APALM 2.4 (2015) by PaGe

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Annals of Pathology and Laboratory Medicine Oct-Dec. 2015; Vol. 2, Issue 4

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Annals of Pathology and Laboratory Medicine Co-Editor in Chief

Dr Nasser Said-Al-Naief ODRP/ Anatomic Pathology, Loma Linda Medical Center, Loma Linda, CA, United States Dr Hoda A Hagrass Clinical Pathology dept, Faculty od Medicine Zagazig University, Sharkyia, Egypt Dr Kemal Turker UlutaĹ&#x; Kadirli State Hospital, Central Laboratory, Osmaniye, Turkey Dr Dennis P Oâ&#x20AC;&#x2122;Malley Pathologist, Clarient Pathology Services, Columbia, Aliso Viejo, CA, United States Dr Parthasarathi Pramanik Consultant Forensic Pathologist, Forensic Science Laboratory, Kingston, Jamaica Dr Arvind Rishi Asst. Prof., Dept of Pathology, Hofstra North Shore-LIJ School of Medicine, New York, United States Dr Ahmad Mohammad Ragab - Senior Consultant Pathologist, Kameda Hospital & Oncology Center - JAPAN - National Medical Institute, Egypt Dr Amado Ona Tandoc III Research Institute for Tropical Medicine, Muntinlupa City, Philippines Dr Shamim Sheikh Dept. of Pathology, M.P. Shah Medical College, Jamnagar, Gujarat, India Dr Viral M Bhanvadia Asst. Prof. Dept. of Pathology, Shri M.P. Shah Medical College, Jamnagar, Gujarat, India Dr Navin K Sinha Director-Lab, Artemis Health Institute, Gurgaon, India Dr Soumyesh Ghosh Dept. of Pathology, SDN Hospital, Delhi, India Dr Deepti Mittal Pathologist, Haryana, India Dr Amit Agravat Asso. Prof. Dept. of Pathology, PDU Medical College, Rajkot, Gujarat, India

Dr Prashant Goyal Director-Laboratory, Accuprobe Healthcare and Diagnostics, Delhi, India Dr Shelly Sehgal Specialist Pathologist, Department of Pathology, SDN Hospital, Delhi, India

Associate Editor

Dr Asitava Mondal Clinical Cytologist and Oncopathologist, Kolkata, West Bengal, India Dr Sompal Singh Specialist Pathologist, Dept. of Pathology, N D M C Medical College & Hindu Rao Hospital, Delhi, India Dr Ruchika Gupta Pathologist (Scientist-C), Institute of Cytology & Preventive Oncology (ICPO), Delhi, India Prof. Vatsala Mishra HOD, Dept. of Pathology Moti Lal Nehru Medical College, Allahabad, India Dr Manjusha Biswas Consultant Histopathologist & Oncopathologist, Kolkata, India Dr Mudit Agarwal Director Lab Services, Nishtha Pathology Lab, New Delhi, India Dr A S Ramaswamy Specialist Pathologist, Lifeline Hospital, Salalah, Sultanate of Oman Dr Harsh Vardhan Singh Senior Biochemist, N D M C Medical College & Hindu Rao Hospital, Delhi, India Dr Manu Noatay Head Operations, Niche Theranostics, New Delhi, India Dr Anil Parwani Vice Chair, Anatomical Pathology; Director of Pathology Informatics and Digital Pathology The Ohio State University Wexner Medical Center, Columbus, Ohio, United States

Editorial Board Members

Dr Sarah Iqbal Ch Faculty of Pathology King Edward Medical University, Lahore, Pakistan Dr Jerad M Gardner Asst Prof, Pathology and Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, United States Dr Naila Atif Associate Prof., Histopathology, Central Park Medical College, Lahore, Pakistan Dr Rajan Chopra King Fahad Hospital, Hufof, Saudi Arabia Dr Niti Singhal Abu Dhabi, United Arab Emirates Dr (Prof) Severino Rey Quiron Hospitals and Pontifical Catholic University, Ecuador Dr Rajeshwar Reddy Prof. & Head, Dept. of Microbiology, Gandaki Medical College, Pokhara, Nepal

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Contents Original Article Diagnostic Value of Cytokeratin 5 and Cytokeratin 6 in Benign and Malignant Lesions

A101-A106

Bone Marrow Aspiration Cytology Studies In A Tertiary Hospital, Nigeria: A Serie Of 88 Cases Ademola Samson Adewoyin, Enifome S Ezire, Oluwafemi Adeyemi, Nosakhare T Idubor, Deborah O Edewor-Okiyo

A107-A114

Emergence of Polymyxin B as a Viable Treatment Option in Comparision to Newer Antimicrobials in Intensive Care Units: A study in North India Meher Rizvi, Naushaba Siddiqui, Fatima Khan, Asfia Sultan, Parvez Anwar Khan, Indu Shukla, Haris M. Khan

A115-A119

Cover Image Cyto-Histopathological Correlations of Head and Neck swellings in a Rural Hospital in North Maharashtra: Our experience Kishor H Suryawanshi, Rajshri P Damle, Dhiraj B. Nikumbh, Nandkumar V. Dravid, Dhananjay V. Newadkar

A120-A126

Gastric Carcinoma Diagnosed Incidentally on Cervical Biopsy in a Young Female Mahendra Kumar, Naushad Shah, Jaya Mishra, Ritesh Kumar, Subrat Panda

C208-C212

Cellular Angiofibroma: A Rare Vulvar Neoplasm Distinct from Aggressive Angiomyxoma Jasvinder Kaur Bhatia, R Nangia

C213-C217

Aneurysmal Bone Cyst: An Uncommon and Aggressive Presentation Arnab Chaudhuri, Ayandip Nandi, Sarbani Chattopadhyay, Ranajit Bhatta

C218-C221

Cytomorphology of Primary Adenoid Cystic Carcinoma Of Lung: An Exceedingly Rare Case Rohit V Bhalara, Mital J Gamit, Manisha Popat, Shilpa H Gandhi, Gauravi A Dhruva

C222-C226

Leiomyomatous Hamartoma of The Pyloric Antrum: A Case Report Geetanjali Gupta, Pallavi Agrawal, Hirdaya Nag, Puja Sakhuja

C227-C229

Granular Cell Tumour of the Deltoid Muscle: A Rare Entity in the Musculoskeletal System Chetan Sudhakar Chaudhari, Manisha Khare, Shailesh Vartak, Urmi Chakravarty-Vartak, Prashant Kumavat

C230-C234

Lymphoepithelioma-like Carcinoma of The Breast: A Case Report Trupti R Jansari, Tanvi Gupta, Priti Trivedi, Manoj J Shah

C235-C238

Tubercular Cervicitis Clinically Mimicking Malignancy: Cytodiagnosis of Two Cases Reena Naik, Tribhuwan Kumar Sahu, Kishori Moni Panda

C239-C242

Mucinous Borderline Tumour of the Ovary in a Premenarchal Girl Jyoti Mishra, Sangeeta Nagar, Anil K Verma, Mehtab CA Sangama, Geeta Deshmukh, P L Kariholu

C243-C247

of Breast Kafil Akhtar, Sanjay Bharduaj, Mohammed Naim, Tariq Mansoor, Rana Sherwani

Case Report

III

A Case of Primary Intestinal Lymphangiectasia Rajshri P Damle, Kishor H Suryawanshi, N V Dravid, D V Newadkar

C248-C251

Choroid Plexus Carcinoma: A Case Report Vissa Shanthi, Nandam Mohan Rao, Amit Agrawal, Umamaheswara Reddy, Boddapati Amulya

C252-C255

Lower Abdominal Solitary Fibrous Tumor Suspected as a Urachal Lesion: A Case Report with Cytohistological Correlation Neelam Sood, Priyanka Bhatia Soni

C256-C260

Buschke-Lowenstein Tumor: A Case Report Smita Shripad Pathak, Janice Jaison

C261-C261

Letter to editor Cystic pleomorphic adenoma: A diagnostic challenge on cytology Meghna Singh, Jitendra Chaudhary

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L11-L13

Original Article Diagnostic Value of Cytokeratin 5 and Cytokeratin 6 in Benign and Malignant Lesions of Breast Kafil Akhtar1*, Sanjay Bharduaj1, Mohammed Naim1, Tariq Mansoor2, Rana K Sherwani1 1Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India Department of General Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India

Keywords: Breast Carcinoma, Histopathology, Immunohistochemistry, Cytokeratin

ABSTRACT Background: Correlation of Cytokeratin 5 and Cytokeratin 6 expression in benign and malignant lesions of the female breast-ducts and to find out the utility of Cytokeratin 5/6 in the prognosis of carcinoma breast. Methods: The present study was carried out on 78 benign and malignant lesions of breast. Tissues were fixed in formal saline, processed for paraffin sections and stained with Haematoxylin and Eosin (H&E) stain. Immunohistochemical staining was performed using mouse antihuman polyclonal D5/16B4 antibody for cytokeratin 5/6 and visualization obtained with DAB and the slides were examined for staining pattern (cytoplasmic or membrane), proportion and intensity of staining of tumour cells. Results: Amongst the 78 cases of breast lesions, 38 (48.7%) cases were benign breast disease, 18 (23.1%) were ductal carcinoma in situ and 22 (28.2%) cases were of malignant breast carcinoma. Out of 22 cases of malignant breast disease, 16 (72.7%) cases showed negative cytokeratin reaction with staining score of <2 and 6 (27.3%) cases of triple negative breast carcinoma (TNBC) showed positive cytokeratin expression with staining score of 5-8. Conclusions: Immunohistochemistry is efficiently used for differentiating the UDH (usual-ductal-hyperplasia) from the DCIS (ductal carcinoma in situ), ruling out micro-invasion, distinguishing invasive carcinoma from pseudo-invasive lesions, identifying breast cancer histological sub-type and molecular phenotype.

*Corresponding author: Dr. Kafil Akhtar, Associate Professor, Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh. (U.P) India. E-mail: drkafilakhtar@gmail.com

This work is licensed under the Creative Commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

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CK5 and CK6 in Breast Lesions

Introduction

The rising prevalence of breast cancer and molecular diagnosis of the breast cancer variants continue to concern the medical community. Molecular diagnosis of the breast cancer types depends on highlighting with tumor-marker stains, the molecules considered as signals, symbols or representatives of tumor cells and which are increased in the cancerous conditions. [1] Normal cells also express most of the tumor markers, but quantum of marker molecules distinguishes the tumor cells from the normal cells. Immunohistochemistry (IHC) had already become very important tool in the molecular diagnosis of breast diseases. IHC is efficiently used for differentiating the UDH (usualductal-hyperplasia) from the DCIS (ductal carcinoma in situ), ruling out micro-invasion, distinguishing invasive carcinoma from pseudo-invasive lesions, identifying breast cancer histological sub-type and molecular phenotype, and confirming the breast as the primary site in a metastatic carcinoma. In addition, IHC markers are useful for estimating prognosis and predicting the therapeutic response. The best approach to the use of IHC markers is to couple them with standard haematoxylin-eosin histology and to use panels of the markers. [2,3] The present study was undertaken to correlate Cytokeratin 5 and Cytokeratin 6 expression in the benign and malignant lesions of the female breast-ducts and to find out the utility of Cytokeratin 5/6 in the diagnosis and prognosis of carcinoma breast.

Material and Methods

The present study was carried out on 78 benign and malignant lesions of breast in the Department of Pathology, JNMC, Aligarh, from Nov 2012 â&#x20AC;&#x201C; Dec 2014. The patientâ&#x20AC;&#x2122;s clinical history and examination findings with relevant investigations were obtained from the medical records department at our department and hospital. Tissues were fixed in formal saline, processed for paraffin sections and stained with Haematoxylin and Eosin (H&E) stain. IHC marker staining was performed on the sections mounted on lysin coated clean glass slides. IHC staining was performed using mouse antihuman polyclonal D5/16B4 antibody for cytokeratin 5/6 and visualization was obtained with DAB (3, 3â&#x20AC;&#x2122;- diaminobenzidine, Dako). For the assessment of cytokeratin 5/6, the immunohistochemically stained slides were examined for staining pattern (cytoplasmic or membrane) and proportion and intensity of staining of tumour cells. IHC staining intensity, score and staining proportion score were calculated as below: Final immunostaining score (FIS) was obtained by adding scores from the two categories with a maximum

Intensity score

Proportion score

0= No staining. 1= Weak staining. 2= Moderate staining. 3= Strong staining.

1= <10% positive staining 2= 10-25% positive staining 3= 26-33% positive staining 4= 34-66% positive staining 5= 67-100% positive staining

score not > 8. The breast lesion with score < 2 were termed cytokeratin 5/6 negative while those with score >2 were termed cytokeratin 5/6 positive.[1,4] The statistical analysis was done using basic descriptive statistics, mean and chi-square tests. Differences at p value <0.05 were considered significant. The analyses employed SPSS 10 software.

Results

Amongst the 78 cases of breast diseases presently studied, 38 (48.7%) cases were benign lesions of breast, 18 (23.1%) were premalignant and 22(28.2%) cases were malignant breast carcinoma. All the 38 benign lesions of breast showed positive cytokeratin 5/6 expression with variable staining score (Table I). Fibrocystic disease showed cystically dilated ducts lined by cytoplasmic and membranous cytokeratin 5/6 positive flattened epithelium with mild pericystic fibrosis and inflammation (Figure 1). Cases of duct ectasia showed dilated ducts lined by cuboidal epithelium and granular amorphous debris in the lumen with sparse peri-ductal chronic inflammatory cell infiltration. Fibroadenoma showed proliferating breast ducts with predominantly fibrous stroma around dilated and compressed ducts with cytoplasmic and membranous cytokeratin 5/6 positivity in the outer myoepithelial cell layer only (Figure 2). All the 18 (23.1%) cases of ductal carcinoma in situ and intraductal carcinoma showed proliferative monomorphic tumor cells with low to high N:C ratio, evenly distributed in duct spaces lined externally by a basement membrane, while all the twenty two (28.2%) cases of infiltrating ductal carcinoma showed clusters of malignant cells with high N:C ratio, pleomorphism with surrounding stromal invasion and infiltration into adjacent fatty tissues and vascular spaces. (p<0.05) Out of 22 cases of malignant breast diseases including heterogenous breast duct carcinoma, 16 (72.7%) cases showed negative cytokeratin 5/6 immunoreaction in luminal cells and strong membranous and cytoplasmic cytokeratin 5/6 positivity in the basal cells with staining score of <2 (Figure 3 and Table 2). Six (27.3%) cases of triple negative breast carcinoma (TNBC) showed positive cytokeratin expression with staining score of 5-8 (Figure 4 and Table 3).

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Akhtar et al.

A-103

Table 1: Correlation between benign breast disease and Cytokeratin positivity S No

Histopathological Diagnosis

No. of cases

Age (year)

CK positive cases

CK 5/6 staining Score -Range

Mean of Score ± SD

Fibrocystic disease

18-52

5-6

5.7±0.10

Usual ductal hyperplasia

23-53

5-7

6.6±0.11

Duct ectasia

35-50

5-6

5.4±0.13

Fibroadenoma

16-40

5-8

7.2±0.14

Total

P value: 1:2 = 0.106 (insignificant); 1:3=0.105 (insignificant); 1:4=0.048 (significant), 2:3p=0.003 (insignificant), 2:4= 0.112 (insignificant)

Fig. 1: Fibrocystic disease shows cystically dilated ducts lined by cytoplasmic and membranous cytokeratin 5/6 positive flattened epithelium with mild pericystic fibrosis and inflammation. (H & E and Immunostain Cytokeratin, 125x)

Fig. 3: Cribriform Intraductal carcinoma showing strong membranous and cytoplasmic cytokeratin 5/6 positivity in basal cells and negativity in the luminal cells. (H & E and Immunostain Cytokeratin, 125x)

of cytokeratin positive cases from age group 20-30 year to 50-60 year followed by an increase in number above 60 years of age.

Out of the total 78 cases, 44 (56.4 %) cases showed positive cytokeratin staining with a decline in the number

The mean age of presentation in 16 (72.7%) cases of invasive ductal carcinoma and 6 (27.3%) cases of triple negative breast carcinoma was 57.7 years and 53 years respectively. (Table 3) Lymph node metastasis was positive in 4 cases (66.7%) and negative in 2 cases (33.3%), out of the 6 cases of triple negative breast carcinoma. Amongst the 16 cases of invasive ductal carcinomas, 6 cases (37.5%) were lymph node positive and 10 cases (62.5%) were lymph node negative, with a p value < 0.05, which was statistically significant. Vascular invasion was seen in 5 (83.3%) cases of triple negative breast carcinoma and 12 (75.0%) cases of invasive ductal carcinoma. (Table 3), with a p value < 0.05, which was statistically significant. All the 6 cases of triple negative breast disease showed grade III and variable cytokeratin positivity with staining score between 5 to 8, whereas other breast carcinomas showed a variable grade, from I to III with negative cytokeratin expression and a p value < 0.05, which was statistically significant. (Table 3)

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Fig. 2: Fibroadenoma shows proliferating breast ducts with predominantly fibrous stroma around dilated and compressed ducts with cytoplasmic and membranous cytokeratin 5/6 positivity in the outer myoepithelial cell layer only. (H & E and Immunostain Cytokeratin, 125x)

The hererogenous carcinoma specifically showed multiple tumor-cell components with secretory pattern and solid dedifferentiated carcinoma. The solid component showed triple (ER, PR and Her2) negativity and strong cytokeratin 5/6 positivity. The secretory component showed triple positivity and negative cytokeratin 5/6 immunoreaction (Figure 5).

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CK5 and CK6 in Breast Lesions

Fig. 5: Heterogenous Breast Duct Carcinoma shows multiple pattern with solid and secretory pattern of growth, with the solid component with triple negativity and strong cytokeratin 5/6 positivity (↓) and the secretory component with triple positivity and negative cytokeratin 5/6 immunoreaction (↑) (H & E and Immunostain Cytokeratin, 500x)

Fig. 4: Triple negative breast carcinoma with metaplasia showing cytoplasmic and membranous cytokeratin 5/6 positivity. (H & E and Immunostain Cytokeratin, 125x)

Table 2: Correlation between Premalignant and Malignant Breast disease with Cytokeratin 5/6 expression Histopathological diagnosis

No of cases

Lymph node status

Grade cytokeratin 5/6 Cytokeratin (Bloom Richardson) positive cases 5/6 staining score

Mean of Score ± SD

Premalignant (Fibroadenotic neoplasms)

I-8 II-10

1.8±0.12

Malignant Breast disease Luminal A Luminal B Basal like

+/_

2-6 <2 <2

5.8±0.10 1.8±0.13 1.4±0.12

Total

12 06 04

0 6

III-8 II-6 I-8

p=0.021(p<0.05); significant

Table 3: Characteristics of triple negative breast cancer versus other breast cancer Variable Mean age of diagnosis (years) Positive Negative Mean tumor size(cm) III II I Present Absent Positive Negative CK 5/6 positivity SC

Triple negative breast cancer (Total no=6) 53 Lymph node status: 4 (66.7%) 2(33.3%) 3.0 Tumor grade 06 Lympho-Vascular Invasion 05 (83.3%) 01(16.7%) ER/PR/HER2 status 06 5-8

Other Breast Cancer (Total no=16) 57.7 06(37.5%) 10(62.5%) 2.1 02 06 08 12 (75.0%) 04 (25.0%) 16 -

p value=0.123 (>0.05) insignificant

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Akhtar et al.

Discussion

The present study on 78 cases of breast lesions showed a positive immunohistochemical staining for Cytokeratin 5/6 in the 38 benign lesions with immunoscore of 5-8. All the cases (100%) of UDH showed positive immunostaining for cytokeratin 5/6. None of the 18 (100%) cases of DCIS presently showed positive immunostain for cytokeratin 5/6. Thus cytokeratin 5/6 can be useful in distinguishing UDH from the spectrum of ADH/DCIS. Magali LacroixTriki at el reported positive immunostaining of cytokeratin 5/6 in 31 cases of UDH, 5 cases of ADH and 54 cases of DCIS on a study on 100 breast lesions.[5] Rabban et al, demonstrated higher immunoscores for cytokeratin in benign breast lesions than DCIS. [6] Presently, the in situ and intra-ductal carcinoma cases were observed to be showing positive CK 5/6 staining of the basal cells and negative CK 5/6 in the lining malignant cells. Tan et al have reported that DCIS lesions with spindle cells may show neuroendocrine differentiation and negative immunoreactions with Cytokeratin 5/6.[4] Usual ductal hyperplasia with apocrine change, columnar cells in papillary lesions also do not stain with Cytokeratin 5/6. [7] Therefore, a careful evaluation of the H&E stained sections along with immune-histochemical analysis with Cytokeratin 5/6 is useful for diagnosis of these lesions. Out of the 22 cases of malignant breast lesions in our study, 16 cases (72.7%) showed negative immunoreaction for Cytokeratin 5/6, and 6 cases (27.3%) showed positive immunoreaction. All the 6 cases of breast carcinoma positive for CK 5/6 expression were triple (ER, PR, EGFR) negative. Bocker et al, studied CK 5/6 expression in 23 cases of benign and 25 cases of malignant breast lesions. [8] They found that 100% benign lesions showed positive immunoreaction while 5% of malignant cases showed CK 5/6 expression. None of the cases of DCIS in our study showed a positive immunoreaction whereas 6 cases of advanced malignant lesions (27.3%) showed positive CK 5/6 expression. The slightly higher percentage positivity of CK 5/6 in the present study can be attributed to different patient cohorts or a smaller study sample. No case of medullary carcinoma breast was included in our study. However, Tot reported CK 5/6 positivity in 25% of the typical, 43% of the atypical and 20% of the metastatic medullary carcinomas. [9]

A-105 carcinoma. In radial scar the myoepithelial layer is retained around glandular structures and therefore these can be expected to show positive staining with CK 5/6 and myoepithelial cell markers. In a foci of sclerosing adenosis, the staining is heterogeneous. In low grade invasive carcinomas, the myoepithelial layer is absent and CK 5/6 staining is negative. [10] Out of the total 78 cases, 44 (56.4%) cases showed positive Cytokeratin staining. Number of Cytokeratin positive cases decreased from third decade to sixth decade, followed by an increase in number beyond the seventh decade of life. No definitive correlation was observed between age of the patient and Cytokeratin 5/6 expression in our study. However, Rehim et al showed an inverse correlation of Cytokeratin 5/6 with the patientâ&#x20AC;&#x2122;s age. [11] In the present study, all the triple negative malignant cases showed positive immunoreaction for Cytokeratin 5/6 in the polygonal faint PAS positive non-secretory tumor areas, while the secretory tumor components were negative for CK 5/6 expression. These findings suggested that CK 5/6 positive polygonal components in the breast carcinoma represented de-differentiation of secretory tumor into the breast duct stem cell components, which could be a determinant of poor prognosis. CK 5/6 may be of utility in distinguishing well differentiated luminal cell carcinoma. All the cases were grossly necrotic with mean tumor size of 3 cms and were of grade III. Lakhani et al have also reported that necrosis was a common factor in all the CK 5/6 positive tumors. [12] Naim et al have reported strong CK 5/6 positivity in triple negative breast carcinomas. [13] The mean age of presentation of triple negative breast malignancy was at an younger age (53 years) than other breast cancers. Rehim et al reported a positive correlation of tumor size, local and regional recurrence, distant metastases with CK 5/6 expression and an inverse correlation with patientâ&#x20AC;&#x2122;s age and metastasis.[11] The present study showed no consistent correlation with size and age.

Cytokeratin 5/6 antibody is very frequently applied to help differentiate invasive from non invasive lesions. The common examples include radial scar versus invasive cancer, intraductal papilloma versus papillary intraductal carcinoma and microglandular adenosis versus tubular

In the present study 4 cases (66.7%) of triple negative breast carcinoma cases showed nodal metastasis whereas only 6 cases (37.5%) of other malignant breast carcinomas were lymph node positive. Vascular invasion was seen in 5 cases (83.3%) of triple negative breast carcinoma and 12 cases (75.0%) of other malignant breast carcinomas. Our findings were consistent with the study conducted by Dent et al who demonstrated lymph node positivity and lymph vascular invasion in 55% and 45 % cases of triple negative carcinoma respectively while among other breast carcinomas, 40% and 30% cases showed lymph node and lympho-vascular invasion respectively. [14]

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CK5 and CK6 in Breast Lesions

Van de Rijn et al observed that expression of basal type cytokeratin in node negative breast carcinoma was a prognostic factor independent of tumor size and tumor grade. [15] It was associated with significantly shorter survival, but held no predictive value in patients with known lymph node metastases. On the contrary, Takei et al reported that there was no significant difference in overall survival and relapse free survival in tumors expressing high molecular weight keratin as compared to tumors not expressing it. [16] However further studies with larger sample size are required to established conclusive results.

Conclusions

Immunohistochemistry has an increasing role in the modern pathology of breast disease. IHC markers Cytokeratin 5 and 6 are efficient in differentiating the UDH from the DCIS, ruling out micro-invasion, distinguishing invasive carcinoma from pseudo-invasive lesions, identifying breast cancer histological sub-type, especially triple negative breast carcinoma and heterogenous breast duct carcinomas.

Acknowledgements

9. 10.

We acknowledge the technical staff of the cytopathology lab and the departmental head for the general support.

Funding

11.

None

Competing Interests None declared

References

12.

1. Bhalla A, Mridu M, Kahlon SK, Parbodh K, Nikita K. Cytokeratin 5/6 expression in benign and malignant breast lesions. Ind J Pathol Microbiol 2010; 53: 676-9. 2. Yeh I-Tien and Carolyn M. Application of Immunohistochemistry to Breast Lesions. Archives of Pathol Lab Med 2008; 132: 349-358. 3. Abdel-Fatah, Tarek MA, Desmond GH, Zsolt RF, Jorge SL, Andrew H, et al. Morphologic and molecular evolutionary pathways of low nuclear grade invasive breast cancers and their putative precursor lesions: further evidence to support the concept of low nuclear grade breast neoplasia family. Am J Surg Pathol 2008; 32:513-523. 4. Tan M, Puayhoon AW, Meng Yuan BS, Bay B, Huat S, Lang H et al. Cytokeratins in Papillary Lesions of the Breast: Is There a Role in Distinguishing Intraductal Papilloma From Papillary Ductal Carcinoma In Situ. Am J Surg Pathol 2005; 29 (5): 625-632. 5. Magali Lacroix-Triki, Eliane M, Jean-Jacques V, Luc I, Philippe R. Value of cytokeratin 5/6 immunostaining using D5/16 B4 antibody in the spectrum of proliferative intraepithelial lesions of the

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16.

breast. A comparative study with 34beta E12 antibody. Virchows Archiv 2003; 442(6):548-554. Rabban JT, Frederick C, Koerner M, Melinda FL. Solid papillary ductal carcinoma in situ versus usual ductal hyperplasia in the breast: a potentially difficult distinction resolved by cytokeratin 5/6. Hum Pathol 2006; 37(7): 787-793. Raju U, Crissman JD, Zarbo RJ. Epitheliosis of the Breast- An Immunohistochemical Characterization and Comparison to Malignant Intraductal Proliferations of the Breast. Am J Surg Pathol 1990; 14(10): 939-947. BĎ&#x2020;cker W, Moll R, Poremba C, Holland R, Van Diest PJ, Dervan P et al. Common adult stem cells in the human breast gives rise to glandular and myoepithelial cell lineages: A new cell biological concept. Lab Invest 2002; 82:737-745. Tot T. The cytokeratin profile of medullary carcinoma of the breast. Histopathol 2006; 37: 175-181. Otterbach F, BĂ nkfalvi A, Bergner S, Decker T, Krech R, Boecker W. Cytokeratin 5/6 immunohistochemistry assists the differential diagnosis of atypical proliferations of the breast. Histopathol 2000; 37(3):232-240. Rehim DM, Pinder SE, Paish CE, Bell J, Blamey RW, Robertson JF et al. Expression of luminal and basal cytokeratins in human breast carcinoma. J Pathol 2004; 203(2):661-671. Lakhani SR, Reis-Filho JS, Fulford L, Penault-Llorca F, Van der Vijver M, Parry S et al. Breast cancer linkage consortium: Prediction of BRCA 1 status in patients with breast cancer using estrogen receptor and basal phenotype. Clin Cancer Res 2005; 11:5175-5180. Naim M, Soni M, Khan A. Modified Naim Murad classification of female breast cancer in Breast cancer classification, serum adiponectin and SNP rs 2241766. Lap Lambert academic publications, Germany, 2014; pp 19-59. Dent R, Trudeau M, Pritchard KI, Hanna WM. Triplenegative breast cancer: clinical features and patterns of recurrence. Clin Cancer Res 2007; 13(15): 44294434. Van de Rijn M, Perou CM, Tibshirani R, Haas P, Kallioniemi O, Kononen J et al. Expression of cytokeratins 17 and 5 identifies a group of breast carcinomas with poor clinical outcome. Am J Pathol 2002; 161:1991-1996. Takei H, Iino Y, Horiguchi J, Maemura M, Oyama T, Yokoe et al. Low and high molecular weight cytokeratins in invasive breast carcinoma. Oncol Rep 1997; 4: 33-38.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Original Article Bone Marrow Aspiration Cytology Studies In A Tertiary Hospital, Nigeria: A Serie Of 88 Cases Ademola S. Adewoyin*, Enifome S. Ezire, Oluwafemi Adeyemi, Nosakhare T. Idubor, Deborah O. Edewor-Okiyo Department of Haematology and Blood Transfusion, University of Benin Teaching Hospital, Benin City, Edo State Keywords: Bone Marrow Examination, Bone Marrow Aspiration, Cytology, Trephine Biopsy

ABSTRACT Background: Bone marrow aspiration (BMA), an invasive test is crucial in evaluation of anaemias and other blood diseases, especially in situations where diagnosis remains cryptic after detailed clinical history, physical examination and peripheral blood analysis. BMA is performed by trained haematologists in the course of evaluating patients with primary or secondary haemopathies. However, there is sparse local data/report on its clinical utility. This study therefore assessed the common clinical indications, diagnostic findings and associated complications in our locality. Methodology: A prospective cohort study of 88 cases of BMA procedures among patients managed and co-managed by the adult haematology unit at the University of Benin Teaching Hospital (UBTH), Benin City was carried out. Relevant demographic, clinical data and intra-procedure details were obtained using a structured questionnaire within 24 hours of the procedure during the study period through case file review and patient interview. Intra-procedure intensity was graded in patients above 14 years using numeric pain scale of 0 to 10. All patients were followed up for a period of 1 to 2 weeks post-procedure. Result: The mean (SD) of the subject was 40 ± 24 years. Most (79.5%) of the BMA cytology were performed among adults (≥15 years of age), mostly on in-patient basis (86.4%). Posterior iliac crest was the most commonly used site (83%). Aspiration yield was adequate in 83% of cases. Mean intra-procedure pain score was 5.17 ± 2.01. Most common bone marrow diagnoses were combined (substrate) deficiency (26.1%), acute leukaemias (18.2%), pure megaloblastic anaemia (10.2%), malignant plasmacytosis (7.9%) and marrow carcinomatosis (7.9%). Pain was the most frequent complication, observed in 98.9% of cases. Conclusion: BMA cytology is a highly informative/diagnostic test procedure performed by haematologists in evaluating blood and blood related diseases in our environment. BMA is relatively safe although significant procedure related pain was frequently reported. Efforts should therefore be directed at better analgesia. Patients with unexplained cytopenias and other relevant indications should be referred for haematology consultation and possible BMA.

