Oral cavity salivary gland pleomorphic adenoma: a histomorphological case series.

BACKGROUND: Pleomorphic adenoma (PA), the most common benign salivary gland epithelial lesion, has a biphasic epithelial-mesenchymal pattern and great histopathological diversity. METHODS: This study's objective was to conduct a retrospective clinicopathological analysis, focusing on the histopathology characteristics of salivary gland PA. RESULTS: There were ten cases of pleomorphic adenoma. The mean age was 33.5 years and no gender predilection was observed. All the patients presented with an asymptomatic mass and the duration of presentation was 31.2 ± 19.4 months. The cellular subtype (50 %) of PA was the most common. Capsular infiltration and incomplete capsules occurred in 20 % of cases. All the cases had round (100 %) and myxoid stroma. The cellular subtype was more common in the major salivary glands; showed capsular abnormalities (incomplete capsule, absent capsule, and tumor infiltration); and had more plasmacytoid, angular, spindled non-luminal cells as well as inflammation and cystic degeneration. The classic subtype had more clear and oncocytic cells along with sebaceous and squamous differentiation. The stroma-rich subtype had the shortest duration of complaints (three months) and showed giant cell reaction. CONCLUSIONS: These findings confirm previous studies on the clinicopathological features of pleomorphic adenomas and highlight important morphologic characteristics like capsular invasion and squamous metaplasia, which can otherwise indicate malignancy.

Hemophagocytic lymphohistiocytosis following enteric fever: A rare autopsy case report.

ABSTRACT: Hemophagocytic lymphohistiocytosis (HLH) is a severe and frequently underdiagnosed disorder of systemic immune dysregulation resulting in hypercytokinemia and histologically evident hemophagocytosis, We report a case of a 34-year-old man who presented with breathlessness, generalized weakness, and fever of unknown origin with pancytopenia. Clinically the patient was admitted for febrile illness, and treated symptomatically but his general condition worsened leading to death within 21 hours of admission. A complete autopsy was performed. The deceased had a significant past history of repeated episodes of fever, weight loss, and axillary lymphadenopathy over a period of 8 months with multiple hospital admissions. He was also diagnosed with enteric fever (Widal test and Typhi IgM positive) at the start of these episodes. Hemogram during this period revealed persistent pancytopenia. Serum ferritin, serum triglycerides, and liver function tests were consistently deranged. Investigations for the etiology of fever and blood cultures were negative while the bone marrow aspirate revealed a normocellular marrow. CT abdomen-pelvis showed mild hepatomegaly with enlarged retroperitoneal lymph nodes. Infective endocarditis, lymphoma, and bronchopneumonia were being considered the clinical diagnoses. The significant autopsy findings were hepatosplenomegaly with retroperitoneal lymphadenopathy and multiple gastric ulcers. On microscopy, the liver, spleen, bone marrow, and lymph nodes showed characteristic hemophagocytosis. Post-mortem histopathological examination clinched the diagnosis of HLH and fulfilled six out of eight diagnostic criteria of the HLH-2004 protocol. We discuss the clinical course and diagnosis of this unique case and strive to create awareness about secondary HLH induced by common diseases, such as enteric fever.

Dysregulation of X-ray repair cross-complementing 4 expression in the eutopic endometrium of women with endometriosis.

Recent data suggest that the DNA damage response (DDR) is altered in the eutopic endometrium (EE) of women with endometriosis and this probably ensues in response to higher DNA damage encountered by the EE in endometriosis. DDR operates in a tissue-specific manner and involves different pathways depending on the type of DNA lesions. Among these pathways, the non-homologous end joining (NHEJ) pathway plays a critical role in the repair of dsDNA breaks. The present study was undertaken to explore whether NHEJ is affected in the EE of women with endometriosis. Toward this, we focused on the X-ray repair cross-complementing 4 (XRCC4) protein, one of the core components of the NHEJ pathway. Endometrial XRCC4 protein levels in the mid-proliferative phase were found significantly (P < 0.05) downregulated in women with endometriosis, compared to control women. Investigation of a microarray-based largest dataset in the Gene Expression Omnibus database (GSE51981) revealed a similar trend at the transcript level in the EE of women with endometriosis, compared to control women. Further in vitro studies were undertaken to explore the effects of H2O2-induced oxidative stress on DNA damage, as assessed by γ-H2AX and 8-hydroxy-2'-deoxyguanosine (8-OHdG) immunolocalization, and XRCC4 protein levels in endometrial stromal (hTERT immortalized human endometrial stromal cell line (ThESCs)) and epithelial (Ishikawa) cells. A significant decrease in XRCC4 protein levels and significantly higher localization of γ-H2AX and 8-OHdG were evident in ThESCs and Ishikawa cells experiencing oxidative stress. Overall, the study demonstrates that the endometrial XRCC4 expression is dysregulated in women with endometriosis and this could be due to higher oxidative stress in endometriosis.

