR, and HER2 was carried out in pre and post NACT specimens by an experienced pathologist, and all HER2 with 2+ immunohistochemistry was sent for fluorescence in situ hybridization as per American Society of Clinical Oncology guidelines.ER pre- and postoperatively changed from positive to negative in 17.6% of patients and from negative to positive in 1.1% of patients (P .001). ER status remained stable in 81.3% of patients. PR changed from positive to negative in 13.2% of patients, and from negative to positive in 3.3% of patients (P .001), whereas it remained stable in 83.5% of patients. HER2 changed from positive to negative in 11% of patients, and from negative to positive in 5.5% of patients (P .001), and it remained stable in 83.5% of patients. No significant association was found between overall survival and disease-free-survival with HER2 expression change.NACT can induce changes in the ER, PR, and HER2 status, which should be evaluated post-NACT to choose the optimal treatment regimens.

Background/Introduction Despite advances in the diagnosis and management of breast cancer (BC), it is still associated with high mortality rates. New biomarkers are being developed for the diagnosis, treatment, and prediction of responses of BC. Ceramide (CER), a bioactive sphingolipid, has emerged recently as a useful diagnostic tool in several types of tumors. In this study, we evaluated CER expression in invasive BC and assessed its relation to the molecular subtypes of BC. Materials and methods The clinical data and histopathological slides of 50 patients with invasive ductal carcinoma were retrieved and reviewed. The cases were then stained with a mouse monoclonal anti-ceramide antibody. Pearson correlation was used to assess the correlation between CER percentage and intensity and other clinical and pathological variables. Results CER expression showed a direct relationship with estrogen and progesterone receptors Allred scores. However, it showed an inverse relation with tumor grade, HER2/neu status and Ki-67 index. Conclusions CER expression is likely to be associated with luminal BC molecular subtypes. However, more research is needed to confirm these results and to explore its relation to the different clinical outcomes, including response to treatment and prognosis.

Introduction: Surgical site infections (SSIs) are a major health issue in surgical specialties in terms of health care costs and patients’ clinical outcomes. At the level of the patient, prolonged hospital stays or readmissions for SSIs, can affect the patient’s quality of life. At the level of the health care system, it exhausts the hospital’s resources and increases the burden on the medical staff due to the need for continuous wound care, microbiological cultures, laboratory tests and medications. In this study, we assessed the effectiveness of two antibiotic prophylaxis regimens for the prevention of SSIs in patients undergoing elective hysterectomy surgeries. Methodology: A retrospective cohort, analyzing 141 patients, was conducted between November 2016 and January 2019 at a university hospital. We compared the efficacy of a single dose vs. 24-hour multiple doses of Cefazolin in patients who underwent elective hysterectomy for benign or malignant indications. The secondary objective was to identify potential risk factors associated with SSIs. Results: There was no statistically significant difference between both groups (p = 0.872). Obesity and a laparotomy surgical approach are risk factors to the development of SSIs (p = 0.001 and 0.014, respectively). Other potential risk factors include the duration of hospital stay, the duration of the surgery and the amount of blood loss. Conclusions: Although the rate of SSIs is not significantly different between both groups, risk stratification can be done after screening patients and the prophylactic regimen must be tailored for each patient in a cost-effective manner and using a multidisciplinary approach.

Endometriosis is a relatively common condition in which endometrial tissue is established in locations outside the uterus where, like the eutopic endometrium, it responds to hormonal stimuli and develops internal bleeding, inflammation, and fibrosis. These changes are associated with chronic and often debilitating cyclic pain and infertility. The pathogenesis of endometriosis is multifactorial, and several theories have been proposed to explain it. These include retrograde menstruation, celomic metaplasia, embryologic rests, and lymphovascular spread. Hormones, immunologic status, and genetic factors may also play a role. In most patients, the disease involves pelvic organs, but rarely it may also extend to a large variety of distant locations in the body. Patients with ovarian endometriosis are at higher risk for developing ovarian carcinomas including endometrioid and clear cell carcinomas. Some of these carcinomas may arise in a background of structural and/or nuclear atypia within the endometriotic foci. There is no known cure for endometriosis and treatment mostly consists of managing chronic pain or infertility.

