Well differentiated papillary mesothelioma of abdomen- a rare case with diagnostic dilemma.

Well-differentiated papillary mesothelioma is a rare tumor occurring predominantly in the peritoneum of young women, a few with history of asbestos exposure. A 28-year-old woman presented with ascites and pain abdomen. Ultrasonography and computed tomography scan of the abdomen revealed a mass in the retroperitoneum measuring 15 cm × 12 cm. Histopathological examination along with immunohistochemistry (IHC) confirmed it to be a papillary mesothelioma in the peritoneum. It is difficult to differentiate from more common malignant mesothelioma and papillary adenocarcinoma, which also have poorer prognosis. The difficulty can be resolved by clinico-radiological correlation along with histopathological examination and IHC.

Heterodimer formation by Oct4 and Smad3 differentially regulates epithelial-to-mesenchymal transition-associated factors in breast cancer progression.

The multifunctional cytokine TGF-ß crucially participates in breast cancer (BCa) metastasis and works differently in the disease stages, thus contributing in BCa progression. We address connections between TGF-ß and the stem cell-related transcription factor (TF) Oct4 in BCa. In 147 BCa patients with infiltrating duct carcinoma, we identified a significantly higher number of cases with both moderate/high Oct4 expression and high TGF-ß in late stages compared to early stages of the disease. In vitro studies showed that TGF-ß elevated Oct4 expression, which in turn, regulated Epithelial-to-Mesenchymal transition (EMT)-regulatory gene (Snail and Slug) expression, migratory ability, chemotactic invasiveness and extracellular matrix (ECM) degradation potential of BCa cells. Putative binding sites for Oct4 on the snail, slug and cxcl13 promoters and for Smad3 on the snail and slug promoters were identified. Promoter activities of snail and slug were greater in dual-treated cells than only TGF-ß-treated or Oct4-overexpressing cells. CXCL13 mRNA fold changes, however, were low in cells induced with TGF-ß, compared to dual-treated or Oct4-overexpressing cells. Our co-IP studies confirmed that Oct4 and Smad3 form heterodimers that recognize specific promoter sequences to promote Snail and Slug expression, but which in turn, indirectly inhibits Smad3-mediated repression of CXCL13 expression, allowing Oct4 to act as a positive TF for CXCL13. Taken together, these data suggest that TGF-ß signaling and Oct4 cooperate to induce expression of EMT-related genes Snail, Slug and CXCL13, which accelerates disease progression, particularly in the late stages, and may indicate a poor prognosis for BCa patients.

CCL2 conditionally determines CCL22-dependent Th2-accumulation during TGF-ß-induced breast cancer progression.

We investigated expressions of -CC chemokine ligand 2 (CCL2) and CCL5 in tumor samples from 147 breast cancer (BCa) patients and correlated with transforming growth factor-ß (TGF-ß) expression. We observed an inverse correlation of TGF-ß expression with CCL2, CCL5 expression in early stages of BCa. On contrary, in late stages, CCL2, not CCL5, expression was found to be directly proportional with TGF-ß expression. TGF-ß stimulated MDA-MB-231 cells to express CCL2, however, downregulated both CCL2 and CCL5 in MCF-7. Interestingly, a significant swing of Th1-Th2 ratio towards Th2 is seen within the primary tumors expressing moderate/high-CCL2-low/negative-CCL5. We observed that CCL2-CCR2 interaction induces monocytes/macrophages to secrete Th2-attracting chemokine CCL22 in vitro. Therefore, CCL2 secreted from the tumor microenvironment may attract and interact with monocytes/macrophages, and favor Th2 accumulation by inducing CCL22 secretion. Study in 4T1-BALB/c BCa mouse model demonstrated significant (p<0.05) decrease in CCL2, CCL5 and CCL22 levels and reduction in lung metastatic nodule numbers upon administering TGF-ß inhibitor. These findings collectively indicate that TGF-ß regulates CCL2 and CCL5 expression in a stage-dependent manner during BCa progression, which in turn, determines Th1-Th2 balance within the tumor microenvironment.