Endometrial DNA damage response is modulated in endometriosis.

STUDY QUESTION: Is the DNA damage response (DDR) dysregulated in the eutopic endometrium of women with endometriosis? SUMMARY ANSWER: Endometrial expression of genes involved in DDR is modulated in women with endometriosis, compared to those without the disease. WHAT IS KNOWN ALREADY: Ectopic endometriotic lesions are reported to harbour somatic mutations, thereby hinting at dysregulation of DDR and DNA repair pathways. However, it remains inconclusive whether the eutopic endometrium also manifests dysregulated DDR in endometriosis. STUDY DESIGN, SIZE, DURATION: For this case-control study conducted between 2015 and 2019, eutopic endometrial (E) samples (EE- from women with endometriosis, CE- from women without endometriosis) were collected in either mid-proliferative (EE-MP, n = 23; CE-MP, n = 17) or mid-secretory (EE-MS, n = 17; CE-MS, n = 9) phases of the menstrual cycle. This study compares: (i) DNA damage marker localization, (ii) expression of DDR genes and (iii) expression of DNA repair genes in eutopic endometrial samples from women with and without endometriosis. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included (i) 40 women (aged 31.9 ± 0.81 years) with endometriosis and (ii) 26 control women (aged 31.4 ± 1.02 years) without endometriosis. Eutopic endometrial samples from the two groups were divided into different parts for histological analysis, immunohistochemistry, RNA extraction, protein extraction and comet assays. Eighty-four genes of relevance in the DNA damage signalling pathway were evaluated for their expression in eutopic endometrial samples, using RT2 Profiler PCR arrays. Validations of the expression of two GADD (Growth Arrest DNA Damage Inducible) proteins - GADD45A and GADD45G were carried out by immunoblotting. DNA damage was assessed by immunohistochemical localization of γ-H2AFX (a phosphorylated variant of histone H2AX) and 8-OHdG (8-hydroxy-2'-deoxyguanosine). RNA sequencing data from mid-proliferative (EE-MP, n = 4; CE-MP, n = 3) and mid-secretory phase (EE-MS and CE-MS, n = 4 each) endometrial samples were scanned to compare the expression status of all the genes implicated in human DNA repair. PCNA (Proliferating Cell Nuclear Antigen) expression was determined to assess endometrial proliferation. Residual DNA damage in primary endometrial cells was checked by comet assays. Public datasets were also scanned for the expression of DDR and DNA repair genes as our RNASeq data were limited by small sample size. All the comparisons were made between phase-matched endometrial samples from women with and without endometriosis. MAIN RESULTS AND THE ROLE OF CHANCE: Endometrial expression of DDR genes and intensity of immunolocalized γ-H2AFX were significantly (P < 0.05) higher in EE, compared to CE samples. DDR proteins, especially those belonging to the GADD family, were found to be differentially abundant in EE, as compared to CE. These patterns were evident in both mid-proliferative and mid-secretory phases. Intriguingly, higher DDR was associated with increased cell proliferation in EE-MP, compared to CE-MP. Furthermore, among the differentially expressed transcripts (DETs) encoded by DNA repair genes, the majority showed up-regulation in EE-MP, compared to CE-MP. Interestingly, CE-MP and EE-MP had a comparable percentage (P > 0.05) of cells with residual DNA damage. However, unlike the mid-proliferative phase data, many DETs encoded by DNA repair genes were down-regulated in EE-MS, compared to CE-MS. An analysis of the phase-matched control and endometriosis samples included in the GSE51981 dataset available in the Gene Expression Omnibus database also revealed significant (P < 0.05) alterations in the expression of DDR and DNA repair genes in EE, compared to CE. LARGE-SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: The study was conducted on a limited number of endometrial samples. Also, the study does not reveal the causes underlying dysregulated DDR in the eutopic endometrium of women with endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: Alterations in the expression of DDR and DNA repair genes indirectly suggest that eutopic endometrium, as compared to its healthy counterpart, encounters DNA damage-inducing stimuli, either of higher strength or for longer duration in endometriosis. It will be worthwhile to identify the nature of such stimuli and also explore the role of higher genomic insults and dysregulated DDR/DNA repair in the origin and/or progression of endometriosis. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by the Department of Biotechnology and Indian Council of Medical Research, Government of India. No conflict of interest is declared.