*Corresponding author: Dr Adewoyin Ademola, Department of Haematology and Blood Transfusion, University of Benin Teaching Hospital, PMB 1111, Ugbowo, Benin City, Edo State Phone: +234 7033966347 E-mail: drademola@yahoo.com

This work is licensed under the Creative Commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

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Introduction

Bone marrow aspiration (BMA) is an invasive procedure whereby representative specimen of spongy bone marrow is obtained through a needle aspiration for diagnostic evaluations especially cytology and stem cell harvest.[14] The history of in vivo bone marrow examination dates back to as early as 1876 when Mosler used a regular wood drill to aspirate bone marrow particles from a patient with leukaemia.[2] BMA still remains a veritable tool in the haematologist armamentarium for conducting diagnosis and differentiation of primary and secondary haemopathies. In todayâ&#x20AC;&#x2122;s practice, the clinical relevance of BMA goes beyond cytologic evaluation of haematopoietic and non-haematopoietic marrow cells. BMA specimens are useful in further diagnostic assays including cytochemical/ special stainings, immunophenotyping, microbiologic tests, cytogenetic analysis and molecular studies.[1,2,5] Additionally, BMA is a major source of stem cells for haemopoietic stem cell transplantation.[3] Often, a trephine biopsy is carried out as part of the same procedure.[4] The BMA procedure is performed by a qualified haematologist during clinical evaluation of patients with blood and blood related diseases. BMA is invasive and requires proper patient education and consent. Patients for BMA are carefully selected. Often times, patients with suspected marrow diseases whose diagnosis remains inconclusive after examination of the peripheral blood with full blood count (FBC), peripheral blood film (PBF) and ancillary tests, require BMA. Usually, BMA is engaged in cases of unexplained cytopenia (anaemia, leucopenia, thrombocytopenia), unexplained splenomegaly and lymphadenopathy, diagnosis of acute leukaemia, megaloblastic anaemia, plasma cell myeloma, myelophthisic anaemia, monitoring of success of cancer chemotherapy, staging of lymphoma and other solid tumors, staining for marrow iron stores and other cytochemistries, chromosomal studies/karyotyping and molecular genetic analysis.[1,2,5-8] Before a BMA is performed, clinical history and laboratory tests including FBC, reticulocyte count and PBF must be evaluated. A consultation for BMA is first a consultation to review the patient before the procedure is performed. Patient must be fit for the procedure haemostatically and otherwise. Performing a BMA must meet clear indications. Pre-procedure evaluation of the patient includes establishing clear indications, assessment of the patientâ&#x20AC;&#x2122;s haemostatic status, patient education about the procedure and proper consent. Once the marrow blood is harvested under aseptic protocols, the smear is made, remaining specimen is stored in EDTA anticoagulant bottle and further processing is carried out in the haematology laboratory.[1] Well prepared marrow smears are viewed and reported by the haemato-morphologists. Reports are

subsequently translated to patient care or dispatched to the requesting clinicians.[5] Despite being a highly informative test procedure in diagnostic evaluation of blood and blood related diseases, there is sparse local literature on its indications, diagnostic utility/findings and complications of BMA in Nigeria. This study therefore evaluated and reports on the spectrum of common indications, bone marrow diagnosis and observed complications of the BMA among patients seen at UBTH, Benin City, Nigeria. This would also serve for possible comparison with findings from other parts of Nigeria and beyond.

Materials And Methods

This is a hospital based, prospective study conducted at the University of Benin Teaching Hospital (UBTH), Benin City. UBTH is a referral tertiary health institution located in Egor LGA along Lagos-Benin Expressway. The hospital has different medical and surgical sub specialties including haematology. The haematology unit is concerned with management of blood and blood related diseases, laboratory services, clinical interpretation of laboratory tests, consultations to other specialties. BMA examinations are performed by the haematology team of the hospital in the course of her clinical duties and consultations on both own patients and referred patients. All the BMA examinations performed over a period of twelve months (between January 2014 and January 2015) were profiled using a structured, intervieweradministered questionnaire. Relevant clinical data of the patient, laboratory tests, intra- and post-procedure details were recorded. BMA were performed using a standard unit protocol as adapted from ICSH guidelines and other authorities.[1,5] Intra-procedure pain severity was quantified using a validated pain scale in all patients above 14 years of age.[9] Patients were followed up for a minimum period of 1week for post-procedure complications. Patients with known coagulopathies or thrombocyte counts less than 20,000/ul were deferred from the procedure until adequate blood component supports were given. Similarly, patients on anti-platelet medications were deferred for a few days. All BMA were performed after detailed explanation of the procedure to the patient and or parents and proper consent obtained. All data were inputted and analyzed using Statistical Package for Social Sciences (SPSS) 16. Descriptive statistics were performed as appropriate. Level of association between sepsis and cytopenia was performed using chi square analysis. Association of intra-procedure pain severity scores with variables such as sex, aspiration site, number of aspirations, BMA with or without trephine

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Adewoyin. et al. biopsy were tested using student T test or Analysis of Variance (ANOVA) as appropriate. Findings are presented in frequencies and tables. Statistical significance is set at probability level of 5% (i.e. p-value = 0.05)

Result

A total of 88 cases of BMA were profiled during the study period. Majority of the subjects (79.5%) were aged 15 years and above (Table 1). Mean (SD) age of the subjects was 40 ± 24 years with a male to female ratio of 1.05:1. Most BMA procedures (86.4%) were done on patients during admission, the remaining were performed on outpatient basis (Table 1). The blood cell counts of the patients were highly variable with a mean total white blood count of 23,500/ul, granulocyte count of 13,600/ul, platelet count of 152,000/ul and haematocrit of 23.02%. About 10% of the subjects had inter-current significant bleeding disorders (severe thrombocytopenia and coagulopathy) for which they were corrected and stabilized prior to the procedure (Table 1). Local anaesthesia with lidocaine was used in all patients. A few (3.4%) of the patients aged less than 15 years were sedated with promethazine/pentazocine combination in order to achieve better analgesia and patient cooperation (Table 2). Most of the aspirates (83%) were taken from the posterior iliac crest, the rest were taken from anterior iliac bone and femur in children less than 2 years (Table 2). Multiple aspirations were performed in about 16% of the subjects (Table 2). The most frequent indications for initiation of BMA studies were unexplained anaemia (46.6%), suspected leukaemias (17%) and monitoring of cytotoxic therapy success in treated cases (13.6%) (See Table 1). About 44% of the subjects had concurrent bone marrow aspiration and trephine biopsy, while the remaining had solely a BMA procedure. Indications for concurrent BM trephine included evaluation of marrow cellularity in suspected aplastic anaemia cases, dry tap/inadequate marrow yield to enable imprints and others (Table 2). Intra-procedure pain severity was observed to be 5.17 (total of 10). Mild non-opioid analgesia with paracetamol was the commonly prescribed post-procedure in 67% of the subjects (Table 3). The common marrow diagnosis (in order of decreasing frequencies) were combined (substrate) deficiency (26.1%), acute leukaemia (18.2%), pure megaloblastic anaemia (10.2%), malignant plasmacytosis (7.9%), marrow carcinomatosis (7.9%), chronic leukaemia (6.8%), marrow involvement by solid blood tumors such as non-Hodgkins’ lymphoma (6.8%). No conclusive report was made in 4.5% of cases. The most frequently reported/observed post-procedure complications were local pain at the site of the procedure (98.9%) and local sepsis (3.4%) (Table 3). There is no significant association between leucopenia/granulocytopenia and sepsis in the studied population. However, septic complication was www.pacificejournals.com/apalm

A-109 significantly associated with BMA procedures performed on outpatient basis (Table 4). The mean pain severity score was observed to be slightly higher in females, in-patients, use of the posterior iliac crest, multiple intra-procedure aspirations and trephine biopsy but were not statistically significant (Table 5). TABLE 1A: PATIENT CHARACTERISTICS Characteristics

Frequency Percentage (n) (%) Age < 15 years 18 20.5 (years) ≥ 15 years 70 79.5 Mean ± SD = 40.07 ± 24.16, Median = 43, Minimum = 11 weeks, Maximum = 90 years Sex Male 45 51.1 Female 43 48.9 M : F Ratio: 1.05 : 1 Location In-Patient 76 86.4 Outpatient 12 13.6 Bleeding Thrombocytopenic 8 9.1 Disorder Coagulopathy 1 1.1 Nil 79 89.8 N = 88 (100%)

Table 1B Indications of Bone marrow aspiration BMA indications

Frequency Percentage (n) (%)

Unexplained Anaemia

46.6

Unexplained Leuco-/ Thrombocytopenia

2.3

Unexplained Pancytopenia

1.1

Suspected Leukaemia

Suspected Plasma Cell Dyscrasia

9.1

Monitoring Therapy

13.6

Staging/Diagnosis Of Lymphoma

2.3

Unexplained Spleen/ Lymphadenopathy

4.5

Others

3.4

Total White Cell Count (/ul) Granulocyte Count (/ul) Platelet Count (/l) Haematocrit (%)

Min Max Median Mean ± Value Value SEM 800 720000 6350 23500 ± 8713 200 573000 3050 13600 ± 6633 20000 615000 120000 152000 ± 11050 6 46.8 21.8 23.02 ± 1.03

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Table 2: Intra-Procedure Details VARIABLES Lidocaine Anaesthetic/ Sedative* Promethazine Pentazocine Anterior ilium Posterior ilium Aspiration Site Sternum Femur Single Number Of Aspiration Sites Multiple Adequate Aspiration Yield Not Adequate Dry Tap Yes Trephine Biopsy No None Overall cellularity/suspected aplastic anaemia Trephine Biopsy Indications Dry Tap/Inadequate yield Others Not Clear Not assessed** 0 – 3 (mild) Pain Intensity 4 – 7 (moderate) 8 – 10 (severe) Mean Pain Score (±SD) = 5.17 ± 2.01

Frequency (n) 88 3 3 13 73 2 74 14 73 10 5 39 49 49

Percentage (%) 100 3.4 3.4 14.8 83.0 2.3 84.1 15.9 83.0 11.4 5.7 44.3 55.7 55.7

9.1

7 18 6 18 18 45 7

8 20.5 6.8 20.5 20.5 51.1 8.0

N = 88 (100%), * multiple responses, **not assessed in children less than 15 years

Table 3: Post Procedure Findings Variables Nil Mild Non-Opioid Analgesia NSAID Opioid Acute Leukaemia Malignant Plasmacytosis Haematologic Remission Relapse/Refractory Leukaemia Failed/Partial Induction Inconclusive/Not Diagnostic Marrow Carcinomatosis Diagnostic Findings* Marrow Infiltration Of Blood Cancers Combined (Substrate) Deficiency Chronic Leukaemia Megaloblastic Anaemia Myelodysplasia Suspected Aplastic Anaemia Others Local Pain Haemorhage Local Sepsis Procedure Related Complications Needle Breaks Haematoma Vascular Injury

Frequency (N) 7 59 10 12 16 7 2 1 2 4 7 6 23 6 9 1 3 4 87 2 3 1 -

Percentage (%) 7.9 67.0 11.4 13.6 18.2 7.9 2.3 1.1 2.3 4.5 7.9 6.8 26.1 6.8 10.2 1.1 3.4 4.5 98.9 2.3 3.4 1.1 -

N = 88 (100%), *multiple responses

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Table 4: Association Between Sepsis And Cytopenia/ Patient Location LEUCOPENIA

p-Value

SEPSIS

YES

0.620

GRANULOCYTOPENIA YES

YES

0.688

58 Patient Location

IN-PATIENT

OUT-PATIENT

YES

0.048

to the possible fatal risk of damage to the great vessels during sternal puncture.[8,10] The tibia is the preferred site in children aged less than 18 to 24 months.[2,6,8] Cytopenias generally results from accelerated peripheral destruction of blood cells as in auto-immune disease, underproduction or maturation defects.[11] Most times, if the cause is not found peripherally, there is need for examination of the bone marrow, the site of haematopoiesis. It is therefore not surprising that unexplained cytopenia was the most frequent indication for bone marrow examination in the index study. BMA are carried out principally to permit cytologic evaluation of marrow cells (haemopoietic and non-haemopoietic). BMA specimens are also relevant for additional investigations including cytogenetic, molecular studies, flow cytometry/Immunophenotyping, cytochemistry, microbiological studies and others.[1,2,4]

Most cases of BMA studies were performed on in-patient basis, suggesting that most of the patientsâ&#x20AC;&#x2122; symptomatology and their management required hospitalization. Clinically significant bleeding disease was observed in 10% of the cases, which is a relative contraindication to the procedure except corrections for thrombocytopenia or coagulopathy were made. Most of the aspirate specimens were taken from the posterior iliac crest, anterior ilium was less favoured. The sternum was totally avoided. This may be related

Though a small series, this study however provides useful information on predominant causes of reticulocytopenic anaemia (bone marrow suppression) in this locality. Most common bone marrow diagnosis was combined (substrate) deficiency anaemia, observed in 26% of cases (see Figure 1). This is not unexpected as the most common cause of anaemia in a developing nation like Nigeria is reported to be nutritional deficiency.[12-14] This is comparable to a local report by Damulak et al, who reported the most frequent marrow diagnosis as nutritional deficiency anaemias in one-third of marrow aspirates, followed by leukaemias. [15] However, in another retrospective study of 185 BMA cytologies in Jos, Egesie et al observed acute leukaemias to be most common cause of anaemia in the locality followed by nutritional deficiency anaemias.[16] In this index study, diagnosis of acute leukaemias were the second most frequent diagnosis following bone marrow examination in some of the cases (see Figure 2). Similarly, in an Indian study, erythroid hyperplasia, acute leukaemias and megaloblastic anaemia were reported as the most common diagnostic findings.[17] The pattern of marrow diagnosis in a Ghanian study appears different from that observed in this index study, which reported lymphoma as the most frequent diagnosis.[18] Again, in a report from Saudi Arabia, the most common diagnoses encountered were acute leukaemia, immune thrombocytopenia, hypersplenism, chronic granulocytic leukaemia and megaloblastic anaemia.[19] These differences may be related to pattern of bone marrow requests, clinical indications for bone marrow evaluation and possible geographic difference in the patterns of marrow diseases. Other patterns of bone marrow diagnosis in the index study included marrow carcinomatosis and malignant plasmacytosis (Figures 3 and 4 respectively).

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N = 88 (100%)

Table 5: Association Of Pain Severity Scores With Other Variables VARIABLES

PAIN SCORE MEANS

SEM

p-value

Sex

Male

5.09

0.36

Female

5.25

0.32

Df = 1, F = 0.112, p = 0.739

Patient Location

In patient

5.28

0.28

Outpatient

4.67

0.33

BMA site

Posterior ilium

5.28

0.28

Anterior Ilium

4.67

0.39

Number of BMA aspirates

Single

5.10

0.27

Multiple

5.55

0.49

Trephine Biopsy

Yes

5.21

0.34

5.13

0.34

Df = 1, F = 0.915, p = 0.342 Df = 1, F = 0.915, p = 0.342 Df = 1, F = 0.450, p = 0.505 Df = 1, F = 0.024, p = 0.876

N = 70 (79.5% of total cases)

Discussion

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Bone Marrow Aspiration Cytology Studies In A Nigeria

Fig. 1: Mixed deficiency anaemia. BMA smear shows erythroid hyperplasia with several late and intermediate megaloblasts and dying cells. Micronormoblasts were also present (Leishman stain X1000).

Fig 2: BMA cytology showing immature lymphoid cells (blasts) of varying sizes, high nuclear:cytoplasmic ratio, some with prominent nucleoi and occasional cytoplasmic vacuolations (see inset). Diagnosis: Acute lymphoblastic leukaemia FAB L2 (Leishman stain x1000, inset x400)

Fig 3: Marrow carcinomatosis. BMA smear shows a nest, cluster of pleiomorphic looking, non haematopoietic cells (see inset) (Leishman stain x1000, inset x100)

Fig 4. Malignant plasmacytosis. BMA showing crowding of the marrow by malignant plasma cells with features of increased peri-nuclear halo and prominent nucleoli (see inset). (Leishman stain x400, inset x1000)

Dry tap or inadequate aspirate yield, as observed in some of the cases, is an indication for trephine biopsy (TB).[14] TB allows for preparation of imprints and better assessment of overall cellularity, marrow architecture or infiltrations.[1,2,5] Dry taps are due to hypercellularity or fibrosis caused by the underlying disease or an inadequate technique.[1,5]

Non steroidal anti-inflammatory drugs (NSAIDS) were less frequently used possibly due to its propensity for platelet dysfunction. Marked variation in intra-procedure pain severity may be related to patient factors such as individual pain thresholds, anxiety and apprehensiveness, skills and expertise of the operator or the differing quality of the anaesthetic agent.

Pain was a main complication of BMA in this study and poor pain control may dissuade patients in event of a need for repeat procedures. Though 92.3% of the patient-cases received post-procedure analgesia, most of the analgesia (67%) was conducted with mild non-opioid (paracetamol).

In a large series of over 50,000 cases, haemorhage and local infection were very rare. Fourteen cases had serious haemorhage with one death and six required transfusion. [20] In the index study, local sepsis occurred in a few

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Adewoyin et al. of the patients but was not found to be associated with/ related to leucopenia or granulocytopenia. BMA cases performed on outpatient basis were significantly associated with sepsis. The quality of post-procedure care including adherence to aseptic protocol in wound care/dressing may have a significant bearing on the incidence of septic complications among out-patients. Other complications such as neuropathy, osteomyelitis, needle breakages, vascular injury, fracture or mortality were either minimal or not present. Needle breakage occurred in one of the cases. This is possibly attributable to re-use of needles following requisite sterilizations.

Conclusion

BMA should be performed by a qualified haematologist who is conversant with the procedure and its potential complications. Bone marrow studies may be safely performed at platelet counts above 20,000/ul in the absence of platelet dysfunction. Preferably, BMA should be performed at platelet counts above 50,000/ul especially in patients with aplastic anaemia or platelet consumption diseases.[6,8,20] To allay fears/anxiety and reduce procedure related pain, it is recommended that patients/candidates for bone marrow studies should be properly educated about the procedure, its indication and potential risks. Informed consent should be obtained and documented. Local anaesthesia should be allowed the minimum time of onset to take effect before the procedure. Additional skills such as oral analgesia may help with pain relief intra-procedure. BMA related analgesia should be individualized, tailored to individual needs, upon careful evaluation of prior analgesic history and co-morbidities, as pain severity and duration may be related more to the individual patient pain thresholds. Careful attention should be paid to adequate intra- and post-procedure analgesia. BMA should not be a first line investigation. It is often indicated after initial evaluation of the peripheral blood and other ancillary tests, in patients with blood or blood related diseases. As such, patients with unexplained cytopenias should be referred to and co-managed with haematology team.

Acknowledgements None

Funding none

Competing Interests None declared

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Reference

1. Bain BJ. Bone marrow aspiration. J Clin Pathol 2001; 54: 657-63. 2. Ryan DH, Felgar RE. Examination of the marrow. In: Lichtman MA, Kipps TJ, et al (eds). William’s haematology 7ed. New York, McGraw Hill 2006; 3: 21-31. 3. Gluckman E. Choice of the donor according to HLA typing and stem cell source. Apperley J, Carreras E, Gluckman E, Masszi T (eds). Haemotopoietic Stem cell transplantation. EBMT Handbook 6ed; 2012; 6: 90-107. 4. Bolan CD, Kurlander RJ, Schechter GP. Interpretation of standard hematologic tests. In: Rodgers GP, Young NS. The Bethesda handbook of clinical hematology. 3ed. 27: pp405 – 426. 5. Lee SH, Erber WN, Porwit A, et al: ICSH guidelines for the standardization of bone marrow specimens and reports. Int J Lab Hematol 2008; 30: 349 – 364. 6. Abla O, Friedman J, Doyle J. Performing bone marrow aspiration and biopsy in children: Recommended guidelines. Paediatr Child Health 2008; 13 (6): 499 – 501. 7. Halim NKD, Famodu AA, Wemanbu SNC. Textbook of Clinical Haematology and Immunology. Indications for bone marrow aspiration. 2nd Edition, Ambik Press; 2001: 10. 8. Trewhitt KG. Bone Marrow Aspiration and Biopsy: Collection and Interpretation. Continuing Education - Oncology nursing forum 2001; 28(9): 1409 – 1417. 9. 0 – 10 Numeric Pain Rating Scale. In: McCaffery M, Pasero C (eds). Pain: Clinical Manual. Mosby Inc. St. Louis, 1999, pg. 16. 10. Thieml H, Diem H, Haferlach T (eds). Procedures, Assays and Normal values. In: Color Atlas of hematology. Practical microscopic and clinical diagnosis. Thieme Stuttgart New York. 2ed, 2002; 2: 9 – 28. 11. Adewoyin AS, Nwogoh B. Peripheral Blood film: a review. Annals of Ibadan Postgraduate Medicine 2014; 12(2): 71 – 79 12. Jean-François L, Photis B. Pathophysiology and differential diagnosis of anaemia. In: Beaumont C, Beris P, Beuzard Y, Brugnara C (eds). ESH Handbook on Disorders of erythropoiesis, erythrocytes and iron metabolism. 2009, 4: pp108 – 141. eISSN: 2349-6983; pISSN: 2394-6466

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13. WHO/UNICEF/UNU. Iron deficiency anaemia: assessment, prevention and control. Geneva: World Health Organization 2001. 14. Erythropoiesis and general aspects of anaemia. In: AV Hoffbrand, PAH Moss, JE Pettit. Essential Haematology. 5th edition. 2006. 2: pp 12 - 27 15. Damulak OD, Damen JG. Diagnostic outcome of bone marrow aspiration in a new centre in Nigeria. Global Advanced Research Journal of Medicine and Medical Sciences 2012; 1(7): 166 – 171. 16. Egesie OJ, Joseph DE, Egesie UG, Ewuga OJ. Epidemiology of anaemia necessitating bone marrow aspiration cytology in Jos. Niger Med J 2009; 50: 61 – 63. 17. Pudasaini S, Prasad KBR, Rauniyar SK, Shrestha R, Gautam K, Pathak R, et al. Interpretation of bone

marrow aspiration in hematological disorder. Journal of Pathology of Nepal 2012; 2: 309 – 312. 18. Bedu-addo G, Amoako YA, Bates I. The role of bone marrow aspirate and trephine samples in haematological diagnoses in patients referred to a teaching hospital in Ghana. Ghanian Medical journal 2013; 47(2): 74 – 78. 19. Bashawri LA. Bone marrow examination. Indications and diagnostic value. Saudi Medical Journal 2002; 23(2): 191 – 196. 20. Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol 2003; 121(6): 949 – 951.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Original Article Emergence Of Polymyxin B As A Viable Treatment Option In Comparision To Newer Antimicrobials In Intensive Care Units: A Study In North India Meher Rizvi, Naushaba Siddiqui *, Fatima Khan, Asfia Sultan, Parvez A. Khan Indu Shukla, Haris M.Khan Department of Microbiology, Jawahar Lal Nehru Medical College, Aligarh, India Keywords: Resistance, ICU, Polymyxin B, Tigecycline, Floroquinolones, Carbapenem

ABSTRACT Background: Multidrug resistance (MDR) among gram-negative bacilli has increased substantially limiting the choice of antimicrobials. This study was conducted with the objective to determine the efficacy of tigecycline , polymyxin B, newer floroquinolones and newer carbapenems against MDR gram negative isolates. Methods: 90 clinical samples were obtained from ICU patients. On the basis of antibiotic susceptibility to first line antibiotics isolates were divided into 3 groups- a) sensitive to all the first line drugs, b) sensitive only to injectable and c) resistant to all antibiotics except imipenem. These groups were then tested against enoxacin (10 μg), gemifloxacin (5μg), moxifloxacin (5μg), prulifloxacin (5μg), ertapenem (10μg), faropenem (5μg), tigecycline (15μg) and polymyxin B (300 units). Isolates were screened for ESBL, AmpC, CRE and MBL. Results: All the isolates in group 1 were uniformly sensitive to all the new antimicrobials tested. In group 2 susceptibility profile was as follows- 100% sensitive to polymyxin B, 16.6% to tigecycline, 10% to enoxacin, 3.3% to gemifloxacin, moxifloxacin, prulifloxacin, ertapenem and faropenem. In group 3, 81.5% of the isolates were sensitive to polymyxin B, 13.2% to tigecycline, 3.3% each to gemifloxacin and ertapenem.. Isolates of the three groups were uniformly sensitive to imipenem(100%). 2(6.67%) of the isolates were ESBL producers and 30 (33.3%) were AmpC producers. No CRE and MBL were detected. Conclusion: Polymyxin B emerged as most effective antimicrobial in group 2 and group 3 with 100% and 81.5% sensitivity respectively. Use of polymyxin B will prevent injudicious use of imipenem and will decrease escalation of MBLs in our facility.

*Corresponding author: Dr. Naushaba Siddiqui, Department of Microbiology, J.N Medical College, AMU, Aligarh (UP) INDIA Phone: + 919897520952 E-mail: naushsid@gmail.com

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Newer Antimicrobials For Treatment In ICU

Introduction

The prevalence of multidrug resistance (MDR) among gram-negative bacilli has increased substantially over the years.[1]Infections by these MDR gram-negative bacilli often lead to prolonged hospitalization, increased mortality, and greater costs of treatment.[2] The emergence and spread of these pathogens in health care settings, has lead to an acute shortage of effective antibiotics which can be effectively used in initial empiric therapy.[3]The emergence of extended spectrum β lactamases (ESBL) and AmpC production by Gram negative bacteria further limits the choice of antimicrobials.[4]Ultimately carbapenems are used as the drugs of last resort in the treatment of life threatening infections. Unfortunately in recent years carbapenem resistance is increasingly being reported in Gram negative bacteria.[5] Given the alarming state of drug resistance, clearly there is an urgent need for newer antimicrobial agents with novel mechanisms of action to reduce the burden on carbapenems and thus in the process decrease the emergence of carbapenemases. This study was conducted with the objective to determine the in-vitro activity of tigecycline , polymyxin B, newer floroquinolones and newer carbapenems against MDR gram negative isolates.

Materials and Methods

Study group: The study was conducted in the Department of Microbiology on patients admitted to the Intensive Care Unit, Jawaharlal Nehru Medical College and Hospital. The study group comprised of 90 clinical samples from ICU patients obtained from the following sources: surgical site infections [SSI] (70) ,drains (10), urine (5), tracheal aspirate (3), sputum (1) and Foley’s catheter tip (1). Rigorous precautions were taken during sample collection. Clinical significance of the bacteria from tracheal aspirate was assessed as per Shin et al.[6] Briefly, sample was rejected if >10 epithelial cells were seen under low power in a direct smear of agram stained slide. Uncentrifuged urine samples were screened for significant pyuria by direct wet mount. Semiquantitative cultures were put up by using filter paper method.[7] Collection and transport was done as per standard protocol.[7] Processing of sample: Culture was performed on 5% sheep blood agar, Mac Conkey agar and BHI broth. Identification was done as per standard guidelines.[8] Anti-microbial susceptibility testing: Antibiotic susceptibility testing was performed on Mueller Hinton agar by Kirby Bauer disc diffusion technique as per the CLSI guidelines.[8] Bacterial isolates were tested first

against routinely used antibiotics: gentamicin (10μg), amikacin(30μg), amoxicillin (20μg), ceftriaxone (30μg), cefotaxime (30μg), cefoperazone+ sulbactum (75/75μg), cefixime (15μg), cefoperazone (75μg), cefepime (30μg), ofloxacin (5μg) piperacillin (100μg), piperacillin tazobactum (100/10μg), tobramycin (10μg) and imipenem (10μg).Antimicrobial susceptibility controls used was Escherichia coli ATCC 25922 and Pseudomonas aeruginosa 27853. Using this set of antibiotics, ESBLs , Amp Cs and CRE’s were detected as follows: Detection of extended spectrum beta lactamases : Screening of possible ESBL production was done by using ceftriaxone (30μg) and cefoperazone (75μg). Those isolates with zone diameters less than 25mm for ceftriaxone and less than 22mm for cefoperazone were subsequently confirmed for ESBL production. Confirmation was done by noting the potentiation of the activity of cefoperazone in the presence of cefoperazone sulbactum.[8] Detection of inducible and derepressed AmpC beta lactamase: Detection of AmpC betalactamase was done on isolates resistant to ceftriaxone (30μg), cefixime (15μg), cefoperazone (75μg) and cefoperazone sulbactum (75/75μg).Induction of AmpC synthesis was based on the disc approximation assay using imipenem as inducer.[8] Detection of CRE (Carbapenem resistant Enterobacteriaceae): Isolates demonstrating zone sizes of less than16 mm around imipenem were identified as CRE. Detection of Metallo-beta-lactamases: MBL were detected by modified Hodge test and Double Disc synergy test using EDTA.[9] Study groups: On the basis of susceptibility profile to first line drugs and drug resistance markers, the isolates were divided into 3 groups: Group 1- 30 bacterial isolates susceptible to all the routinely used/ tested antibiotics. Group 2- 30 bacterial isolates resistant to all the routinely tested antibiotics except to injectable drugs (amikacin, gentamycin, cefoperazone+sulbactum, piperacillin+tazobactum, tobramycin). This group contained ESBL producers. Group 3- 30 bacterial isolates resistant to all drugs except imipenem. This group consisted of AmpC producers. Susceptibility to newer antimicrobials: These group were were further tested against enoxacin(10 μg), gemifloxacin(5μg), moxifloxacin(5μg), prulifloxacin(5μg), ertapenem(10 μg), faropenem (5μg) tigecycline (15μg)

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and polymyxin B (300 units). All discs were obtained from HiMedia, India.

Result

The organisms isolated were Escherichia coli (n=45), Klebsiella pneumoniae(n=20), Citrobacter species (n=15), Serratia species (n=5), Acinetobacter species (n=4) and Proteus mirabilis (n=1).. Amongst them 2 (6.67%) of the isolates were ESBL producers and 30(33.3%) were AmpC producers. Table 1 shows the susceptibility pattern to injectable antibiotics in group 2. All the isolates were susceptible to amikacin (100%), 3(10%) to gentamicin, 2(6.67%) each to cefoperazone/sulbactum, tobramycin and piperacillin/tazobactum. No MBL and CRE were detected. Table 2 shows comapres susceptibility of the three groups to newer antimicrobials. All the isolates in group 1 were uniformly sensitive to all the routine and the newer antimicrobials tested. In group 2 which also contained ESBLs, susceptibility profile was as follows100% sensitivity was observed to polymyxin B, 16.6% to tigecycline, 10% to enoxacin, 3.3% to gemifloxacin, moxifloxacin, prulifloxacin , ertapenem and faropenem. In group 3, 81.5% of the isolates were sensitive to polymyxin B, 13.2% to tigecycline, 3.3% each to gemifloxacin and ertapenem. All the isolates were resistant to moxifloxacin, Table 1-Susceptibility profile of pathogens to Injectable Antibiotics in Group 2 Antibiotics

NO. of isolates (n=30)

Amikacin,

30(100%)

Gentamicin

3(10%)

Cefoperazone+sulbactum

2(6.67%)

Piperacillin+tazobactum

2(6.67%)

Tobramycin

2(6.67%)

prulifloxacin, enoxacin and faropenem. Group 3 isolates showed high level of resistance to both aminoglycosides and floroquinolones. Isolates of the three groups were uniformly sensitive to imipenem (100%). Figure 1 shows trend of antimicrobial sensitivity in different groups. Barring imipenem, only polymyxin B followed by tigecycline demonstrated encouraging results. Both polymyxin B and tigecycline worked better in group 2 than in group 3.