Histopathological study of gallbladder carcinoma and its mimics with role of carcinoembryonic antigen immunomarker in resolving diagnostic difficulties.

BACKGROUND: Gallbladder carcinoma (GBC) sometimes presents with nonspecific signs, without forming a mass, mimicking benign gallbladder (GB) diseases. On the contrary, benign GB diseases may mimic GBC. MATERIAL AND METHODS: We retrospectively reviewed 107 cases over a period of 3 years (May 2012-April 2015), which included 41 review cases and 66 departmental cases. Carcinoembryonic antigen (CEA) immunomarker expression was done. RESULTS: In 27 of the 41 review cases, the diagnoses were benign diseases of GB associated with mild-to-moderate dysplasia of mucosal glands; however, after review in our department, it was found that of these 27 cases, nine cases were actually well-differentiated adenocarcinoma of GB with diffuse CEA expression and were mis diagnosed as benign diseases of GB with dysplasia. In 32 out of 66 departmental cases, initial histopathological diagnoses were benign diseases of GB associated with dysplastic mucosal glands. After CEA staining, 11 out of these 32 cases turned out to be adenocarcinoma of the GB. Among the rest 34 (34/66) departmental primary GBC cases, no CEA expression was seen in six cases, focal expression was seen in 12 cases, and diffuse expression was seen in 16 cases. No diffuse CEA expression was seen in benign diseases of the GB with dysplasia. CONCLUSION: GBC sometimes may not be diagnosed radiologically and grossly as it often presents without any mass and specific signs, which lead to under diagnosis. Some benign cases may mimic GBC and may complicate histological diagnosis. CEA expression may aid as an additional diagnostic aid in resolving diagnostic dilemmas.

Desmoplastic small round cell tumor: Diagnostic dilemma and uncertain prognosis: Report of few cases.

Desmoplastic small round cell tumor (DSRCT) is rare and highly malignant neoplasm. DSRCT affects usually young males but can occur in adults also. Intra-abdominal pelvic region is the preferred site. Though confirmed by histology, immunohistochemistry (IHC) plays a key role in diagnosis. IHC profile is characteristic, it shows simultaneous expression of epithelial (epithelial membrane antigen (EMA) and cytokeratin (CK)), muscular (desmin), and neural (neuron-specific enolase) markers. Many cases of DSRCT are diagnosed as poorly differentiated carcinoma due to lack of proper panel of IHC. It is difficult to predict if there has been a true increase in incidence. Prognosis is uncertain in such an aggressive neoplasm as chemotherapy (CT) or radiotherapy (RT) shows various outcomes. Here in; we report four cases, all of which showed diagnostic dilemma and uncertain prognosis.

Schwannoma of the hard palate.

Schwannomas are benign encapsulated perineural tumors. The head and neck region is the most common site. Intraoral origin is seen in only 1% of cases, tongue being the most common site; its location in the palate is rare. We report a case of hard-palate schwannoma with bony erosion which was immunohistochemically confirmed. The tumor was excised completely intraorally. After two months of follow-up, the defect was found to be completely covered with palatal mucosa.

Cytodiagnosis of myxoid adrenocortical carcinoma and role of immunocytochemistry to differentiate it from renal cell carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy and cytodiagnosis of this tumor is not routinely encountered by a cytopathologist. Here, we report a case of ACC initially diagnosed by computed tomography (CT)-guided fine needle aspiration cytology (FNAC) with the help of immunocytochemistry. A 48-year-old lady presented with flank pain and abdominal mass for the last 6 months. A CT scan of her abdomen revealed a large mass arising from the upper part of the left kidney. CT-guided FNAC was performed. Cytologic smears showed pleomorphic large cells arranged discretely and in small aggregates against a myxoid background. The cells had a high nucleocytoplasmic ratio, anisonucleosis and conspicuous nucleoli. Based on cytomorphology, differential diagnoses of ACC and renal cell carcinoma (RCC) were made. On immunocytochemistry, the tumor cells were synaptophysin, inhibin, vimentin and Melan-A positive but cytokeratin and epithelial membrane antigen negative. Thus, a cytodiagnosis of myxoid ACC was made and histopathologic examination was suggested. Subsequent histologic examination and immunohistochemistry proved the case to be myxoid ACC.

