Annals of Pathology and Laboratory Medicine

Bone Marrow Cytomorphology And Clinico-Hematological Profile of Metastatic Solid Tumors: A 5-Year Audit from A Tertiary Care Centre in Northern India

Vijay Kumar — 2019-03-16

Introduction: Metastasis to bone marrow by solid malignancies is a rare event and it upgrades the tumor thereby worsening the prognosis. This is caused by an impaired response to therapy and other manifestation resulting from decreased hematopoiesis. The common malignancies to metastasize in male and female are carcinoma prostate and carcinoma breast, respectively. It is noted that metastasis from small round cell tumor (SRCT) predominates in children. Here, we present a series of cases of bone marrow metastasis by solid organ malignancies over a period of 5 years.

Objectives: The aim of this study was to investigate the clinical and hematological characteristics of patients with BM metastases of solid tumors diagnosed by bone marrow (BM) aspiration.

Materials & methods: In this study, we reviewed 3520 bone marrow aspirates in our hospital from January 2013 to December 2017. Patients diagnosed with solid malignancies metastasizing to bone marrow were selected.

Results: We found a total of 26 cases of solid malignancies with metastasis to bone marrow. The age of the patients ranged from 2–88 years (mean age of 46 years). Most of the patients were adults (19/26), of which 77.7% were males. Seven of the 26 patients were in the pediatric age group, with an age range of 2-11 years. Various malignancies metastasizing to marrow were evaluated and clinical and hematological correlation was done. The common presenting sign & symptoms were fever, anorexia and bodyache and organomegaly. Anemia was the most common hematological finding at the time of admission. Carcinoma prostate was the most common metastatic tumor in adults and small round cell tumor in children.

Conclusion: BM is one of the important and infrequent sites of metastasis of solid tumors. Detection of bone marrow metastasis has significant clinical implication with impact on therapeutic decisions and is associated with poor prognosis. Aspiration of the BM provides an easy and quick way of detecting involvement, however, biopsy with immunohistochemical and/or molecular techniques may be needed in case of microscopical tumor burden.

Celiac Disease: Comparison of Oberhuber Classification and Corazza- Villanacci Classification

Shikha Ghanghoria — 2019-03-17

Background: Celiac disease occurs in genetically predisposed individuals on consumption of certain grains. The diagnosis is based on biopsy showing the presence of characteristic histological changes in duodenum and jejunum that improve after gluten free diet. The Oberhuber Classification is very widely used by pathologists. The new Corazza-Villanacci Classification simplifies the criteria.

Methods: Retrospectively diagnosed 200 patients of Celiac disease according to Oberhuber classification over duration of 05 years were considered. The 200 cases were retrieved from the records and were sent to two pathologists, who were blinded to each other and were not given any clinical information. Each pathologist received the set of biopsy specimens on two separate occasions and had reclassified them according to both grading systems in a random order. The interobserver variation was then determined after re-examination according to Oberhuber classification and after using to Corazza-Villanacci classification too

Result: Mean kappa values were 0.77 (good) for the Oberhuber classification versus 0.98

(very good) for the Corazza -Villanacci classification

Conclusion: The Corazza-Villanacci classification gives better interobserver agreement compared with the Oberhuber classification and contributes to the validity of diagnosis in celiac disease.

Correlation of Serum Tissue Transglutaminase Antibody Levels and Marsh Grading of Duodenal Biopsy in Patients of Celiac Disease

Benjith Paul — 2019-03-17

Background: Celiac disease (CD) is a chronic small intestinal immune-mediated enteropathy precipitated in genetically predisposed individuals by ingestion of wheat gluten and related proteins of barley and rye. It is an under-diagnosed gluten-sensitive enteropathy, usually presenting with atypical/extra-intestinal features. Duodenal biopsy is considered as the gold standard in the diagnosis of CD. Serum anti tissue transglutaminase (anti-tTG) antibodies is auto antibodies directed against tissue transglutaminase (tTG) enzyme. Aims and objective: The aim of the study is to find out the prevalence of CD among clinically suspected cases of malabsorption, to assess the correlation of anti-tTG levels with modified Marsh grading of duodenal biopsy, to find out sensitivity, specificity and predictive values of anti-tTG test and to calculate the cut off values of anti-tTG diagnostic of high grade CD.

