Heterotopic Ossification After Reconstruction with Free Fibula Flap - an Ambiguous Mishap.

Heterotopic ossifications (HO) are rare, yet, well reported complications after free flap transfer. We present a case of HO that occurred within a month, and has not been previously described in the literature. This serves as a reminder that bony hard swellings proximal to the free flap within a month should raise the suspicion of HO.

Malignant giant cell tumour of distal ulna.

Giant cell tumour (GCT) accounts for 5% of all primary bone tumours. GCT in the distal third of ulna is quite rare. We present a case of recurrent GCT in distal third of ulna with malignant features involving tenosynovium. The case was treated by wide resection of tumour and on follow up, patient recovered well with no evidence of further recurrence. Considering the features, according to the literature reviewed, is the first case of its type.

Pathological fracture treated with total femoral replacement in a case of chondrosarcoma involving the entire-length femoral shaft.

INTRODUCTION AND IMPORTANCE: We here present a case of chondrosarcoma of the diaphysis of the femur with extensive involvement of the length of the bone and with the pathological fracture at the mid-shaft level. Total femur replacement was done in this case with a bipolar head and repair of abductors and hip flexors to the implanted prosthesis. CASE PRESENTATION: An elderly female in her late 60s presented to the trauma department with sudden onset pain and inability to bear weight on her left lower limb following a trivial slip and fall. The Radiographs revealed a pathological spiral mid-shaft displaced fracture of the femur with an extensive mixed lesion throughout the femur. Magnetic Resonance imaging revealed involvement of more than 90% of the femur with lesion extension into the quadriceps and hamstrings. Histopathology confirmed grade-II conventional chondrosarcoma. Metastatic work-up showed no distant spread. Wide-local resection and total femur endo-prosthetic reconstruction were done. No recurrence or infection was evident at the 18-month follow-up. In elderly non-metastatic pathological fractures, limb salvage with endo-prosthetic reconstruction can be a preferred treatment. CLINICAL DISCUSSION: This case is unique in describing a rare presentation of chondrosarcoma of the diaphysis of the femur, which eventually landed in a pathological fracture. The fracture may increase the tumour's aggressiveness, but wide-margin resection should be the mainstay treatment for primary or recurrent chondrosarcoma, irrespective of pathological fracture. CONCLUSION: In well-indicated cases (no distant spread - N0M0 disease), Total Femur Replacement (TFR) is an excellent option for limb salvage in tumours with extensive involvement of the femur.

Human epidermal growth factor receptor 2/neu expression in urothelial carcinomas.

Introduction: Urothelial carcinomas of the bladder are more common in males, making them the sixth-most common cancer in men and the tenth-most common cancer overall, worldwide. Current guidelines do not recommend routine testing for human epidermal growth factor receptor (HER2/neu) expression on the biopsy specimens of patients with urothelial carcinoma. This study was aimed at determining the expression pattern of HER2/neu and its usefulness in muscle-invasive and nonmuscle-invasive urothelial carcinoma. Methods: HER2/neu expression was assessed in 89 specimens of urothelial cancer by immunohistochemistry (IHC), and equivocal cases were subjected to fluorescent in situ hybridization (FISH). Results: On IHC for HER2/neu, 17.9% (7/39) of the muscle-invasive bladder cancers (MIBCs) showed a 3+ expression, whereas 22% (11/50) of the non-muscle invasive cancers were positive with a score of 3+. A significant correlation between HER2/neu status and muscle invasion could not be established in the current study (P = 0.74, Fisher's exact test). Three cases of muscle-invasive (7.7%) and 2 cases (4%) among nonmuscle invasive cancers showed equivocal expression. All the cases with equivocal (2+) expression on IHC were subjected to FISH and none showed gene amplification on hybridization and were considered as negative. Conclusion: Overexpression of HER-2/neu was seen in 17.9% of MIBCs and 22% of non-MIBCs. There are no norms for routine testing of HER2/neu expression in the biopsy specimens of urothelial carcinoma. There is an unmet need to establish guidelines for HER2/neu scoring, similar to that for breast and gastric cancers, to determine the proportion of positive cases and help in identification of those who may benefit from targeted therapies.

Primary amelanotic malignant melanoma masquerading as adenocarcinoma prostate - A pathological dilemma.

A rare disease at an aberrant location can mimic a usual presentation of another disease. We report a case of primary amelanotic malignant melanoma of the prostate with clinical and histological characteristics that closely mimic poorly differentiated adenocarcinoma prostate.

Primary Ewing's sarcoma of the talus.