Radiological differentiation of phaeochromocytoma from other malignant adrenal masses: importance of wash-in characteristics on multiphase CECT.

Rationale and introduction: To evaluate the computerised tomography (CT) characteristics of phaeochromocytoma (PCC) that differentiate them from other non-benign adrenal masses such as adrenocortical carcinoma (ACC), primary adrenal lymphoma (PAL) and adrenal metastases (AM). Methods: This retrospective study was conducted at a tertiary health care institute from Western India. Patients presented between January 2013 and August 2016 with histological diagnosis of PCC or other non-benign adrenal mass having adequate reviewable imaging data comprising all four CECT phases were included. Results: The study cohort consisted of 72 adrenal masses from 66 patients (33 PCC, 22 ACC, 4 PAL, 13 AM). Unlike other masses, majority of PCC (25/33) showed peak enhancement in early arterial phase (EAP). PCC had significantly higher attenuation in EAP and early venous phase (EVP), and higher calculated percentage arterial enhancement (PAE) and percentage venous enhancement (PVE) than other adrenal masses (P < 0.001). For diagnosis of PCC with 100% specificity, PAE value ≥100% and EAP attenuation ≥100 HU had 78.8 and 63.6% sensitivity respectively. ACC were significantly larger in size as compared to PCC and metastasis. The adreniform shape was exclusively found in PAL (two out of four) and AM (4 out of 13). None of the enhancement, wash-in or washout characteristics were discriminatory among ACC, PAL and AM. Conclusion: Peak enhancement in EAP, PAE value ≥100% and EAP attenuation ≥100 HU differentiate PCC from other malignant adrenal masses with high specificity.

Primary pigmented nodular adrenocortical disease (PPNAD): single centre experience.

Background Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Cushing's syndrome (CS) in childhood. We describe a case series of patients presenting at our centre along with a review of the literature. Methods A retrospective analysis of six index cases and one family were done for demographic features, hormonal profile, imaging findings, genetic mutation status, histopathologic findings and follow-up details. Diagnosis was based on biochemistry and confirmed with histopathology and or genetic mutation. All patients had suppressed 8 am adrenocorticotropic hormone (ACTH) (<10 pg/mL) despite evidence of hypercortisolism. Results The mean age in our cohort was 8.2 years (range 15 months to 20 years). All patients presented with overt CS, including one patient with cyclic Cushing's. Three patients had additional features of Carney complex (CNC). Imaging did not reveal any obvious mass lesions on computed tomography (CT), the classical beaded appearance was present in only two of the patients. Mutation analysis was positive in three patients. Five patients underwent bilateral adrenalectomy and had features of PPNAD on histopathology. Conclusions PPNAD is a rare cause of ACTH-independent CS in childhood and may signal underlying CNC. Patients with younger age of onset with overt CS may still have a mutation in the PRKAR1A gene and warrant genetic testing.

Endoscopic ultrasound guided brush/fine-needle aspiration cytology: A 15-month study.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become increasingly popular for the diagnosis and staging of gastrointestinal diseases and peri-gastrointestinal lesions. The application of FNA/Brush has dramatically expanded the clinical utility of EUS. AIMS AND OBJECTIVE: To evaluate the diagnostic accuracy, study the spectrum of lesions encountered in EUS-FNAC/brush cytology of gastrointestinal and peri-gastrointestinal lesions. MATERIALS AND METHODS: Total of 124 patients during the period from August 2015 to November 2016 was included in the study. Routine staining was done. RESULTS: A total of 124 cases were studied with 86% (107 cases) being satisfactory for evaluation. M:F ratio was 1:1.03, mean age of 50.5 years. The most common site was common bile duct (CBD) (37%) followed by lymph node (21%), pancreas (17.7%), esophagus (17%), stomach (3.5%), liver (1.8%), gallbladder (1%), and spleen (1%). In total, 53.4% lesions were benign, in 6.5% atypical cells were seen, 12.1% were suspicious for malignancy, and 28% cases were positive for malignancy. Follow-up was available in 102 cases with cyto-histopathological concordance rate of 90%. CONCLUSION: EUS-FNA/Brush is a reliable, sensitive, specific and minimally invasive way to establish a diagnosis. It can be utilized as a pre-operative procedure for the management of many intra-abdominal lesions and prevent unnecessary invasive procedures.

Heterotopic Prostate at Autopsy- An Unusual Mass at the Dome of the Urinary Bladder.

Heterotopic prostate in the dome of the urinary bladder is extremely rare and difficult to diagnose. It is often mistaken for neoplastic masses and histopathological examination is warranted for diagnosis. We report an autopsy case of an ectopic prostate at the dome of the bladder which mimicked a neoplasm on gross pathology.