Highlights • Retroperitoneal schwannoma is a rare disease and needs a high index of suspicion to be diagnosed. • Generally, retroperitoneal schwannomas are known to be non-sensitive either to radiation or to chemotherapy. • Retroperitoneal schwannomas therefore, requiring complete surgical excision with negative margins. • In retroperitoneal schwannomas, due to the presence of multiple surgical approaches and different presentations, surgical access should be individualized., Introduction Soft tissue tumors of Schwann cells in either the peripheral or cranial nerves are known as schwannomas or also as neurilemmomas. Limited data exists regarding psoas muscle schwannoma in the literature. Therefore, we have done an extensive literature review and found a total number of 46 cases of intra-psoas schwannoma including our case, which are summarized in this article along with reporting our new case. Presentation of case We report a very rare case of primary left intra-psoas muscle schwannoma in a 39-year-old Saudi gentleman, smoker with an unremarkable medical and surgical history. The patient presented to the emergency department with exacerbated chronic lower abdominal pain since almost 2 years. After conforming the diagnosis, the patient was admitted electively and underwent uneventful laparoscopic hand-assisted resection. Discussion Schwannomas are neurogenic tumors which known to be solitary, benign, well circumscribed, encapsulated, and slow-growing tumors. Multiple imaging modalities are used to detect such a tumor. Although there is no consensus on the best surgical approach, endoscopic mini-laparotomy, laparoscopy (anterior [as in our case] or lateral), and robotic resection were reported with good outcomes. Conclusion Retroperitoneal schwannoma and intra-psoas muscle variant are a rare entity, with slow growing rate and risk of malignant transformation. Therefore, high index of suspicion, good follow-up, and large-cohort studies are encouraged.

Triple-negative breast cancer (TNBC) is a very aggressive subtype with high recurrence rate and no molecular targets for therapies. This subtype is characterized by high expression/secretion of the proinvasive/metastatic interleukin-6 (IL-6) cytokine. In the present study, we have shown that tocilizumab inhibits the IL-6/STAT3 signaling and suppresses the cancer/inflammatory epigenetic IL-6/STAT3/NF-κB positive feedback loop. Furthermore, tocilizumab inhibited the proliferative and the migratory/invasiveness capacities as well as the epithelial-to-mesenchymal transition (EMT) process in TNBC cells. Importantly, tocilizumab suppressed the stemness-related characteristics of TNBC cells, through the inhibition of the Wnt/β-catenin breast cancer stem cell-related pathway. Additionally, we have shown that tocilizumab suppresses the paracrine activation of normal breast stromal fibroblasts to myofibroblats. Moreover, tocilizumab sensitized TNBC cells to the cytotoxic effect of cisplatin in vitro. Furthermore, pharmacological inhibition of IL-6 by tocilizumab had great inhibitory effect on tumor growth and the EMT process in humanized orthotopic breast tumors in mice. In addition, tocilizumab potentiated the proapoptotic effect of cisplatin in humanized breast tumors. Together, these findings indicate that tocilizumab can suppress the prometastatic capacity of TNBC cells and enhances the cytotoxic effect of cisplatin against these cells. Therefore, tocilizumab could be of great therapeutic value for these hard-to-treat TNBC patients.

Patient: Female, 46-year-old Final Diagnosis: Microcystic stromal tumor of the ovary Symptoms: Abdominal pain • vaginal bleeding Medication: — Clinical Procedure: — Specialty: Pathology Objective: Rare disease Background: Microcystic stromal tumor (MCST) of the ovary is a rare entity with distinct pathological and molecular features. However, a lack of awareness of ovarian MCST can lead to delayed diagnosis or misdiagnosis. We present a case of ovarian MCST and review all previously reported cases and discuss their clinical and pathological characteristics. Case Report: A 46-year-old woman with primary infertility due to polycystic ovary syndrome presented with bleeding and pain. Radiological images showed a complex solid and cystic adnexal mass. Microscopically, the tumor was lobulated with cellular regions separated by fibrous plaques and small anastomosing cysts, consistent with an ovarian MCST. The tumor cells showed positive staining for vimentin, CAM 5.2, CD10, β-Catenin, CD99, and cyclin D1. Genetic sequencing showed a point mutation in the CTNNB1 gene, with no mutations in the APC, BRCA1, and BRCA2 genes. The patient underwent surgery and was disease-free at 24 months after her initial diagnosis. Conclusions: The diagnosis of ovarian MCST should consider the differential diagnosis of cystic tumors of the ovary. Further research is encouraged to elucidate the various molecular pathways involved in the pathogenesis of this tumor and to determine its optimal treatment and long-term prognosis.