Ewing's sarcoma is a malignant round cell tumour of bones and soft tissues that usually arises from the diaphyseal or meta-diaphyseal parts of long bones and less commonly from flat bones. It occurs rarely in the foot and if occurs, the calcaneus and the metatarsals are commonly involved. We present a case of a young woman diagnosed with primary Ewing's sarcoma of the talus with local spread to adjacent tarsals and the ankle joint. Ewing's sarcoma of feet, if present with even a trivial suspicion of spread either locally or distant, makes limb salvage surgery difficult. So, the treatment with radical surgery or by combined chemotherapy and radiotherapy should be considered-keeping in mind the complex anatomy of the foot and the difficulty in achieving tumour-free margins. Based on this experience, she underwent below-knee amputation. The patient received adjuvant chemotherapy and survived with a disease-free survival at the latest follow-up of 1 year.

The Colossal Mandibular Ameloblastoma: Surgical Challenges and Current Perspectives of Management.

Ameloblastoma is the most common aggressive benign odontogenic tumour of the jaws. Ameloblastoma is a benign epithelial odontogenic tumour that typically arises in the mandible or maxilla. A clinical, radiographic and histopathological report is presented of a case of giant acanthomatous ameloblastoma in the left hemi mandible of a 46-year-old healthy lady. The histopathological examination of the removed specimen revealed the histopathological pattern of an acanthomatous ameloblastoma. The radiographic appearance of the lesion showed the presence of multilocular radiolucencies, which were crossing the midline, which is rarely found in ameloblastoma. Due to its rarity and lack of data, we take this opportunity to present a case of advanced acanthomatous ameloblastoma and its surgical challenges.

Expression of Programmed Cell Death Ligand-1 and Mismatch Repair Status in Endometrial Carcinomas.

Background and Aims: Programmed death ligand-1 (PD-L1) is a co-regulatory molecule that suppresses local immunity, and mismatch repair (MMR) deficiency (dMMR) is reported to influence the response to anti-PD-L1-targeted therapy. This study was conducted to find the PD-L1 status, the occurrence of dMMR in endometrial carcinomas, and the association between them. Materials and Methods: The study included 35 resected specimens of endometrial carcinomas represented on formalin-fixed paraffin-embedded sections from January 2016 to July 2020. The clinicopathologic information including patient age, tumor histologic type, grade, stage, lymphovascular invasion, the extent of myometrial invasion, and the percentage of tumor-infiltrating lymphocytes (TILs) were obtained in all cases. The expression of PD-L1 and MMR antibodies including mutS homolog 2 (MSH-2), MSH-6, mutL homolog 1 (MLH-1) and MLH-3, and postmeiotic segregation 2 were assessed using immunohistochemistry. The statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 26. Results: PD-L1 expression was noted in 48.6% of the cases in tumor cells and 65.7% of the cases in TILs and MMR was deficient in 28.6% of endometrial carcinomas. A statistically significant relation was noted between dMMR and TILs, PD-L1 expression in tumor cells and TILs, PD-L1 expression in tumor cells, and extent of myometrial invasion. Although there was no statistically significant association between MMR status and PD-L1 expression in tumor cells or TILs, 60% of patients with dMMR were PD-L1 positive. Conclusion: Sixty percent of dMMR cases showed PD-L1 expression in tumor cells. We conclude, ECs that are MMR deficient might get better response to anti-PD-L1 therapy. This study also revealed the prognostic use of TILs in PD-L1-expressed tumors.

Secretory carcinoma of parotid gland masquerading as acinic cell carcinoma on cytology: Case report and review of literature.

Secretory carcinoma is a relatively recently discovered low-grade salivary gland carcinoma with morphological similarities to its breast counterpart. The histopathological features of this entity are well established; however, the cytomorphological features are not well evaluated, leading to diagnostic challenges and pitfalls. We report a case of secretory carcinoma (SC) of the parotid gland, which was misdiagnosed as acinic cell carcinoma (ACC) on fine-needle aspiration cytology, to describe the cytological features.

Interesting Presentation of Mycosis Fungoides in Staging on F-18 FDG PET/CT.

Mycosis fungoides is the major form of primary cutaneous T cell lymphoma. Its staging is based on the percentage of body surface involvement and biopsy-proven extra cutaneous nodal or visceral involvement. Literature shows F-18 FDG accumulation in disease-involved nodes and viscera with non-specific uptake due to co-existing inflammation limits its specificity. We report an interesting case of mycosis fungoides with bilateral upper limb edema and share its findings on F-18 FDG PET/CT.