Evaluation of vaginal cytology in female sex-workers: A study in a tertiary hospital of eastern India.

BACKGROUND: Papanicolaou (Pap) test is an important and easy diagnostic tool to detect any abnormalities on vaginal cytology. Pap test is routinely done in women of reproductive age group in many countries. AIM: The aim of this study was to detect spectrum of abnormalities in female sex workers (FSWs) on vaginal cytology. MATERIALS AND METHODS: A total of 60 cases were included over a period of 1 year (July, 2011-June, 2012). The age range of the patients was 14-61 years. Pap stained slides were evaluated by two consultant cytopathologists and reported as normal smear, inflammatory smear, specific infection, low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), atypical squamous cell of undetermined significance (ASCUS), squamous cell carcinoma (SCC) and atypical glandular cell of undetermined significance (AGUS). RESULTS: Most of the smears were abnormal accounting for 86.7% of total cases (52/60). Incidence of HSIL was very high in FSWs. Out of 60 cases, 8 normal smears (13.3%), 12 inflammatory smears (20%), 3 cases of infections (5%), 9 cases of LSIL (15%), 23 cases of HSIL (38.3%), 2 cases (3.3%) each of ASCUS and SCC and 1 case (1.3%) AGUS were encountered. CONCLUSIONS: Close follow-up and histologic examinations are necessary to avoid unnecessary spread of the neoplastic disease and untimely death of the patients. Awareness about diseases in FSWs and diagnostic utility of Pap test are also a must.

Is there any role of mast cell density and microvessel density in cervical squamous cell carcinoma? A histologic study with special reference to CD-34 immunomarker staining.

BACKGROUND: Mast cells are involved in induction of angiogenesis in the early-stages of tumor development and in modulating blood vessel growth in the later stages of tumor progression. AIMS AND OBJECTIVES: This study was carried out to evaluate the association between mast cell density (MCD) and microvessel density (MVD) in carcinoma in situ (CIS), microinvasive carcinoma (CA) and invasive squamous cell CA of cervix. MATERIALS AND METHODS: Six cases of CIS, four cases of microinvasive CA and 38 cases of invasive CA were studied over a period of 2 years from August, 2011 to June, 2013. Ten control samples were included in the study. Routine histologic examination was done. Toluidine blue stain was used for MCD determination. Immunohistochemical analysis with CD-34 was done for assessing MVD. Student's t-test was used to calculate the statistical significance of MCD and MVD. RESULTS: Both MCD and MVD increased from normal samples through CIS to invasive cervical CA. In the four cases of microinvasive CA, the MCD and MVD were more than that of the control samples, but less than that of the six cases of CIS. CONCLUSION: There is a correlation between mast cell accumulation and angiogenesis in CIS, microinvasive CA and invasive cervical squamous cell CA. MCD and MVD in invasive CA exceed those in CIS and microinvasive CA. It gives us an opportunity to postulate that therapeutic strategies against mast cell mediators and angiogenesis may be of benefit in patients of early-stage cervical CA.

Effect of lymphangiogenesis and lymphovascular invasion on the survival pattern of breast cancer patients.