Fig. 1: Trend of antimicrobial sensitivity in different groups

Discussion

Increasing bacterial resistance to the commonly used antimicrobial agents is increasing and is a matter of grave public health concern, particularly in patients with serious and complicated nosocomial infections. The emergence of ESBL and AmpCs, not to mention the MBLs has led to severely limited therapeutic options, resulting in increased morbidity and mortality. In this study, prevalence of ESBL was 6.67% while AmpC was much higher at 33.3% . In other studies, AmpC levels were usually lower than ESBLs.[10,11,12] The elevated levels of AmpC is alarming as the usage of imipenem increases accordingly.

*Maximum isolates were sensitive to Amikacin (100%)

Table 2- Comparision of Susceptibility of the Three Groups to Newer Antimicrobials Antibiotics

Group 1(n=30)

Group 2(n=30)

Group 3(n=30)

Enoxacin

30(100%)

3(10%)

0(0%)

Gemifloxacin

30(100%)

1(3.3%)

Moxifloxacin

30(100%)

1(3.3%)

0(0%)

Prulifloxacin

30(100%)

1(3.3%)

0(0%)

Ertapenem

30(100%)

1(3.3%)

Faropenem

30(100%)

1(3.3%)

0(0%)

Tigecycline

30(100%)

5(16.6%)

4(13.2%)

Polymyxin B

30(100%)

24(81.5%)

Polymyxin B emerged as the most effective antimicrobial in group 2 and group 3 with 100% and 81.5% sensitivity respectively. The result was similar to the study done by Castanheira who reported 88.1% of CRE isolates were susceptible to Polymyxin B.[13]There has been resurgence in the use of polymyxins as the drugs of last resort for the treatment of infections caused by MDR gram negative pathogens which are resistant to all other currently available antibiotics. Polymyxin B,a polypeptide cationic antibiotic is active against a variety of gram negative bacilli, including most clinically relavent enterobacteriaceae. It is rapidly acting bacteriocidal agent with dose adjustments required for patients with renal impairment, including decreasing daily dose and extending administration intervals.[14]

* Tigecycline and Polymyxin B showed better results in group 2 as compared to group 3

In our study, only 16.6% of the bacterial isolates in group 2 and 13.2% of the isolates in group 3 showed susceptibility

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Newer Antimicrobials For Treatment In ICU

to tigecycline but it had a better susceptibility profile than other newer antimicrobials tested including ertapenem and faropenem. Other studies however have reported good activity.[15,16,17]Tigecycline, a newer semi-synthetic glycylcycline derived from minocycline is a promising molecule in the treatment of infections caused by MDR organisms.It is a bacteriostatic agent and has potent invitro activity against several bacteria including ESBL producing Enterobacteriaceae and carbapenem resistant Acinetobacter spp. Furthermore, it is unaffected by the known mechanisms of resistance to tetracycline and minocycline such as efflux pumps and ribosomal protective mechanisms. Although ertapenem is approved for complicated intraabdominal infections, complicated skin and skin structure infections, community acquired pneumonia, complicated urinary tract infections including pyelnephritis due to susceptible pathogens, and acute pelvic infections,we observed an unexpectedly low sensitivity of 3.7% for ertapenem in our study . This is in sharp contrast to other studies which reported that ertapenem was strongly active against ESBL and AmpC producing gram negative bacteria.[18,19] As there is a need for new oral options for treatment of multidrug resistant gram negative bacteria, we also evaluated the in vitro activity of faropenem, an oral penem. But again resistance ranging from 96.3% to 100% was observed. Other studies have shown better activity of faropenem against MDR bacteria.[20,21] The newer fluoroquinolones like enoxacin, prulifloxacin, gemifloxacin and moxifloxacin have broad-spectrum bactericidal activity, excellent oral bioavailability, good tissue penetration and favorable safety and tolerability profiles. This is the first study which evaluated the role of newer fluoroquinolones moxifloxacin, prulifloxacin, gemifloxacin and enoxacin in MDR gram negative bacteria from India. However poor results were elicited with low sensitivity (0%-11.1%). Enoxacin was active against 3.7% isolates in group 2 patients. In group 3, the picture was even more dismal.

Conclusion

After assessing 8 drugs of four antimicrobial groups, we recommend Polymyxin B as empiric treatment in seriously ill patients.

Funding None

Competing Interests None declared

References

1. Nordmann P, Cuzon G, Naas T. The real threat of Klebsiella pneumonia carbapenemase producing bacteria. Lancet Infect. Dis. 2009;9:228– 236. 2. Lautenbach E, Patel JB, Bilker WB, Edelstein PH, Fishman NO. Extended- spectrum b-lactamaseproducing Escherichia coli and Klebsiella pneumoniae: risk factors for infection and impact of resistance on outcomes. Clin Infect Dis 2001; 32:1162–1171. 3. Reinert RR, Low DE , Rossi F, Zhang X, Wattal C, Dowzicky MJ. Antimicrobial susceptibility among organisms from the Asia/Pacific Rim, Europe and Latin and North America collected as part of TEST and the invitro activity of tigecycline. J Antimicrob Chemother 2007;60: 1018-1029. 4. Rizvi M, Khan F, Shukla I, Malik A, Shaheen. Rising Prevalence of Antimicrobial Resistance in UTI During Pregnancy: Necessity for Exploring Newer Treatment Options. Journal of Laboratory Physicians 2011;3:98103. 5. Pramod MS, Robin DI. Ertapenem, the first of a new group of carbapenems. J. Antimicrob. Chemother. 2003; 52: 538-542. 6. Shin YM, Oh YM, Kim MN, Shim TS, Lim CM. Usefulness of Quantitative Endotracheal Aspirate Cultures in Intensive Care Unit Patients with Suspected Pneumonia. Korean Med Sci 2011; 26: 865-869. 7. Collee JG, Fraser AG, Marmion BP, Simmons A. Mackey and McCartney practical Medical Microbiology. In: Collee JG, Miles RS, Watt B, ed: Tests for the identifi cation of Bacteria. 14th ed. New Delhi, India: Elsevier, 2006:131-149. 8. Clinical and Laboratory Standards Institute 2014.. Performance standards for antimicrobial susceptibility testing: twenty fourth informational supplement: Approved standards M100-S24. Clinical and Laboratory Standards Institute, Baltimore, USA. 2014. 9. Lee KY, Chong HB, Shin YA, Yong KD, Yum JH. Modified Hodge test and EDTA disc synergy tests to screen metallo beta lactamase producing strains of Pseudomonas and Acinetobacter species. Clin Microbiol Infect 2001; 7:88-91. 10. Singh RK, Pal NK, Banerjee M, Sarkar S, Gupta MS. Surveillance on extended spectrum β lactamase and ampc β lactamase producing gram negative isolates from nosocomial infections Archives of Clinical Microb. 2012,3:1-7. 11. Grover N, Sahni AK, Bhattacharya S. Therapeutic challenges of ESBLS and AmpC beta-lactamase

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producers in a tertiary care center. Med. J armed forces, India, 2013;69: 4 -1 0. Singhal S, Mathur T, Khan S, Upadhayay DJ, Chugh S. Evaluation of methods for Amp C β lactamase in gram negative clinical isolates from tertiary care hospitals. Indian J of Med. Microb. 2005;3:120-124. Castanheira M, Sader HS, Deshpande LM, Fritsche TR, Jones RN. Antimicrobial activities of tigecycline and other broad-spectrum antimicrobials tested against serine carbapenemase and metallo-blactamase-producing Enterobacteriaceae: report from the SENTRY Antimicrobial Surveillance Program. Antimicrob Agents Chemother 2008;52:570–573. Argyris M, Matthew EF. Colistin and Polymyxin B in Critical Care. Crit Care Clinics 2008;24(2):377–391. Sekar M, Sekar U. Tigecycline Against Gram Positive and Gram Negative Isolates in a Tertiary Care Hospital .J of Clin and Diagnos Research, 2011;5(8): 15591563. Behera B, Das A, Mathur P, Kapil A, Gadepalli R, Dhawan B. Tigecycline susceptibility report from an Indian tertiary care hospital. Indian J Med Res 2009;129:446-450.

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17. Manoharan A, Chatterjee S, Madhan S, Mathai D. Evaluation of tigecycline activity in clinical isolates among Indian medical centers..Indian J Pathol Microbiol 2010;53 (4):734-737. 18. Livermore DM, Oakton KJ, Michael W C, Warner M. Activity of Ertapenem (MK-0826) versus Enterobacteriaceae with Potent β Lactamases. Antimicrobial agents and chemother. 2001;45:2831– 2837. 19. Lee NY, Lee CC, Huang WH, Tsui KC, Hsueh PR, Ko WC. Carbapenem therapy for bacteremia due to extended-spectrum-β-lactamase-producing Escherichia coli or Klebsiella pneumoniae: implications of ertapenem susceptibility.Antimicrob Agents Chemother. 2012 ;56:2888-2893. 20. Mushtaq S, Hope R, Warner M, David M. Livermore Activity of faropenem against cephalosporinresistant Enterobacteriaceae. Journal of Antimicrobial Chemotherapy 2007; 59:1025–1030. 21. Livermore DM, Mushtaq S, Nguyen T, Warner M. Strategies to overcome extended-spectrum β-lactamases (ESBLs) and AmpC β-lactamases in shigellae. Int J Antimicrob Agents, 2011;37(5):405409.

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Original Article Cyto-Histopathological Correlations of Head and Neck Swellings In A Rural Hospital In North Maharashtra: Our Experience Kishor H. Suryawanshi*, Rajshri P. Damle, Dhiraj B. Nikumbh, N.V. Dravid, D.V. Newadkar Department Of Pathology, A.C.P.M. Medical College, Dhule, Maharashtra. India. Keywords: Head and Neck, FNAC, Histopathological Examination, Diagnostic

ABSTRACT Background: The head and neck encompass a relatively small anatomic area. But anatomy and pathology of this region is extremely complex with multitude of congenital, inflammatory or neoplastic lesions. Fine needle aspiration cytology (FNAC) is a simple, feasible, cost effective and minimally invasive procedure. But histopathological examination is more valuable for confirmatory diagnosis in suspected lesions. Aim: 1.To study the diagnostic accuracy of FNAC by comparative study with histopathological examination. 2. To study the spectrum of non-neoplastic and neoplastic lesions of head neck in rural population. Methods: A retrospective research study included 363 patients presented with head and neck swellings in a rural hospital from April 2013 to April 2015. Detailed clinical history of patient was noted. Aspirations were done and smears were stained with PAP, Haematoxylin and eosin and Leishman stain. Cytomorphological diagnosis was given. Cytohistopathological correlations were done in 205 cases. Result: Out of 363 patients studied, lymph node (39.66%) was the predominant site aspirated followed by thyroid lesions (30.30 %), salivary gland (19.00%), soft tissue and miscellaneous (7.71%). FNAC was inconclusive in 3.30 % cases. A histopathological correlation was done in 56.47% cases. Overall accuracy rate of FNAC was 97.07%. The sensitivity, specificity, positive predictive value, negative predictive value of test was 80.00 %, 98.91 %., 88.88% and 97.86 % respectively. Conclusion: Though, FNAC is a rapid, cheap diagnostic tool now-a-days, excisional biopsy remains the gold standard for diagnosis of suspected or grey zone of head and neck lesions.

*Corresponding author: Dr. Suryawanshi Kishor H. Department Of Pathology, A.C.P.M. Medical College, Dhule, Maharashtra. India. 424005 Phone: + 919403424244 E-mail: ompathologylab@gmail.com

This work is licensed under the Creative Commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Suryawanshi et al.

Introduction

The head and neck area is a complex anatomical structure which includes various non-neoplastic and neoplastic lesions of lymph node, salivary gland, thyroid gland and soft tissue. Proximity of tissues of various types and wide range of primary and metastatic neoplasms are responsible for this site being the most common in FNAC diagnosis.[1] FNAC is relatively painless, cheap, repeatable and useful for multiple lesions and has low risk of complications. FNAC is applicable to easily palpable lesions of thyroid, breast, salivary glands, superficial lymph nodes, superficial growth of skin & soft tissue. [1] Head and neck neoplasms is a major form of cancer in India accounting for 23 % of all cancer in males and 6 % in females.[2,3] FNAC of head and neck region is a generally well accepted technique with high specificity.[4] Psychological and economical advantage of an immediate diagnosis in outpatient clinic is obvious. Ancillary techniques done on cytology like flow cytometry, cytogenetic, electron microscopy, cell block preparation, immunocytochemistry have further added a tool in diagnosis. FNAC differentiates non neoplastic lesions from neoplastic lesions thus eliminating need of surgical intervention in these lesions which can be treated conservatively.[5]But histopathological confirmation is mandatory in suspected ,recurrent and neoplastic lesions.

Material and Method

A retrospective study was conducted in Department of Pathology from April 2013 to April 2015 and included 363 patients with head and neck swellings. Outdoor as well as indoor patients with palpable head and neck swellings were referred to cytology department. Detail clinical history and significant findings were noted. After explanation of procedure and taking informed consent of patient, FNAC was done using 10 cc disposable syringe and 22/23 gauge needle taking all aseptic precautions. Both aspiration and non-aspiration techniques were used wherever required. Smears were stained with PAP, Haematoxylin-Eosin stain and Leishman stain. Zeihl-Neelsen staining for acid fast bacilli was done in suspected tubercular lesions. Aspirations taken from various sites include lymph node, thyroid, salivary gland and soft tissue. Cytomorphological diagnosis was given depending upon the pathology. Clinicians were advised excisional biopsy. Excisional biopsy specimens were fixed in 10% neutral buffered formalin processed by paraffin embedding and stained with haematoxylin and eosin stain. Cyto-histopathological correlation was done in those cases.

A-121 75 years. Out of total 2270 cytology patients over a period of 2 years FNAC of head and neck lesions constituted 363 (15.99 %) of cases. Maximum no. of patients were in the age group of 21-30 years (37.23%) followed by 31-40 years (22.40%) and least no. of patients were seen in age group of above 70 years. Out of 363 patients 203 (55.92%) were females and 160 (44.08%) were males. Site wise distribution of head and neck FNAC [Table-1] shows lymph nodes lesion as the predominant site of FNAC followed by thyroid lesions (30.30%), salivary glands (19.00%) and soft tissue (7.71%). FNAC was inconclusive in 12 (3.30%) cases. Table-1: Distribution of Head & Neck Lesions [Cases=363] Site

No. of Cases

Lymph Node

144

39.66

Thyroid gland

110

30.30

Salivary gland

19.00

Soft tissue & miscellaneous

7.71

Inconclusive

3.30

In 144(39.66%) cases of lymph node lesions, tubercular lymphadenitis (44.44%) was the predominant finding observed followed by reactive lymphadenitis in 52(36.11%) cases. Malignant lesions included 7 cases (4.86%) of metastatic epithelial malignancy and two cases (1.38%) of lymphoma. Histopathological examination done in 76 cases confirmed diagnosis in 73 cases with two false negative and one false positive result. [Table-2] [Figure-1]

The present study included 363 cases of head and neck lesions from various departments as an OPD as well as indoor patient. Age group of patients ranged from 1 year to

Fig. 1: Lymph node lesions (a) FNAC showing necrotic background with epithelioid cell granuloma (Leishman Stain; x400); (b) HPE -Tubercular Lymphadenitis (H&E; x100); (c) Z.N. Stain- Acid fast bacilli (Z.N Stain; x400) and (d) HPE- Kikuchiâ&#x20AC;&#x2122;s lymphadenitis (H&E; x400).

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Results

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Table 2: Cytology & Histopathological Co-relation of Various Lymph Node Lesions [N=144] FNAC Diagnosis

No. of cases

HPE Done

Reactive lymphadenitis

36.11

Inflammatory Nonspecific Tuberculosis

19 64

Malignant

Lymphoma Metastasis

Total

Diagnosis Consistent with cytology 1

HPE Diagnosis Inconsistent with cytology 1

13.19 44.44

5 59

5 58

-1

1.38

7 144

4.86 100

RLH- Reactive lymphoid hyperplasia LN-Lymphadenitis TB-Tuberculosis

HPE Diagnosis

RLH- 1 case Granulomatous LN-1 Chronic Nonspecific LN-5 Granulomatous LN S/O TB-58 Kikuchi Disease-1 NHL-1 RFH-1 SCC- 5 & ADC-1

SCC-squamous cell carcinoma ADC- Adenocarcinoma RFH-Reactive Follicular Hyperplasia

In salivary glands lesions, sialadenitis was observed in 59.41% of cases. Benign neoplasm included 20 (28.98%) cases of pleomorphic adenoma, four cases (5.79%) of benign lymphoepithelial cyst and one case of basal cell adenoma .3 cases of malignant neoplasms were reported including one case of each of carcinoma ex pleomorphic adenoma, mucoepidermoid carcinoma and anaplastic carcinoma. Histopathological study of 39 cases confirmed cytological diagnosis in 38 cases with one false positive result.[Table-3 ][Figure-2]

were observed. Out of 68 cases cyto-histopathological correlation was found in 66 cases with two false negative results. [Table-4]

In 110 (30.30%) cases of thyroid lesions, 28(25.45%) of cases of inflammatory lesions including Hashimoto’s thyroiditis, chronic lymphocytic thyroiditis were reported. Benign neoplastic lesions constituted 74.53% of cases. In malignant lesions two cases (1.81%) of papillary carcinoma

Diagnosis consistent with cytology was available in all 24 cases. A cyto-histopathological correlation was done in 205 (56.47%) cases. Histological diagnosis found consistent with cytology in 199 (97.07%) cases while inconsistent with cytology in 6 (2.93%) cases.

FNAC of soft tissue and miscellaneous constituted 28 cases (7.71%) with varied pathological lesions like lipoma (25.00%), epidermal cyst (46.42%), benign adnexal tumor (3.57%) and malignant neoplasms including squamous cell carcinoma, basal cell carcinoma, malignant melanoma and metastatic epithelial neoplasm. [Table-5] [Figure-3]

Table 3: Cytology & Histopathological Co-relation Of various Salivary gland lesions [n= 69] Salivary gland lesions

No. of cases

1.Acute sialadenitis 2. Chronic sialadenitis

14 27

20.28 39.13

1.Pleomorphic adenoma 2.Benign lymphoepithelial lesion 3.Basal cell Adenoma

20 4 1

28.98 5.79 1.44

1.Carcinoma ex pleomorphic adenoma 2.Mucoepidermoid carcinoma

3.Anaplastic carcinoma Total

HPE Done

HPE HPE Diagnosis Diagnosis Inconsistent with cytology

1.44

Diagnosis Consistent with cytology Inflammatory 2 2 9 9 Benign 20 20 4 4 1 1 Malignant 1 1

1.44

1 69

1.44 100

– –

Acute sialadenitis-2 Chronic sialadenitis-9

– – –

Pleomorphic adenoma-20 Benign lymphoepithelial cyst-4 Basal cell Adenoma-1

Carcinoma ex pleomorphic adenoma-1 Pleomorphic adenoma with squamous metaplasia-1 Anaplastic carcinoma-1

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Fig. 2: Salivary gland lesions (a) FNAC showing benign pleomorphic adenoma (Pap Stain; x100) ;(b) HPE- benign pleomorphic adenoma (H&E; x400) ;(c) FNAC showing basal cell adenoma (Pap Stain; x100) and (d) HPE-basal cell adenoma (H&E; x400) .

Fig. 3: (a) FNAC of thyroid gland showing follicular lesion (H&E; x100); (b) FNAC showing papillary carcinoma of thyroid (Leishman Stain; x400) ;(c) FNAC showing malignant melanoma (Leishman Stain; x400) and (d) FNAC showing squamous cell carcinoma of soft tissue (Pap Stain; x400)

Table 4: Cytology & Histopathological Co-relation Of various Thyroid lesions [n= 110] Thyroid lesions

No. of cases

HPE Done

Diag. Consistent with cytology

HPE Diag. Inconsistent with cytology

HPE Diagnosis

Inflammatory

25.45

–

Thyroiditis-5

1.Colloid /nodular goitre

49.09

Colloid/nodular goiter-44 Follicular adenoma-1

2.Hurthle cell neoplasm

9.09

–

Hurthle cell Neoplasm-5

3.Thyroglossal cyst

7.27

–

Thyroglossal cyst-5

4.Follicular neoplasm

7.27

Follicular adenoma-5 Follicular carcinoma-1

5.Papillary carcinoma

1.81

–

Papillary carcinoma-2

Total

110

100

Table 5: Cytology & Histopathological Co-relation Of soft tissue & miscellaneous lesions [n=28] No. of cases

HPE Done

1.Lipoma 2.Epidermal cyst 3.Benign adnexal tumor

7 13 1

25.00 46.42 3.57

7 12 -

1.Squamous cell carcinoma 2.Basal cell carcinoma 3.Malignant melanoma 4.Metastatic epithelial tumor Total

4 1 1 1 28

14.28 3.57 3.57 3.57 100

3 1 1 –

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Diagnosis Consistent with cytology Benign 7 12 – Malignant 3 1 1 –

Diagnosis HPE Diagnosis Inconsistent with cytology – – –

Lipoma-7 Epidermal cyst-12 –

– – – –

Squamous cell carcinoma-3 Basal cell carcinoma-1 Malignant melanoma-1

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Head and Neck Lesions

Discussion

More no.of metastasis in lymph node is due to consumption of tobacco in various forms in our area leading to high incidence of malignancy in aerodigestive tract.

Head and neck neoplasm constitute a major form of cancer in India accounting for 23% of all cancer in males and 6% in females[2,3] and approximately 5% all childhood neoplasms.[6] Increased prevalence of malignancies may be due to use of various forms of tobacco in our country. Lesions of head and neck include variety of developmental, inflammatory and neoplastic lesions.

FNAC of thyroid lesions revealed colloid/nodular goiter (49.09%) as the predominant finding in benign lesion followed by inflammatory lesions consisting of Hashimotoâ&#x20AC;&#x2122;s thyroiditis, chronic lymphocytic thyroiditis. Two cases of papillary carcinoma were detected which were confirmed on histopathology. Muddegowda et al [8] and Rathod et al [12] also found thyroid lesions as the predominant site of FNAC in their study with colloid goiter as the predominant finding. Female preponderance was observed in FNAC of thyroid lesion in our study with similar findings reported by Rathod et al [12] and Muddegowda et al. [8]

In 1930, Martin and Ellis described and first introduced the technique of FNAC for diagnosis of organ lesion.[7] The two fundamental requirements on which success of FNA depends are representative sample and high quality of preparation. These two prerequisites will always remain a sine qua non, no matter how sophisticated supplementary techniques.[1]

In salivary gland lesions acute and chronic sialadenitis together comprised 59.41% followed by pleomorphic adenoma in 20 cases (28.98%) , benign lymphoepithelial cyst in four cases (5.79%) and basal cell adenoma in one case. Three cases of malignant neoplasms were reported including one case of each carcinoma ex pleomorphic adenoma, mucoepidermoid carcinoma and anaplastic carcinoma. However the case reported as mucoepidermoid carcinoma on cytology turned out to be pleomorphic adenoma with squamous metaplasia on histopathological examination. Sharma et al[11] and Rathod et al[12] found inflammatory lesions as the commonest findings followed by benign neoplasms including pleomorphic adenoma while Bhagat et al[9] found benign pleomorphic adenoma as the predominant salivary gland lesion in his study.

The present study was carried out over a period of 2 years find out the diagnostic accuracy of FNAC by comparative study with histopathological diagnosis and also compares its findings with various national and international studies published in the literature.[Table-6] Majority of patients were females with male to female ratio of 0.78:1 and the study included patients of all age group. Similar results of female preponderance were also reported by Muddegowda et al [8], Sharma et al [11] and Ahmad T et al.[13] In our study predominant site of FNAC was lymph node lesions (39.66%) followed by thyroid gland. Similar result reported by various studies. [Table-6] In lymph node lesions tubercular lymphadenitis was the most common pathological findings followed by reactive lymphadenitis which is in concordance with Bhagat et al [9], Sharma et al [11], Ahmad T et al [13] and El Haq et al [4].In malignant neoplasms, epithelial metastasis was found in 7 cases (4.86 %) and two cases of lymphoma were found. Out of six cases five confirmed metastatic squamous cell carcinoma and one case of metastatic adenocarcinoma histopathologically.

Benign lesions comprised of 13 cases (46.42%) of epidermal cyst, 7 cases (25.00%) of lipoma and one case (3.57%) of benign adnexal tumor were commonest findings in soft tissue and miscellaneous lesions .Seven cases of malignant neoplasms comprising of 4 cases of squamous cell carcinoma and one case of each basal cell carcinoma,

Table-6: Comparison of Results of Various National and International Studies Our study 2015

Muddegowda et al [8] [2014]

Bhagat VM Mohmed et al [9] MH[10] [2013] [2013]

Sharma R[11] Rathod [2012] G [12] [2012]

Ahmad T[13] [2008]

El Hag [2003]

Kamal F[14] [1996]

No. Of Patients

363

100

701

125

200

225

847

M:F ratio

0.78:1

0.29:1

0.53:1

-----

---

0.64:1

1.43:1

0.47:1

---

Predominent site

Lymph Node

Thyroid

Lymph Node

Thyroid

Lymph Node

Malignant Neoplasm (%)

5.78

20.68

Benign neoplasm (%)

14.87

6.56

12.5

Inconclusive

3.30

3.2

4.5

1.3

[4]

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Suryawanshi. et al.

A-125

malignant melanoma and metastatic epithelial tumor to scalp was reported. Bhagat et al [9] reported neoplastic lesions in 63% cases with lipoma as the predominant benign tumor and squamous cell carcinoma as the commonest malignant neoplasm. In 3.30 % of cases cytology was inconclusive. The causes of unsatisfactory aspirates were smaller lesions, poor handling of material, inadequate aspirate. Incidence of inadequate reports ranged from 0 to 10 % in varies studies in the literature. Cyto-histopathological correlation was done in only 205 cases (56.47%). Out of 330 benign lesions in 187 cases only cyto-histopathological correlation was possible. Cytomorphological diagnosis was in concordance with histopathological diagnosis in 183 cases (97.86%) while 4 cases showed false negative results. One case reported on cytology as reactive lymphadenitis turned out to be tubercular lymphadenitis on histopathological examination. The probable reason may be focal epithelioid granuloma was missed during aspiration hence multiple passes in various directions is necessary to avoid false negative result. Another case reported on cytology suggestive of NHL was confirmed as reactive follicular hyperplasia on histopathology. Differentiation between lymphoma and follicular hyperplasia is very difficult on cytology and require biopsy for primary diagnosis. One more case reported as tubercular lymphadenitis on cytology turned out to be Kikuchiâ&#x20AC;&#x2122;s lymphadenitis on histopathological examination. On the basis of findings of necrotic background, epithelioid histiocytes cytological diagnosis of granulomatous lymphadenitis suggestive of tuberculosis was offered. Characteristics features like central necrotic debris, peripheral palisading histiocytes, plasmacytoid monocytes and immunoblast suggest Kikuchiâ&#x20AC;&#x2122;s lymphadenitis on cytology. Other case reported as a follicular neoplasm of thyroid on cytology turned out to be follicular carcinoma on histopathological examination. This is one of the known limitations of FNAC in thyroid follicular lesions and both lesions can not be differentiated cytologically. One case of nodular colloid goiter turned out

to be follicular adenoma histopathologically. The probable cause of this discrepancy was due to aspiration of follicular focus from nodular goiter. Hence multiple passes from different areas avoid such discrepancy. Out of 18 malignant cases reported on cytology, in 16 cases cytological diagnosis was consistent with histopathological diagnosis. One case reported as mucoepidermoid carcinoma on cytology turned out to be pleomorphic adenoma with squamous metaplasia on histopathological examination. So presence of metaplastic squamous cells on cytology should raise suspicion of this entity while reporting. In this study overall accuracy rate of FNAC was 97.07% with sensitivity of 80.00 %, specificity of 98.91 %, and positive predictive value of 88.88% and negative predictive value of 97.86 %. Cyto-histopathological correlation was done by Sharma et al [11] in 71 cases out of 125 cases with sensitivity of 89.28%, specificity of 90.69%, positive predictive value of 85% and negative predictive value of 90.14%. Tilak et al [15] studied cyto-histopathological correlation in 55 out of cases 154 with overall diagnostic accuracy rate of 92.75%, sensitivity of 90.91% and specificity of 93.18%. Maniyar et al [16] studied cyto-histopathological correlation in 92 (23.90%) cases out of 385. Out of these 92 cases, in 79(85.87%) cases histopathology diagnosis was consistent with cytology while in 13(14.13%) cases cyto-histopathological diagnosis were different. Cytohistopathological correlation was done by Fernandez H et al [17] in 129 cases out of 620 cases with sensitivity of 83.33%, specificity of 100%, positive predictive value of 97% and negative predictive value of 97%. [Table 7]In most of the national studies including our study inflammatory and nonneoplastic lesions were the predominant cause of head and neck masses while neoplastic lesion were the commonest finding in various international studies. The present study highlights the limitations of FNAC in diagnosis of thyroid follicular lesions, borderline and grey zone lesions of lymph node and soft tissue. A histopathological examination is mandatory for

Table- 7 â&#x20AC;&#x201C;Comparison of various studies Author study

No. of Cytology cases

HPE Done

Sensitivity %

Specificity %

Accuracy rate of FNAC %

Sharma et al [11] 2012

125

89.28

90.69

90.14

Tilak et al [15] 2002

154

90.91

93.18

92.75

Maniyar et al [16]2013

385

98.46

100

98.91

Fernandez H et al [17] 2009

620

129

83.33

100

Our study ,2015

363

205

80.00

98.91

97.07

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Head and Neck Lesions

confirmatory diagnosis of such lesions. Non-neoplastic lesions remain the predominant cause of palpable swellings in our locality which is comparable with other studies. To avoid or minimize false positive results various factors including regenerative changes, metaplasia and others should be taken into considerations while reporting. False negative results may be due to cystic change, necrotic and hemorrhagic areas revealing no diagnostic cellular yield. Repeat FNAC of solid areas or adjacent area may minimize false negative results in such cases. In this study it is observed that though FNAC is a rapid, cost effective, highly accurate and feasible first line diagnostic tool in management of head and neck swellings histopathological confirmation is required for especially for neoplastic lesions to avoid false negative results and proper management of patient.

Conclusion

Though FNAC is a rapid, cheap diagnostic tool now-adays with overall accuracy rate more than 90 %, excisional biopsy remains the gold standard for diagnosis of head and neck neoplastic lesion. To obtain maximum diagnostic accuracy cyto histopathological correlation is must.

Acknowledgements Nil

Funding NIL

Competing Interests None

References

1. Orell SR, Sterrett GF, Walters MN-I, Whitaker D: Manual and Atlas of Fine Needle Aspiration Cytology. 2nd edn. New York: Churchill Livingstone; 1992.p. 2-36. 2. Ahluwalia H, Gupta SC, Singh M, Gupta SC, Mishra V, Singh PA. Spectrum of head and neck cancers at Allahabad.J Otolaryngol Head Neck Surg. 2001;53:1620.