Cytomorphology of paediatric hepatocellular carcinoma: A useful diagnostic adjunct.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a common primary malignancy of the liver but is rare in the paediatric age group; thus, it may be misdiagnosed as the more common tumour, hepatoblastoma. Management varies in both these tumours, and pathological diagnosis thus plays an important role for definitive therapy. Only a few case reports available in the literature have described the cytological characteristics of paediatric HCC. The present study was thus planned to evaluate the cytomorphological features of paediatric HCC. METHODS: Cases diagnosed with HCC on ultrasound-guided fine needle aspiration cytology over a period of 14 years were retrieved. The cases were evaluated for detailed cytological features including cellularity, architecture, sinusoidal wrapping, trabecular thickness, necrosis, anisonucleosis, chromatin, nucleoli, nuclear contours, bi- or multinucleation, intranuclear and intracytoplasmic inclusions, naked nuclei, extra-medullary haematopoiesis, monomorphism, and nuclear overlapping. RESULTS: Twelve cases of HCC were included in the study. The median age at diagnosis was 10 years. Serum alpha-fetoprotein level was raised in most of them. Five of the 12 cases were characterised as moderately differentiated, three as poorly differentiated, two as well differentiated, and two as the fibrolamellar type of HCC. Cytohistological correlation was performed in seven cases. CONCLUSIONS: Ultrasound-guided fine needle aspiration serves as a useful tool to diagnose paediatric HCC and differentiate it from other primary hepatic malignancies, especially hepatoblastoma which closely mimics HCC in this age group, as serum alpha protein levels and imaging findings are unable to distinguish these two tumours.

Mucormycosis: An Epidemic Complicating the COVID-19 Pandemic.

COVID-19 is a relatively new disease whose complete pathogenesis and complications have not been elucidated. Apart from the morbidity and mortality caused by the virus itself, it is noted that patients affected with this virus have a higher susceptibility to bacterial and fungal co-infections. Mucormycosis is a rare and life-threatening fungal infection generally associated with uncontrolled diabetes mellitus and immunosuppression. It tends to rapid disease progression and poor prognosis if not diagnosed and managed promptly. There has been a sudden increase in the number of mucormycosis cases in patients with moderate to severe COVID-19 infection in the past few months. Herein, we present a series of 10 mucormycosis cases diagnosed over one week.

18 F-FDG PET/CT of Alveolar Rhabdomyosarcoma of Prostate in a 17-Year-Old Boy.

ABSTRACT: Rhabdomyosarcoma of the prostate is a rare malignancy that usually presents in childhood and adolescence with symptoms of bladder outlet obstruction. Serum prostate-specific antigen is usually normal, and 18 F-FDG PET/CT has a crucial role to rule out distant metastases. We present a case of alveolar rhabdomyosarcoma of the prostate in a 17-year-old boy.

Pelvic Synovial Sarcoma Clinically Masquerading as an Ovarian Malignancy.

Background: Synovial sarcoma, a malignant mesenchymal tumor, commonly involves the extremities and is rarely found in the pelvis. Cytology with a biphasic pattern can suggest the diagnosis of synovial sarcoma. Case Report: A 32-year-old female presented with complaints of abdominal distension. She was initially evaluated in another hospital where she underwent ultrasound-guided fine needle aspiration cytology (FNAC) of the abdominal mass. The mass was diagnosed as ovarian adenocarcinoma, and the patient underwent 3 cycles of chemotherapy. After 3 months, she was referred to our institute for surgical excision of the mass. Contrast-enhanced computed tomography of the abdomen suggested a well-circumscribed, heterogeneous, solid-cystic mass in the left adnexal region measuring 13.9 × 10 × 9.1 cm and compressing the adjacent structures. No previous radiologic investigations were available. We reviewed the FNAC slide from the outside hospital and made a preliminary diagnosis of biphasic synovial sarcoma. The patient underwent debulking surgery consisting of panhysterectomy with excision of the pelvic mass. Microscopic examination of the pelvic mass showed a biphasic tumor composed of epithelial and mesenchymal components, suggestive of synovial sarcoma. The immunohistochemistry profile supported the morphologic diagnosis. Bilateral ovaries were unremarkable. The patient received 4 cycles of adjuvant chemotherapy and is presently asymptomatic. Conclusion: Although primary pelvic synovial sarcoma is a rare occurrence, this case illustrates that synovial sarcoma can be diagnosed or at least suspected on FNAC. Because of the importance of adjuvant chemotherapy, synovial sarcoma must be high on the list of differential diagnoses of high-grade intra-abdominal masses.

Renal Squamous Cell Carcinoma Presenting With Renohepatic Fistula: A Rare Amalgam.