BACKGROUND: Invasion of breast cancer cells into blood and lymphatic vessels is one of the most important steps for metastasis. In this study the prognostic relevance of lymphangiogenesis and lymphovascular invasion (LVI) in breast cancer patients was evaluated in terms of survival. MATERIALS AND METHODS: This retrospective study concerned 518 breast cancer patients who were treated at Department of Surgical Oncology, Saroj Gupta Cancer Centre and Research Institute, Kolkata-700063, West Bengal, India, a reputed cancer centre and research institute of eastern India between January 2006 and December 2007. RESULTS: The median overall survival and disease free survival of the patients were 60 months and 54 months respectively. As per Log-rank test, poor overall as well as disease free survival pattern was observed for LVI positive patients as compared with LVI negative patients (p<0.01). Also poor overall as well as disease free survival pattern was observed for perineural invasion (PNI) positive patients as compared to PNI negative patients (p<0.01). CONCLUSIONS: From this study it is evident that LVI and PNI are strongly associated with outcome in terms of disease free as well as overall survival in breast cancer patients. Thus LVI and PNI constitute potential targets for treatment of breast cancer patients. We advocate incorporating their status into breast cancer staging systems.

Malignant lymphoma in Eastern India: a retrospective analysis of 455 cases according to World Health Organisation classification.

BACKGROUND: Malignant lymphoma (ML) is one of the most common cancers and is most prevalent in developed countries. The distribution of different subtypes of ML varies in the different geographical locations according to World Health Organization (WHO) classification. AIMS AND OBJECTIVES: The study was aimed to analyze different patterns of ML in Eastern India and to compare it with other geographical locations. MATERIALS AND METHODS: Four hundred and fifty five patients of two large hospitals in Eastern India were included over a period of four years and were categorized according to WHO classification, using morphology and immunohistochemistry (IHC). RESULTS: There were 347 (76.3%) non Hodgkin lymphomas (NHL), and 108 (23.7%) Hodgkin lymphomas (HL). Diffuse large B cell lymphoma (DLBCL) was the most common of the NHL type (35.2%) followed by the follicular lymphoma (19.3%). B cell lymphoblastic lymphoma was the least common type of NHL (1.4%). Mixed cellularity (33.3%) and nodular sclerosis (26.9%) were the two most common type of HL. Childhood lymphoma comprised of 12.5% of all ML. T cell NHL and HL were the common lymphomas in this age group. CONCLUSION: Incidence of follicular lymphoma is lower compared to western studies and mixed cellularity is most common subtype of HL unlike nodular sclerosis subtype in western world. Burkitt's type NHL though is the most common subtype of childhood ML in many studies but in our study T cell NHL is the most common type of childhood ML.

Primary pleomorphic rhabdomyosarcoma of breast: Report of a rare neoplasm.

Primary sarcoma of the breast is very rare and constitutes less than 1% of all breast cancers. Herein, we report a case of pleomorphic rhabdomyosarcoma (PRMS) of the right breast in a 49-year-old female patient presented with a mass (7 cm × 6.5 cm). Mammography and ultrasonography suspected a malignant lesion and a diagnosis of poorly differentiated carcinoma was made on fine needle aspiration cytology. Modified radical mastectomy was carried out. Histopathological examination revealed a high grade stromal sarcoma with rhabdoid morphology and multinucleated tumor giant cells. The tumor cells were strongly positive for desmin, vimentin and Myo D1 focally. The tumor cells were immunonegative for cytokeratin, epithelial membrane antigen (EMA), CD34, CD45, SMA, S100, CD68 and HMB45. A final diagnosis of PRMS was rendered. Surgical margins were free and no metastasis was seen in axillary lymph nodes. Neither post-operative radiotherapy nor adjuvant chemotherapy was given and the patient has remained disease free 12 months post-operatively.

CXCL13-CXCR5 co-expression regulates epithelial to mesenchymal transition of breast cancer cells during lymph node metastasis.