Methodology: The present study included 118 clinically suspected patients of malabsorption in which both duodenal biopsy and anti-tTG test was done. The mucosal damage graded according to the modified Marsh grading and anti-tTG tests were done in serum using ELISA kit.

Results: The prevalence of CD among clinically suspected cases of malabsorption was 12.7%. The incidence was highest in middle aged male patients. The most common clinical symptom was chronic diarrhea and commonest presenting sign was anemia. Anti-tTG levels were found to be proportionately increasing with the severity of CD and showed a positive correlation(r=0.433). Patients with anemia and chronic diarrhea showed statistically significant (p value=0.0242 and 0.0089 respectively) mean anti-tTG levels in Celiac patients in relation to non-Celiac patients. Although the mean levels of anti-tTG was 6.3 times higher than baseline in grade 3 disease, the ROC analysis showed that anti-tTG in isolation had no significance in exactly grading the disease (AUC=0.30).

Conclusion: Positive correlation was found between anti-tTG levels and modified Marsh grading. Anti-tTG showed proportionate increase with severity of duodenal damage. Anti-tTG test showed low sensitivity (42.86%) and high specificity (84.34%). Hence it is not a reliable tool in isolation to screen CD but should be used in combination with duodenal biopsy. It can be used to assess the severity of CD and for follow up.

Meningioma: A Clinicopathological Correlation

Asha Shenoy — 2019-03-26

Background: This study aimed at classifying meningioma and its variants based on histology, and study its clinicopathological correlation. This analytical study conducted in a tertiary referral centre included clinical presentation, radiological features and histopathological correlation of meningioma. The grading system of meningioma is based on histological features. Difference in subjective assessment can hamper this grading system. A continuous revision of the histopathology of meningiomas and taking into account precise definitions of features such as small cell changes, hypercellularity, sheeting, necrosis, and mitotic count is necessary to improve the accuracy for diagnosis grading of these tumours.

Methods: A retrospective and prospective study of meningiomas was carried out in the department of Pathology at a tertiary care hospital over a period of 5 years (July 2011 to June 2016). Clinical presentation, radiological features and histological findings were taken into consideration.

Result: Of the 277 cases of lesions of central nervous system, 63 cases were diagnosed as meningioma, the incidence being 22.74%. Most these cases were in the 4th to 6th decade of life (71.42%). The overall male to female ratio was 1: 2.3. The commonest clinical feature was headache (58.73%) followed by limb weakness (33.33%). The most common location was cerebral hemisphere (49.20%). There were 7 cases of spinal meningioma. Most of the meningiomas were hyperdense (60.8%) on CT and iso to hypointense (90%) on MRI.Most of the cases were Grade I meningiomas (88.89%), meningothelial and transitional being the most common histological subtypes. Two of the grade II meningioma cases showed presence of brain invasion.

Conclusion: Histopathological examination is an imperative tool for confirmatory diagnosis due to the diverse histological variants. Also, the prognosis of the disease depends on histopathological grading of the lesion.

Role and Significance of Hematological parameters in Diabetes Mellitus

Rafae Farooqui — 2019-03-26

Background: Diabetes mellitus is a global metabolic disorder characterized by persistent hyperglycemia and increased risk of microvascular and macrovascular complications. Consistent elevation of HbA1c can be associated with functional and structural changes in hemoglobin molecule, cytoplasmic viscosity and osmotic disturbances within red cell. These changes may be reflected in the red cell analytical parameters.

Methods: 120 subjects were studied. 41 were non diabetic healthy subjects (Group1). 79 were known diabetic patients, divided into two groups: HbA1c <7(39 subjects) Group 2 and HbA1c >7(40 subjects) Group 3.

Sample for glucose estimation and CBC were collected in vacutainers containing sodium Fluoride and K ₂EDTA respectively. Glucose, HbA1c and CBC estimation was carried out by auto analyzers.