We report a middle aged man who was admitted with severe necrotising fasciitis following a motor vehicle accident (MVA). Histopathology of the excised tissue suggested mucormycosis while a bone tissue culture revealed fully sensitive Mycobacterium tuberculosis. He received intravenous liposomal amphotericin B combined with multiple surgical debridements and ended with right shoulder disarticulation. In addition he completed a nine months course of anti-tuberculosis treatment. He remained stable one year following his admission.We believe that trauma contributed to both conditions by direct inoculation of fungal spores and through immunological reactivation of old healed tuberculosis focus. This case highlights the importance of considering diagnosis of invasive fungal infections following MVA. Keywords: Motor vehicle accident, Necrotising fasciitis, Mucormycosis, Immunocompetent, Mycobacterium tuberculosis

Papillon–Lefèvre syndrome (PLS) is a rare autosomal recessive disorder characterized by palmoplantar keratoderma and early-onset periodontitis. It was first described by Papillon and Lefèvre in 1924. PLS is caused by mutations in the cathepsin-C (CTSC) gene. The development of malignant skin neoplasms in PLS patients is extremely rare. To date, there have been two cases of malignant melanoma (MM) in PLS patients reported in international journals. Further, only one case of squamous cell carcinoma (SCC) has been reported in PLS patients. To the best of our knowledge, no cases with basal cell carcinoma in PLS patients have been reported in literature. Thus, we report a case of a 55-year-old male from Arabic Saudi with PLS and basal cell carcinoma. The patient was homozygous for a G-to-C substitution at the nucleotide position 815 (CTSC, c.815G>Cp.(Arg272Pro), which is a pathogenic variant. Since this is not the first case of skin cancer in PLS patients, we are supporting the possibility that cathepsin-C play a role in cancer development.

Patient: Female, 71-year-old Final Diagnosis: Giant cell carcinoma Symptoms: Vaginal bleeding Medication:— Clinical Procedure: Bilateral salpingo-oophorectomy • hysterectomy • lymph node excision Specialty: Obstetrics and Gynecology • Pathology Objective: Rare disease Background: Giant cell carcinoma of the endometrium is one of the rare variants of endometrial carcinoma, with a very limited number of reported cases and limited follow-up data. The purpose of this case report is to present yet another example of endometrial giant cell carcinoma, discuss its differential diagnosis and management course, and review all previously reported cases. Case Report: We report a case of a 71-year-old woman who presented with vaginal bleeding. Her laboratory investigations were within normal limits except for her glycated hemoglobin, which was 10%. Ultrasound and computed tomography scans showed an endometrial mass invading the myometrium. Microscopically, the tumor is comprised almost exclusively of multinucleated giant cells. The patient underwent a total robotic hysterectomy with bilateral salpingo-oophorectomy and lymph nodes dissection, and she is currently undergoing adjuvant radiotherapy. Conclusions: Giant cell carcinoma of the endometrium is a rare diagnosis that can be established by histopathological examination after excluding the other common giant cell-rich lesions that may occur in the endometrium.

Background Breast cancer screening is currently predominantly based on mammography, tainted with the occurrence of both false positivity and false negativity, urging for innovative strategies, as effective detection of early-stage breast cancer bears the potential to reduce mortality. Here we report the results of a prospective pilot study on breast cancer detection using blood plasma analyzed by Fourier-transform infrared (FTIR) spectroscopy – a rapid, cost-effective technique with minimal sample volume requirements and potential to aid biomedical diagnostics. FTIR has the capacity to probe health phenotypes via the investigation of the full repertoire of molecular species within a sample at once, within a single measurement in a high-throughput manner. In this study, we take advantage of cross-molecular fingerprinting to probe for breast cancer detection. Methods We compare two groups: 26 patients diagnosed with breast cancer to a same-sized group of age-matched healthy, asymptomatic female participants. Training with support-vector machines (SVM), we derive classification models that we test in a repeated 10-fold cross-validation over 10 times. In addition, we investigate spectral information responsible for BC identification using statistical significance testing. Results Our models to detect breast cancer achieve an average overall performance of 0.79 in terms of area under the curve (AUC) of the receiver operating characteristic (ROC). In addition, we uncover a relationship between the effect size of the measured infrared fingerprints and the tumor progression. Conclusion This pilot study provides the foundation for further extending and evaluating blood-based infrared probing approach as a possible cross-molecular fingerprinting modality to tackle breast cancer detection and thus possibly contribute to the future of cancer screening.