5. Klijanienko J. Head and Neck and Salivary gland. In: Layfield LJ, editor. Atlas of Fine Needle Aspiration Cytology,1st edn.New Delhi:Jaypee Publishers;2014.p.11. 6. Ponder TB, Smith D, Ramzy I. Lymphadenopathy in children and adolescents: role of fine-needle aspiration in management. Cancer Detect Prev. 2000; 24:228–33. 7. Martin HE, Ellis EB. Biopsy of needle puncture and aspiration. Ann Surg. 1930; 92:169-81. 8. Muddegowda PH, Srinivasan S, Lingegowda JB, Ramkumar KR, Murthy KS. Spectrum of Cytology of Neck Lesions: Comparative Study from Two Centers. Journal of Clinical and Diagnostic Research. 2014; Vol-8(3): 44-45. 9. Bhagat VM, Tailor HJ, Saini PK, Dudhat RB, Makawana GR, Unjiya RM. Fine Needle Aspiration Cytology In Nonthyroidal Head And Neck Masses-A Descriptive Study In Tertiary Care Hospital. National Journal Of Medical Research. 2013; volume 3(3):27376. 10. Mohamed MH, Hitam S, Brito-Mutunayagam S, Yunus MRM. Role of FNAC in evaluation of neck masses. J Curr Surg. 2013;3(1):19-23. 11. Sharma R, Mathur DR. Fine needle aspiration cytology (FNAC) of palpable lesions of head and neck region. Int J Cur Res Rev 2012; Vol 04 (22):74-84. 12. Rathod GB, Parmar P. Fine needle aspiration cytology of swellings of head and neck region. Indian J Med Sci 2012;66:49-54. 13. Ahmad T, Naeem M, Ahmad S, Samad A, Nasir A. Fine needle aspiration cytology (FNAC) and neck swellings in the surgical outpatient. J Ayub Med Coll Abbottabad 2008;20:30-2. 14. Kamal F, NiazI S, Nagi AH, Jaradi MA, Naveed IA. Fine needle aspiration cytology (FNAC): an experience at King Edward Medical College, Lahore. Pak J Pathol 1996;7:33–6. 15. Tilak V, Dhaded AV, Jain Raginiet al : Fine needle aspiration cytology of Head and Neck masses. Indian J Pathol Microbiol 2002; 45(1):23-30.

3. Mehrotra R, Singh M, Gupta RK, Singh M, Kapoor AK. Trends of prevalence and pathological spectrum of head and neck cancers in North India. Indian J Cancer. 2005;42:89-93.

16. Maniyar AU,Patel HL,Parmar BH.Study of Cytodiagnosis of Head and Neck Neoplastic Lesions and comparision with histopathology.RRJMHS 2013;2(2):54-9.

4. El Hag IA, Chiedozi LC, al Reyees FA, Kollur SM. Fine needle aspiration cytology of head and neck masses. Seven years’ experience in a secondary care hospital. Acta Cytol. 2003;47:387–92.

17. Fernandes H,D’Souza RS,Thejaswini BN. Role of Fine Needle Aspiration Cytology In Palpable Head and Neck Masses.Journal of clinical and diagnostic research 2009;3:1719-25.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Case Report Gastric Carcinoma Diagnosed Incidentally on Cervical Biopsy in A Young Female Mahendra Kumar1, Naushad Shah1, Jaya Mishra1*, Ritesh Kumar2, Subrat Panda3 Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India Department of Radiotherapy, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India 3 Department of Obstetrics & Gynecology , North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, India `1

Keywords: Metastatic Carcinoma; Krukenberg Tumor; Signet Ring Cells; Gastric Malignancy; Cervix Carcinoma.

ABSTRACT Gastric carcinoma usually metastasizes to liver, peritoneum, lymphnodes, ovary, lung and brain. But gastric malignancy metastasizing to cervix is extremely rare and even rarest in young patients. Reaching to the primary site of hidden gastric malignancy on a cervical biopsy was very interesting in present case. Distinction of primary cervical malignancy to metastasis is very important for clinical and pathological point of view which helps in the diagnosis, staging, treatment and prognosis of the patient. Here we are documenting a case of gastric malignancy which presented as cervical mass and bilateral ovarian enlargement in a 22 years old female.

*Corresponding author: Dr. Jaya Mishra, Associate Professor, Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Mawdiangdiang, Shillong, 789018, Meghalaya, India Phone: +91 - 96824331357 E-mail: jayamishraxyz@gmail.com

This work is licensed under the Creative Commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

Kumar et al.

Introduction

Metastatic cervical carcinomas are generally originate from intrapelvic organs, however, they may receive metastasis from extrapelvic organs rarely.[1,2] In scientific literature, the most common organ which metastasizes to cervix is ovary followed by gastro-intestinal tract (GI tract), uterine tube and breast.[3,4,5] Metastatic ovarian adenocarcinoma (Krukenberg tumour, KT) are uncommon which originates in the stomach in the vast majority of cases, however may come from other organs such as intestine, breast, gallbladder, uterine cervix or appendix also. [6].Prognosis of KT is extremely poor as compared with primary ovarian cancer(s).[7] Its management is further complicated by simultaneous involvement of other organ such as cervix in present case. Here we are documenting an incidentally diagnosed case of gastric carcinoma presented with cervical growth and KT in young female.

Case Report

A 22-years-old married woman was referred from a local hospital to Gynaecology OPD of our Institute with chief complaints of progressive enlargement of abdomen along with dragging pain in lower abdomen and difficulty in breathing for last 3 weeks. Bowel habit was normal. Menstrual history and other gynecological history were non contributory and did not suggest pregnancy and other gynecological disorders. General physical examination revealed mild pallor with Hb of 7 gm/dl, however, there were no icterus or lymphadenopathy. Abdominal examination showed markedly enlarged abdomen with tense ascities and

C-209 it was difficult to access any organ or mass per abdomen. Per vaginal examination revealed growth in posterior lip of cervix measuring 1.5× 2cm. Biopsy from cervical mass was taken and sent for histopathological examination. Cervical pap smear was not prepared. Bilateral adnexa and uterus could not be accessed properly due to tense ascitis. Her laboratory investigation was significant for CEA of 10.07 ng/mL (reference range: <3ng/mL), however AFP (<2ng/mL) and ß -HCG (5.17mIU/mL) were within normal range. Cytological evaluation of ascetic fluid showed scanty cellularity and few scattered cells of suspicious nature. Further, radiological investigations (Ultrasonography and CT-scan) revealed enlarged ovaries measuring 4.9×3.9×4.6cm and 6.2×4.4×5.2cm with solidcystic component. These findings suggested the possibility of bilateral ovarian neoplasm on radiology. Histological examination of cervical biopsy showed frank epithelial malignancy which occupied most of the sub epithelial region (FIGURE-1A) and causing disarrays of lining cervical epithelium with focal ulceration, leading to confusion between primary cervical carcinoma and metastasis (FIGURE-1B). The tumor cells were arranged mainly in sheets, showing moderate pleomorphism, round vesicular nuclei and moderate amount of clear to amphophilic cytoplasm (Figure-1b). At places tumor cells had eccentric nuclei and moderate amounts of clear cytoplasm simulating signet ring- like cells (Figure- 2). In the light of radiological findings, a diagnosis of cervical malignancy with a possibility of metastasis from ovary

Fig. 1: Panel of microphotographs from cervical biopsy shows a diffuse tumor (1a, H&E, x10) along with disarray of lining epithelium (1b, H&E, x20). IHC shows CK-20 positivity (1d, x20) & CK-7 negativity (1c, x10) in tumor cells. Unremarkable cervical lining epithelium shows positivity for CK-7 (1c, x10).

Fig. 2: Higher magnification of cervical biopsy highlights signet ring morphology of tumor cells focally (H&E, x40).

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Gastric Carcinoma with Metastasis to Cervix

was considered. Vice-versa, primary cervical carcinoma metastasizing to bilateral ovaries was also considered which is very rare. Presence of few signet like cells had raised a possibility of bilateral ovarian metastasis along with cervical involvement by unknown primary. So, search for primary other than ovary was advised. Further, upper GI endoscopy had detected a large ulcerated growth at lesser curvature of the body of stomach. Endoscopic biopsy was advised from the same which subsequently revealed moderately differentiated adenocarcinoma of stomach. These tumor cells had almost similar morphology as the tumor cells of cervical biopsy (Figure-3a & 3b). All the diagnostic puzzles fell into place when immumnohistochemistry (IHC) panel was performed on both the biopsied specimens (i.e., the cervical and the stomach). The tumor cells were positive for CK-20 (FIGURE 1D & 3C) and negative for CK-7 (Figure 1c & 3d) confirming the GI origin of the adenocarcinoma. In addition to these markers, tumor were also negative for ER, PR, WT1, TTF-1, synaptophysin and chromogranin, which rule out possibility of other metastatic tumor site (breast, ovary, lung and peritoneum) & neuroendocrine nature of tumor. Patient was so sick that further intervention like FNAC and biopsy from ovarian mass could not be performed.

denied for the same due to socio-economic reasons and left the hospital against medical advice.

Discussion

Uterine cervix is an uncommon site for metastatic tumor. [3,4] The most common malignancy spreading to the cervix is the endometrial carcinoma which involves through direct extension and typically involves the endocervical glands with or without stromal involvement. The common primary sites of malignancies which metastasize to cervix are ovary, gastrointestinal tract, uterine tube, breast and peritoneum in descending order of frequency.[3,8] Locoregional characteristics which may explain the low incidence of cervical metastases include - small organ size, reduced blood flow and distal location, as well as the organ’s abundant content of fibrous tissue. All these characteristics make the uterine cervix a medium that is scarcely favorable for the propagation of malignant cells.[9] On the other hand, ovaries are the frequent targets for metastasis for malignant tumors. Metastasis altogether accounts for 10-30% of all the malignant ovarian tumors.[10] Primary sites of malignancy may be either gynecological or non gynecological organs. Non gynecological tumors which metastasize to the ovaries are stomach, breast and colon followed by others.[10] Woodruff and Novak defined the KT as arising in the ovarian stroma and having characteristic mucin-filled signet-ring cells.[11] “Krukenberg tumor” is occasionally used as a synonym for metastatic ovarian tumors from various organs. In general KT is rare in Western countries and accounts for 3–4% of metastatic ovarian tumors.[12] On the other hand, the incidence of KT in Japan is rather high because of the high incidence of gastric cancer.[13,14] Simultaneous involvement of both cervix and ovaries are extremely unusual and very rare in young age.

Fig. 3: Panel of microphotographs of gastric biopsy shows a diffuse tumor (3a, H&E, x4) and high power of same (2b, H&E, x20) highlights minimally pleomorphic tumor cells having moderate amount of eosinophilic to amphophilic cytoplasm. IHC shows CK-20 positivity (3c, x10) and CK-7 negativity (3d, x20) in tumor cells.

Correlating clinical, radiological, biochemical and histological findings, final diagnosis of adenocarcinoma of stomach with metastasis to bilateral ovaries (Krukenberg tumor) and cervix was made. Patient was referred to Oncology & Palliative care unit and offered for systemic palliative chemotherapy but she

Average age of presentation is 45 & 43 years for overall KT and patient with cervical metastasis respectively.[3,15] Average age is slightly lower in gastric primary tumor as compared to other primary sites in both KT and patients with cervical metastasis.[3,15] In the present case patient was 22 year old which was quite young for cervical metastasis along with KT. Clinically, most of the either kind of patients present with abdominal swelling and pain in abdomen as in our case. Some of the patient may have endocrine manifestation such as virilization, hirsutism and vaginal bleeding (estrogenic effect) and very few may be asymptomatic.[3,15] Few patients may have an already known primary tumor and associated symptoms before the diagnosis of metastasis to ovary. A large study has demonstrated that primary tumor was identified only

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Kumar et al. in about 50% cases even after extensive search and 32% of that had diagnosis of primary tumor before ovarian metastasis.[15] Herein patient had abdominal swelling, mild pain and severe ascitis, however did not have any major gynecological symptoms/complains like vaginal bleeding. On colposcopic examination, there was a growth on the posterior vaginal wall from which the biopsy was taken. Common histological features of metastatic carcinoma within the cervix include predominant involvement of the deep stroma, absence of surface involvement and of an in situ component, prominent lymphovascular permeation and entrapment of normal endocervical glands.[4] In contrast to these features, herein biopsy showed superficial stromal infiltration as well as disarray and focal ulceration of lining endocervical epithelium which was very unusual and rare for cervical metastasis. Similar pattern of infiltration has been discussed in a case series of six cases of cervical metastasis. [4] This kind of superficial pattern of involvement raised the possibility of primary cervical carcinoma metastasizing to bilateral ovaries. However in view of few signet rings like cells and bilateral ovarian enlargement possibility of a primary adenocarcinoma outside the genital tract was considered and further investigation revealed tumor with similar morphology in the stomach. To resolve the confusion between primary versus secondary origin of the cervical tumor, IHC was performed and tumor was positive for CK20 and negative for CK 7 which favored the possibility of GI origin of the tumor. Other IHC markers which can be used to rule out other metastatic sites / tumors are ER, PR, WT-1, p53, p16, TTF-1, HMB-45, CEA and thyroglobulin. There are various morphological features which may help to discriminate between primary and secondary nature of tumor in cervix. Primary cervical tumors are characterized by dysplastic epithelium with or without ulceration, in situ epithelial lesions, superficial stromal invasion and absence of prominent lymphovascular permeation. On the other hand secondary cervical malignancy usually lacks these features and there is mainly deep stromal involvement, lymphovascular involvement, entrapment of normal endocervical glands and single cell infiltration with signet ring morphology (specially in gastric signet ring carcinoma).

C-211 cervix leading to poor expected survival of the patient. Considering advance stage of tumor, patient was offered for palliative systemic chemotherapy. But patient left the hospital against the medical advice and lost to follow up. This case emphasizes that systematic work-up for known primary tumor sites is important in suspected cases of metastatic gynecological tumor.

Conclusion

To conclude, cervical metastasis along with bilateral ovarian involvement is uncommon in gastric carcinoma and extremely rare in young female. Clinician should keep the rare possibility of cervical metastasis from gastric primary in their differential diagnosis. It is important for the pathologist to be aware of the possibility of cervical metastasis to avoid an erroneous diagnosis of a primary cervical adenocarcinoma. The detailed histopathological features of the lesion and judicious use of immunohistochemical techniques allow us to determine the true origin of the metastatic tumor.

Acknowledgements

Present case was worked out mainly in Department of Pathology, however we also acknowledge the contribution of Department of Radiology to complete this case.

Funding None

Competing Interests None declared.

Reference

Isolated dissemination to the uterine cervix is more common among patients with ovarian and colorectal cancer compared with those of gastric or breast cancer. In the majority of patients with gastric, breast and ovarian cancer, disease spread to other pelvic or extrapelvic organs. Regarding survival, gastric and colorectal primaries have poorer survival as compared to primary tumor from breast and ovaries.[15] In present case primary tumor was in stomach and has disseminated to the ovaries and

1. Imachi M, Tsukamoto N, Amagase H, Shigematsu T, Amada S, Nakano H. Metastatic adenocarcinoma to the uterine cervix from gastric cancer. A clinicopathologic analysis of 16 cases. Cancer 1993;71:3472-7. 2. Lee P, Paek J, Nam EJ, Kim Y T, Kim SW. A case of stomach cancer metastatic to the uterine cervix. Journal of Womens Medicine, 2011; 4(1): 23-26. 3. Perez-Montiel D, Serrano-Olvera A, Salazar LC, Cetina-Pérez L, Candelaria M, Coronel J, Cantu de Leon D. Adenocarcinoma metastatic to the uterine cervix: A case series. Journal of Obstetrics and Gynaecology Research, 2012; 38(3): 541-549. 4. McCluggage WG, Hurrell DP, Kennedy K. Metastatic carcinomas in the cervix mimicking primary cervical adenocarcinoma and adenocarcinoma in situ: report of a series of cases. The American journal of surgical pathology, 2010;34(5):735-741. 5. Kumar NB, Hart WR. Metastases to the uterine corpus from extragenital cancers. A clinicopathologic study of 63 cases. Cancer 1982;50:2163-9.

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6. Young R: From krukenberg to today: the ever present problems posed by metastatic tumors in the ovary: part I. Historical perspective, general principles, mucinous tumors including the krukenberg tumor. Adv Anat Pathol 2006, 13:205–227. 7. Jiang R, Tang J, Cheng X, Zang RY. Surgical treatment for patients with different origins of Krukenberg tumors: outcomes and prognostic factors. Eur J Surg Oncol 2009; 35: 92-97. 8. Ng AB, Teeple D, Linder EA, Reagan JW. The cellular manifestations of extrauterine cancer. Acta Cytol 1974; 18: 108–117. 9. Esposito JM, Zarou DM, Zarou GS. Extragenital adenocarcinoma metastatic to the cervix uteri: a diagnostic problem. Am J Obstet Gynecol 1965; 92: 792–795. 10. Yada-Hashimoto N, Yamamoto T, Kamiura S, Seino H, Ohira H, Sawai K, Saji F. Metastatic

ovarian tumors: a review of 64 cases.Gynecologic oncology.2003;89(2):314-317. 11. Woodruff JD, Novak ER. The Krukenberg tumor: study of 48 cases from the ovarian tumor registry. Obstet Gynecol 1960;15:351–60. 12. Soloway I, Latour JPA, Young MHV. Krukenberg tumors of the ovary. Obstet Gynecol 1956;8:636–8. 13. Yakushiji M, Tazaki T, Nishimura H, Kato T. Krukenberg tumors of the ovary: a clinicopathologic analysis of 112 cases. Acta Obstet Gynaecol Jpn 1987;39:479–85. 14. Hale RW. Krukenberg tumor of the ovaries: a review of 81 records. Obstet Gynecol 1968;32:221–5. 15. Kiyokawa T, Young RH, Scully RE. Krukenberg tumors of the ovary: a clinicopathologic analysis of 120 cases with emphasis on their variable pathologic manifestations.The American journal of surgical pathology.2006;30(3):277-299.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Case Report Cellular Angiofibroma: A Rare Vulvar Neoplasm Distinct From Aggressive Angiomyxoma Jasvinder Kaur Bhatia*1, R Nangia2 1

Department of Pathology, Armed Forces Medical college Pune, India 2 SR Adv Pathology, CHCC Lucknow, India

Keywords: Cellular Angiofibroma, Vulva, Immunohistochemistry, Aggressive Angiomyxoma.

ABSTRACT Cellular angiofibroma (CA) is a rare benign mesenchymal neoplasm of the genital region of both the genders. In women, it arises in late reproductive age and can be cured by complete local excision. It is characterized by a bland spindle cell population and numerous small- to medium-sized vessels with hyalinization. We report a rare case in a postmenopausal woman with a view to highlight the importance of differentiating it from similar more aggressive tumours like aggressive angiomyxoma. A 56 year old woman presented with superficial painless swelling of the vulva and the mass was surgically excised. Histological examination revealed spindle cell proliferation and hyalinised blood vessels in a loosely cellular stroma. Immunohistochemistry revealed positivity for vimentin and CD34 and positivity for ER & PR.

*Corresponding author: Dr Jasvinder Kaur Bhatia, Department of Pathology, Armed Forces Medical College, Pune-40, India Phone: +91 - 8552825142 E-mail: drjkbhatia@gmail.com

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C-214

Cellular Angiofibroma

Introduction

Cellular Angiofibroma (CA) is a rare benign mesenchymal neoplasm of the genital region of both the genders. It arises in women of late reproductive age [1, 2] and can be cured by complete local excision. It is characterized by a bland spindle cell population and numerous small- to mediumsized vessels with hyalinization. These tumours can be mistaken for more aggressive tumours and one should be aware of similar tumours presenting as vulval swellings and overlapping histological features. We report a case in a postmenopausal woman with a view to highlight the importance of differentiating it from similar more aggressive tumours.

Case Report

Immunohistochemistry: The tumour cells were positive for vimentin and CD34, ER and PR. (Fig 4, 5, 6, 7) The tumour was negative for S-100 protein, actin, desmin and EMA. Histomorphology and immunohistochemistry was compatible with cellular angiofibroma of the vulva.

Discussion

Cellular angiofibromas are rare tumours that present clinically as subcutaneous vulvar swellings in women of reproductive age group. CAs were first described by Nucci et al in 1997 as tumors with a histomorphology consisting of bland spindle cells along with small to medium hyalinized vessels. Mature adipose tissue may be seen in the tumours. [3]

A 56 year old lady presented with a painless vulvar swelling of one year duration. Her general and systemic examination was normal. Routine hematological and biochemical investigations were within normal limits. Per operatively a well-defined mass was seen on the vulva and was excised. Postoperative period was uneventful and there was no recurrence.

These tumours are site specific and one should be able to differentiate these from other spindle cell lesions in the perineum..[4] Aggressive tumours like aggressive angiomyxoma may present like CA. Site specific tumours like angiomyofibroblastoma, spindle cell lipoma, leiomyoma, solitary fibrous tumor and perineurioma may also mimic CA.

Gross Examination: Gross examination of the tumour revealed a well circumscribed tumour measuring 7.4x4.5x2.3cm, with a gray surface. (Fig1). Cut section of the tumour also revealed a well circumscribed grey white tumour. There were no areas of haemorrhage or necrosis.

Cellular Angiofibromas are vimentin positive. CD34 positivity is seen in 60% of the cases. Smooth muscle actin and desmin positivity is less with 20%and 8% of the cases showing positivity. [5]

Microscopic Examination: Histological examination showed a well circumscribed tumour composed of uniform spindle cells arranged in short fascicles. Cells had indistinct cytoplasm and blunt to wavy nuclei. Many small to medium sized vessels with thick walls were Interspersed in these spindle cells. Thin collagen bundles were seen along with mild lymphocytic inflammatory infiltrate. There were no mitotic figures. No necrosis or atypia was noted (Fig2, 3).

Aggressive angiomyxoma is an infiltrative tumour with spindle cells in a myxoid stroma. This is larger than cellular angiofibroma . Vessels are medium-sized to large and show hyalinization. â&#x20AC;&#x153;Myoid bundlesâ&#x20AC;? composed of collections of smooth muscle are seen around blood vessels. Features such as an infiltrative margin and myxoid stroma helps in differentiating this from CA. Immunohistochemically these tumours are positive for desmin and actin in contrast to cellular angiofibroma and negative for CD34. [5,6]

Fig. 1: Gross photograph showing well circumscribed gray white tumour with prominent blood vessels on surface.

Fig. 2: Microphotograph showing short fascicles of spindle cells with hyalinized blood vessels. (H & E, X100)

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Fig. 3: Microphotograph showing spindle cells with eosinophilic cytoplasm and blunt to wavy nuclei and hyalinized blood vessels. (H & E, X400)

Fig. 4: Microphotograph with CD34 Positivity in both the endothelial cells and spindle cells.

Fig. 5: Spindle cells and vessels showing positivity for vimentin.

Fig. 6: Immunopositivity for ER in spindle cells.

Fig. 7: Spindle cells showing positivity for PR.

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Cellular Angiofibroma

Another tumour, which presents in the same site and with similar clinical features is angiomyofibroblastoma (AMF). This is a benign, predominantly superficial circumscribed tumor. It can be differentiated from CA by the presence of alternate areas of cellularity. In addition to spindle cells, it also has epithelioid cells. Vessels in the tumour are capillary sized. The tumour expresses vimentin and desmin and occasionally smooth muscle actin and CD34.

In another study features like presence of adipose tissue, stromal mast cells, stromal lymphoid aggregates, scattered multinucleate cells, hypocellular hyalinized areas, myxoid areas and focal areas of marked cellular atypia reminiscent of symplastic change within a uterine leiomyoma have been described . [10] In these cases immunohistochemistry helps in arriving at a diagnosis. We did not find any of these features in our case.

Spindle cell lipoma is a lobulated, well circumscribed tumour showing admixture of spindle cells in fascicles and mature adipocytes. Spindle cells have poorly defined cytoplasm with uniform nuclei. [7 ]

Conclusion

Solitary fibrous tumor is positive for CD34, CD99 and bcl2 positive, but generally negative for S-100, actin, desmin. Dermatofibrosarcoma protuberans (DFSP) is an uncommon slow growing fibroblastic tumour of the dermis. It most commonly occurs on the trunk but may occur in the vulva. It occurs in women in fourth or fifth decade and has a tendency for local recurrence. Histological features which help in differentiating this tumour from CA are poor circumscription and infiltration into subcutaneous adipose tissue in a lacy pattern. Histological examination shows irregular short intersecting bands of spindle cells forming a storiform pattern. It is separated from overlying epidermis by a grenz zone,and entraps adnexal structures.[8] This tumour is positive for CD34 and negative for factor XIIIa and S100. Perineurioma is a well circumscribed subcutaneous mass. It is characterized by variable cellularity and strikingly whorled, or storiform growth patterns. Cells are positive for EMA. Around 50% cells are CD34 positive and some cases may be S100 positive. Leiomyomas of the vulva are clinically similar to cellular angiofibroma as they generally occur in the reproductive age group. Histomorphology is also similar, characterized by spindle cells in short fascicles. These tumours are positive for Smooth muscle actin. Some studies have suggested a link between cellular angiofibroma, spindle cell lipoma, and mammary-type myofibroblastoma i.e. all the three entities are spectra of one entity depending upon the location of the tumour. [9] Diagnostic difficulty also arises sometimes due to variation in histomorphology of CA as described in a few studies. Some studies have documented increased mitotic figures in a few of these tumours. [10] Atypia has also been described. One of the studies have also documented sarcomatous areas in the tumour. [5]

To conclude, cellular angiofibroma is a rare benign tumour and should be considered in the differential diagnosis of vulvar soft tissue tumors. Characteristic morphological features supplemented by immunohistochemistry helps in arriving at a diagnosis and differentiating from aggressive tumours like aggressive angiomyxoma. Immunohistochemically, these cases are characterized by vimentin positivity and negative staining with smooth muscle markers which assist in excluding many of the other vulvovaginal mesenchymal lesions which enter into the differential diagnosis.

Acknowledgements NIL

Funding None

Competing Interests None declared

References

1. Saichandran S, Koothan V, Ghose S. Cellular angiofibroma of the vulva. Internet J Oncol. 2010; 7. 2. Kerkuta R, Kennedy CM, Benda JA, Galask RP. Vulvar cellular angiofibroma: A case report. Am J Obstet Gynecol. 2005;193:1750–2. 3. Nucci MR, Granter SR, Fletcher CDM. Cellular angiofibroma: a benign neoplasm distinct from angiomyofibroblastoma and spindle cell lipoma. Am J Surg Pathol1997;21:636–644. 4. Nucci MR, Fletcher CD. Vulvovaginal soft tissue tumours: update and review. Histopathology. 2000 Feb; 36(2):97-108. 5. Uta Flucke, J Han JM van Krieken, Mentzel T. Cellular angiofibroma: analysis of 25 cases emphasizing its relationship to spindle cell lipoma and mammarytype myofibroblastoma. Modern Pathology (2011) 24, 82–89. 6. Goyal P, Agrawal D, Sehgal S, Ghosh S, Kumar A, Singh S. Aggressive Angiomyxoma in Pregnancy. Rare Tumors. 2014;6(2):5362. doi:10.4081/rt.2014.5362.

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Bhatia et al. 7. Sharma P, Sood N. Spindle cell lipoma: an unusual lipoma variant. Annals Of Pathology And Laboratory Medicine, 2015;2(3), L9-10.

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8. Goyal P, Sehgal S, Singh S, Rastogi S. Dermatofibrosarcoma Protuberans in a Child: A Case Report. Case Reports in Dermatological Medicine, vol. 2012, Article ID 796818, 4 pages, 2012. doi:10.1155/2012/796818

9. Nucci MR. Tumors of the Female Genital Tract. In, Christopher D.M. Fletcher (ed). Diagnostic histopathology of tumors, 4th edition. China, Saunders, 2013; 658-870. 10. McCluggage WG, Ganesan R, Hirschowitz L, Rollason TP. Cellular angiofibroma and related fibromatous lesions of the vulva: report of a series of cases with a morphological spectrum wider than previously described. Histopathology. 2004 Oct; 45(4):360-8.

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Case Report Aneurysmal Bone Cyst: An Uncommon and Aggressive Presentation Arnab Chaudhuri*1, Ayandip Nandi1, Sarbani Chattopadhyay1, Ranajit Bhatta2 Department of Pathology, Medical College & Hospital, Kolkata, India Department of Orthopedics, Medical College & Hospital, Kolkata, India 1

Keywords: Aneurysmal Bone Cyst, Bone Neoplasms, Giant Cell Reparative Granuloma.

ABSTRACT The solid variant of aneurysmal bone cyst (ABC) is a rare subtype of aneurysmal bone cyst with a preponderance of solid compared to cystic elements. We present a case of solid ABC affecting the proximal tibia-an unusual site, and presenting with rapid progression mimicking malignant neoplasm. A 12 year old girl presented with pain and swelling, just below left knee for 9 months. X-Ray and CT scan demonstrated a lytic expansile lesion over metaphyseal region of tibia and diagnosed radiologically as ABC. Histology of curettage established it as solid variant of ABC. After 5 months, patient presented with a fungating mass over skin below knee with foul smelling discharge. Histology of incisional biopsy from outside suggested osteosarcoma, though no osteoid was found. Above knee amputation was done and histology of the whole specimen conclusively proved it to be a case of solid variant of ABC. Solid ABC has been of great interest because it may be mistaken for malignant tumor, mainly giant cell tumor, osteosarcoma or synovial sarcoma, because of cellularity and variable mitotic activity.

*Corresponding author: Arnab Chaudhuri, Department of Pathology, Medical College & Hospital, Kolkata, India Phone: +91 - 9433133833 E-mail: dr.arnab1234@gmail.com

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Introduction

joint space. MRI (Fig. 2C) revealed soft tissue extension, skin involvement over wound and almost whole upper end of tibia was lytic. No calcification was noted in MRI. Incision biopsy from the fungating mass was done and sent to two different labs. One reputed private laboratory gave diagnosis of osteosarcoma, although no osteoid formation could be detected. We reviewed the sections and stuck to the diagnosis of solid variant of ABC (Fig 2D).

An aneurysmal bone cyst (ABC) is a benign, often rapidly expanding, locally destructive cystic lesion of the bone. Although ABC affects all age groups, the peak incidence is in the first and second decades of life. It accounts for about 1% to 2% of biopsied primary bone tumors. It may be of conventional or solid type. [1,2] The solid variant is a rare sub-type, and it is more difficult to recognize. The term “giant cell reparative granuloma” has been used as a synonym in the pathology literature to describe this variant. Locations include the small bones of the hand and feet, vertebrae, sacrum, and less commonly – long bones. [3] Although it is considered to be reactive in nature, there is evidence that some ABCs are true neoplasms. We present a case of solid ABC affecting the proximal tibia, and presenting with rapid progression mimicking malignant neoplasm.

Case Report

A 12 year old girl from Bihar presented to us with complaints of pain and swelling just below left knee for last 9 months. On X-Ray, a lytic expansile septate lesion was found over metaphysis of tibia. Joint was spared. Provisional diagnosis of ABC was made from X-Ray (Fig. 1A). Her hematological and biochemical parameters were within normal limit. On examination, single ipsilateral lymph node (1x0.5cm) was found in inguinal region. Curettage was attempted. On OT, whole bone fragments came out with haemorrhage and necrotic material. Histopathological examination (HPE) was done and sections(Figure 1B and 1C) showed fragments of bone and a mass predominantly localized in soft tissue composed of cystic and solid areas. Mass was composed of oval to spindle cells diffusely arranged and osteoclastic type giant cells were scattered among the stroma. Mitotic activity was brisk, but atypical mitosis was absent. Very small foci of necrosis were present. A provisional diagnosis of solid variant of Aneurysmal Bone Cyst was made. Patient was put on follow up and discharged. Lymph node found in inguinal region showed reactive hyperplasia. Four months later, patient came with severe bleeding over wound site and was complaining of weakness. Hb% was 3.6 gm/dl. Color Doppler study revealed arterial sprouting at wound site. Embolisation was done followed by pressure packing over wound. Again, after one month, patient came with a fungating mass over wound (Fig 2A) with foul smelling discharge. Culture sensitivity of the discharge revealed Pseudomonas and appropriate antibiotic treatment was given. Patient was complaining of continuous boring pain in the whole limb. X-Ray (Fig. 2B) showed destruction of upper tibia with cortical breach at www.pacificejournals.com/apalm

Decision of amputation with whole mass excision was taken in Medical Board partly due to discrepancy of diagnosis and also because reconstruction was not possible as joint cavity was left with no or little tibial shaft. Above knee amputation was done after obtaining informed consent. Whole mass was sent for Histopathological Examination. During the whole period although the mass was rapidly progressing, but patient’s general condition was not deteriorating. Chest x-ray and USG abdomen did not reveal any lesion in lung or liver. Gross examination of amputated specimen showed a globular mass measuring 19x11x5cm, with grayish white outer surface with blackish and necrotic cystic areas and ulceration of skin. On serial sections multiple wellcircumscribed blood filled cavities were seen separated by fibrous bands (Fig. 2E). No calcification was noted in the mass. Microscopic examination showed spindle cells in haphazard arrangement interspersed with blood filled cavities. The cells showed minimal pleomorphism with focal reactive atypia, necrosis and few scattered mitotic

Fig. 1A : Initial x-ray showing punched out osteolytic lesion in metaphysis, joint cavity intact. 1B: Initial curettage showing cystic solid mass predominantly consist of plump spindle cells ( x200, H&E) 1C: Initial curettage showing scattered osteoclastic type giant cells and cystic spaces without endothelial lining (x400, H&E).