Result: Mean RBC count of diabetics with HbA1c<7 was less when compared to non-diabetic individuals. Significant decrease was noted in the mean RBC count, Hb, HCT and MCV of diabetics with HbA1c>7 when compared to non diabetic individuals. There was significant decrease in mean Hb, HCT, MCV, MCH of diabetics with HbA1c >7 when compared to diabetics with HbA1c <7.

Conclusion: The findings in the present study suggest that diabetic patients with poor control are more prone to develop anemia. This indicates a need for routine CBP examination for early detection and management of anemia in diabetic patients at the primary care setting to reduce associated morbidity due to lowered immunity associated with anemia and complications such as diabetic ketoacidosis.

Histopathological Spectrum of Oral Cavity Lesions at A Tertiary Care Hospital in South India

Beena Mary Thomas — 2019-03-27

Background: Oral cavity lesions are usually asymptomatic. Oral cancer is the most common type of cancer among males in India. Proper management of patients begins with an accurate diagnosis and histopathology is considered as the gold standard. The objective is to study the pattern of oral cavity lesions in a tertiary care hospital, Kannur, Kerala.

Methods: A 1 ½ year retrospective study was carried out and included all the oral cavity specimens received in the Department of Pathology. The parameters analyzed were age, gender, site & histopathological diagnosis of the lesion. H & E slides were reviewed.

Result: A total of 107 cases were studied. Age ranged from 5 years to 90 years. Males and females were equally affected (M:F = 1.05:1). Buccal mucosa was the commonest site involved. 24 cases (14 malignant,10 benign and 4 premalignant) were neoplastic and the rest were non neoplastic. Squamous cell carcinoma (11.2%) was the most common malignant lesion with favoured sites being buccal mucosa followed by tongue and tonsil.

Conclusion: Good clinical examination combined with accurate histopathological study is essential to confirm the nature of the lesion.

Study to Evaluate Prediction of Invasion in Breast Carcinoma Diagnosed on FNAC

Alpeshpuri P Goswami — 2019-03-27

Background: FNAC is minimally invasive, produces a speedy result and is inexpensive than biopsy. This remains one of the most important technique from a practical point of view for diagnosis in most of breast lesion. Tubular or angular epithelial structures, malignant cells adherent to fibrous stroma, presence of intracytoplasmic lumina in malignant cells, fibroblast proliferation and fragments of elastoid stroma were predictive of invasion if associated with breast carcinoma.

Objectives: To evaluate invasion criteria in fine needle aspiration cytology (FNAC) of histologically diagnosed invasive breast carcinoma.

Material and methods: A prospective study of FNAC of breast lesions was carried out along with its histopathological correlation. All cases were diagnosed as invasive breast cancer in histopathological examination. All cytological breast cancer was evaluated for five features of invasive carcinoma.

Results: We found that out of five predictive features Malignant Cells Adherent to stroma and Fibroblast Proliferation are most frequently seen in invasive breast carcinoma and their predictive value 78.26% for the both. Intracytoplasmic lumina in malignant cells and Fragments of elastoid stroma are the least features seen in invasive breast carcinoma and their predictive value 39.13% and 52.17%.

Conclusion: In our study of prediction of invasion in breast carcinoma by FNAC, malignant cell adherent to stroma and Fibroblast proliferation are most consistent findings in invasive breast carcinoma. Intracytoplasmic lumina in malignant cells is least seen among breast carcinoma.

Evaluation of The Role of Transrectal Fine Needle Aspiration As A Diagnostic Modality in The Diseases of Prostate with Review of Literature

Ansar A Khan — 2019-04-08

INTRODUCTION: Transrectal fine needle aspiration cytology is feasible, reliable and highly sensitive diagnostic tool for the diagnosis of prostatic diseases. It mostly involves the elderly men, whose population is increasing in our country with the demographic shift of longitude.

AIMS AND OBJECTIVES: To evaluate the sensitivity, specificity and positive productive value of transrectal fine needle aspiration cytology in addition to other advantages so that it could be accepted as a primary screening tool in the selection of the patients for biopsy and treatment of prostatic lesions.