We investigated the expression of -CXC chemokine ligand 13 (CXCL13) and its receptor -CXC chemokine receptor 5 (CXCR5) in 98 breast cancer (BC) patients with infiltrating duct carcinoma, out of which 56 were found lymph node metastasis (LNM) positive. Interestingly, co-expression of CXCL13 and CXCR5 showed a significant correlation with LNM. Since, epithelial to mesenchymal transition (EMT) is highly associated with metastasis we investigated EMT-inducing potential of CXCL13 in BC cell lines. In CXCL13-stimulated BC cells, expression of various mesenchymal markers (Vimentin, N-cadherin), EMT regulators (Snail, Slug), and matrix metalloproteinase-9 (MMP9) was increased, whereas the expression of epithelial marker E-cadherin was found to be decreased. In addition, expression of receptor activator of nuclear factor kappa-B ligand (RANKL), which is known to regulate MMP9 expression via Src activation, was also significantly increased after CXCL13 stimulation. Using specific protein kinase inhibitors, we confirmed that CXCL13 stimulated EMT and MMP9 expression via RANKL-Src axis in BC cell lines. To further validate this observation, we examined gene expression patterns in primary breast tumors and detected significantly higher expression of various mesenchymal markers and regulators in CXCL13-CXCR5 co-expressing patients. Therefore, this study showed the EMT-inducing potential of CXCL13 as well as demonstrated the prognostic value of CXCL13-CXCR5 co-expression in primary BC. Moreover, CXCL13-CXCR5-RANKL-Src axis may present a therapeutic target in LNM positive BC patients.

Clear cell sarcoma of the kidney: a case report.

Clear cell sarcoma of the kidney is a rare malignant neoplasm of childhood, known for its aggressiveness, its tendency for recurrence, and to metastasize to bone. We report the observation of 8-month-old child presenting with a large abdominal mass. Clinically, it was diagnosed as Wilm's tumor, and left nephrectomy was done. Grossly, 10 cm×8 cm×3.5 cm globular, white, encapsulated, smooth mass uniformly involving the whole kidney was noted. Histologically, the tumor was diagnosed as clear cell sarcoma with renal vein showing presence of tumor embolus in lumen. The tumor was given stage-II (NWTS-5 protocol). Immunohistochemistry showed vimentin positive and cytokeratin negative tumor cells. The child is currently undergoing chemotherapy and has not yet shown any sign of bony metastasis.

A comparative study of Hasford score and Sokal index in prognostication of the novo chronic myeloid leukemia patients and a search for new prognostic markers.

INTRODUCTION: Chronic myeloid leukemia (CML) is a common myeloproliferative disorder. Based on clinical and hematological parameters, two prognostic scoring systems, i.e., Hasford and Sokal index scoring systems are available to predict survival duration of CML patients on imatinib therapy. AIMS AND OBJECTIVES: Our study's objective is to compare Hasford score with Sokal index for the prognostication of de novo CML patients on therapy and find out new prognostic markers. MATERIALS AND METHODS: This is a retrospective study. The study population comprised 66 patients who were followed up for 60 months. For each patient, at presentation, scoring was performed as per Hasford and Sokal index and Philadelphia chromosome analysis was carried out by conventional cytogenetics. Thereafter, hematological parameters were assessed 3 monthly and conventional cytogenetics was done yearly. RESULTS: Out of these 66 patients, the number of patients belonging to low, intermediate and high risk categories are 21, 33 and 12 respectively by Hasford score and 12, 32 and 22 respectively by Sokal index. Eight patients, who had been categorized into high risk group by Sokal index but intermediate risk group by Hasford score, have shown better survival possibility as monitored by hematological and cytogenetic parameters. Ten cases, categorized into intermediate risk group by Sokal index but low risk group by Hasford score, is doing well till date. CONCLUSIONS: This study shows that Hasford score predicts survival of the patients better than Sokal index. However, multicentric study over a large population is needed to give the final verdict.

Histopathological study of adrenocortical carcinoma with special reference to the Weiss system and TNM staging and the role of immunohistochemistry to differentiate it from renal cell carcinoma.