PURPOSE Luminal, human epidermal growth factor receptor 2–negative breast cancer represents the most common subtype of breast malignancies. Neoadjuvant strategies of operable breast cancer are mostly based on chemotherapy, whereas it is not completely understood which patients might benefit from neoadjuvant hormone therapy (NAHT). MATERIALS AND METHODS The SAFIA trial is a prospective multicenter, international, double-blind, neoadjuvant phase III trial, using upfront 21-gene Oncotype DX Breast Recurrence Score assay (recurrence score [RS] < 31) to select operable luminal human epidermal growth factor receptor 2–negative patients, for induction hormonal therapy HT (fulvestrant 500 mg with or without goserelin) before randomly assigning responding patients to fulvestrant 500 mg (with or without goserelin) plus either palbociclib (cyclin-dependent kinase 4/6 inhibitor) or placebo. The objectives of this interim analysis were to assess the feasibility of upfront RS determination on core biopsies in the Middle-East and North Africa region and evaluate the efficacy of induction NAHT in patients with an RS < 31. RESULTS At the time of this interim analysis, 258 patients with relative risk were accrued, including 202 patients (RS < 31% to 78.3%) treated with induction NAHT and 182 patients evaluable so far for response. The feasibility of performing the Oncotype DX assays on core biopsy specimens was optimal in 96.4% of cases. Overall, 93.4% of patients showed hormone sensitivity and no difference in NAHT efficacy was noticed between RS 0-10, 11-25, and 26-30. Interestingly, patients with high RS (26-30) showed a trend toward a higher major response rate ( P = .05). CONCLUSION The upfront 21-gene assay performed on biopsies is feasible in our population and has allowed us to select patients with high hormone sensitivity (RS < 31). This approach could be an alternative to upfront surgery without significant risk of progression, particularly during pandemic times.

Most cervical carcinomas and their related lesions are attributed to an infection by human papillomavirus (HPV). The infection usually starts in the basal cells at the squamocolumnar junction. It causes cell proliferation and maturation abnormalities along with nuclear abnormalities resulting in low-grade squamous intraepithelial lesions. An overwhelming majority of these lesions spontaneously disappear, and the infection is cleared. In a small subset of high-risk HPV infection cases, the lesions may persist and progress to high-grade squamous intraepithelial lesions. These are associated with the incorporation of the viral genome into the human genome. Some of the high-grade squamous intraepithelial lesions, over several years, progress to invasive carcinoma. Carcinomas of the cervix are usually squamous cell carcinomas (SCCs), but 20% to 25% of the cases may manifest as adenocarcinomas. Similar to SCC, adenocarcinomas may initially manifest as adenocarcinomas in situ and may progress to invasive carcinomas after a variable period of time. In the recently published World Health Organization classification of female genital tumors, SCCs, and adenocarcinomas of the cervix are divided into HPV-associated and HPV-independent tumors. This review draws on the latest terminology and the several morphologic subtypes recognized for each category.

Patient: Female, 32-year-old Final Diagnosis: Leiomyoma with massive cystic hydropic degeneration Symptoms: Abdominal distension • abdominopelvic mass • pelvic pain • urinary frequency Medication: — Clinical Procedure: Surgery Specialty: Obstetrics and Gynecology • Pathology • Surgery Objective: Rare disease Background: Leiomyomas are the most frequent benign tumors of the uterus. They often exhibit degenerative changes (hyaline, myxoid, hemorrhagic, hydropic, and cystic), which lead to varying and sometimes challenging clinical, radiological, and histopathological features. We present this case to highlight the importance of recognizing these variants and their differential diagnosis since they resemble forms of uterine sarcomas with a potential for misdiagnosis. Case Report: A 32-year-old single woman presented with large pelviabdominal masses mimicking, clinically and radiologically, an aggressive uterine or ovarian tumor. The masses collectively measured 33×24×15 cm, and a definite intraoperative diagnosis could not be made. Resection showed a giant leiomyoma with massive cystic hydropic degeneration. The patient underwent myomectomies with transposition of the ovaries into the lateral abdominal wall. Although the surgery was complicated by a massive hemorrhage with an approximate blood loss of 6 liters requiring blood transfusion and bilateral internal iliac artery ligation, the patient was discharged home on the fourth day after surgery, with an uneventful 16-month follow-up. Conclusions: Few leiomyomas showing this marked degree of hydropic degeneration have been reported in the literature. The differential diagnosis includes uncommon variants of leiomyomas (eg, intravenous leiomyomatosis), as well as uterine sarcomas (eg, low-grade endometrial stromal sarcoma) and ovarian carcinomas. Therefore, appropriate evaluation of the clinicopathological features is vital to ensure appropriate management and not to erroneously diagnose a benign leiomyoma as a more aggressive type of tumor.