MATERIAL AND METHODS: Transrectal FNAC was performed in 49 patients, in clinically diagnosed cases of prostate diseases. Histomorphology was also carried out.

RESULTS: Satisfactory smears could be obtained in 93.9% cases on first aspiration. The diagnostic accuracy for inflammatory disease was highest (100.0%), followed by malignant (88.8%), and benign lesions (82.9%), with a positive predictive value of 100.0% for malignancy of the prostate. False positivity was seen in 2.09% and false negativity in 11.2% cases.

CONCLUSIONS: Transrectal FNAC is an accurate, sensitive, highly specific procedure with a high positive predictive value with negligible complication with an additional advantage of possible assessment of prognosis.

Cutaneous Pseudolymphoma: A Brief Review and Report of a Case Treatment Using Rituximab

Akbar Mokhtarpour Neilagh — 2019-03-17

Cutaneous pseudolymphoma (C-PSL) is characterized by heterogenous lymphoproliferative processes contributing to skin lesions which histologically and clinically mimic malignant cutaneous lymphomas. It is of most importance to diagnose such case precisely and discriminate them from malignant lymphomas since treatment protocols are distinctive. Standard medical approaches for C-PSL includes elimination of causative factors, topical, intralesional and systemic steroids, hydroxychloroquine, and photodynamic therapy. Rituximab as an anti CD20 monoclonal antibody was used in this study to treat a patient with 8 years clinical features of pseudolymphoma with no positive response to routine medications. Follow up of almost more than 18 months revealed a successful treatment without noticeable side effects or disease recurrence.

Pancoast Tumor: A Rare presentation of Hepatocellular Carcinoma

Enam Murshed Khan — 2019-03-19

Lung is the first most common site for metastasis of hepatocellular carcinoma. Pancoast’s tumor is usually caused by adenocarcinoma of lung. Hepatocellular carcinoma is very notorious in remaining asymptomatic for prolonged time. But metastatic Hepatocellular carcinoma presenting as apical lobe lung mass eroding the ribs (Pancoast’s tumor) is unusual.

We, describe here a 66year old male who presented with left shoulder pain which was subsequently diagnosed to be due to metastatic tumor of upper lobe lung from liver primary.

To our knowledge Pancoast’s syndrome due to metastatic hepatocellular carcinoma is rare and only two cases have been reported previously to the best of our knowledge. This case report will allow the clinicians to consider metastatic HCC as a differential for Pancoast’s tumor.

Diagnostic Pleural Fluid Cytology of Nocardial Infection in A Patient of Systemic Lupus Erythematosus

Sneha Singh — 2019-03-19

Systemic lupus erythematous is a chronic autoimmune inflammatory connective tissue disease. Infection remains the major cause of morbidity and mortality in such autoimmune disorders. Nocardia is an uncommon opportunistic pathogen. Due it its low incidence it is often missed by clinicians and pathologists. Delay in diagnosis and treatment is the major cause of dissemination and complications of this disease. Here we report a case of nocardiosis diagnosed on pleural fluid cytology smears using special stains.

A known case of systemic lupus erythematous diagnosed 7 years back complained of heaviness in chest, shortness of breath and fever. Ultrasonography of chest showed pleural effusion and consolidation of underlying lung. Pleural fluid was aspirated and sent for cytology. Giemsa and Papaniculaou stained smears showed dense degenerated acute and chronic inflammatory cells in a necrotic background with negatively stained shadows which were negative for ZN and PAS stains. However, gram stain and modified ZN stain (1%H2SO4) showed positively stained clumps of long branching filamentous organism; consistent with Nocardia spp which was later confirmed by culture studies.

This case highlights the importance of high index of suspicion for nocardia in cytology samples of pulmonary origin, especially in cases patients with immunosuppressed states. More so special stains like Gram’s stain and modified ZN stain in such cases can aid in a definitive diagnosis.

Typical Carcinoid: Cytological Diagnosis of a Case and Mimickers in Cytological Sampling Techniques with Brief Review of Literature

Shashikant Singh — 2019-03-19

Typical carcinoids are the most well differentiated and least aggressive of pulmonary neuroendocrine tumors. Cytologic diagnosis on trans bronchial needle aspirate (TBNA) smears is quite diagnostic; however, may be challenging on other cytologic specimens like bronchial brushings and bronchial washings. We discuss such a case of typical carcinoid in a 30 years old female.