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Solid Aneurysmal Bone Cyst Over Tibia

figures (Fig. 3D). However, atypical mitosis could not be detected in any sections. Hypocellular areas with fibromyxoid degeneration (Fig. 3C), inflammatory cells and histiocytes were scattered at places. Stromal spindle cells were arranged in storiform pattern in few places (Fig. 3A). Collection of osteoclast like giant cells was present haphazardly. The blood filled cavities lacked any endothelial lining and were lined by fibroblasts and giant cells instead (Fig. 3B). Osteoid formation could not be detected in any of the sections despite thorough search. Overall histopathological features were suggestive of solid aneurysmal bone cyst/ giant cell reparative granuloma. Patient was then put on follow up with prosthesis. Currently patient is doing well.

Discussion

Solid ABC is a rare ABC variant with the same or similar clinical, radiologic features and prognosis as a conventional lesion of an ABC, but with the preponderance of solid to cystic elements. In 1983, Sanerkin et al. [4] first described a variant of ABC in which the predominant histological features were solid, and they used the term â&#x20AC;&#x153;solid variant of aneurysmal bone cystâ&#x20AC;?. Solid aneurysmal bone cysts are most commonly located in the small bones of the hand and feet, vertebrae, sacrum,

Fig. 2A: Fungating mass over leg involving skin and soft tissue 2B: X-ray showing destruction of upper tibia with cortical breach near joint space. 2C: MRI of left upper tibia showing contrast enhancing mass extending from bone into joint and soft tissue 2D : solid sheet like plump spindle cells with focal atypia (x400, H&E) 2E : gross picture of amputated mass showing blood filled cystic and solid septate areas.

and less commonly involves long bones of extremities. [3] In the latter locations, they tend to have a metaphyseal location. In our case, considering the age group, site of tumor and aggressive presentation, the following possibilities were kept in mind as differential diagnosis: Giant Cell Tumor (GCT), Osteosarcoma, spindle cell sarcomas like Malignant Fibrous Histiocytoma (MFH), Synovial Sarcoma, Fibrosarcoma. Histological examination remained the main tool in differentiating solid ABC from other type of tumors. Although Giant cell tumor is rarely seen in patients below 20 years of age, it is more common in women and the classic location is the epiphysis of a long bone, from which it may spread into the metaphyseal area, break through the cortex, invade intermuscular septa, or even cross a joint space. The sites most commonly affected are the lower end of the femur, the upper end of the tibia. Histologically Giant cell tumors have a uniform distribution of the giant cells and diffuse arrangement of round to oval stromal cells. In our case histologically the giant cells were usually scattered or gathered in small clusters around the cystic spaces which lacked endothelial lining. The stromal cells were spindle-shaped without histologic evidence of sarcomatous transformation. These favored more towards a non-GCT neoplasm like ABC. [5]

Fig 3A : Storiform pattern of spindle cell in amputated specimen (x200, H&E) 3B :Scattered osteoclastic type giant cells, vascular spaces, and cysts without endothelial lining (x200,H&E) 3C : Myxoid hyaline areas in tumour mass (x400, H&E) 3D :Mitotic figure in tumour mass (x400, H&E)

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Chaudhuri et al. Osteosarcoma usually occurs in patients between 10 and 25 years of age. Most osteosarcomas are located in the metaphyseal area of the long bones, particularly the lower end of the femur, the upper end of the tibia, and the upper end of the humerus. Both age distribution and tumor location were similar but in our case the pattern of reactive bone production was different, from the malignant hyaline lacy osteoid that one expects to see in low-grade and high-grade osteosarcomas [6]. In ABCs, the reactive bony trabeculae are lined by plump, benign-appearing osteoblasts, which are not a feature of osteosarcomas. The stromal cells also showed less atypia and no atypical mitosis which further point towards a benign lesion like ABC. Spindle cell sarcomas like MFH, Synovial Sarcoma and Fibrosarcoma were considered as differential diagnosis because of the very aggressive presentation of the tumor and they also show storiform pattern and cellular atypia [7, 8]. But the high degree of nuclear pleomorphism and atypical mitosis which are typical in these sarcomas were lacking in our case. Clinico-radiological correlation, absence of atypical mitotic figure and typical immunohistochemical features may help to distinguish. Although ABCs are known to be non-neoplastic and probably reactive lesions, more recent studies have shown that at least some of the ABCs of all types are of a neoplastic nature, owing to clonal chromosomal aberrations like clonal rearrangements of chromosomal bands 16q22 and 17p13, indicating a neoplastic basis in at least some ABCs[9]. Differentiation of ABC from other malignant bony neoplasm is of utmost importance, because chemoradiation is not indicated in ABC; also prognosis is drastically different. Aneurysmal bone cysts are usually treated by thorough curettage. Occasionally they recur, and further curettage with either cryosurgery or phenol instillation can be used[10].

Conclusion

Solid variant of ABC is a challenging entity both to clinicians, radiologists and histopathologists, because of its diverse morphological picture in different areas and resemblance to other mesenchymal neoplasm. Immunohistochemistry is not very helpful in these cases. The unique feature of this case is aggressive presentation of a benign bony neoplasm.

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Funding None

Competing Interests None declared

Reference

1. Bertoni F, Bacchini P, Capanna R, Ruggieri P, Biagini R, Ferruzzi A, et al. Solid variant of aneurysmal bone cyst. Cancer 1993;71:729–34. 2. Unni KK, Inwards CY. Tumors of the osteoarticular system. In: Fletcher CDM, editor. Diagnostic Histopathology of Tumors, 3rd edn. Vol. 2. New York: Churchill Livingstone; 2007;p.1634–36. 3. Ilaslan H, Sundaram M, Unni KK. Solid variant of aneurysmal bone cysts in long tubular bones: giant cell reparative granuloma. Am J Roentgenol 2003;180:1681-7. 4. Sanerkin NG, Mott MG, Roylance J. An unusual intraosseous lesion with fibroblastic, osteoclastic, osteoblastic, aneurysmal and fibromyxoid elements. “Solid” variant of aneurysmal bone cyst. Cancer 1983;51:2278-86. 5. Chakarun CJ, Forrester DM,Gottsegen CJ,Patel DB, White EA,Matcuk GR. Giant Cell Tumor of Bone: Review, Mimics, and New Developments in Treatment. RadioGraphics 2013;33:197–211. 6. Klein MJ, Siegal GP. Osteosarcoma: Anatomic and Histologic Variants. Am J Clin Pathol 2006;125:55581. 7. Fisher C. Synovial Sarcoma. Ann Diagn Pathol 1998;2(6):401-21. 8. Eyden BP, Manson C, Banerjee SS, Roberts ISD, Harris M. Sclerosing epithelioid fibrosarcoma: a study of five cases emphasizing diagnostic criteria. Histopathology 1998;33:354–60. 9. Sciot R, Dorfman H, Brys P, Dal CP, De Wever I, Fletcher CD, et al. Cytogenetic-morphologic correlations in aneurysmal bone cyst, giant cell tumor of bone and combined lesions: a report from the CHAMP study group. Mod Pathol 2000;13:1206-10.

Dr. Milan Ruidas, D.Ortho PGT, Dept. of Orthopedics, Medical College, Kolkata, for assistance in data collection and technical support.

10. Schreuder HWB, Veth RPH, Pruszczynski M, Lemmens JAM, Koops HS, Molenaar WM. Aneurysmal bone cysts treated by curettage, cryotherapy and bone grafting. J Bone Joint Surg [Br] 1997;79-B:20-5.

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Acknowledgements

Case Report Cytomorphology of Primary Adenoid Cystic Carcinoma of Lung: An Exceedingly Rare Case Rohit V Bhalara *, Mital J Gamit, Manisha Popat, Shilpa H Gandhi, Gauravi A Dhruva Department of Patholoy, P.D.U. Medical College, Rajkot, India Keywords: Adenoid Cystic Carcinomas, Pulmonary Tumor, Cytology, Hyaline Globules.

ABSTRACT Primary adenoid cystic carcinoma (ACC) of lung is a rare tumor, and probably accounts for 0.04-0.2% of all primary pulmonary tumors. It was formerly referred to as bronchial adenoma implying a benign glandular neoplasm. However, it is now considered to be a low-grade bronchial carcinoma. Pulmonary ACC usually arise in the proximal tracheobronchial tree, and are regarded as a slowly growing tumor. A 20 year female was admitted with complain of cough without expectoration, weight loss, fever and anorexia since 20 days. In Ultrasound Sonography (USG) approx. 10x7 cm in size of well defined mixed echogenic lesion was noted at left upper zone. USG guided Fine Needle Aspiration Cytology was done. Cytopathology was suggesting of primary adenoid cystic carcinoma of lung. Fine needle aspiration cytology is simple method and useful in pre-operative diagnosis. However, diagnosis of adenoid cystic carcinoma of lung is difficult by cytologically. So, it is confirmed by histolopathological study.

*Corresponding author: Dr. Rohit V Bhalara, Satyam, 2- Ramnagar, Gondal Road, Rajkot- 360004, India Phone: +91 - 9427433471 E-mail: dr_rohitvb@yahoo.com

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Bhalara et al.

Introduction Adenoid cystic carcinoma (ACC) occurs most commonly in the salivary glands and less commonly, at other sites such as the breast, skin, uterine cervix, upper aero digestive tract, and lung. [1]Primary ACC of lung is a rare tumor, and probably accounts for 0.04-0.2% of all primary pulmonary tumors. [2] Primary lung ACC tends to occur in the 4th and 6th decades of life and there is no sex predominance. It is very rarely seen below 30 years. [1] The development of the disease has no association with cigarette smoking or other carcinogens. [3]

C-223 chest pain since 20 day, also having weight loss, fever and anorexia but no history of hemoptysis. No history of any addiction or old pulmonary tuberculosis. Other systems were normal on physical examination. Laboratory findings were normal. Than USG is done and approx. 9x8 cm in size of well defined mixed echogenic lesion was noted at left upper zone and chest X ray (postero-anterior view) revealed homogeneous soft tissue opacity in left upper and mid zone (figure 1). Thorax Computerized tomography (CT) was performed and finding were showing a well defined large lobulated heterogeneously enhancing soft tissue density mass lesion of size 104x 84x 88 mm is noted in left upper lobe (Figure 2).

A 20 year old female was admitted with complain of dyspnea on exertion, cough without expectoration, and

USG guided FNAC was done with 22 G needle and 10 cc syringe. Blood mixed aspirate came out. Slides were prepared by crush method. Slides were stained by MayGrunwald-Giemsa, haematoxylin & eosin stains. On microscopy- Smears show moderate cellularity and contain poorly cohesive clusters and complex sheets of epithelial cells. Cells show monomorphic, bland finely granular hyperchromatic nuclei, smooth nuclear border and scanty cytoplasm. Epithelial cells embedded within eosinophilic homogenous hyaline globules with even distribution. (fig.3-4) Cells also dispersed individually on blood mixed background. Overall findings are suggestive of primary pulmonary salivary gland type of tumor most likely adenoid cystic carcinoma of lung. However that is

Fig. 1: (Chest X Ray PA view ) Homogenous Opacity In Left Upper Zone

Fig. 2: (CT scan) Heterogeneously Enhancing Mass In Left Upper Lobe.

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The tumors are often asymptomatic, but can also be present with dyspnea, cough, fever and hemoptysis.[1] It was formerly referred to as bronchial adenoma implying a benign glandular neoplasm. However, it is now considered to be a low-grade bronchial carcinoma.[4] Pulmonary ACC usually arise in the proximal tracheobronchial tree, and are regarded as a slowly growing tumors.[5] Case Report

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also confirmed by true cut biopsy taken from upper zone of left lung with histopathological examination. Grossly the tissue was 0.5x0.2 cm sized and grayish white in color. Histopathological section showed proliferation of neoplastic cells arranged in cribriform pattern forming cystic spaces containing eosinophilic hyaline material. Cell shows round, mildly atypical nuclei and scanty to moderate amount of cytoplasm (Figure 5). Overall findings are in favors of salivary gland type tumor â&#x20AC;&#x201C; adenoid cystic carcinoma of lung. On immunohistochemistry study, tumor cells were found to be C-kit (CD117) positive, MIB1 positive (2-5%). (fig.6).

Discussion

featurs. [1] ACC is a rare, less than one percent, distinctive salivary gland-type malignant epithelial neoplasm that arises infrequently as a primary tumor in the lung. ACC of the lung typically arises in the trachea and large airways. There are some reports that it may arise as peripheral lung tumour[5].In our case also tumour was located in the upper lobe of the lung. In an earlier published report [6] primary adenoid cystic carcinoma of lung presenting as peripherally located lung mass in 33 year old male, and in second case[7] the age of patient was 29 year old female. It is very rarely seen below 30 years.[2] In our case the patientâ&#x20AC;&#x2122;s age was 20 year, which is an uncommon age for this tumor to present with. So it is an exceedingly rare case presentation.

ACC, also known as cylindroma in the past, is a variant of adenocarcinoma with distinct histopathologic and clinical

Cytologically tumor shows monomorphic epithelial cells embedded with hyaline globules. Tumor cells show

Fig. 3: Prominent Hyaline Globule and monomorphic with hyperchromatic Tumor cells (H & E, 10x)

Fig. 4: Prominent Hyaline Globule (MGG stain 40x)

Fig. 5: Tissue section: Cribriform pattern of growth of ACC (H & E, 10 X)

Fig. 6: Tissue section: Positivity for C-KIT In Tumor Cells

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hyperchromatic nuclei, high nuclear/cytoplasmic ratio and scanty cytoplasm and at places nuclear molding and naked nuclei. So overall findings are characteristic and specific diagnostic criteria help to differentiate other tumor /lesions and it can diagnosed easily by cytologically. The cytopathological differential diagnosis of pulmonary ACCs include reserve cell hyperplasia, carcinoid tumor, small cell carcinoma, well differentiated adenocarcinoma etc. [8] In reserve cell hyperplasia cells are compactly arranged in sheets with characteristic, attached, columnar cells. cribriform and tubular structures are also not seen. In carcinoid tumor, absence of mucoid globules within glandular structure differentiates it from ACCs. In small cell carcinoma, small cell show typical nuclear molding and nuclear streaking. The presence of spherical hyaline globules and basement membrane material surrounded by neoplastic cells favors a diagnosis of ACCs over small cell carcinoma. The well differentiated Adenocarcinoma can be ruled out by glandular arrangement of cells, clusters of uniform cells with cystic spaces.

in peripheral tumors .Radiological guided aspiration cytology of lung lesions is easy to perform, rapid and useful in pre-operative diagnosis. Primary pulmonary salivary gland type neoplasms are difficult to diagnose on cytomorphology. However adenoid cystic carcinoma of lung has a characteristic cytomorphology which is helpful in diagnosis or to rule out other tumor/lesions of lung. But still final confirmation of diagnosis should be done by histopathology examinations. IHC study can be also useful for confirmation of diagnosis. So ACC should be considered in the differential diagnosis of a primary lung tumor, even when present in the peripheral lung, although it is rare.

Histologically the tumor has 3 major growth patterns namely cribriform, tubular and solid .The most commonly found subtype is the cribriform pattern [9] .In our case the classical cribriform pattern was evident on histopathological examination. The tumor cells containing dense basophilic nuclei inconspicuous nucleoli and cell borders are indistinct. Prognosis depends on the histological pattern (tubular having the best prognosis and solid having the worst) and clinical stage of the tumour. [9] C-kit expression is commonly detected by IHC in adenoid cystic carcinoma. [10] In our case C-kit (CD117) positive (fig 8) MIB1 positive (2-5%), TTF1 negative.

None declared

Treatment for this tumor is not well defined. Complete excision of the tumor followed by adjuvant radiotherapy is by far the consensus treatment. [11] In one study from India[12], oral imatinib, tyrosine kinase inhibitor, showed good response in an inoperable case of primary adenoid cystic carcinoma of lung. In our case the patient is shift to higher centre for further treatment .Now patient is on tab imatinib, and having good prognosis.

6. S.Mukherjee. A Rare Case of Primary Adenoid Cystic Carcinoma of Lung, Kolkata, India 2014:56:175-177.

Conclusion

This study highlights the utility of Radiological guided FNAC in the diagnosis of primary pulmonary ACC, mainly

9. Mondal A, Saha DK. Primary adenoid cystic carcinoma of the lung: a clinicopathologic study. Indian J Thorac Cardiovascular Surg 2008; 24:240-3.

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Acknowledgements none

Funding None

Competing Interests References

1. Moran CA, Suster S, Koss MN. Primary adenoid cystic carcinoma of the lung. Clinicopathologic and immunohistochemical study of 16 cases. Cancer 1994; 73:1390-7. 2. Travis WD, Travis LB, Devesa SS. Lung cancer. Cancer 1995;75:191-202. 3. Travis WD, Brambilla E, Muller-hermelink HK, Harris CC. Pathology and genetics of lung, Pleura, thymus, and heart. Lyon: IARC press;2004,p65-6. 4. Spencer H. Pathology of the lung. 4 th ed. Oxford: Pergamon; 1985. p. 968-9. 5. Reid JD. Adenoid cystic carcinoma (cylindroma) of the bronchial tree. Cancer 1952;5:6894.

7. Dixit R, Nuval P. Pulmonary adenoid cystic carcinoma: an unusual presentation. Lung India 2007;24:28-9. 8. Sterrett G, Frost F, Whitaker D. Tumors of lung and mediastinum. In: Gray W, McKee GT, editors. Diagnostic cytopathology. 2nd ed. London: Churchill Livingstone; 2003. p. 97-131.

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10. Holst VA, Marshall CE, Moskaluk CA, Frierson HF Jr. KIT protein expression and analysis ofc-kit gene mutation in adenoid cystic carcinoma. Mod Pathol 1999; 12:956-60. 11. Kawashima O, Hirai T, Kamyoshihara M, Ishikawa S,Morishata Y. Primary adenoid cystic carcinoma

in the lung:report of two cases and therapeutic consideration. Lung Cancer 1998; 19:211-7. 12. Bhattacharyya T, Bahl A, Kapoor R, Bal A, Das A, Sharma SC.Primary adenoid cystic carcinoma of lung: a case report andreview of the literature. J Can Res Ther 2013; 9:302-4.

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Case Report Leiomyomatous Hamartoma of The Pyloric Antrum: A Case Report Geetanjali Gupta1, Pallavi Agrawal*1, Hirdaya H Nag2, Puja Sakhuja1 Department of Pathology, Govind Ballabh Pant Institute of Post-graduate Medical Education & Research, New Delhi Department of Gastrointestinal Surgery, Govind Ballabh Pant Institute of Post-graduate Medical Education & Research, New Delhi 1

Keywords: Gastric antrum, Hamartoma, Leiomyoma

ABSTRACT Leiomyomatous hamartomas are extremely rare lesions with very few cases being reported in the lungs and the oral cavity. There has been no published report of gastric leiomyomatous hamartoma till date. We present a case of leiomyomyomatous hamartoma in the pyloric antrum clinically mimicking a gastrointestinal stromal tumour. A 49-year old female presented with abdominal pain since 3 months. Endoscopy and Contrast-enhanced CT showed a large, welldefined, submucosal lesion in the antropyloric region, causing mild luminal compromise. In our case, distal gastrectomy (Bilroth 1) was done. Histopathological examination revealed a lesion comprising of proliferating connective tissue with smooth muscle fascicles dispersed in loose fibrous stroma, nerves and multiple small vessels. Immunophenotyping with smooth-muscle actin and desmin supported the diagnosis. We report this rare case and suggest the inclusion of leiomyomatous hamartoma in the differential diagnosis of gastric lesions with smooth muscle as a dominant component.

*Corresponding author: Dr. Pallavi Agrawal, Assistant Professor, Department of Pathology, Govind Ballabh Pant Institute of Post-graduate Medical Education & Research, New Delhi, India Phone: +91 - 7739165410 E-mail: dr.pallavimamc@gmail.com

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Introduction

Magnus-Alsleben first described gastric hamartoma in 1903. [1] In 1904, Alberecht[2] defined hamartomas as nonneoplastic malformations presenting as overgrowths of abnormal mature tissues, haphazardly arranged and indigenous to a specific site. The diagnosis is based on the histological appearance with smooth muscle bundles comprising as a dominant component along with multiple small vessels, and is confirmed by immunohistochemistry (IHC) with positivity for smooth muscle actin (SMA) and desmin.

smooth muscle bundles for SMA and Desmin and an immunonegativity for CD117. The lesion in the omentum showed only benign adipose tissue.

Case Report

A 49-year old female presented with pain abdomen since 3 months. The pain was of moderate intensity, not related to food intake and was relieved by oral analgesics. There was no associated history of loss of weight or appetite. On clinical examination, the abdomen was soft and non-tender and there was no organomegaly. Endoscopy revealed a large submucosal lesion with central umbilication in the gastric antrum. Contrast enhanced CT scans confirmed a well-defined rounded mass lesion in the antropyloric region, causing mild luminal compromise. A clinical diagnosis of gastrointestinal stromal tumour was made. Distal Gastrectomy (Billroth 1) was done. The surgical specimens were formalin fixed and paraffin embedded. The sections were stained with routine hematoxylin and eosin stain. IHC staining was performed by the streptavidin-biotin-peroxidase method and diaminobenzidine as chromogen. The antibodies used included SMA, Desmin, CD117, S-100 and CD34. Appropriate positive and negative controls were performed. Grossly, gastrectomy specimen was received measuring 9 x 5 x 3.5cm. A single globular lesion was identified in the submucosa measuring 5 x 3.5 x 2cm. A separate small nodule is identified in the attached omental tissue measuring 1 cm in diameter. Microscopically, the lesion in the stomach comprised of loosely arranged smooth muscle fascicles with benign spindle-shaped cells having abundant eosinophilic cytoplasm and plump nuclei displaying minimal atypia. These fascicles were dispersed in loose fibrous stroma, nerves and multiple small vessels. Misplaced gastric glands were seen in the hamartomatous area which confirmed the diagnosis of a leiomyomatous hamartoma. However, no atypical changes were observed either in the epithelial or mesenchymal components. Additional investigations with Masson’s trichrome allowed the redstained smooth muscle cells to be clearly distinguished from the blue stained surrounding collagen fibres. Immunohistochemistry revealed a strong positivity of

Fig. 1: (A) Gross photograph showing a submucosal lesion in the pyloric antrum. (B) Proliferating smooth muscle cells in a collagenous stroma intermixed with blood vessels (H&E, 4x). (C) Misplaced gastric glands in a hamartomatous area. (D) Smooth muscle fascicles scattered in a fibrous stroma (Masson’s trichome stain).

Fig. 2: (A) Smooth muscle bundles showing a strong positivity for smooth muscle actin (IHC) (B) Smooth muscle bundles showing a strong positivity for Desmin (IHC).

Discussion

Hamartomatous growth of the pyloric antrum is not common. They are rare benign tumours of the gastrointestinal tract. An abnormally arranged benign growth of cells normally found in that organ or site is defined as a hamartoma. Leiomyomatous hamartoma represents a ‘true’ hamartoma or abnormal growth with smooth muscle tissue as dominant component. A few cases have been reported in the lungs and oral cavity. A review of the published reports regarding pulmonary and oral leiomyomatous hamartomas suggests that young females are predominantly affected with the most common age group being 0-8 years.3

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The exact pathogenesis of this tumor is controversial. Some authors claim it to be metastases from a benign metastasizing leiomyoma or leiomyosarcoma, most often from the uterus,4 in which the tumor cells show monoclonal neoplastic proliferation of smooth-muscle cells; whereas others consider it as a primary smooth-muscle hyperplasia, tumor or hamartoma,5 showing polyclonal non-neoplastic proliferation of smooth muscle cells. Underlying dysgenic events that might affect the blood vessel formation may also lead to the development of leiomyomatous hamartoma.

desmin. Additional markers like Collagen IV and CD34+ have been studied by few authors,7 showing collagen IV immunopositivity in the basement membrane of smoothmuscle cells.

Histologically, the lesion is comprised of a wellcircumscribed nodule composed of smooth-muscle cells with numerous small vessels. In our case, a few misplaced gastric glands were seen entrapped within the smooth muscle component, with no atypical changes. The two conditions, benign metastasizing leiomyoma and a â&#x20AC;&#x2DC;true hamartomaâ&#x20AC;&#x2122;, or benign muscular proliferation, are indistinguishable from each other.6

None.

Differential diagnoses include primary leiomyoma, primary leiomyosarcoma, metastatic leiomyosarcoma, fibroleiomyomatous hamartoma or benign metastasizing leiomyoma, lymphangioleiomyomatosis and leiomyomatous hyperplasia. Primary leiomyoma is displays a characteristic whorling pattern and immunopositivity for SMA and Vimentin. Leiomyosarcoma shows frequent mitosis, nuclear atypia and is also immunoreactive for SMA and Vimentin. Fibroleiomyomatous hamartoma is seen mainly in lungs. There are whorled interlacing and communicating bands of smooth muscle which are separated by collagen, hyalinized stroma and fibrous tissue. The entity of lymphangioleiomyomatosis (LAM) is seen rarely in lungs and kidney. In LAM lung disease there is abnormal proliferation of smooth muscle cells that line the lung airways and blood vessels. Leiomyomatous hyperplasia is characterized by abnormal proliferation of smooth muscles resembling benign leiomyoma but whorling pattern is not seen. Previous published reports of oral and pulmonary leiomyomatous hamartoma have used SMA and desmin for confirmation of diagnosis. In the present case also, the tumor cells showed intense positivity for actin and

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We report this rare case and suggest the inclusion of leiomyomatous hamartoma in the differential diagnosis of gastric lesions with smooth muscle as the predominant component.

Acknowledgements Funding None

Competing Interests None Declared

Reference

1. Magnus-Alsleben E. Adenomyoma des pylous. Virchows Arch 1903; 173:137-56. 2. Alberecht H. Hamartoma. Verh Dtsch Ges Pathol. 1904;7:153-57. 3. Nava-Villalba M, Ocampo-Acosta F, SeamandurasPacheco A, Aldape-Barrios BC. Leiomyomatous hamartoma: report of two cases and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:e39-e45. 4. Wolff M, Kaye G, Silva F. Pulmonary metastases (with admixed epithelial elements) from smooth muscle neoplasms. Report of nine cases, including three males. Am J Surg Pathol. 1979;3:325-42. 5. Gal AA, Brooks JSJ, Pietra GG. Leiomyomatous neoplasms of the lung: a clinical, histologic, and immunohistochemical study. Mod. Pathol. 1989;2:209-216. 6. Itoh H, Yanagi M, Setoyama T, et.al. Solitary fibroleiomyomatous hamartoma of the lung in a patient without a pre-existing smooth muscle tumor. Pathology International. 2001; 51: 661-65. 7. Zaitoun H, Triantfyllou A. Smooth muscle hamartoma of the hard palate. J Oral Pathol Med. 2007;36:245-49.

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Case Report Granular Cell Tumour of the Deltoid Muscle: A Rare Entity in The Musculoskeletal System Chetan S Chaudhari*, Shailesh S Vartak, Urmi S Chakravarty, Manisha S Khare, Prashant V Kumavat Dept. of Pathology, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India Keywords: Deltoid Muscle, Granular Cell Tumour, Musculoskeletal System

ABSTRACT Granular Cell Tumours are a rare mesenchymal soft tissue tumours that arise throughout the body and are believed to be of neural origin. They are so named because composition of characteristic nesting pattern of polyhedral cells with abundant granular eosinophilic cytoplasm. They often present as asymptomatic, slow-growing, benign, solitary lesions but may be multifocal. 1-2% of cases are malignant and can metastasise. Granular cell tumour commonly occurs in head and neck,with a particular predisposition for the tongue. The authors describe an unusual location of this tumour within the deltoid muscle of the arm. A 55 year old female presented with mass and tenderness at the distal end of deltoid site since 2 years. MRI showed a mass within deltoid muscle, 5x3x2 cm. Intraoperative frozen and later surgically resceted specimen showed histopathological features of benign granular cell tumour, at unusal site and a rare entity in the musculoskeletal system , witin deltoid muscle.

*Corresponding author: Dr. Chetan S Chaudhari, 11, Jagannath Darshan, M.D. Keni Road near RBI Quarters, Bhandup Village (E), Mumbai, Maharashtra, India Phone: +91 - 9819133606 E-mail: drchetanchaudhari26@yahoo.co.in

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Introduction

increased abnormal mitotic figures,prominent nucleoli or necrosis were seen.No areas of infiltration at the edges or destructive activity of surrounding muscle fibres was seen,ruling out its malignant nature. Tumour cells exhibited strong and diffuse positivity for immunostain S-100 and positivity for intracytoplasmic granules with periodic acid-Schiff (PAS) staining with resistant to diastase (Fig 4). Some schwannomas and neurofibromas may show granular changes in parts, but the changes are never extensive enough to create a major diagnostic challenge. Moreover, schwannomas are encapsulated which shows central hypointense and peripheral hyperintense (rim sign) on T2 MRI images, these features and other stigmata of von Recklinghausen disease associated with neurofibromas were absent in this case. Rhabdomyomas and hibernomas can show superficial resemblance and may be considered as differentials at deltoid muscle site, however tumour cells do not showed cytoplasmic striations or vacuoles and were negative for skeletal muscle markers and fat stains. Alveolar soft part sarcoma also shows organoid growth pattern and periodic acid-Schiff (PAS)â&#x20AC;&#x201C;positive intracellular crystalloids. The characteristic rhomboid crystalloids seen in alveolar soft part sarcoma, were absent in this tumors. Hence, the diagnosis of benign granular cell tumour at unusal site of deltoid muscle was made.

Granular cell tumour (GCT) is an uncommon benign neoplasm, first described by Abrikossoff in 1926 [1] The tumour was initially called â&#x20AC;&#x2DC;granular cell myoblastomaâ&#x20AC;&#x2122; due to its possible proposed origin from skeletal muscle. Granular cell tumour is so-named due to its arrangement of nests of polyhedral cells with abundant granular eosinophilic cytoplasm. Various theories on the origin of GCT have subsequently been proposed, including its origin from striated muscle and histiocytes and a neural origin. Granular cell tumours can affect any organ or region of the body. Most GCTs occur in the head and neck region, especially in the tongue, cheek mucosa, and palate. [2] Other common sites include the respiratory tract, the breast, and the gastrointestinal tract. These tumours typically present as a solitary mass. The vast majority are benign, with only approximately 2% of lesions demonstrating malignant histology and behaviour. [3] The authors present a case of benign granular cell tumour in a distinctly unusual location within the deltoid muscle of the arm with only a sparse of such cases reviewed in literature. Clinical features, magnetic resonance imaging (MRI) features with characteristic histopathological features of the lesion are discussed, along with a review of the current literature.