Background: Primary squamous cell carcinoma (SCC) of the kidney, a rare malignancy that accounts for less than 1% of all urinary tract malignancies, is usually diagnosed in late stages because of the lack of characteristic clinical and imaging features and aggressive behavior. Case Report: A 66-year-old male presented with complaints of right flank pain. Imaging suggested the differential diagnoses of xanthogranulomatous pyelonephritis or renal malignancy extending into segment VI of the liver. Right subcapsular nephrectomy was performed, and nonbilious fluid from the liver cavitary lesions was drained. Histopathologic examination showed that the lesion was a renal SCC with contiguous malignant infiltration of the liver that led to a renohepatic fistula. Conclusion: Renal SCC is a rare high-grade neoplasm and can present in an unusual form with a poor prognosis.

Comparison of GATA-3, Mammaglobin and GCDFP-15 Expression in Primary, Metastatic and Triple Negative Breast Carcinomas: An Indian Scenario.

BACKGROUND AND OBJECTIVE: Mammaglobin and GCDFP-15 are traditional immunohistochemistry (IHC) markers utilized to recognize metastasis of breast carcinoma in an unknown primary. GATA-3 is increasingly being used as a marker of primary breast origin. This study was done to evaluate and compare GATA-3 with GCDFP-15 and Mammaglobin in invasive primary including metastatic and triple negative breast carcinomas. METHODS: Immunohistochemistry for GATA-3, GCDFP-15 and Mammaglobin was applied on 100 cases of primary breast carcinomas, including 20 triple negative cases and 30 cases of metastatic breast carcinomas. Staining scores were given for each marker by multiplying the percentage of positive tumor cells by the intensity of staining (1+, 2+ or 3+), with scores ranging from 0 to 300. Staining score of 1 or more was considered positive. RESULTS: GATA-3 was expressed in 92% of primary, 80% of metastatic and 60% of triple negative breast carcinomas, with an average staining score of 270. Mammaglobin was expressed in 68% of primary, 56.6% of metastatic and 25% of triple negative breast carcinomas, with an average staining score of 180. GCDFP-15 was expressed in 48% of primary, 26.6% of metastatic and 05% of breast carcinomas, with an average staining score of 60. GATA-3 demonstrated to have higher staining score (average of 270) than other two markers in maximum number of cases. CONCLUSION: GATA-3 has a higher sensitivity and increased staining scores in primary breast carcinomas, metastatic breast carcinomas as well as in triple negative breast carcinomas.

Malignant rhabdoid tumour of liver: Conundrum on ascitic fluid.

Ascitic fluid analysis is an important tool for diagnosis and staging. Cytological analysis is routinely done as a part of workup for ascites. This is challenging in paediatric malignancies where multiple differentials need to be considered at times with limited cellularity. We present a case of malignant rhabdoid tumour of liver in a young child presenting with abdominal lump and ascites. The diagnosis was offered on ascitic fluid cytology based on cytomorphology, supporting immunohistochemistry and later confirmed on biopsy. This report briefly discusses its differentials and approach to diagnosis.

Clinical triad with multi-biopsy histopathology as a reliable diagnostic marker of mycetomas: a retrospective review from a tertiary care center.

BACKGROUND: Mycetoma is a neglected tropical infectious disease which runs a prolonged and protracted course. Microbiological confirmation is diagnostic yet unreliable due to poor sensitivity and variable availability of culture facilities in resource poor settings. METHODS: A retrospective review was performed on electronic records (histopathology, microbiology, and radiology) of all patients who underwent skin biopsies with mycetoma as one of the clinical differential diagnoses from year 2016 to 2020. RESULTS: Out of 73 patients biopsied with a differential of mycetoma, 42 fit the clinical triad of swelling-sinuses-granules. After clinical, microbiological, pathological, and radiological correlation, 31 cases were of eumycetoma and seven were of actinomycetoma. Mean patient age was 37.58 ± 13.8 years with a male to female ratio 2.45 : 1 and mean disease duration of 11.31 ± 10.9 years. Histopathological findings revealed fungal hyphae in 18 cases and gram-positive bacteria in six cases. Fungal culture was positive in 13 cases with the three commonest organisms being Madurella mycetomatis in five cases, Fusarium and Aspergillus nidulans in two cases each. X-ray changes of soft tissue, bones, and joints were seen in 25 cases, and "dot-in-circle" sign was seen in eight of nine MRIs. CONCLUSION: Eumycetoma was more common than actinomycetoma in our setup, ratio being 4.43 : 1. A clinical triad of swelling, multiple sinuses and grainy discharge with any one diagnostic support (histopathology/radiology) is sufficient to make a definitive diagnosis of mycetoma in the absence of microbiological identification.