Young Immunocompetent Individual Positive for Histoplasma Capsulatum on Bronchoalveolar Lavage Fluid Cytology

Nabila Afsar — 2019-03-27

Primary pulmonary histoplasmosis is a lung disease caused by dimorphic fungus Histoplasma Capsulatum. Bronchoalveolar fluid cytology is routinely performed as an inexpensive test even in under equipped laboratories. A 26 year old female, presented with persistent cough, evening rise of temperature and generalised weakness since 3 months and streaky hemoptysis since 3 weeks. CT showed consolidation in lower lobe of left lung and multiple mediastinal nodes in perivascular (aortic arch ) region and in sub carinal region. Bronchoscopy showed purulent exudates in lower lobe (6^th segment of left lung). Bronchoalveolar lavage fluid was obtained and subjected to cytological evaluation and microbiological examination for Acid Fast bacillus. Cytosmears revealed macrophages with engulfed clusters of single walled yeast cells. The suspicion of Histoplasma was raised and the fluid was sent for fungal culture and Antigen testing was performed.

Histoplasma Capsulatum can present in immunocompetent individuals and a strong suspicion must be made in patients with history of travel to endemic areas. Pathologist needs to look for the yeast cells even in immunocompetent individuals while routine screening of the BAL fluid cytosmears. Special staining may be resorted to, in individuals with high suspicion and positive history. Confirmation may be done by fungal cultures and antigen testing.

Amoebic Cerebral Abscess: Still A Diagnostic Dilemma with Fatal Outcome

Akriti Jindal — 2019-03-27

Amoebiasis is defined as infection with Entamoeba histolytica, which enters the body through feco – oral route after consumption of food or water contaminated by cysts. We present a rare case of amoebic brain abscess in a 45 years old patient who came with headache, fever and right sided weakness for 15 days. He was emperically being treated for tuberculosis. As Entamoeba was not suspected, no serological or microbiological investigations for the same were done. Histopathological examination of abscess sent after frontal lobectomy revealed trophozoites of Entamoeba histolytica. Demonstration of trophozoites of Entamoeba on histopathology sections was a surprising finding which clinched the diagnosis in this case. Amoebic brain abscess should be considered as differential diagnosis in all patients who present with signs & symptoms of central nervous system involvement in endemic areas. Early diagnosis and aggressive management with metronidazole is imperative to limit the morbidity and prevent the mortality.

Case of Squamous Cell Carcinoma Transformation in Ovarian Mature Cystic Teratoma

Pratibha Chandra — 2019-03-27

Mature cystic teratoma (MCT) is the commonest benign tumour arising in an ovary. Malignant transformation in a MCT of ovary is exceptionallyrare, seen only in1-2% cases.The most common malignant transformation in a benign teratoma of ovary is squamous cell carcinoma. The other malignant transformations in teratoma include adenocarcinoma, melanoma and basal cell carcinoma. The patients having this malignant transformation in teratoma have a very low 5-year survival rate of 20% approximately. Here; we describe a case of advanced-stage squamous cell carcinoma arising in a mature cystic teratoma in a 34-year-old woman.This solid high grade malignancy was missed in the pre-operative imaging which showed a right adnexal mass with echogenic foci within and septations, and was reported as a dermoid cyst. The intraoperative frozen section too taken from the thin portion of the cyst wall was reported as cystic teratoma. However in the staging laparotomy,right salpingo-oophorectomy and left oophorectomy, specimen the patient was reported to have moderately differentiated squamous cell carcinoma arising in a benign mature cystic teratomawith extensive tumour necrosis with omental tumour deposits.In view of initial incomplete surgery and advanced stage, decision of completion cytoreductive surgery was taken. The patients with mature cystic teratoma with high age (post-menopausal), a size of more than 10 cm and increased serum tumour markers should be suspected to have a malignant transformation and should be investigated thoroughly.