Case Report

A 55 year old female presented with mass and tenderness at the distal end of deltoid site since 2 years. There was no pain at rest and there were no systemic symptoms. She had no significant past medical or surgical history and was not on any medications. There was no family history of tumours. On Clinical examination, there was evidence of a mass measuring approximately 5x3 cm in size located anterior to the shoulder joint. The mass appeared to be deep in position and related to the deltoid muscle. It did not appear fixed and was mobile when the arm was in a relaxed position.All other routine hematological and biochemical investigations were within normal limits.Plain radiograph of shoulder showed no osseous abnormality. MRI examination showed a solitary poorly circumscribed mass, measuring 5x3x2 cm within deltoid muscle at its distal end. The mass was hypointense to muscle on unenhanced T1-weighted images and away from neurovascular structures.No intratumoural calcification, hemorrhages or necrosis was seen.(Fig1) Preoperative FNAC procedure for mass was not performed. Intraoperative frozen section was sent.Patient underwnt surgical excision of mass, which was poorly circumscribed, lobulated,homogenous, and was greyish tan (Fig2). It showed on frozen and on histopathology poorly circumscribed mass composed of lobules and cords of polyhedral to epitheloid cells having centrally located vesicular, round nuclei and abundant granular eosinophilic cytoplasm (Fig 3).No areas of

Fig. 1: M.R.I. Scan showing a solitary poorly circumscribed mass, hypointense to muscle on unenhanced T1-weighted images, measuring 5x3x2 cm within deltoid muscle at its distal end.

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Fig. 2: Gross: Mass measuring 5x3x2 cm, poorly circumscribed, lobulated,homogenous, greyish tan.

Fig. 3 A: Tumour composed of lobules and cords of polyhedral to epitheloid cells (H & E, x40, x100X)

4A Fig. 3: B: Tumour cells showing centrally located vesicular, round nuclei and abundant granular eosinophilic cytoplasm. (H & E x400X)

Fig. 4A: Tumour cells showing PAS positive granules in cytoplasm (PAS, x400X),

Fig. 4B: Tumour cells showing strong and diffuse immunoreactivity for S-100 immunostain.

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Discussion

Granular cell tumours (GCT) are rare and the literature relating to them is sparse. Abrikossoff was the first to describe this tumour in the literature in 1926 [1] as a myoblastoma, since it was reported as a tumour arising from muscle in the tongue. Over the following 60 years the tumour was thought to be neural in origin since it was observed that tumours arising in the extremities were related to the radial and sciatic nerve trunks [2, 3]. Current opinion concurs with this. Although the etiology of GCT is still controversial, the currently most accepted hypothesis is that the tumour arises from Schwann cells or their precursors [3, 4]. Immunohistochemical analysis has shown a strong and consistent positivity for protein S-100, a finding supporting the hypothesis that GCT is of peripheral nerve sheath origin [4]. GCT is a rare tumour that can affect various regions of the body, such as the skin, soft tissues, breast, and lungs [4]. However, GCT is more frequently found in the head and neck region, which accounts for 45% to 65% of all sites affected by the tumour. Of these, 70% are located in the oral cavity, especially the tongue, oral mucosa, and hard palate [4, 5]. Of the reported cases, approximately 30% arise in the oral cavity, with the tongue being the predominant site of occurrence. Another 30% originate in the skin and subcutaneous tissues, while 15% are localised in the breast and 10% in the respiratory tract. The tumour has also been described in skeletal muscles, gallbladder, urinary bladder, female genitals, and the peripheral and central nervous system. [5] The average age of patients is 32 years, with a typical age range of 15 to 60 years. GCT seems to be more prevalent among women, but a gender preference is not unanimously accepted. Tsuchida et al. reviewed the reported cases of granular cell tumours in the English and Japanese literature [6].They found a 2.9: 1 female to male preponderance for the tumour and compared it with previous reported series (1.8:1) and average age 32 years [7]. 26.8% of cases were in the lower extremities and previous reports showed that benign tumours were uncommon (6.4%) in the lower extremities. Of 11 lesions presenting in the upper and lower extremities 36% were within muscle and only 4% of those were benign. Clinically, benign GCT manifests as a nodular lesion that is generally asymptomatic and solitary, although cases of multiple lesions have been reported [7, 8]. Grossly, granular cell tumours appear as poorly demarcated homogenous, greyish-white or tan nodules, that rarely exceeds 3 cm in diameter. Most granular cell tumours are poorly circumscribed nodules, typically measuring less than 3 cm in maximum diameter. However, there is a range of sizes and www.pacificejournals.com/apalm

C-233 appearances, and sizes of over 10 cm have been described in the literature. Growth tends to be very slow except for the rarer malignant granular cell tumours, in which growth is generally much more rapid [9].Conventional granular cell tumours are benign neoplasm. Malignancy occurs in less than 2% of patients. Microscopically, the benign tumours are characterised by nests and cords of large polyhedral cells with centrally located, small, evenly-stained nuclei. As their name suggests, there is abundant granular eosinophilic cytoplasm. In some cases, the epithelium that covers the tumour exhibits pseudoepitheliomatous hyperplasia [7,8,9]. Our case illustrates a benign granular cell tumor in a distinctly unusual location within the deltoid muscle of the arm. Diagnosis was confirmed as benign granular tumour on characteristic histopathological morphology, PAS positive with diastase resistant cytoplasmic granules,intense immunoreactivity for S-100 protein on IHC examination and with clinic-radiological features. The tumours are typically poorly circumscribed, with the granular cells trailing off into surrounding tissues from the main mass of cells. Although GCT is an uncommon benign neoplasm,cases of malignant GCT have been reported in the literature. Malignancy is diagnosed by a combination of histological findings, including cellular pleomorphism and elevated mitotic activity, and clinical malignant behaviour. [9] Clinical suspicion of malignancy should be higher if the lesion is large or growing rapidly, or if there is evidence of distant spread. Not only do malignant lesions tend to be larger and more aggressive in behaviour, but they also tend to occur at different sites than the benign variety. While oral lesions are the primary site for benign tumours, malignant lesions are most common within the chest wall, followed by the thigh. Fanburg-Smith et al. defined the diagnostic criteria for malignant granular cell tumours and correlated their findings with previous series. [10] Radiologically, granular cell tumours are best evaluated with MRI. Typically the tumours are slightly hypointense on T1-weighted sequences, and show homogenous contrast enhancement after intravenous injection of Gadolinium. On T2-weighted sequences, tumours generally show a heterogeneous increased signal. While the MRI tissue characteristics are non-specific, MRI does allow precise localisation of the tumours and is invaluable in the preoperative evaluation of patients with a granular cell tumour. Surgical excision with a wide margin is the treatment of choice for Granular cell tumour, although this is not always possible because the tumour lacks a capsule, a condition histologically demonstrated by an undefined cell margin. Where there are clinical or histological features of eISSN: 2349-6983; pISSN: 2394-6466

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malignancy, patients should undergo a more comprehensive imaging evaluation, including CT of the chest, in order to evaluate for metastatic disease

3. Payne-James JJ, Watkins RM. Granular cell tumour (myoblastoma): two cases and a review of the literature. Br J Clin Pract 1990;44:334-362

Conclusion

4. Rejas RAG, Campos MS, Cortes ARG, Pinto DS, de Sousa SCOM: The neural histogenetic origin of the oral granular cell tumor: an immunohistochemical evidence. Med Oral Patol Oral Cir Bucal 2011, 16:e610.

In summary, granular cell tumour presenting in the deltoid muscle is distinctly unusual. MRI was useful in this case, both to confirm the presence of a mass, and to detail its location and relationship to other structures prior to surgery. Frozen section was necessary to make the diagnosis, as the imaging findings of granular cell tumour are often nonspecific. Pathologists evaluating such mass at unusual deltoid muscle site need to be aware of the entity and give diagnosis with help of imaging, histology, special stains and IHC as it generally carries a good prognosis.

Acknowledgements

Dr. A.D. Kalgutkar, Prof & Head, Dept of Pathology, LTMMC & LTMGH, Sion, Mumbai, India

Funding None

Competing Interests None declared

Reference

1. Abrikossoff A. Über myome, ausgehend von der quergestreiften willkürlichen Muskulatur. Virch Arch 1926, 260:215-233. 2. Becelli R, Perugini M, Gasparini G, Cassoni A, Fabiani F. Abrikossoff’s tumor. J Craniofac Surg 2001, 12:78-81.

5. Zangari F, Trombelli L, Calura G. Granular cell myoblastoma. Review of the literature and report of a case. Minerva Stomatol 1996;45:231-237. 6. Tsuchida T, Okada K, Itoi E, Sato T, Sato K. Intramuscular malignant granular cell tumor. Skeletal Radiology.1997; 26:116–121. 7. Lack EE, Worsham GF, Callihan MD. Granular cell tumor.A clinicopathologic study of 110 patients. Journal of Surgical Oncology. 1980;13(4):301–316. 8. Blacksin MF, White LM, Hameed M, Kandel R, Patterson FR, Benevenia J. Granular cell tumor of the extremity: magnetic resonance imaging characteristics with pathologic correlation. Skeletal Radiology, 2005; 34(10):625–631. 9. Cadotte M. Malignant granular cell myoblastoma. Cancer, 1974;33:1417–1422. 10. Fanburg-Smith JC, Meis-Kindblom JM, Fante R, Kindblom LG. Malignant granular cell tumor of soft tissue: diagnostic criteria and clinicopathologic correlation. American Journal of Surgical Pathology. 1998; 22: 779–794.

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Case Report Lymphoepithelioma-Like Carcinoma of The Breast: A Case Report Trupti R Jansari*, Tanvi Gupta, Priti P Trivedi, Manoj J Shah Department of Pathology, The Gujarat Cancer And Research Institute, Ahmedabad, Gujarat, India Keywords: Breast, Differential Diagnosis, Lymphoepithelioma-Like Carcinoma.

ABSTRACT Lymphoepithelioma-like carcinoma (LELC) is an undifferentiated carcinoma, it occurs in the organs that exclude nasopharynx, but has the same morphology as that of nasopharangeal lymphoepithelioma. It has been described in several organs, however it is rarely seen in the breast. Due to the undifferentiated appearance of neoplastic cells and the presence of prominent lymphocytic infiltrate, LELC can wrongly be diagnosed as lymphoma and medullary carcinoma. In this case, we present the LELC of the breast in a 39 year-old woman with clinical, histological and immunohistochemical features with differential diagnosis.

*Corresponding author: Dr Trupti R. Jansari, Room no. 412, Histopathology department, The Gujarat Cancer And Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat. 380016. India Phone: +91 - 9586727494 E-mail: dr.truptijansari@gmail.com

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Introduction

Lymphoepithelioma, which was first described in the nasopharynx by Regaud and Reverchon, and Schminke in 1921, is an undifferentiated carcinoma composed of malignant epithelial cells with prominent lymphoid infiltration.[1] Lymphoepithelioma- like carcinomas (LELCs) are tumors with the same morphological features as undifferentiated nasopharyngeal carcinomas. LELCs have been reported in the salivary glands, stomach, lungs, and thymus, and less often in the skin, uterine cervix, and bladder.[2] The cells may be arranged singly (Schminke’s pattern) or in syncytial masses, nests, or cords (Regaud’s pattern).[3] Breast LELC was first reported by Kumar et al. in 1994.[4] Although it was shown that there is a relationship between LELCs in the stomach, lungs, and salivary glands, and Epstein-Barr virus (EBV), such a relationship has not yet been observed in other organs, including the breast.[2]

and CD2 and negative for CD30. Estrogen receptor(ER), progesterone receptor(PR) and HER-2 neu was negative[figure – 2(a-f)]. Finally, diagnosis of LELC breast was given. For further management, left modified radical mastectomy was planned. But, unfortunately patient was lost to follow-up.

Here we present a patient diagnosed with breast LELC, its clinical, histological, and immunohistochemical features, and a discussion based on a review of the literature.

Case report

A 39 year old female presented with lump in left breast since one month, which was gradually increasing in size but was not associated with any pain or nipple discharge. Physical examination revealed firm to hard non-tender mobile lump measuring 4.0cm×3.5 cm in the upper quadrant (at 12 o’clock position) of the left breast. Axillary lymph nodes were not palpable. Mammography showed a 42mm×36 mm dense lobulated lesion in the upper quadrant at 12 o’clock of left breast. Lesion had ill-defined margins without any evidence of significant calcification and was found to be suspicious for malignancy. We received core needle biopsy of the lesion which was diagnosed as Lymphoplasmacytic cell mastitis with invasive carcinoma. Patient underwent lumpectomy outside and then came to this hospital for expert opinion. Microscopic examination revealed multinodular growth pattern consisting of predominantly lymphoplasmacytic cells and in between clusters of malignant cells showing syncitial pattern, having eosinophilic cytoplasm, vesicular nuclei and prominent nucleoli. Focal area showed histiocytic giant cells [figure – 1(a-c)]. No in-situ carcinoma was identified in adjacent breast parenchyma and necrosis was absent. Histological features favoured lymphoepithelioma-like carcinoma of the breast. Immunohistochemistry showed positivity of tumor cells for AE1, CK7 and EMA while lymphocytic population was reactive for LCA, CD20

Fig. 1: Lymphoepithelioma-like carcinoma of the breast. A) Multinodular growth pattern (H&E, 10x), b) Neoplastic cells showing eosinophilic cytoplasm, vesicular nuclei and prominent nucleoli (H&E, 40x) c) Histiocytic granuloma (H&E, 10x).

Discussion

Lymphoepithelioma is an undifferentiated carcinoma, which was originally described in the nasopharynx. [2] LELCs are tumors that occur in all organs, except for the nasopharynx, and they have the same morphological features as nasopharyngeal lymphoepithelioma.[5] LELCs are characterized by malignant epithelial cells, which are

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Fig. 2. IHC results. a) EMA Positive, b) AE-1- Positive, c) CK-7- Positive, d) LCA- Positive in lymphocytes , e) ER- Negative, f) PR- Negative.

in the form of islets or cords, or are syncytial in structure or scattered individually. They contain prominent lymphoid stroma. Because medullary carcinoma, atypical medullary carcinoma, and some ductal or lobular carcinomas can have prominent lymphoid stroma, they should be considered in the differential diagnosis of LELCs.[6,7] In addition, the differential diagnosis of LELC should include Non-Hodgkinâ&#x20AC;&#x2122;s lymphoma. Lymphomas have diffuse neoplastic proliferation of lymphoid cells, but do not have an epithelial component; however, sometimes in H&Estained sections it can be difficult to differentiate between malignant epithelial cells and mononuclear lymphoid cells.[7] EMA and cytokeratin stains, which are used for immunohistochemical analysis, are very useful in showing the nature of tumor epithelial cells located between lymphocytes and plasma cells.[5,6]

The resetting of lymphoid cells around the large tumor cells simulated the pattern seen in T-cell-rich B-cell lymphoma. Some of the more pleomorphic tumor cells had the characteristic nuclear features also seen in anaplastic large cell lymphoma. This resemblance was further accentuated by the focal clustering of the tumor cells. Immunohistochemistry rules out the lymphoma as a differential diagnosis. [1]

LELC raised the possibility of Hodgkin disease, so called T-cell-rich B-cell lymphoma, and anaplastic large cell lymphoma. The tumor cells resembled mononuclear Hodgkin cells, especially set in the background of lymphocytes, plasma cells, and occasional eosinophils.

In invasive ductal or lobular breast carcinomas the inflammatory infiltrate may be observed in the stroma, however, the quantity of mononuclear infiltrate is low and not more than that observed in LELCs. Nonetheless, structural growth patterns (tubular, cribriform structures,

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LELCs that exhibit a syncytial growth pattern in the presence of dense lymphoid cell infiltration are sometimes misdiagnosed as medullary carcinoma. In medullary carcinoma, the tumoral margin is typically well circumscribed pushing type. Tumor cells are separated from adjacent stroma by a sharp border. Cells have high grade nuclear features and are arranged in syncytial pattern (>75%).[5, 7]

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diffuse sheets), cytological features (monomorphic low nuclear grade nuclei, distinct cell borders, intracytoplasmic lumens), and stromal desmoplasia are helpful in differentiating ductal or lobular carcinoma with inflammatory stroma from LELC.[7] The relationship between LELC and EBV varies by organ. The presence of the EBV genome in LELC was observed in the salivary glands, lungs, stomach, and thymus, whereas the relationship was not observed elsewhere. In terms of the relationship between EBV and breast LELC, in all previous reports of breast LELC the presence of the EBV genome, which was investigated by various methods, was not noted.[2] Regarding IHC studies on LELC, Kumar et al., Pesterelli et al., and Ilvan et al. reported ER and PR positivity in tumor cells,[4,6,8] whereas Dadmanesh et al. reported that in all but 1 of their cases ER and PR positivity was not noted.[7] Again, HER-2 positivity was observed only by Kurose et al., while the other reported cases were HER-2 negative.[5] In a study of 6 cases by Dadmanesh et al. low molecular weight cytokeratin and EMA were positive, and high molecular weight cytokeratin and actin were negative in all the cases.[7] In the presented case, tumor cells were positive for AE1, CK7 and EMA, while negative for ER, PR and HER-2. As with all breast cancers, surgery is the primary therapy for LELC of the breast. Breast LELC was reported to have a good prognosis.[2] Axillary lymph node metastasis occurred in 1 of the 6 cases reported by Dadmanesh et al., and in 1 case reported by Naidoo et al. and Pesterelli et al., whereas in the other reported cases axillary lymph node metastasis was not observed.[1-2,7-8] To conclude, LELC of the breast is a rare clinical entity. Pathologic diagnosis depends on a thorough histological and immunohistochemical examination. The known characteristic pathologic features of LELC ensure an appropriate diagnosis.

Funding None

Competing Interests None declared

References

1. Naidoo P, Chetty R. Lymphoepithelioma-like carcinoma of the breast with associated sclerosing lymphocytic lobulitis. Arch Pathol Lab Med2001;125: 669-72. 2. Kucukzeybek BB, Postaci H, Ozguzer A, Yakan S, Denecli AG. Lymphoepithelioma-like Carcinoma of the Breast: A Case Report and Review of the Literature. Int J of Hematol and Oncol; 2011:21:115-119 3. Dinniwell R, Hanna W et al. Lymphoepithelioma-like carcinoma of the breast: a diagnostic and therapeutic challenge. CurrOncol 2012;19: 177-183. 4. Kumar S, Kumar D. Lymphoepithelioma-like carcinoma of the breast. Mod Pathol 1994;7: 129-31. 5. Kurose A, Ichinohasama R, Kanno H, et al. Lymphoepithelioma- like carcinoma of the breast. Report of a case with the first electron microscopic study and review of the literature. Virchows Arch 2005;447: 653-659. 6. Ilvan S, Celik V, Akyildiz EU, et al. Lymphoepitheliomalikecarcinoma of the breast: is it a distinct entity? Clinicopathologicalevaluation of two cases and review of the literature. The Breast 2004; 13: 522-26. 7. Dadmanesh F, Peterse JL, Sapino A, et al. Lymphoepithelioma-like carcinoma of the breast: lack of evidence of Epsteinâ&#x20AC;&#x201C;Barr virus infection. Histopathology 2001;38: 54-61. 8. Pestereli HE, Erdogan O, Kaya R, Karaveli FS. Lymphoepithelioma-like carcinoma of the breast.A newly recognized subtype of lobular carcinoma. APMIS 2002;110: 447-450.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Case Report Tubercular Cervicitis Clinically Mimicking Malignancy: Cytodiagnosis of Two Cases. Reena Naik*1, Tribhuwan Kumar Sahu2, Kishori M Panda1, 1

Department of Pathology, Govt. Medical College (LSLAMMC), Raigarh, Chhattisgarh. India 2 Department of Obs & gynaec , Govt Medical College (LSLAMMC), Keywords: Genital Tuberculosis, Pap Smear, Tubercular Cervicitis, Genital Tract

ABSTRACT Genital tuberculosis (TB) in females is found in 0.75-1% of gynecological admissions in India with considerable variation from place to place and occurs in 10% cases of pulmonary TB. During colposcopy a bulky, necrotic cervix with parametrial thickening in pelvic TB often elicits an initial diagnostic impression of carcinoma of cervix. As the detection rate of AFB is low, definitive diagnosis of genital TB in females often depends mainly upon the cytological and histopathological examination. Here we describe two cases of cervical TB diagnosed by PAP smear, which showed granulomata consisting of multinucleated giant cells, histiocytes, epithelioid cells, lymphocytes and fibroblasts. Both the cases were clinically suspicious of carcinoma cervix. Diagnosis was confirmed in the first case by other supportive evidence like associated pulmonary TB and therapeutic response to ATT. Histopathology confirmation was done in the second case.

*Corresponding author: Dr Kishori M. Panda, Prof & HOD, of Pathology, Govt Medical College(LSLAMMC), Raigarh, Chhattisgarh. INDIA E-mail: drkishoripanda@gmail.com

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Tubercular Cervicitis

Introduction

Cervical tuberculosis (TB) accounts for 0.1-0.65% of all case of TB and 5-24% of genital tract TB. [1] Mostly occurs in reproductive age group (15-45year) and commonly affects fallopian tubes making many Indian women infertile. Early diagnosis is difficult because of lack of specific symptoms and this form of TB is continued to be ignored in TB control programmes. In advanced stages it can clinically mimic malignancy. Here we report two such cases of cervical TB diagnosed by cytology.

Case Report

Case 1: A 38 year multiparous female complained of menstrual irregularities since 2 years, pain in lower abdomen and post coital bleeding since 6 months. There was no history of significant weight loss or contact with tuberculosis or genital malignancy in the past and in the family. Per speculum examination revealed an unhealthy cervix with a small ulcer. Pap smear was done from unhealthy cervix. Cytology smears showed epithelioid granulomas with multinucleated giant cells suggestive of granulomatous cervicitis (Fig-1) and was advised biopsy to rule out tuberculosis. Then the patient was referred to chest and TB department for further workup and management. Further investigations showed positive mantoux test

Fig. 1: (A) Granuloma composed of, histiocytes, epithelioid cells, lymphocytes. (Pap, 10x); (B) Epithelioid histiocytes in cluster. (Pap, 10x); (C) Multinucleated foreign body giant cell (Pap, 40x)

(24 mm), ESR â&#x20AC;&#x201C; 40mm in 1st hour and a single lesion in chest x ray. All other hematology and biochemical parameters were normal. Based on cytology and other supportive evidence, patient was put on antitubercular therapy. Patient took complete treatment and cured .Cervical lesion also resolved. Case 2: A 40 year old female complained of white discharge per vaginum since 3 years. She was treated in a local hospital and improved a little but not relieved completely. Then the patient was referred to our hospital. There was no significant past or family history of contact with tuberculosis. Per speculum examination revealed erosion of anterior lip of cervix measuring 3x2cm, hard, congested, and was bleeding on touch. Clinical diagnosis was suspicious of carcinoma cervix. Pap smear from the lesion showed epithelioid granulomas with multinucleated giant cells suggestive of granulomatous cervicitis and was advised biopsy for confirmation. Biopsy showed epithelioid cell granuloma with an occasional Langhans type giant cell (Fig-2&3). Caseation necrosis was not seen and AFB stain was positive (Fig-3). She is currently under follow up and have received anti-tubercular therapy (ATT) for five months. Now cervix appears almost healthy in per speculum examination.

Fig. 2: Multiple non-caseating granuloma in cervical tissue. (H&E,10x)

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Naik et al.

C-241 miliary forms may also occur. Histology shows typical caseating granulomatous inflammation with Langhans giant cells and sometimes marked inflammatory atypia along with frequent hyperplastic mucosal changes in epithelial cells. This condition may resemble invasive carcinoma, both grossly and with the colposcope. [4, 5] Hence histological proof is of utmost importance. Staining for acid-fast bacilli was not found to be very useful. Isolation of the mycobacterium is the gold standard for diagnosis but a third of cases are culture negative. Therefore, the presence of typical granulomata with Langhans giant cells is sufficient for diagnosis if other causes of granulomatous cervicitis are excluded or a primary focus identified.

Fig. 3: (A) Granuloma composed of multinucleated Langhans type giant cells surrounded by histiocytes, epithelioid cells, lymphocytes and fibroblasts.(H&E, 40x) (B) Pink stained acid fast bacilli, arrow marked. (ZN Stain, 100x)

Discussion

Incidence of TB is still high in India. The true incidence of genital TB is not known due to subtle presentation. It has been estimated that approximately 5% of females presenting to infertility clinics worldwide have genital TB. [2] However, estimated incidence varies from less than 1% in the United States to 19% in India. About 80% to 90% female genital TB is diagnosed in 20–40 years old patients, often during workup for infertility. [2] Genital TB occurs mostly secondary to pulmonary tuberculosis, commonly by the haematogenous route. The fallopian tubes are affected in almost 100% of the cases, followed by the endometrium in 50%, ovaries in 20%, cervix in 5% and vagina and vulva in <1%.[1] The lesions in the cervix and vagina are rare and usually present as isolated, chronic, ulcerative lesions.[3] The infectious agent in TB is usually Mycobacterium tuberculosis and occasionally Mycobacterium bovis. Clinical symptoms can be variable. Infertility (in 60% of cases), pelvic pain and menstrual disorders like scanty menstruation and amenorrhea, post coital bleeding are the usual presentation and some patients may be asymptomatic.[1]

The cytopathologic examination of the cervix may reveal multinucleated Langhans type giant cells, histiocytes, epithelioid cells arranged in clusters, lymphocytes and fibroblasts simulating the appearance of the granulomata. There may be associated epithelial atypia from which dyskaryotic cells are shed.[4,6] Rarely, exclusion of tuberculosis or its distinction from a healing nontuberculous chronic cervical lesion is quite difficult. Histopathological confirmation is needed in such cases. [7] In both the cases we did not find Langhans giant cells in Pap smear. So our final diagnosis was based on clinical and therapeutic response in the 1st case and histologic confirmation of tuberculous cervicitis in the 2nd case. Differential diagnosis included other granulomatous diseases of the cervix like amoebiasis, sarcoidosis, leprosy, crohn’s disease, actinomycosis, granuloma inguinale, schistosomiasis, foreign body reaction, Brucellosis, tularaemia, filarial, syphilis and silicosis .[8] The diagnosis of the disease is difficult. Apart from varied clinical presentation, a past history of tuberculosis or a history of contact may not be forthcoming and an evidence of tuberculous lesion elsewhere may be lacking. Therefore, all the available diagnostic techniques should be combined judiciously and correlated with the clinical profile prior to instituting the antituberculosis treatment (ATT). The total duration of treatment should be six months to a year.[9,10] Prompt ATT and appropriate surgical intervention has improved the results in terms of cure from the disease, restoration of female reproductive function and reduction of procedural and postoperative complications.

Conclusion

Macroscopic changes of tuberculous cervicitis are not specific, may appear normal or inflamed. The most common type is the ulcerative form, although papillomatous and

If kept high index of suspicion and awareness, diagnosis of tuberculous cervicitis can be made with simple, non invasive, low cost test like papanicolaou (PAP) smear test. Finding of only epithelioid granuloma in PAP smear without typical Langhans’ giant cells, caseation necrosis and AFB positivity necessitates histologic confirmation and correlation with other supportive investigations.

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Tubercular Cervicitis

Funding None

Competing interests None

References

1. Dawn CS. Pelvic infections. Textbook of Gynaecology and Contraception. 9th ed. Calcutta: Arati Dawn; 1998,321. 2. Schaefer G. Female genital tuberculosis. Clin Obstet Gynecol. 1976; 19:223. 3. Miller JW. Vulval tuberculosis. Tubercle1979; 60:173. 4. Bhambani S, Das DK, Singh V. Cervical tuberculosis with carcinoma in situ: A cytodiagnosis (letter). Acta Cytol. 1985; 29:87. 5. Kobayashi-Kawata T, Haramik C. Tuberculous cervicitis. Acta Cytol. 1978; 22:193.

6. Angrish K, Verma K. Cytologic detection of tuberculosis of uterine cervix. Acta Cytol. 1981; 25:160. 7. Seth A, Kudesia M, Gupta K, Pant L, Mathur A. Cytodiagnosis and pitfalls of genital tuberculosis: A report of two cases. J Cytol. 2011; 28: 141–143. 8. Koller AB. Granulomatous lesions of the cervix uteri in black patients. S Afr Med J. 1975; 49:1228–32. 9. Chong VH, Rajendran N. Tuberculosis peritonitis in Negara Brunei Darussalam. Ann Acad Med Singapore. 2005; 34:548–52. 10. Bilgin T, Karabay A, Dolar E, Develioglu OH. Peritoneal tuberculosis with pelvic abdominal mass, ascites and elevated CA 125 mimicking advanced ovarian carcinoma: a series of 10 cases. Int J Gynecol Cancer. 2001; 11:290–4.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Case Report Mucinous Borderline Tumour of The Ovary in A Premenarchal Girl Jyoti Mishra*1, Sangeeta Nagar1, Anil Verma1, Mehtab CA Sangma1, Geeta Deshmukh1, P.L.Kariholu2 Department of Pathology, School of Medical Sciences and Research, Sharda Hospital, Greater Noida, India 2 Department of Surgery, School of Medical Sciences and Research, Sharda Hospital, Greater Noida, India

Keywords: Borderline Tumor; Mucinous tumor; Ovary; Premenarchal

ABSTRACT Epithelial ovarian tumors are common in adult women, but rare in children. Mucinous cystadenoma (MCA) are rare, with only 16 cases in premenarchal girls reported to date. Low grade (borderline) tumors are even exceptionally rarer. To the best of our knowledge, only few cases of an ovarian borderline intestinal-type mucinous tumor in premenstrual girl have been reported in literature. We present a rare case of an ovarian mucinous borderline tumor in a thirteen year old girl. The histological features of low grade borderline tumors, rapid enlargement of the ovarian mass, the young age and the difficulty in diagnosis, make this case interesting for publication.

*Corresponding author: Dr. Jyoti Mishra, Assistant Professor, Department of Pathology, School of Medical Sciences and Research, Sharda Hospital, Greater Noida, Uttar Pradesh, India-201306 Phone: + 91 120-2329700 E-mail: drm714@gmail.com

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Mucinous Borderline Ovarian Tumor in A Young Girl

Introduction

Ovarian neoplasm, though unusual in the pediatric age group, if present the majority are of germ cell origin. [1] Mucinous cyst adenoma of the ovary constitutes about 15% of ovarian tumors. [2, 3] It is more common in women between 20 and 40, but is rare in teenagers and exceptional in pre-menstrual girls. [4] Though mucinous borderline tumors can be seen in a wide range from 13-88 years, but still these are extremely rare in young children. [5] As far as we know, though approximately 16 cases of benign mucinous cyst adenoma have been reported in young, only a few case reports of borderline mucinous tumor exist. [6, 7] Here the authors present a rare case of an ovarian mucinous borderline tumor in a thirteen year old girl.