Patient: Male, 11-month-old Final Diagnosis: Microphthalmos with massive retinal gliosis Symptoms: Microphthalmos with no useful vision, left eye Medication: — Clinical Procedure: Enucleation, left eye Specialty: Ophthalmology • Pathology Objective: Congenital defects/diseases Background: Massive retinal gliosis (MRG) is a rare benign intraocular tumor that results from the proliferation of well-differentiated glial cells in response to long-standing pathological processes, including glaucoma, trauma, chronic inflammation, vascular disorders, and congenital anomalies. This lesion is considered to be nonneoplastic and occurs ≥10 years after the predisposing insult. It usually affects children and can mimic other conditions, including uveal melanomas, vasoproliferative tumors of the retina, astrocytic hamartomas, and retinal hemangioblastomas. Case Report: We present a case of infant MRG with severe left eye microphthalmia. An 11-month-old boy was presented by his parents in the Oculoplastic Unit of a teaching university hospital with bilateral incomplete cryptophthalmos and small globes. An enucleation of the left globe was carried out to stimulate orbital bone growth and to improve the cosmetic outcome. The histopathological examination revealed a microphthalmic globe with sclerocornea and disorganized intraocular anterior segment structures. The retina was dysplastic with proliferating spindle-shaped glial cells showing fibrillar eosinophilic cytoplasm and filled most of the vitreous cavity. The glial origin of the cells was confirmed by the immunohistochemical markers (glial fibrillary acidic protein and synaptophysin), supporting the diagnosis of MRG. The optic nerve was markedly hypoplastic. Conclusions: MRG is a rare intraocular tumor that is clinically difficult to diagnose. A definite diagnosis can be made only on the basis of a histopathological examination and immunohistochemical markers.

Mental health issues during the perinatal period are common, up to 29% of pregnant and 15% of postpartum women meet psychiatric diagnostic criteria. Despite its ubiquity, little is known about the longitudinal trajectories of perinatal psychiatric illness. This paper describes a collaboration among six perinatal mental health services in Quebec, Canada, to create an electronic databank that captures longitudinal patient data over the course of the perinatal period. The collaborating sites met to identify research interests and to select a standardized set of variables to be collected during clinical appointments. Procedures were implemented for creating a databank that serves both research and clinical purposes. The resulting databank allows pregnant and postpartum patients to complete self-report questionnaires on medical and psychosocial variables during their intake appointment in conjunction with their clinicians who fill in relevant medical information. All participants are followed until 6 months postpartum. The databank represents an opportunity to examine illness trajectories and to study rare mental disorders and the relationship between biological and psychosocial variables.

Purpose: Triple-negative breast cancer (TNBC) is a subset of breast cancer which is known to carry a poor prognosis because of lack of targets for hormonal therapy. Research efforts have focused in recent years on discovering biomarkers of management in TNBCs. KI-67 Labelling Index (LI) is a nuclear protein which has proven to play diagnostic and prognostic roles in many cancers. Materials and methods: We analysed the expression of KI-67 LI by immunohistochemistry in TNBC cases from the University hospital. This expression was cross-checked against clinical-pathological criteria of TNBC patients and against Vimentin expression in TNBC patients with significant KI-67 expression. Results: KI-67 LI was significantly expressed in the majority of TNBC cases. This expression was significantly correlated with lymph node metastases, tumour invasion, high tumour nuclear grade, clinical stage, adverse survival outcome, and failure to achieve pathological complete response. TNBCs’ KI-67 LI expression was also correlated with Vimentin expression, the mesenchymal chief marker of the EMT phenomenon. Conclusion: Collectively, our study presents a strong argument for the use of KI-67 LI as a biomarker of aggressive, metastatic TNBC disease with poor outcome. This study, along with mounting evidence in the scientific literature, presents a case for the use of this nuclear protein in diagnosis, prognosis, and follow-up of patients with this difficult diagnosis.