Pure Villous Adenoma of the Vesicoureteric Junction Presenting as Pyonephrosis.

Villous adenomas of the urinary tract are uncommon neoplasms which share similar morphological features with gastrointestinal villous adenomas. Only two case series and around 20 scattered case reports of villous adenoma in the urinary tract have been published in English literature till date. They have been identified mainly in the urinary bladder, urethra, prostate and urachus, but the occurrence of villous adenomas at the vesicoureteric junction has not been described. We present a case of villous adenoma of the vesicoureteric junction which completely occluded the lumen and led to gross pyonephrosis.

Utility of the Paris System in Reporting Urine Cytology.

OBJECTIVE: To find out the utility of The Paris System (TPS) in reporting urine cytology and to compare it with the reporting system currently used in our laboratory. STUDY DESIGN: This retrospective study was undertaken over a period of 1 year during which slides of all the urine specimens sent for cytological examination were retrieved from our laboratory filling system. They were blindly reviewed and reclassified according to TPS. Surgical follow-up was obtained from the uropathology services of our department. RESULTS: A total of 176 cases were meticulously reviewed. The mean age of the patients was 52 years, and 71% of cases presented with hematuria. Histopathological follow-up was available in 34 cases. Reporting by TPS detected 13.0% high-grade urothelial carcinoma (HGUC) and 5.1% atypical urothelial cells versus 7.3 and 11.9% by the current reporting system, respectively. The sensitivity and diagnostic accuracy for detecting HGUC of TPS were higher than those of our reporting system. CONCLUSION: TPS has increased the rate of detection of HGUC and reduced the rate of reporting "atypical" urothelial cells. TPS has also standardized the diagnostic criteria, thereby bringing uniformity and reproducibility into the system of reporting for urine cytology.

Evaluation of thyroid nodules classified as Bethesda category III on FNAC.

BACKGROUND: The Bethesda (BSRTC) category III has been ascribed a malignancy rate of 5-15%, however, the probability of malignancy remains variable. AIM: To evaluate category III with respect to its rate and risk of malignancy and substratify it. SETTINGS AND DESIGN: Atypia of undetermined significance/Follicular lesion of undetermined significance (AUS/FLUS) percentage, cytohistological correlation, and risk of malignancy were analyzed and substratification was done. MATERIAL AND METHODS: Category III cases over a 2-year period were analyzed retrospectively. STATISTICAL ANALYSIS: Two-tailed Fisher exact test, with a level of significance set at 0.05, was performed for data analysis. RESULTS: Of 1169 thyroid fine needle aspirations (FNAs), 76 (6.5%) were category III. A total of 48 patients had follow up; 24 patients underwent surgery, 12 repeat FNA, and 12 were clinically followed. Repeat FNA cytology was unsatisfactory in 8.3%, benign in 66.7%, AUS in 8.3%, and follicular neoplasm in 16.7%. Of the 24 operated, 8 (33.3%) were malignant (follicular variants of papillary thyroid carcinoma), 5 (20.8%) were follicular adenomas, and 11 (45.8%) were non-neoplastic. Among all AUS/FLUS nodules with follow-up, malignancy was confirmed in 16.7% (8/48) whereas with nodules triaged to surgery only, the malignancy rate was 33.3% (8/24). Substratification into categories of "cannot exclude PTC" and "favor benign" helped detect malignancy better, as 85.7% cases in the first subcategory (P < 0.001) and none (P < 0.02) in the last proved malignant. CONCLUSION: Though the rate of Category III in our study is in accordance to BSRTC, the risk of malignancy in AUS/FLUS nodules is higher. Substratification of AUS/FLUS may help better patient management.

Germline mutations and genotype-phenotype correlation in Asian Indian patients with pheochromocytoma and paraganglioma.