Case Report

We report the case of a thirteen year old girl who presented to our hospital with an increase of abdominal girth during last 20 months. It was associated with mild on & off pain in the epigastric region. Her menarche was not attained and she denied the use of any illicit drugs. There was no significant family history. Physical examination revealed pale skin, a temperature of 36.1oC, respiratory rate 22 breaths/minute, pulse rate 78/minute, blood pressure at 180/140 mmHg, normal cardiac and respiratory sounds. Her abdomen was distended, tense due to ascites and abdominal girth measured 130cm, with dullness on percussion and superficial dilated veins. She was admitted to surgical ward for diagnosis and treatment. Laboratory test revealed normal complete blood count, kidney and liver function test. CEA, Alpha fetoprotein and CA-125 were with in normal level. Ascitic fluid cytology revealed total leukocyte count of approximately 250/cmm with predominantly lymphocytes & occasional neutrophils & mesothelial cell. The chest radiograph showed an upward compression of her diaphragm. Abdominal ultrasonography study showed massive ascites along with a huge multiloculated abdominal mass. The origin of this mass could not be delineated due to massive fluid (Figure1A). Computed tomography (CT) showed heterogenous enhancing large cystic lesion of size approx 30x18 cm arising from left adnexa. There was heterogenous enhancing solid component of 6x6 cm size with multiple enhancing fine and thin septations (2 to 3 mm thickness). The mass was displacing bowel laterally. Ultrasonography showed moderate ascites and no focal lesion was seen in liver. There was no fat component or calcification. No abnormal lymphadenopathy was noted. (Figure 1B) So clinico-radiologically, the provisional diagnosis of malignant germ cell tumor was kept. Preoperatively temlisartan and amlodipine was given to control the B.P of the patient. Left salpingo-oophorectomy was performed.

Fig. 1: (A) USG: A complex, multiseptate predominantly cystic mass extending from the pelvis into the upper abdomen. (B) CT SCAN: Complex multiseptate mass arising from the left ovary and a moderate amount of ascites.

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Mishra et al. (Figure 2A). There was no adverse outcome on surgery. Specimen received in the pathology department, showed an ovarian mass and measured 30x25x10cm and weighed 7 kgs. External surface was smooth and glistening. Cut surface showed a large multiloculated cyst filled with mucin. (Figure 2B). Thirty five sections were taken based on CAP protocol and were subjected to careful microscopic examination. Microscopically the tumor sections showed cysts, glandular and papillary structures

C-245 lined by epithelium of intestinal type. The epithelium was focally stratified up to three layers and showed mild to moderate atypia at places. No definite stromal invasion was seen. Mitotic figures were rare. Focal areas of necrosis and mild chronic inflammation were seen. (Figure 3, 4, 5) The final diagnosis of borderline mucinous tumor, intestinal type (left ovary) was rendered. Postoperative course was uneventful. No evidence of recurrence has been seen during one year postoperatively.

Fig. 2: (A)Tumor delivered from abdominal incision while performing left salpingo-oophorectomy.(B) Cut section showing multilocular mucinous with multiple small cysts filled with mucus material in their lumens.

Fig. 3: The papillae were lined by mucinous intestinal type of epithelium displaying stratification at focal areas, hyperchromasia and mild to moderate nuclear atypia (H&E, 40X).

Fig. 4: The central delicate stromal cores supporting intraluminal projections along with focal epithelial proliferation at places (H&E, 40X)

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Mucinous Borderline Ovarian Tumor in A Young Girl

Conclusion

This is a case report of primary retroperitoneal mucinous borderline tumor in teenager who was initially thought to be a surgical case of retroperitoneal mass. On ultrasonography the origin of this mass could be delineated from ovary. Later further on CT scan it was suspected to arise from ovary, considering the age of patient the diagnosis of malignant germ cell tumor was kept. During the surgery the origin was confirmed to be from the ovary. On histopathological examination final diagnosis of mucinous borderline tumor was rendered. Knowledge of the clinical presentation, imaging, and histologic characterization of this entity can lead to correct diagnosis and appropriate treatment as long term follow up is required in such cases.

Acknowledgement Fig 5: Section showing focus with borderline morphology displaying stratification, moderate nuclear atypia and occasional mitotic figures (H&E, 100X).

Discussion

Ovarian masses in children are an uncommon occurrence. They represent less than 2% of all tumors in girl less than 16 years of age.[1]Mucinous tumors of the ovary including borderline tumors occur in middle adult life and are extremely rare prior to menarche.[2-7]Mucinous borderline tumors of low malignant potential are usually large, multilocular cyst. These exhibit an epithelial proliferation of mucinous type cells greater than that seen in benign counterparts but without stromal invasion. The epithelial components resembling intestinal epithelium almost always contain goblet cells, usually contain neuroendocrine cells and rarely contain Paneth cells. In borderline areas the cells lining the cysts are stratified (usually not more than 3 layers) and may form filliform intracystic papillae with at least minimal stromal support. There is mild nuclear atypia and few mitotic figures are also seen. [9, 10, 11] In our case microscopic examination of huge ovarian mass showed multilocular cyst lined by papillary structures displaying columnar epithelium with stratification up to 3 layers. Fair number of goblet cells and mild to moderate nuclear atypia was evident. Bearing these features in mind, the final diagnosis of ovarian borderline mucinous tumor, intestinal type was given. The patient was discharged on 12th day after removal of sutures. She is doing fine for last two months and has put on 1Kg weight without any treatment. Surgical management to excise all visible tumor tissue remains the keystone of therapy. Even in advanced disease there is no proven benefit of adjuvant chemotherapy or radiotherapy.[12]

We authors thank Mr. Ankit Singh, histopathological technician, for providing technical help.

Funding None

Competing Interests None declared

References

1. Liu F1, Wei J, Shen D, Liu J. Mucinous borderline tumor involving fallopian tube: case report and review of the literature. J Clin Exp Pathol. 2013; 15: 962-5. 2. Sri Paran T, Mortell A, Devaney D, Pinter, A, Puri, P. Mucinous cystadenoma of the ovary in perimenarchal girls. Pediatric Surgery International 2006; 22: 224-7. 3. Hohne S, Milzsch M, Stiefel M, Kunze C, Hauptmann S, Finke R. Ovarian Borderline Tumors in PreMenarche Girls. 2013; 30:253-62. 4. Vizza E, Galati GM, Corrado G, Atlante M, Infante C, Sbiroli CJ. Voluminous mucinous cystadenoma of the ovary in a 13-year-old girl. Pediatr Adolesc Gynecol. 2005; 18:419-22. 5. Fattaneh AT, Devilee P. Tumors of the Breast and female genital organs World Health Organization Classification of tumors. 2003; 14 edition:125-6. 6. Horiuchi A, Kameoka K, Sato K, Yamamoto Y, Watanabe Y. Huge mucinous borderline ovarian cystadenoma in a premenarchal girl. Open Journal of Pediatrics, 2012, 2, 82-86. 7. Karaman A , Azili MN, Boduroglu EC, Karaman I, Erdogan D, Cavusoglu YH, Aslan MK, Cakmak O. A huge ovarian mucinous cystadenoma in a 14-year-old premenarchal girl: review on ovarian mucinous tumor in premenarchal girls. J Pediatr Adolesc Gynecol. 2008;21:41-4.

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8. Deprest, J, Moerman P, Corneillie P, Ide P. Ovarian borderline mucinous tumor in a premenarchal girl: Review on ovarian epithelial cancer in young girls. Gynecologic Oncology, 45, 219-24. 9. Hart RW. Borderline epithelial tumors of the ovary. Modern Pathology 2005; 18:33-50. 10. Wasaki, M, Taira, K, Kobayashi H, Saiga T Ovarian mucinous cystadenoma of borderline malignancy in a premenarchal girl. Journal of Pediatric and Adolescent Gynecology 2010; 23:119-23.

11. Ronnett BM, Kajdacsy-Balla A, Gilks CB, Merino MJ, Silva E, Werness BA, Young RH. Mucinous borderline ovarian tumors: Points of general agreement and persistent controversies regarding nomenclature, diagnostic criteria, and behavior. Human Pathology 2004; 35: 949-60.

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12. Haritwal A, Makhija B, Arora M, Agrawal D, Goyal P. Management Dilemmas in Borderline Ovarian Tumor. IJWHR 2014; 2: 219â&#x20AC;&#x201C;224. DOI: 10.15296/ ijwhr.2014.3.

Case Report A Case of Primary Intestinal Lymphangiectasia Rajshri P. Damle*, Kishor H. Suryawanshi, N. V. Dravid, D.V. Newadkar Department of Pathology, JMFâ&#x20AC;&#x2122;s ACPM Medical College, Dhule. Maharashtra. India Keywords: Intestinal Lymphangiectasia, Diarrhea, Edema

ABSTRACT Primary intestinal lymphangiectasia (PIL) is an uncommon disorder and important cause of protein losing enteropathy due to congenital malformation or obstruction of intestinal lymphatic drainage. No accurate serological or radiological tests available for the diagnosis of intestinal lymphangiectasia. Endoscopy and biopsy are currently the only diagnostic modality with certainty. Hence histopathological examination is the gold standard for the diagnosis of intestinal lymphangiectasia which shows dilated intestinal lymphatics with broadened villi of the small bowel. Herein we report a case of intestinal lymphangiectasia in a 4-year-male child presented with chronic diarrhea and edema. Patient was treated by resection of small intestine and postoperatively patient showed improvement with small bowel movements and disappearance of edema.

*Corresponding author: Dr. Rajshri P. Damle, Assistant Professor, Department of Pathology, JMFâ&#x20AC;&#x2122;s ACPM Medical College, Dhule. 424001 Maharashtra. India Phone: + 91 9767637624 E-mail: rajshriborase@gmail.com

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Damle et al.

Introduction

Primary intestinal lymphangiectasia (PIL) is a relatively rare disorder and main cause of protein losing enteropathy. It is caused by congenital malformation or secondary obstruction of intestinal lymphatic drainage and characterized by diffuse or marked dilation of the enteric lymphatics.[1] Intestinal lymphangiectasia is manifested by an extreme loss of proteins into gastrointestinal tract (GIT) resulting in diarrhea, edema, hypoalbuminemia, hypogammaglobulinemia, sometimes pleural effusion and ascites. In 1961, Waldmann and Schwabb reported this rare entity of intestinal lymphangiectasia.[1]

C-249 appearance and cut surface showed multiloculated cystic areas measured 0.5 cm to 3 cmin diameter with thinning of intestinal wall. [figure 1] Microscopically multiple serial sections showed broadened villi with dilated lymphatic channels within mucosa and submucosa. Lamina propria showed few inflammatory cells infiltrate. [Figure: 2 and 3] Based on clinical and histopathological findings confirmed the diagnosis of lymphangiectasia. Patient was started on medium chain triglyceride diet along with high protein diet.

It can be primary or secondary type. Primary intestinal lymphangiectasia (PIL) usually occurs in children and adolescents resulting from a congenital deformity of the small bowel lymphatic system. Secondary intestinal lymphangiectasia is more often seen in adults and occurs due to an elevated lymphatic pressure as in lymphoma, systemic lupus erythematosus, sarcoidosis, scleroderma, inflammatory bowel disease, malignancies, constrictive pericarditis and cardiac surgery. [2,3]The diagnosis is based on the upper gastrointestinal endoscopy and histopathological examination which are showing diffuse scattered mucosal white lesions with typical histological findings of abnormal lymphatic dilation. Herein we report a case of primary intestinal lymphangiectasia (PIL) in a 4-year-male child who presented with chronic diarrhea and edema.

Case History

A 4-year-male child presented with history of diarrhea with upper and lower limb edema since 5-6 months. He also complained of abdominal distension and weight loss since 2-3 months. He had 4-5 watery stools per day and mixed with mucus. There was no history of fever, vomiting, abdominal pain, skin rash or urinary symptoms. On examination he had generalized anasarca and abdominal distension. General physical examination and systemic examination were normal. His routine hematological and biochemical investigation were normal except serum protein. Total serum protein -3.7 gm/dl, albumin- 1.37gm/ dl and globuline-2.4 gm/dl. Routine microscopic stool examination for common parasites was negative. A probable clinical diagnosis of malabsorption syndrome due to protein losing enteropathy was made. Patient underwent gastrointestinal endoscopy and revealed numerous whitish spots over the mucosa of ileum and biopsy was taken. Histopathological examination of ileum biopsy showed dilated lymphatics. Then affected part of ileum was resected and sent for histopathological examination. On gross examination resected loop of small intestine measured 10 cm x 3 cm. External surface showed whitish

Fig. 1: Cut surface of piece of small bowel showed multiloculated cyst like areas with thinning of intestinal and whitish in appearance.

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Fig. 2: Microscopy showed broadened villi with dilated lymphatic channels in mucosa and submucosa. [H & E, x 100]

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Intestinal Lymphangiectasia The lymphatic hypoplasia results in an obstruction in lymph flow, which leads to increased pressure within the lymphatics. This, in turn, causes dilation of the lymphatic channels in the intestine and finally leads to the rupture of the channels with discharge of the lymph into the lumen of the bowel. As lymphatic fluid contains a lot of protein, fat and lymphocytes and leakage of lymph causes hypoproteinemia, lymphocytopenia and decreased serum levels of immunoglobulin.[6] [5]

Fig. 3: Microscopy showed broadened villi with dilated lymphatic channels in mucosa and submucosa. Lamina propria showed few inflammatory cells infiltrate. [H&E, x400]

Discussion

Primary intestinal lymphangiectasia (PIL) or Waldmann’s disease is characterized by markedly dilation of the mucosal, submucosal and subserosal intestinal lymphatics resulting in leakage of lymph into the lumen of small intestine that may be associated with protein losing enteropathy resulting in hypoalbuminemia, hypogammaglobulinemia, diarrhea, edema and sometimes effusions.[4] It is diagnosed before 3 years of age but occasionally may be diagnosed in late childhood. Both sexes are equally affected. It may appear as a primary form caused by congenital malformation of lymphatic system. Primary intestinal lymphangiectasia is primarily affecting children and young adults which can occur as an isolated disorder (from birth) or as a part of syndrome such as Noonan, Klippel-Trennay-Weber, Von Recklinghausen, Hennekan and Yellow nail syndrome.[4] Secondary form occurs due to various condition including inflammatory bowel disease, lymphoma, SLE, sarcoidosis, scleroderma, malignancies, constrictive pericarditis and cardiac surgery. [2,3] In the small intestine delicate thin-walled lymph vessels, known as lacteals which absorb nutritional fat and proteins. But in lymphangiectasia the mechanism of protein loss is not well understood. In the literature many theories regarding the mechanism for the increased loss of protein into the bowel in intestinal lymphangiectasia have been proposed. The most accepted theory is an increase in the pressure of the lymph channels which causes protein loss.

Clinically patients present as fatigue, abdominal pain, nausea, vomiting, edema, weight loss and diarrhea.[5] Few patients can also develop hypocalcemia secondary to failure to absorb fat and fat-soluble vitamins. Laboratory investigation show lymphopenia, hypoalbuminemia and low immunoglobulin levels due to lymph leakage from the ruptured lymph vessels.[7] Our patient presented as diarrhea with pain in abdomen, edema and hypoalbuminemia. Edema may be due to lymphatic abnormality of the affected extremity. The whole lymphatics system below the diaphragm may be abnormal and outflow towards the thoracic duct may be obstructed.[8] In our case based on clinical features and laboratory investigation clinical diagnosis of malabsorption syndrome due to protein losing enteropathy was considered. Protein losing enteropathies include various conditions such as Whipple’s disease, Crohn’s disease, Ulcerative colitis, sprue and intestinal lymphangiectasia. Gastrointestinal endoscopic findings and intestinal mucosal biopsy are essential to differentiate the various causes of protein losing enteropathy. A diagnosis of Primary intestinal lymphangiectasia (PIL) is based on endoscopic findings and histology in intestinal biopsy specimen.[3] Endoscopic abnormalities such as scattered white plaques covering the mucosa have been observed but it may be negative when intestinal lesions are patchy in such cases video capsule endoscopy and double balloon enteroscopy assisted biopsy helps to make the histological diagnosis. Other tests proposed to diagnose intestinal lymphangiectasia (IL) are albumin scintigraphy, which shows the albumin leakage into the bowel, CT scan showing diffuse, nodular, small bowel wall-thickening and edema.[4] In our patient upper gastrointestinal endoscopy was done and showed numerous whitish spots over the mucosa of ileum. We did small bowel resection and marked improvement was observed.

Conclusion

PIL is a rare condition that presents in early childhood with diarrhea. It should be consider as a differential diagnosis of

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Damle et al. diarrhea and edema in a childhood age group. Therefore, detailed clinical examination, thorough investigation and follow-up are mandatory.

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1. Waldmann TA, Steinfeld JL, Dutcher TF, Davidson JD, Gordon RS Jr. The role of the gastrointestinal system in “idiopathic hypoproteinemia”. Gastroenterology 1961; 41:197-207 2. Fang YH, Zhang BL, Wu JG, Chen CX. A primary intestinal lymphangiectasia patient diagnosed by capsule endoscopy and confirmed at surgery: A case report. World J Gastroenterol 2007;13: 2263-5. 3. Freeman HJ, Nimmo M. Intestinal lymphangiectasia in adults. World J Gastrointest Oncol 2011; 3:19-23.

4. Vignes S, Bellanger J. Primary intestinal lymphangiectasia (Waldmann’s disease). Orphanet J Rare Dis 2008; 3:5 5. Mistilis SP, Skyring AP, Stephen DD. Intestinal lymphangiectasia mechanism of enteric loss of plasma protein and fat. Lancet 1965; 1:77-9. 6. Wen J, Tang Q, Wu J, Wang Y, Cai W. Primary intestinal lymphangiectasia: Four case reports and a review of the literature. Dig Dis Sci 2010;55:3466-72 7. Hauser B, Moreels T, Urbain D, Van Marck V, Pletincx M, Devreker T, et al. Intestinal lymphangiectasia. J Pediatr Gastroenterol Nutr. 2009 ;48(2):125. 8. Levine C. Primary disorders of the lymphatic vessels – A unified concept. J Pediatr Surg 1989; 24: 233-24.

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References

Case Report Choroid Plexus Carcinoma: A Case Report Vissa Shanthi*1, Nandam Mohan Rao1, Amit Agrawal2, Umamaheswara Reddy V3, Boddapati Amulya1,

1 Department of pathology, Narayana Medical college and Hospital, Nellore, Andhra Pradesh, India. Department of Neurosurgery, Narayana Medical college and Hospital, Nellore, Andhra Pradesh, India 3 Department of Radiology, Narayana Medical college and Hospital, Nellore, Andhra Pradesh, India

Keywords: Choroid Plexus, Childhood Tumors, Carcinoma

ABSTRACT The tumors arising from choroid plexus epithelium are more common in the pediatric age group. Choroid plexus tumors are Choroid plexus papilloma (WHO grade I), Atypical choroid plexus papilloma (WHO grade II) and Choroid plexus carcinoma (WHO grade III). In children, choroid plexus carcinoma constitutes 15 to 20% of the choroid plexus tumors. These aggressive tumors have tendency for recurrence and metastatic dissemination along the cerebrospinal fluid (CSF) pathway. We report a case of Choroid plexus carcinoma in 1 year female child who presented with hydrocephalus.

*Corresponding author: Dr. V. Shanthi, Flat no. 301, Anjani SVGK Towers, Sri Hari nagar, Ramalingapuram, Nellore, Andhra Pradesh, India. Phone: + 91 9849052179 E-mail: santhijp@gmail.com

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Shanthi et al.

Introduction

Choroid plexus tumors represent 0.3 to 0.6% of all tumors of central nervous system. These tumors were first described by Geurard in 1832[1] . They constitute nearly 5% of brain tumors occurring in childhood and 20% of the brain tumors occurring with in the first year of life[2] . Rarely they occur as congenital and fetal tumors[3] . Among the choroid plexus tumors, papillomas are 5 times more common than carcinomas and most of the carcinomas occur in infants less than 3 years of age. Choroid plexus carcinomas should be distinguished from Choroid plexus papilloma by their growth pattern and histopathological features like papillary architectures covered by layers of pleomorphic choroid plexus epithelial cells, presence of necrosis and increased mitotic activity. Aggressive surgical resection with chemotherapy and with or without radiotherapy is required for survival and has very poor prognosis if the surgery is incomplete.

C-253 cells had round to oval vesicular nuclei with prominent nucleoli. Most of the tumor cells had scant eosinophilic to clear cytoplasm. Atypical mitotic figures and foci of necrosis were seen. The interstitial fibrous septa showed lymphocytic infiltrate. Few foci showed normal choroid plexus lined by benign cuboidal epithelial cells (Figure 3).On immunohistochemistry tumor cells were

Case report

A 1 year old girl came to the neurosurgery with history of vomit since 25 days. There was regression of motor mile stones and progressive enlargement of head. On examination head circumference was 47cms. Anterior fontanella was open and bulging. Patient had dolicocephaly and right sided Bells palsy. Her heart rate was 122/min regular and respiratory rate was 28/min. On ophthalmic examinations mild papilledema with blurring of disc margin in both eyes were noted. Haematological examination showed normal hemoglobin (13.1gm/dl), raised total count (15,400/cumm) and raised ESR (29mm/hr) remaining parameters were within normal range. Magnetic resonance imaging (MRI) reveal Axial T1W image showing iso/hypo intense mass in the fourth ventricle, Axial T2 W image showing brain stem displacement and infiltration. There was inferior beaking of the tonsil through foramen magnum suggesting herniation and anteromedial displacement of basilar artery. Coronary FLAIR image showed mass and dilatation of ventricles (Figure 1). Axial post contrast spoiled gradient images showed intense heterogenous enhancement of the mass (Figure 2). Based upon radiological findings, a clinical diagnosis of right cerebellar medulloblastoma was considered. A right Parieto-occipital craniotomy was done and the tumor was sent to pathology department for histopathological examination.

Fig. 1: (A) Axial T1W image showing iso/hypo intense mass in the fourth ventricle. (B) Axial T2W image showing heterogeneously hyperintense mass with peripheral cystic areas. (C) Sagittal T2W image showing brain stem displacement and infiltration. Also note the inferior beaking of the tonsil through foramen magnum suggestive of herniation and anteromedial displacement of basilar artery. (D) Coronary FLAIR image showing mass and dilatation of ventricles.

Grossly we received multiple gray white irregular soft tissue bits . Histopathological examination revealed tumor cells arranged in solid sheets and in papillary pattern. Papillae had delicate fibrovascular core and were lined by several layers of tumor cells. The tumor

Fig. 2: Axial post contrast spoiled gradient images showing intense heterogenous enhancement of the mass

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Choroid Plexus Carcinoma

positive for cytokeratin and S-100 (Figure 4). They were negative for GFAP. The tumor was diagnosed as Choroid plexus carcinoma depending upon the histopathological and immunohistochemical features.

Fig. 3: (A) Tumor cells arranged in papillary pattern (H&E, X50). (B) Papillae having fibrovascular core and are lined by layers of tumor cells (H&E, X100). (C) Tumor showing areas of necrosis (H&E, X100). (D) Right side showing benign choroid plexus lined by cuboidal epithelium and left side showing tumor cells (H&E,X400)

Fig. 4: (A) Tumor cells are cytokeratin positive (CK, X100). (B) Tumor cells are S-100 positive (S-100, X100).

preexisting choroid plexus papilloma. These tumors have been found to be associated with Simian virus 40 (SV40) and also dysfunction of p53 which is a tumor suppressor gene. They are also described in a association with LiFraumeni syndrome, where the TP53 germ line mutations are carried in families. Radiological features of choroid plexus carcinomas are markedly enhancing intraventricular tumors invading the adjacent brain parenchyma. On non-contrast computed tomography, these tumors are heterogenous and are typically iso to hyperdense to grey matter. 20 – 45% of cases show calcifications. Contrast enhanced CT shows tumor prominently and is heterogenous with areas of necrosis and cyst formation. On Magnetic resonance imaging, T1 image is iso to hypointense and T2 image is usually iso to hypointense with hyperintense necrotic areas. Before surgery, imaging of entire neural axis should be done as the tumors have CSF seeding[7] . In our case as the choroid plexus carcinoma was not suspected clinically, entire neuraxis imaging was not done. Choroid plexus carcinoma (WHO grade III) should be differentiated from papilloma (WHO grade I) which has papillary configuration. Papillomas mimic the structure of normal choroid plexus but have more exuberant papillae with branching. Papillae have delicate fibrovascular cores lined by single layer of columnar to cuboidal epithelium which have round to oval basally placed monomorphic nuclei and eosinophilic cytoplasm. These benign tumors do not have cellular atypia and necrosis. Atypical mitotic figures are also rarely present. Choroid plexus tumors are termed as “Atypical papilloma” when the cells lining the papillae show pleomorphism, have focal necrosis and occasional atypical mitotic figures.

Choroid plexus tumors causes increased intracranial pressure and most of the patients present as hydrocephalus. Some of the cases present with convulsions and intracranial hypertension[6] . As the choroid plexus carcinomas invades into the brain parenchyma, the patient may have focal neurological dysfunction.

In choroid plexus carcinoma, the characteristic features are blurring of papillary features, cellular atypia, invasion to adjacent brain parenchyma, areas of necrosis and increased mitotic activity. The presence of features like transitions from normal choroid plexus to abnormal confirms the origin of the lesion which was present in our case. The cellular atypia includes variation in chromatin of the tumor cells, acinar and glandular structures, solid sheets and atypical mitotic figures. Our case showed cellular atypia, blurred papillary structures lined by layers of tumor cells and areas of necrosis. Immunohistochemically, the tumor cells of choroid plexus carcinomas stain positive for cytokeratins, S-100 and Transthyretin. Approximately 20% of these tumor may express GFAP. The tumor cells are typically negative for EMA.

Choroid plexus carcinoma may arise denovo from the choroid plexus epithelium or may develop from the

Differential diagnosis for these tumors include papillary variant of ependymoma, papillary meningioma, cerebellar

Discussion

Choroid plexus carcinoma are rare tumors occurring more often in children[4] . These tumors are of neuroectodermal origin and correspond to WHO grade III tumor. They are also considered as congenital brain tumor as few cases have been reported in premature infants[5] .

Annals of Pathology and Laboratory Medicine, Vol. 02, No. 04, October - December 2015

Shanthi et al. medulloblastoma and astrocytoma. Papillary variant of ependymoma shows tumor cells having nuclei with stippled chromatin and micronucleoli. Ependymal rosettes and perivascular pseudorosette with tumor cells having their tapered cell processes oriented towards the blood vessel should be present[8] . These tumor cells in ependymoma will be positive for GFAP on immunohistochemistry. Our case did not show rosettes or pseudorosettes and the tumor cells were negative for GFAP. Papillary meningioma (WHO grade III) may occur in pediatric age group and can arise in the choroid plexus[9] . On immunohistochemistry, the tumor cells will be negative for cytokeratin. In our case, the tumor cells were strongly positive for cytokeratin on immunohistochemistry. Astrocytomas are GFAP positive tumors and in our case the tumor cells were GFAP negative.

C-255 chemoradiation is preferred in patients older than 3 years and chemotherapy alone in younger patients.

Acknowledgement None

Source of Fund None

None

References

Choroid plexus carcinoma is rare tumor occurring in the lateral and fourth ventricles and has poor prognosis. This tumor should be considered as possibility in the intraventricular papillary neoplasm in children. Gross total resection of the tumor is treatment of choice though it is difficult due to increased vascularity and poor demarcation from the adjacent brain parenchyma. Adjuvant

1. Hyun-Seung Kang, Kyu-Chang Wang, Yeon- Mee Kim, In-One Kim, Seung-Ki Kim, Je G.Chi, ByungKyu Cho. Choroid plexus carcinoma in an infant. JKMS 1997;12:162-7. 2. Louis DN, Ohgaki H, Wiestler OD, Carenee WK. WHO classification of tumors of the central nervous system. Lyon: IARC;2007. 3. Raisanen J, Davis RL. Congenital brain tumors. Pathology (phila) 1993;2:103-116. 4. Mishra A, Srivastava C, Singh SK, Chandra A, Ojha BK. Choroid plexus carcinoma: case report and review of literature. J Pediatr NeuroSci. 2012;7:71-73. 5. Wakai S, Arai T, Nagai M. Congenital brain tumors. Surg Neurol 1984;21:597-609. 6. Bleggi-Torres LF, Urban LA, Antoniuk A, Carboni P, Ramina R, Gugelmin ES. Choroid plexus carcinoma: Report of 15 cases. Arq Neuropsiquiatr 2000;58:50511. 7. Wolff JE, Sajedi M, Brant R, et al.Choroid plexus tumors. Br J Cancer 2002;87:1086-1091 8. Adesina AM. Intraoperative consultation in the diagnosis of pediatric brain tumors. Arch Pathol Lab Med. 2005;129:1653-1660. 9. Singh A, Vermani S, Sharma S, Chand K. Papillary meningioma: a rare but distinct variant of malignant meningioma. Diagn Pathol. 2007;2:3 10. Menon G, Nair SN, Baldewa SS, Rao RB, Krishna kumar KP, Gopala Krishnan CV. Choroid plexus tumors: An institutional series of 25 patients. Neurol India 2010;58:429-35. 11. Packer RJ, Perilongo G, Johnson D, Sutton LN, Vezina G, Zimmerman RA, Ryan J, Reaman G, Schut L. Choroid plexus carcinoma of childhood. Cancer 1992;69:580-5.

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Cerebellar medulloblastomas have tumor cells which are arranged in sheet like pattern. Homer-Wright Rosettes are usually found. The tumor cells have large hyperchromatic nuclei and background is highly fibrillar. The tumor cells are positive immunohistochemically for neuronal markers like NFP, Neu-N and synaptophysin and are negative for S-100 and Cytokeratin. The mainstay of treatment is surgical resection. The extent of tumor resection is an important factor in determining the long-term survival of patients. Due to hypervascularity and poor demarcation from the adjacent brain parenchyma, the gross total removal of the tumor becomes difficult. In such cases residual tumor can be removed after radiotherapy and chemotherapy. Radiotherapy helps to increase the survival[10] . But it cannot be used in many patients due to their younger age and also the size of the field which has to be irradiated. Chemotherapy helps for the long term survival and is indicated in young children with residual tumor after surgical resection and also in patients with metastasis[11] .

Conclusion

Case Report Lower Abdominal Solitary Fibrous Tumor Suspected As A Urachal Lesion : A Case Report with Cytohistological Correlation Neelam Sood, Priyanka Bhatia Soni* Department of Pathology, Deen Dayal Upadhyay Hospital , New Delhi, India. Keywords: Solitary Fibrous Tumor, Uncommon, Urachus, Intraabdominal

ABSTRACT Urachus is the embryological remnant of urogenital sinus and allantois. Benign urachal neoplasms including adenomas, fibromas, fibroadenomas, fibromyomas, and hamartomas have been reported. However, no cases of solitary fibrous tumour of the urachus have been reported. An 18 year old male presented with a lower abdominal mass with pain and urinary frequency. Computed tomography showed a mass abutting dome of the urinary bladder and anterior abdominal wall; however, the fat plane was maintained. Fine needle aspiration cytology was suggestive of a mesenchymal lesion. Surgical exploration revealed a mass attached to umbilicus on one end and dome of bladder on the other. Histopathological diagnosis was solitary fibrous tumor which was corroborated with immunohistochemistry findings. Patient has not reported back with recurrence. This case is being presented because of its unusual location and clinical suspicion of urachal lesion with no residual histological evidence of its remnant in the tumour.

*Corresponding author: Dr Priyanka Bhatia Soni, 24/1-A , Mall Road, Tilak Nagar, New Delhi 110018. India Phone: + 91 9871404026 E-mail: priyanka_bh_1981@yahoo.com

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Sood et al.