Introduction Cervical cancer (CC) is the 8th most common cancer among Saudi women of all ages. With limited national data, we aimed to evaluate the public awareness in regards to CC risk factors, HPV infection and HPV vaccines in the different regions of Saudi Arabia. Methods This is a survey-based cross-sectional study that encompassed 564 Saudi women during a period of a month. A self-administrated questionnaire was distributed through different social media platforms. Data collected included socio-demographic variables and questions assessing the awareness of CC and the attitudes in regards to CC screening and HPV vaccine. Result Most respondents were aware of CC (474, 84.0%) though their primary source of information was the internet. However, only 45 females (8%) gave a history of cervical screening. Furthermore, most females did not know that HPV is transmitted sexually (78.9%) or that it causes genital warts (81.7%) and CC (81.9%). In regards to the HPV vaccine, 100 females (17.7%) have heard about it but only 11 (2%) took the vaccine though more than half of the respondents (305, 54.1%) were willing to take the vaccine after being informed about it. Conclusion There is a remarkably lack of awareness within the Saudi women regarding the HPV clinical implications, HPV vaccine, its importance and its availability. The main resource of information for most Saudi women is the internet which may be unreliable or providing misleading information that may delay screening or discourage vaccination. Thus, organized campaigns by the Ministry of Health or other health advocating agencies are strongly encouraged.

Patient: Female, 30-year-old Final Diagnosis: Early detection of rectal cancer in pregnancy with good outcome Symptoms: Rectal bleeding Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology Objective: Unusual clinical course Background: Colorectal cancer (CRC) in pregnancy is very rare. It is often associated with poor prognosis which is contributed to delayed diagnosis due to the overlapping symptoms of CRC and pregnancy. The purpose of this case report is to highlight the importance of early diagnosis and treatment of CRC in a young pregnant patient with good maternal and fetal outcomes. Case Report: A 30-year-old patient, gravida 3, presented at 9-week gestation with a history of sudden painless, fresh, rectal bleeding with no aggravating factors such as constipation or hemorrhoids. Sigmoidoscopy showed a small fungating, intramural mass, 40 cm from the anal verge, which easily bled upon touch. The rest of the colon up to the terminal ilium was normal. The mass was completely removed during the sigmoidoscopy procedure, and the histopathological diagnosis was a tubulovillous adenoma with focal intramucosal carcinoma. After the polypectomy procedure, the patient had an uneventful, bleeding-free pregnancy and delivered a healthy baby at full term. The sigmoidoscopy procedure was considered to be both diagnostic and therapeutic since the entire mass was completely removed. Conclusions: Early diagnosis and intervention are critical in improving the overall outcome of CRC in pregnancy and requires a high index of clinical suspicion. Taking a detailed patient history, exercising attentiveness, and conducting thorough investigations of all symptomatic pregnant women are recommended. Treatment options should involve a multidisciplinary team with consideration to the patient’s own choices.

Mucormycosis is a rare fungal infection with an extremely high morbidity and mortality. Data on the burden of the disease in the Arab world is lacking. The aim of this study is to highlight the incidence and outcome of this infection in a tertiary care center in the Kingdom of Saudi Arabia (KSA). In this retrospective study we included all mucormycosis cases admitted to our center between January 2013 and December 2019. A total of 18 proven patients with a median age of 43.5 years (range 13–72 years, 72% males) were identified. The most common presentation was cutaneous and rhino-orbito-cerebral, followed by gastrointestinal mucormycosis. Apophysomyces variabilisRhizopus oryzae) were the main fungal isolates on molecular testing. Trauma was the chief underlying etiology (41.0%) with motor vehicle accident (MVCs) being the predominant type (43.0%). For this reason, most of our patients were young with cutaneous disease and had a better prognosis. All patients received liposomal amphotericin B alone or in combination with other antifungal agents. Repeated aggressive debridement and reversal of the underlying factor was attempted in all patients. This underscores the lower mortality (27.8%) seen in this group. The diagnosis of Mucorales infection is challenging. A high index of suspicion with prompt treatment is required to improve the high mortality of this aggressive disease. Further studies are needed to understand the epidemiology and outcome of this disease in Saudi Arabia.