BACKGROUND: Genetic aetiology of pheochromocytoma (PCC) and paraganglioma (PGL) is increasingly being studied; however, Asian Indian data on this aspect are scarce. OBJECTIVE: To study the prevalence of germline mutations and genotype-phenotype correlation in Asian Indian PCC/PGL patients. DESIGN: In this study, 150 index patients (M:F, 73:77) with PCC/PGL were evaluated. Phenotypic data were collected. Germline mutations in five susceptibility genes (RET, VHL, SDHB, SDHD and SDHC) were tested by sequencing and NF1 was diagnosed according to phenotype. RESULT: Of the total population, 49 (32.7%) PCC/PGL patients had germline mutations (VHL: 23 (15.3%), RET: 13 (8.7%), SDHB: 9 (6%), SDHD: 2 (1.3%) and NF1: 2 (1.3%)). Amongst the 30 patients with familial and/or syndromic presentation, all had germline mutations (VHL: 14 (46.7%), RET: 13 (43.3%), SDHB: 1 (3.3%) and NF1: 2 (6.7%)). Out of 120 patients with apparently sporadic presentation, 19 (15.8%) had a germline mutation (VHL: 9 (7.5%), SDHB: 8 (6.7%) and SDHD: 2 (1.7%)). Mutation carriers were younger (29.9 ± 14.5 years vs 36.8 ± 14.9; P = 0.01) and had a higher prevalence of bilateral PCC (26.5% vs 2.9%, P < 0.001) and multifocal tumours (12.2% vs 0.96%, P = 0.06). Based on syndromic features, metastasis, location and number of tumours, around 96% mutations in our cohort could be detected by appropriately selected single gene testing. CONCLUSION: Asian Indians with PCC/PGL differ from Western cohorts in having preponderance of VHL mutations in multifocal tumours and apparently sporadic unilateral PCC. Syndromic presentation, metastasis, location and number of PCC/PGL can be effectively used for guiding genetic prioritisation.

Surgical Management of Ectopic Kidney with Bilateral Iliac Vein Invasion.

Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. We come across a 61-year-old gentleman with a history of 2 months of gross, painless haematuria and palpable pelvic mass on examination. CT scan showed 6.5cm X 5.1cm X 5.8cm mass in pelvic kidney with bilateral iliac vein invasion. With the help of intra-operative ultra-sound, tumour thrombus was extracted from both iliac veins with en mass removal of tumour. Patient was well intraoperatively as well as in postoperatively. We also presented an elegant imaging for the case.

A triad of telomerase, androgen receptor and early growth response 1 in prostate cancer cells.

Telomerase activation is one of the key mechanisms that allow cells to bypass replicative senescence. Telomerase activity is primarily regulated at the level of transcription of its catalytic unit- hTERT. Prostate cancer (PCa), akin to other cancers, is characterized by high telomerase activity. Existing data suggest that hTERT expression and telomerase activity are positively regulated by androgenic stimuli in androgen-dependent prostate cancer (ADPC) cells. A part of the present study reaffirmed this by demonstrating a decline in the hTERT expression and telomerase activity on "loss of AR" in ADPC cells. The study further addressed 2 unresolved queries, i) whether AR-mediated signaling is of any relevance to hTERT expression in castration-resistant prostate cancer (CRPC) and ii) whether this signaling involves EGR1. Our data suggest that AR-mediated signaling negatively regulates hTERT expression in CRPC cells. Incidental support for the possibility of EGR1 being a regulator of hTERT expression in PCa was provided by i) immunolocalization of hTERT and EGR1 proteins in the same cell type (secretory epithelium) of PCa and BPH tissues; ii) significantly (p< 0.001) higher levels of both these proteins in CRPC (PC3 and DU145), compared with ADPC (LNCaP) cells. A direct evidence for the role of EGR1 in hTERT expression was evident by a significant (p<0.0001) decrease in the hTERT transcript levels in the EGR1-silenced CRPC cells. Further, "gain of AR" led to a significant reduction in the levels of hTERT and EGR1 in CRPC cells. However, restoration of EGR1 levels prevented the decline in the hTERT transcript levels in these cells. Taken together, our data indicate that AR regulates the expression of EGR1, which in turn acts as a positive regulator of hTERT expression in CRPC cells. Thus, AR exerts an inhibitory effect on hTERT expression and telomerase activity by modulating EGR1 levels in CRPC cells.

Amyloid goiter: cytomorphological features and differential diagnosis on fine needle aspiration cytology: a case report.

BACKGROUND: Amyloid goiter is a rare cause of thyroid enlargement which can be confused clinically as well as cytologically with both colloid goiter and neoplastic process of thyroid. CASE: A 30-year-old man, diagnosed with chronic kidney disease 5 months previously and currently on dialysis and awaiting renal transplant, was referred by clinicians for fine needle aspiration cytology (FNAC) for thyroid swelling. FNAC showed dense amorphous clumps of extracellular material which appeared magenta colored on Giemsa and eosinophilic on Papanicolaou stain. Congo red staining and polarization showed characteristic apple green birefringence, thus confirming the material as amyloid, and the diagnosis of amyloid goiter was made. CONCLUSION: Amyloid on FNAC smears can be easily mistaken for colloid, and correct interpretation can avoid a false diagnosis of colloid goiter. A search should be made to look for any features suggestive of medullary carcinoma of the thyroid as amyloid is more often associated with it.