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Introduction

Urachus is the embryological remnant of urogenital sinus and allantois. It extends upward from the anterior dome of the bladder towards the umbilicus and normally involutes before birth, remaining as a musculofibrous band in the form of median umbilical ligament with no known function.[1] It lies between the transversalis fascia anteriorly and the peritoneum posteriorly. Persistence of urachal remnant ( seen in 50 % cases ) or incomplete regression of urachus can give rise to various clinical problems. Benign urachal neoplasms including adenomas, fibromas, fibroadenomas, fibromyomas, and hamartomas have been reported. Malignant urachal neoplasms are also seen representing less than 0.5% of all bladder cancers, and are typically silent because of their extraperitoneal location. [2] However no cases of Solitary fibrous tumour (SFT) urachus have been reported. SFT represent a group of rare tumours of mesenchymal origin usually identified in the pleura. [3] Herein we report a case of intraabdominal SFT at the site of urachus.

Case Report

A 18 year old male presented with a lower abdominal mass of 6 months duration, with complaints of non specific abdominal and urinary frequency. On examination per abdomen a mass arising from the pelvis 2 cm, below the umbilicus was seen. (figure 1A) Computed tomography (CT) showed a, infraumbilical well circumscribed mass displaying peripheral solid component and intralesional hypodense areas of myxoid change, hemorrhage and necrosis, abutting the dome of the urinary bladder and the anterior abdominal wall; however, the fat plane was maintained. (figure 1B) The bowel loops were splayed around the lesion with no obvious evidence of infiltration. Cystoscopy revealed a bulging mass measuring 7.5x7.0x7.0 cm with no significant mucosal changes. Ultrasound guided fine needle aspiration cytology (FNAC) done twice showed hypocellular smears with occasional clusters of plump to ovoid spindle shaped cells, at places entrapped in pink stroma along with numerous acellular stromal fragments in a hemorrhagic background. A possible diagnosis of mesenchymal lesion was given; (Figure 2B) however, in view of the size excision was advised. Surgical exploration revealed that the mass was attached to umbilicus on one end and dome of bladder on the other. (figure1C) The mass was excised as a suspected urachal lesion along with bladder dome to rule out any malignancy. The excised mass was well circumscribed with attached umbilicus on one end with intervening fat and no fibrous band. On the other end of the tumor a part of bladder wall clearly separated from the tumor was identified. Grossly, the tumor was well encapsulated and nodular measuring 7.5 x 7.0 x 7.0cm with attached bladder dome clearly separated www.pacificejournals.com/apalm

from the mass at one end and umbilicus at the other. Intervening fatty area was identified; however, no fibrous band was seen (Figure 2A). Cut section was grey white firm with solid and cystic areas. Microscopically sections showed spindled fibroblasts with minimal pleomorphism and negligible mitosis arranged in a patternless pattern with hyper and hypocellular areas, interlacing and intersecting fascicles with focal myxoid areas along with staghorn vascular proliferation, hemangiopericytoma like areas and perivascular hyalinization. (Figure 2C&D) Immunohistochemical (IHC) staining was performed with 5 micron thick sections on Poly-L-Lysine coated slides, which were stained with monoclonal antibodies against CD 34, CD 99 vimentin, Bcl2, Desmin, CD117, Smooth Muscle Actin (SMA), Epithelial membrane antigen (EMA), S-100 and cytokeratin (CK)(AE1/AE3). Also to evaluate the proliferative activity of neoplastic cells Ki 67 marker was used. Tumour cells were positive for Vimentin, CD34 and CD99, however negative for Bcl2, SMA, Desmin, EMA, S100, cytokeratin and CD-117 (Figure 3). The Ki-67 labelling index was <1% . A final diagnosis of benign SFT was given. However extensive histological examination of the tumour did not reveal any urachal remnants. The patient was from a far area village, so the follow up was hampered although has not reported back with any recurrence.

Fig. 1: (A) Patient presenting with a lower abdominal mass arising from the pelvis 2 cm below the umbilicus. (B) Computed tomography showed a well circumscribed mass with peripheral solid component and internal septations with areas of myxoid change , hemorrhage and necrosis abutting the dome of the urinary bladder and the anterior abdominal wall, however the fat plane was maintained. (C) & (D) Tumor removed en bloc together with the umbilicus and bladder dome.

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Solitary Fibrous Tumor mimicking as a Urachal lesion

Fig. 2: (A) Cut section shows well encapsulated, nodular grey white tumor mass with solid and cystic areas. Arrow shows intervening fat and no fibrous band. (B) Cytosmear showing a stromal fragment with ovoid to spindle shaped cells and mild inflammatory infiltrate in the background. ( Giemsa 40 X ). (C) Sections showing hyper and hypocellular areas with interlacing and intersecting fascicles with focal myxoid areas ( H&E, 10X). (D) Sections showing staghorn vascular proliferation hemangiopericytoma like areas with focal perivascular hyalinization. (H&E, 10X) Inset shows fibroblasts with minimal pleomorphism and negligible mitosis. (H&E, 40X )

Fig. 3: (A) Strong cytoplasmic Vimentin (V9, IgG/1kappa, RTU, mouse monoclonal, Biocare) positivity ( 10 X ). (B) Diffuse cytoplasmic immunoreactivity of CD 34 (QBEND/10, IgG1/kappa, RTU, mouse monoclonal, Dako) ( 10 X ). (C) Strong CD 99 (H036-1.1, IgM, RTU, mouse monoclonal, Biocare), positivity ( 10 X ). Inset shows CD 117 (Y145, IgG, RTU, Rabbit monoclonal, Biocare) and S-100 (15E2E2+4C4.9, IgG2ak+IgG2a, RTU, mouse monoclonal, Biocare) negative (10X). (D) Desmin (D33, IgG1/kappa, RTU,mouse monoclonal, Biocare) negativity ( 10 X). Inset shows SMA(IA4, IgG2a/kappa, RTU, mouse monoclonal, Biocare) negative ( 40X ) and dual staining pattern with trichrome.

Discussion

Histologically, (Table 1) SFTs are well circumscribed, encapsulated, solid, hypervascular tumor masses showing collagenous matrix with arrays of bland spindle cells arranged in a patternless pattern as hyper and hypocellular areas along with numerous branching staghorn vessels , also called as hemangiopericytoma like pattern. [3,4]

SFT is a rare benign neoplasm arising from the submesothelial mesenchymal layer first described by Klemperer and Rabin in 1931. It most commonly arises in the pleura, though also recognized in extrapleural locations such as lung, mediastinum, pericardium, mesentery, peritoneum, extraperitoneal spaces, nose and paranasal sinuses. [4] Extrapleural SFTs represent 0.6% of all soft tissue tumors. SFTs of the abdominal wall are extremely rare, with only 16 cases reported in the literature till date. [3] Wherein no urachal origin was suggested. SFTs usually present as an asymptomatic mass which can become painful as it grows , compressing the surrounding structures. [3] In our case the patient presented with non specific abdominal pain and urinary frequency , due to its pressure on bladder dome. SFTs have a same sex incidence being more frequent in 20-70 years age group, however female predominance has been observed in case of the abdominal wall tumors unlike in our case who is a 18 year old male with intra abdominal mass.

As per latest WHO classification 2013 the term “haemangiopericytoma” is abandoned . It is now used only to describe a morphological pattern that is shared by different entities. Currently, solitary fibrous tumour, haemangiopericytoma, lipomatous haemangiopericytoma and giant cell angiofibroma are all lumped under the category of “extrapleural SFT ” .[3,4,5,6] Because SFTs lack distinctive histological features, immunologic staining has frequently been employed to exclude other neoplasms in the differential diagnosis. Usually the ubiquitous and indolent nature of SFTs obscures and delays the diagnosis. Immunohistochemically, (Table 1) SFTs commonly show strong and diffuse staining for vimentin in 100% of the

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cases, CD34 in 85 %, bcl2 in 65 % and CD 99 in 40 %. 2035% variable positivity for EMA and SMA is seen. S100 proteins, cytokeratin and/or desmin usually show negative staining in majority, however focal and limited reactivity has also occasionally been reported.[3,4,6,7,8,9] But because of its very rare positivity none of the studies mentions the exact percentage positivity of these markers. The diagnosis of SFT in our case was not made easily. At the first glance by H&E staining, many differentials (Table 2) with one or some features similar to solitary fibrous tumour were considered.[3] Compared with these tumours, the distinct features of solitary fibrous tumour were observed on H & E. IHC showed weak and patchy CD 34 positivity, diffuse CD 99 and vimentin positivity . Bcl2, desmin, CD117, SMA, EMA S-100 and CK were negative. Cytokeratin was used with the aim to rule out a epithelial lesion and also to detect any urachal epithelial remnants. However no remnant of urachal tissue was identified microscopically. Histologically normal urachus consist of an epithelial canal lined by transitional epithelium (in 70%) and columnar epithelium (30%) surrounded by connective tissue and musculature.[2] While completely obliterated urachus appears as a fibrous band.

About 80% of SFTs are benign, malignancy is seen in 10â&#x20AC;&#x201C;30% of the patients with prolonged follow up. [3] Such behavior has been related to certain histological features of these tumors. Criteria for malignancy, though still controversial, include tumor size (>5 cm), infiltrative growth, high cellularity, nuclear pleomorphism, necrosis and mitosis > 4/10Hpf , corresponding to a level of Ki 67 staining greater than 10%. [3,4,6,7] In a study of all the potential predictors of malignancy, only mitotic index was associated with malignant behavior.[7] However occasional studies consider tumor size as an independent prognostic factor.[4] A weak/negative expression of CD 34 has been associated with more aggressive behaviour and an increased incidence of malignancy. [3,8] The staining is nearly uniform in histologically benign cases and patchy in malignant cases. [8] In the present case the tumor size was more than 5 cm and CD 34 staining was weak and patchy; although, the tumor cells showed minimal pleomorphism , negligible mitosis (<1/hpf) and no areas of necrosis. Keeping this in mind the patient was kept on follow up to look for relapse. Also the histological features of the cases negative for Bcl2 as in our case did not differ significantly from those of the positive cases. [8]

TABLE 1: HISTOPATHOLOGY AND IHC OF SFT [3,4,6,7,8] GROSS

HISTOPATHOLOGY

IMMUNOHISTOCHEMISTRY

Well defined

Patternless pattern

CD 34 (85%), Bcl2 (65%), CD99 (40%)

Solid

Hypo and hypercellular areas

EMA and SMA occasional positive

Hypervascular

Thick collagen bundles, Branching vessels S-100, Desmin & cytokeratin rare positive

TABLE 2: DIFFERENTIAL DIAGNOSIS OF SOLITARY FIBROUS TUMORS [3] DIFFERENTIAL TUMOUR

SIMILARITIES WITH SFT

DIFFERENCES FROM SFT

Haemangiopericytoma

- Mesenchymal origin - Staghorn vascular spaces - Spindle-shaped tumor cells

- No combination of varying growth patterns - No collagenous stroma - Reticulin staining pattern - Weakly positive for CD34; negative for CD99

Deep fibrous histiocytoma

- Storiform pattern - Occasional presence of bizarre mesenchymal giant cells

- More circumscribed - More uniform growth pattern - Negative for CD34 - Positive for factor XIIIa

Smooth muscle tumor

- Fascicular growth of spindle cells

- Positive for Smooth muscle actin and desmin - Negative for CD34

Gastrointestinal stromal tumor

- Staghorn vascular spaces - Positive for CD34

- No collagenous stroma - CD 117 positive - Negative for bcl-2

Nerve sheath tumors

- Focal CD 34 positive

- No collagenous background or vascular pattern - Frequent palisading - S-100 positive

Low grade Fibromyxoid sarcoma

- Alternating fibrous and myxoid patterns - EMA and SMA weak occasionally

- No prominent vascular proliferation - Lacks thick collagen bundles - Collagenous rosettes, CD 34 negative

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Surgical excision is the treatment of choice and it exhibits a favorable clinical behaviour, with an overall 10 year survival rate in 54-89% after primary surgical resection.[3] Similar dilemma in the presentation was noted by Mizusawa et al [10] in their study. We report a case of lower abdominal SFT mimicking as a primary lesion of urachus radiologically and surgically presumptively, due to its location. Although the preoperative diagnosis was a urachal tumor, the pathological diagnosis was a SFT.

Conclusion

4. Lau MI, Foo FJ, Sissons MC and Kiruparan P. Solitary fibrous tumor of small bowel mesentery : a case report and review of the literature. Tumori 2010;96:10351039. 5. Saanna GA, Bovee J, Hornick J, Lazar A. A review of the WHO classification of tumours of soft tissue and Bone 4th edition Lyon, IARC Press; 2013. 6. Demicco EG, Park MS, Dejka DM, Fox PS, Bassett RL, Pollock RE et al. Solitary fibrous tumor: a clinicopathological study of 110 cases and proposed risk assessment model. Modern Pathology 2012;25:1298-1306.

This case is being presented because of its unusual location suspected clinically as a urachal lesion with no residual histological evidence of its remnance in the tumor. Care should be taken not to be too invasive, considering the possibility of a benign tumor.

7. Moraa NS, Presmanesb MC, Monroyc V, Albinanab LC, Aladrob MH , Fernándezb EA. Clinicopathological Features of Solitary Fibrous Tumors of the Pleura: A Case Series and Literature Review. Arch Bronconeumol 2006;42:96-99.

References

8. Hasegawa T, Matsuno Y, Shimoda T, Hirohashi S, Hirose T, Sano T. Frequent Expression of bcl-2 Protein in Solitary Fibrous Tumors. Japanese Journal of Clinical Oncology 1998;28:86-91.

1. Rodrigues JCL, Gandhi S. Don’t get caught out! A rare case of a calcified urachal remnant mimicking a bladder Calculus. J Radiol Case Rep Mar 2013;7:34– 38. 2. Yu JS, Kim KW, Lee HJ, Lee YJ, Yoon CS, Kim MJ. Urachal Remnant Diseases: Spectrum of CT and US Findings. Radiographics 2001;21:2451-8. 3. Costa M, Oliva A, Velez A, Bento A, Garcia H, Oliveira F. Solitary Fibrous Tumor of the Abdominal Wall. J Clin Case Rep 2014;4:363.

9. Khanchel F, Driss M, Mrad K, Romdhane KB. Malignant solitary fibrous tumor in the extremity : Cytopathologic findings. J Cytol 2012; 29: 139–141. 10. Mizusawa H , Oguchi T , Domen T , Koizumi K , Mimura Y , Saito T et al. Two cases of lower abdominal tumors difficult to differentiate from urachal tumors. Nihon Hinyokika Gakkai Zasshi 2014;105:1721.

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Case Report Buschke-Lowenstein Tumor: A Case Report Smita Shripad Pathak*, Janice Jaison Department of Pathology, MIMER Medical College Talegaon Dabhade Pune, India Keywords: Buschke-Lowenstein Tumor, Human Papilloma Virus, Recurrence

ABSTRACT Giant Condyloma Acuminata also known as Buschke-Lowenstein tumor is a relatively rare sexually transmitted disease. It is characterized by rapid growth, local destruction, lack of spontaneous resolution, poor response to conservation therapy and high recurrence rate. Human Papilloma Virus has been implicated as an etiologic agent for this tumor. Radical excision of the lesion is generally recommended as the first line of therapy and close vigilance & follow up are essential. We report a case of 25 year old male who presented with large, exophytic mass in the perianal region which was surgically excised and after histopathological examination diagnosis of Buschke-Lowenstein tumor was made.

*Corresponding author: Dr. Smita Pathak, Professor, Department of Pathology, Mimer Medical College Talegaon Dabhade Pune, India Phone: + 91 9850437955 E-mail: smitapbhide@gmail.com

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Buschke-Lowenstein Tumor

Introduction

Giant Condyloma Acuminata also known as BuschkeLowenstein tumor was first described by as Buschke & Lowenstein in 1925.1 They observed a penile lesion that clinically resembled both common Condyloma Acuminata & Squamous Cell Carcinoma but differering from both of them regarding the biologic behaviour & histopathologial appearance.[2] It is a slow growing, locally destructive tumor. It is thought to be induced by Human Papilloma Virus types 6 & 11 and occasionally types 16 & 18.[1] The most important treatment modality is surgical excision of the mass.[3] A regular follow up is necessary because of the frequent recurrences & possible malignant transformation[4] We report a case of a patient with Buschke -Lowenstein tumor located in the perianal region that reached huge dimensions and was treated with surgical excision.

Case Report

A 25 year old heterosexual male presented with progressively enlarging mass in the perianal region since 6 months. He complained of difficulty in walking, pruritus & occasional pain at the site of mass. He did not report any risk factors for HIV infection. On examination, the mass was located in perianal region, bulky, exophytic & cauliflower like measuring 12x8x6xcm. The mass was tender to touch. No inguinal lymphadenopathy was noted. Systemic examination as well as basic haematological & biochemical investigations were within normal limit. Patientâ&#x20AC;&#x2122;s HIV test was nonreactive. The mass was surgically excised.

Fig. 1: Specimen showing bulky, exophytic, papillary cauliflower like tumor mass

The specimen of tumor mass with surrounding normal skin was received in the histopathology section of the department of Pathology. Tumor mass measured 15x10x6 cm. Externally the tumor showed exophytic, papillary cauliflower like growth. (Fig No 1) Cut section of the mass was solid, greyish white without areas of haemorrhage & necrosis. Microscopically it showed stratified squamous epithelium showing hyperkeratosis, parakeratosis, acanthosis & papillomatosis with minimal cytological atypia. Koilocytic change was also evident in the epithelium. The underlying fibrocollagenous tissue showed scant chronic inflammatory infiltrate. ( Fig. 2 &3) From the above histological findings diagnosis of Buschke-Lowenstein tumor was made. Careful clinical follow up was advised.

Discussion

Giant Condyloma Acuminata also known as Buschke - Lowenstein tumor is a very rare sexually transmitted disease. It was originally described in 1896 by Buschke & Lowenstein in 1925 and later on was named by Lowenstein as benign carcinoma like Condyloma Acuminata of the penis.[2] Itâ&#x20AC;&#x2122;s incidence is estimated to be 0.1 % in general population. [5] Human Papilloma Virus DNA types 6 & 11 have been most commonly recovered from the pathological specimens. Risk factors for HPV transmission include multiple sexual partners, prostitution, homosexuality, lack of hygiene & chronic genital infections. Buschke - Lowenstein tumor is always preceded by Condyloma Acuminata. It can be associated with congenital or acquired

Fig. 2: Photomicrograph showing stratified squamous epithelium showing acanthosis hyperkeratosis & papillomatosis ( H& E, 5X)

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C-263 be of interest to avoid mutilating surgical interventions such as laser, radiotherapy, intralesional interferon alfa or topical imiquimod.

Fig. 3: Photomicrograph showing stratified squamous epithelium showing koilocytic change, minimal cytologic atypia & intact basement membrane (H&E , 10X)

immunodeficiency, alcoholism, diabetes or chemotherapy or immunosuppressive therapy.[6] Males are most commonly (M: F 2.7:1) but some cases have also been seen in females & children.[7] The tumor is located on the penis in 81-94 % of cases, in the anorectal area in10-17% cases and in urethra in 5% of cases. In females the location is chiefly vulva (99 %) and an anorectal location is less frequent.[6] Clinically the tumor presents as exophytic fungating mass sometimes with cauliflower like morphology.[1,6] The characteristic histologic feature is a well differentiated hyperplastic, hyperkeratotic & parakeratotic stratified squamous epithelium showing papillomatosis with minimal atypia. Koilocytic change has also been observed.[8] Even though Buschke - Lowenstein tumor has a histologically benign appearance, it clinically behaves in a malignant fashion destroying the adjacent tissues. It is an intermediate entity between an ordinary Condyloma Acuminata & Squamous Cell Carcinoma.[1] Some authors suggested that Giant Condyloma Acuminata or Buschke- Lowenstein tumor is a type of low grade Squamous Cell Carcinoma but others disagree.[8] It can be differentiated from Squamous Cell Carcinoma by itâ&#x20AC;&#x2122;s characteristic pushing endophytic margins, negligible cellular atypia & low mitotic rate. Buschke â&#x20AC;&#x201C; Lowenstein tumor is classified as Verrucous carcinoma by some of the authors.[4] Verrucous carcinoma resembles Buschke â&#x20AC;&#x201C; Lowenstein tumor in clinical appearance and histology. So they consider these lesions to be similar. However , Buschke-Lowenstein tumor is generally the name given to a Verrucous carcinoma in genital regions by some of them. [5]

Vigilant & prolonged surveillance & regular follow up is necessary because of the frequent recurrences & possible malignant transformation.[4] Local recurrence rate after surgical excision is high, up to 60-66 % .[4&5] Malignant transformation occurs in 30-50 % of patients which is again associated with high recurrence rate & poor prognosis.[4] Malignant transformation is suspected when bleeding, pain and rapid increase in the size of the tumor .[5] The biopsy must be wide & deep enough to accurately determine the extension of the tumor and the possible presence of Squamous Cell Carcinoma.[2] Our patient was a 25 year old heterosexual male who presented with bulky cauliflower like mass in the perianal area which was treated with wide surgical excision. Histopathological diagnosis of Buschke- Lowenstein tumor was made. The patient is on regular clinical follow up & is free from any recurrence till now i.e.10 years.

Conclusion

Since all lesions of Buschke - Lowenstein tumor initially start as Condyloma Acuminata & progress over many years, early surgical excision in the treatment of Condyloma Acuminata prevents development of Buschke- Lowenstein tumor. Buschke - Lowenstein tumor represents a constant challenge for the surgeons. The surgical excision remains the gold standard treatment. A detailed histopathology examination is mandatory because microscopic excision with tumor free margin presents a decreased recurrence rate compared to macroscopic excision. [3,6]

Acknowledgements Not applicable

Funding None

Competing Interests None declared

References

1. Pinto AR, Guedes-Martins L, Marques C, Cabral JM. Buschke-Lowenstein Tumor. Acta Med Port. 2012 ; 25:345-347

Most author recommend radical surgical excision allowing complete histopathological examination & assessment of tumor for resected margins. Other adjuvant modalities could

2. Agarwal S, Nirwal GK, Singh H. Buschke Lowenstein tumor of glans penis. International journal of Surgery Case Reports. 2014; 5:215-218

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3. Tas S, Arik MK, Oztekin F, Akagun Y. Perianal Giant Conndyloma Acuminatum - Buschke Lowenstein tumor: A Case Report. Case Reports in Surgery. 2012; Article ID 507374, 3 pages. doi:10.1155/2012/507374 4. Martin JM, Molina I, Monteagudo C, Marli N, Lopez V, Jorda E. Buschke Lowenstein tumor. Journal of Dermatological Case Reports.2008; 2:60-62 5. Ahsain M, Tahiri Y, Tazi MF, Elammari J, Mellas S, Khallouk A, et al. Verrucous carcinoma arising in an extended giant condyloma acuminatum (Buschke Lowenstein tumor): a case report and review of the litreture. Journal of Medical Case Reports. 2013;7:273

6. Sandhu R, Min Z, Bhanot N. A Giagantic Anogenital Lesion: Buschke Lowenstein Tumor. Case Reports in Dermatological Medicine. 2014; Article ID 650714, 3 pages. doi:10.1155/2014/650714 7. Spinu D, Radulescu A, Bratu O, Checherita IA, Raneti AE, Mischianu D. Giant Condyloma Acuminatum Buschke Lowenstein Diseaseâ&#x20AC;&#x201C; a Literature Review. Chirurgia. 2014; 4: 445-50 8. Chu GY, Chang TCC,Â Chang CH. BuschkeLowenstein tumor (giant condyloma acuminatum) successfully treated by topical photodynamic therapy: a case report. Dermatologica Sinica. 2013;31:94-97.

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Letter to Editor Cystic Pleomorphic Adenoma: A Diagnostic Challenge On Cytology Meghna Singh1*, Jitendra Chaudhary2 Department of Pathology, Shankar Diagnostic Centre, Agra, India Department of Radiology, Shankar Diagnostic Centre, Agra, India

1 2

Keywords: Pleomorphic Adenoma, Cystic Change, Foamy Macrophages, Squamous Metaplastic Cells

Dear Sir,

Although fine needle aspiration cytology (FNAC) is a highly accurate tool for the diagnosis of pleomorphic adenomas, even this common salivary gland neoplasm can be diagnostically challenging and cause pitfalls in cytodiagnosis. In particular, the presence of cystic degeneration and squamous metaplasia may cause diagnostic confusion and stresses the need for guarded approach while interpreting such lesions. A 36 year old male presented with a painless, left preauricular swelling since 3 months. Ultrasonography of the lesion revealed a lobulated hypoechoic mass lesion measuring approximately 27x18 mm in upper lobe of left parotid gland. The lesion showed few cystic areas. Diagnosis of Pleomorphic Adenoma with Cystic Degeneration was given. Routine FNAC yielded a mucoid fluid mixed with blood. Cytologic smears revealed predominantly foamy macrophages in a mucoid and hemorrhagic background. Only one smear revealed fibrillary chondromyxoid material. An ultrasound guided FNAC was then performed from the solid part of the lesion. The smears revealed oval to spindle myoepithelial cells entrapped within fibrillary chondromyxoid matrix. Multiple hyaline stromal globules were evident. Squamous metaplastic cells were seen in fair numbers. Few oncocytic cells were also noted. Background was mucoid and hemorrhagic and showed fair number of foamy macrophages. A cytologic diagnosis of Pleomorphic Adenoma with Cystic Change was rendered and histopathology was advised. The patient then underwent left superficial parotidectomy. Grossly, the specimen had 4 pieces measuring 3.5x1.7x1.7 cm to 1.4x1x0.2 cm and weighed 15 gm. On cutting a capsulated growth of 2x1.5 cm with tan fleshy appearance was seen. It was solid with partial cystic area. Microscopically, biphasic

appearance was seen resulting from intimate admixture of epithelium with stroma. Epithelial component was forming tubules within chondromyxoid matrix. There were cystic spaces filled with mucinous material. Squamous and oncocytic metaplasia was seen. No necrosis or nuclear atypia was appreciated, thus the histopathologic diagnosis was consistent with Pleomorphic Adenoma with Cystic Change. A wide variety of neoplastic and non-neoplastic lesions of the salivary glands may present as either partial or completelely cystic masses. The non-neoplastic cystic lesions include developmental anomalies such as polycystic disease of the parotid glands, benign lymphoepithelial cysts and degenerative changes of the salivary gland duct system, such as mucus retention cyst and mucus extravasation reaction. The neoplasms that may present with a cystic component include pleomorphic adenoma, Warthinâ&#x20AC;&#x2122;s tumor, low-grade mucoepidermoid carcinoma, intraductal papilloma, acinic cell carcinoma and mucinous adenocarcinoma.[1] Other than cystic changes, pleomorphic adenomas may often be associated with changes such as squamous,[2-6] mucinous and sebaceous cell metaplasia.[4,7] Diagnosing pleomorphic adenoma accurately in such a situation may be challenging for cytologists.[7] There have been rare studies[1] and a few case reports[4,6] in the literature highlighting the diagnostic problems encountered with the cystic lesions of the salivary glands on FNAC. Such interpretive problems may result in false positive or false negative diagnosis. Most often, the false positive diagnosis occurs as a result of metaplastic epithelial components in the aspirates, in particular the squamous metaplastic cells.[8,9] and false negative diagnosis occurs as a result of dilution of diagnostic tumor cells by the cyst fluid. In cytology, aspirates from cystic pleomorphic adenomas showing epithelial metaplastic changes, especially in

*Corresponding author: Dr Meghna Singh, 10 Laxman Nagar, Near Arjun Nagar, Agra, Uttar Pradesh, 282001, India Phone: +91-8126738984 E-mail: dr.singhmeghna@gmail.com

This work is licensed under the Creative Commons Attribution 4.0 License. Published by Pacific Group of e-Journals (PaGe)

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Cystic Pleomorphic Adenoma

the absence of characteristic chondromyxoid stroma, may be misinterpreted as malignancy in general, and mucoepidermoid carcinoma in particular.[7] There have been cases in the literature in which such metaplastic changes have misled cytologists, resulting in either suspicion or misinterpretation of pleomorphic adenoma cases as mucoepidermoid carcinomas.[4,7] However, the presence of characteristic fibrillary chondromyxoid stroma as in our case excludes this possibility. It is also worth remembering that conditions such as mucus retention cysts, mucus escape reactions and papillary cystadenocarcinoma may also have a mucoid or mucoid/myxoid background in the cytologic smears. However, in general, an epithelial component is absent in cases of mucus retention cysts and the mucus escape reactions, with a cellular component consisting of lymphocytes and histiocytes only; papillary cystadenocarcinomas with mucoid aspirates generally contain at least a few papillary fragments or other features of glandular differentiation. Due to the fact that the mucoid aspirates are seen also in nonneoplastic lesions, salivary gland tumors with mucoid aspirates may often be misinterpreted as non- neoplastic cysts. Layfield and Gopez,[1] in their series of cystic lesions of the salivary glands, encountered a case of pleomorphic adenoma that yielded predominantly mucoid extracellular material, initially suggesting a mucous retention cyst. However, additional aspirates in that case showed characteristic myxoid and chondroid fragments, leading to an accurate diagnosis. This fact emphasizes the importance of a repeat FNAC in such situations, to obtain a more representative sample as in our case.

Fig. 2: Histologic sections showing (a) epithelial component forming tubules within chondromyxoid stroma ( H & E, x100), (b) cystic spaces filled with mucinous material (H & E, x100)

A cystic pleomorphic adenoma with squamous metaplasia is a diagnostic dilemma for cytopathologists. A cautious and systematic approach in such a situation helps in its accurate diagnosis.

Acknowledgements None

Funding None

Competing Interest None declared

Reference

1. Layfield LJ, Gopez EV: Cystic lesions of the salivary glands: Cytologic features in fine needle aspiration biopsies. Diagn Cytopathol 2002;27: 197–204 2. Aker H, Ozturk M, Ozec I, Ozer H: An unusual buccal adenoma with extensive squamous metaplasia. J Chin Med Assoc 2003;66:184–188 3. Li S, Baloch ZW, Tomaszewski JE, LiVolsi VA: Worrisome histologic alterations following fine needle aspirations of benign parotid lesions. Arch Pathol Lab Med 2000;124:87–91 4. Brachtel EF, Pilch BZ, Khettry U, Zembovicz A, Faquin WC: Fine needle aspiration biopsy of cystic pleomorphic adenoma with extensive adnexa like differentiation: Differential diagnostic pitfall with mucoepidermoid carcinoma. Diagn Cytopathol 2003;28:100–103 5. Abiko Y, Kaku T, Shimono M, Noma H, Shigematsu T: Large cyst formation in pleomorphic adenoma. Bull Tokyo Dent Coll 1993;34:9–11

Fig. 1: Cytologic smears showing (a) foamy macrophages ( MGG, x400), (b) myoepithelial cells entrapped within fibrillary chondromyxoid matrix ( MGG, x400), (c) hyaline stromal globule ( MGG, x400), (d) squamous metaplastic cells ( MGG, x400)

6. Lam KY, Ng IO, Chan GS: Palatal pleomorphic adenoma with florid squamous metaplasia: A potential diagnostic pitfall. J Oral Pathol Med 1998;27:407–410 7. Siddiqui NH, Wu SJ: Fine needle aspiration biopsy of cystic pleomorphic adenoma with adnexa like

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differentiation mimicking mucoepidermoid carcinoma: A case report. Diagn Cytopathol 2005;32:229–232 8. Jayaram G, Pathmanathan R, Khanijow V: Cystic lesion of the parotid gland with squamous metaplasia mistaken for squamous cell carcinoma. Acta Cytol 1998;42:1468–1472

9. Orell SR, Sterret GF, Walters MN-I, Whitaker D: Head and neck: Salivary glands. In Manual and Atlas of Fine Needle Aspiration Cytology. Third edition. Edited by SR Orell, GF Sterret, D Whitaker, MN-I Wal- ters. Edinburgh, Churchill Livingstone, 1999, pp 40–72.

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