Gonadoblastoma is an uncommon ovarian tumor arising primarily in females with gonadal dysgenesis and a 46, XY karyotype. Germ cell tumors arising within and/or overgrowing a gonadoblastoma have been reported. We report a rare case of a malignant mixed germ cell tumor (yolk sac tumor and choriocarcinoma) arising in a gonadoblastoma of the left ovary in a 19-year-old female with a 46, XX karyotype. The patient's initial α-fetoprotein level was 20 000 KIU/L. The patient underwent a laparoscopic unilateral salpingo-oophorectomy with omentectomy and peritoneal washing followed by adjuvant chemotherapy.

Background Most breast cancer-associated fibroblasts (CAFs) are active and important cancer-promoting cells, with significant impact on patient prognosis. Therefore, we investigated here the role of the protein kinase ATR in breast stromal fibroblasts in the prognosis of locally advanced breast cancer patients. Methods We have used immunohistochemistry to assess the level of ATR in breast cancer tissues and their adjacent normal tissues. Immunoblotting as well as quantitative RT-PCR were utilized to show the role of breast cancer cells and IL-6 as well as AUF-1 in downregulating ATR in breast stromal fibroblasts. Engineered human breast tissue model was also used to show that ATR-deficient breast stromal fibroblasts enhance the growth of breast cancer cells. Results We have shown that the protein kinase ATR is downregulated in cancer cells and their neighboring CAFs in breast cancer tissues as compared to their respective adjacent normal tissues. The implication of cancer cells in ATR knockdown in CAFs has been proven in vitro by showing that breast cancer cells downregulate ATR in breast fibroblasts in an IL-6/STAT3-dependent manner and via AUF-1. In another cohort of 103 tumors from locally advanced breast cancer patients, we have shown that absence or reduced ATR expression in tumoral cells and their adjacent stromal fibroblasts is correlated with poor overall survival as well as disease-free survival. Furthermore, ATR expression in CAFs was inversely correlated with tumor recurrence and progression. Conclusion ATR downregulation in breast CAFs is frequent, procarcinogenic, and correlated with poor patient survival.

Objectives To study the correlation between endometrial thickness (ET) and histopathological hyperplasia to come up with an algorithm to guide the management of patients with postmenopausal bleeding when endometrial sampling is not possible for any reason such as patient refusal, or unavailability of the test. Methods In this retrospective cohort, we identified 121 patients with histopathological confirmation of endometrial hyperplasia (EH) then we reviewed their ET on ultrasound scans (USS) at the time of obtaining their endometrial samplings using different cutoffs. Results The sensitivity of the ultrasound, using the cutoff for the ET as 8 mm was 84.3%. The positive predictive value (PPV) of the USS was found to be 61.4% with a prevalence of 56.3%. When we used 7mm as cutoff, the sensitivity of the ultrasound to identify the patients with EH was 90.9%. The PPV was found to be 58.8%. When we used 6mm as cutoff, the sensitivity of the ultrasound to identify the patients with EH was 96.7%. The PPV of the US was found to be 57.9%. Conclusions In postmenopausal women, endometrial thickness correlates significantly with histopathological EH. In the absence of endometrial sampling, the presence of thickened endometrium is an independent predictor for EH specifically if there is one or more of the risk factors for endometrial cancer such as Obesity, DM or HTN. An algorithm using ET and risk factors can be of great help in guiding the management of these patients where endometrial sampling is not possible.

Objective : To evaluate the molecular subtypes of Mammary Paget’s disease (MPD) and the associated breast carcinomas. Methods : This retrospective study was carried out at King Khalid University Hospital and King Faisal Specialist Hospital, Riyadh, Saudi Arabia. Data from MPD patient cases from January 2010 to June 2016 were reviewed. The molecular subtypes were determined based on estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) expression with immunohistochemical staining. The relative frequencies of the luminal A and B, HER2-enriched and basal-like molecular subtypes were calculated and compared for MPD and the associated breast carcinomas. Results : Among 22 patients with MPD, HER2-enriched was the most frequently occurring molecular subtype and was observed in 11 (50%) patients. Mammary Paget’s disease was classified as basal-like in 5 (22.7%) patients, and luminal A and B were each detected in 3 (13.6%) patients. The molecular subtype of MPD corresponded with the subtype of the associated breast carcinoma in 18 out of 20 patients (90%). Conclusions : The HER2-enriched subtype is the most frequently occurring molecular subtype in MPD. The molecular subtype of the associated breast carcinoma is usually similar to that of MPD. The molecular subtypes vary between MPD associated breast carcinoma and overall breast carcinoma. The HER2-enriched subtype is the most frequently occurring subtype of MPD associated breast carcinoma, while luminal subtypes are more common in overall breast carcinoma. Saudi Med J 2019; Vol. 40 (5): 440-446 doi: 10.15537/smj.2019.5.23967 How to cite this article: Arafah M, Arain SA, Raddaoui EMS, Tulba A, Alkhawaja FH, Al Shedoukhy A. Molecular subtyping of mammary Paget's disease using immunohistochemistry. Saudi Med J . 2019 May;40(5):440-446. doi: 10.15537/smj.2019.5.23967.