BACKGROUND: Adrenocortical carcinomas (ACC) are rare tumors with an incidence of 1-2/million/year. They account for 0.05-0.2% of all malignancies. AIMS AND OBJECTIVES: This study was aimed to evaluate the Weiss system to diagnose ACCs and to compare it with TNM staging. The role of immunohistochemistry (IHC) was also evaluated to differentiate ACC from other differential diagnoses especially, renal cell carcinoma (RCC). MATERIALS AND METHODS: A total of 10 ACCs were included from April, 2000 to March, 2012. All the relevant information like weight, tumor size, gross features was recorded. Multiple sections were taken for histologic examination. Immunomarkers like vimentin, synaptophysin, Melan-A, calretinin, inhibin, EMA, cytokeratin, and Ki-67 were used. RESULTS: Out of 10 cases of ACCs (diagnosed by the Weiss system), the tumors were in TNM stage I (1 case), stage II (2 cases), stage III (5 cases), and stage IV (2 cases). The Weiss score in stages I-IV was 4; 5-7; 6-8; and 5-9 respectively. ACCs were positive for vimentin, inhibin, Melan-A, calretinin and negative for EMA and cytokeratin. Proliferative index (Ki-67/MIB-1) was ≥ 20 % (20-65%). CONCLUSION: Both the Weiss system and TNM staging are useful in predicting the malignant behavior and prognosis of ACC. Weight and tumor size, though originally not included in the Weiss system, are also important parameters. In lower stages (stages I and II), the Weiss score is low (4-7) while the score is high (6-9) when the tumor is in higher stages (stages III and IV). IHC plays a vital role to confirm the diagnosis and to exclude the possibility of RCC.

Primary squamous cell carcinoma with mucormycosis in a diabetic foot ulcer.

The diabetic foot ulcer is one of the major complications of diabetes mellitus leading to prolonged hospital stay. Non-healing foot ulcers in diabetes may be due to peripheral neuropathy and/or vasculopathy. Non-healing occurs following a trivial trauma due to loss of local immunity and increased infection by bacteria and fungus. Candida and mucormycosis are common fungal infection in diabetic foot ulcer. Squamous cell carcinoma in any non-healing ulcer is a common occurrence. But squamous cell carcinoma in non-healing diabetic foot ulcer is rarely reported. Here, mucormycosis in a diabetic foot ulcer which turned into squamous cell carcinoma is reported in a 62-year-old male with poor glycaemic control for last 21 years who presented with a non-healing ulcer of 8 months' duration over dorsum of left forefoot. Microbiological examination revealed presence of mucormycosis infection and histopathology of ulcer showed infiltrating well-differentiated squamous cell carcinoma. The clinicians and pathologists should be aware of these combinations because only eradication of mucormycosis may not cure the ulcer, rather presence of squamous cell carcinoma may be ignored that may be an immediate threat to the patient's life.

Immunocytochemistry: It's role in diagnosis of undifferentiated neoplasms by fine needle aspiration cytology.

BACKGROUND: Fine needle aspiration cytology (FNAC) is a rapid, cheap and reliable method for diagnosing any accessible lesion. However, there remains a group of malignant undifferentiated neoplasms, which can only be categorized with the help of immunocytochemistry (ICC). The categorization is important due to their vast difference in treatment and prognosis. AIM: To evaluate the effectiveness of ICC in categorizing the undifferentiated neoplasms diagnosed on routine FNAC smears. MATERIALS AND METHODS: Thirty six cases of undifferentiated neoplasms were selected from a group of total 78 cytology cases of undifferentiated tumors from different sites like head and neck, lymph node, soft tissue etc. These were then subjected to a panel of ICC markers based on the clinical and cytomorphological features. RESULTS: Of these, 21 were simple, ten were computerized tomography guided and five were ultrasound guided FNACs respectively. All the 78 cases were confirmed by histopathological examination and immunohistochemistry. Of the 36 cytological cases, final diagnosis correlated in 30 cases histologically. The six cases were incorrect either due to inadequate material on the smears (three cases) or false positive staining (three cases). CONCLUSIONS: Our study found that ICC is a sensitive and specific method for early and definitive diagnosis of undifferentiated neoplasms. However, selection of antibodies must be judicious to make it cost effective.