Ethnopharmacology relevance Schinus terebinthifolius is traditionally used for its anti inflammatory capacity, and indicated as a cardioprotective agent, whereas, its preventive effect against atherogenic diet fed (AD) induced metabolic disorders and the underlying mechanisms has not yet been explored. Aim of the study This study was undertaken to investigate the ameliorative role of Schinus terebinthifolius fruits extract (STFE) against cardiovascular problem, oxidative and inflammatory status related to obesity in rats fed an atherogenic diet. Materials and methods The metabolites profile in STFE was evaluated using HPLC-DAD-ESI-QTOF-MS/MS analysis. In Wistar rats, atherogenic diet was added for 9 weeks to induce lipid accumulation simultaneously with STFE (50 mg/kg b. w) or saline treatment. Biochemical, oxidant, and inflammatory criteria together with hepatic and arterial integrity examination were assessed. Results A total of thirty three metabolites were identified using HPLC-DAD-ESI-QTOF-MS, among them masazino-flavanone was the major compound (2645.50 μg/g DW). The results indicated that STFE supplementation during 9 weeks (50 mg/kg b. w.) significantly attenuated the altered lipid profile by decreasing the levels of TC, TG, LDL-C and increasing the HDL-C content both in plasma and liver, when compared with the AD-group. The histological analysis using ORO staining revealed a decrease in the lipid droplet deposit in the cytoplasm of hepatocytes of STFE + AD group. The addition of STFE could improve the glycemic status of AD-treated rats by decreasing the glucose and insulin secretion, and ameliorating the hepatic glycogen synthesis. The harmful effects of atherogenic diet on hepatic oxidative stress indicators (MDA, PC, GSH, SOD, CAT, and GPx), biochemical markers (AST, ALT, LDH and ALP), and liver function, were found to be decreased by the addition of STFE. Moreover, the reduction of inflammatory markers (CRP, IL-6 and TNF-α), associated to alleviating of aortic oxidative stress and integrity, highlighted the positive anti-atherogenic effect of STFE. Conclusion Overall, the pleiotropic protective effect observed with S. terebinthifolius fruits might be related to the presence of various bioactive compounds.

Introduction: Early detection of breast cancer plays a pivotal role in the outcome of the disease. Diagnostic modalities encompass radiological and pathological findings. The aim of this study is to evaluate the correlation between the results of these two modalities in a tertiary hospital. Materials and Methods: From a total of 180 patients, 203 ultrasound-guided breast core needle biopsies (US-CNBs) were included in this study over a period of a year (May 2015 - May 2016). All clinical parameters, the site of the biopsy, the size of the needle, the radiological findings, the pathological diagnoses as well as all available follow-up data were reviewed. The concordance between the radiological and pathological results was studied and a statistical analysis conforms to the Pearson Chi-square test was applied. Results: The majority of our patients were above 40 years of age. A strong and statistically significant association was noted between radiological findings and histopathological results (Pearson's Chi-square test = 186.28, P ≤ 0.0001) with only four discordant cases (1.97%). This discrepancy was not statistically associated with age, site of biopsy, needle size, or number of cores obtained (P = 0.621, P = 0.584, P = 0.786, and P = 0.478, respectively). Conclusions: US-CNB is an accurate method in the diagnosis of breast lesions. Radiological and pathological correlation is of utmost importance in relation to patient's care and to reduce false rates. Follow-up of concordant benign lesions is essential. In addition, the importance of a multidisciplinary breast conference during which input from all teams caring for the patient is strongly emphasized.