Diagnostic Accuracy of Fine Needle Aspiration Cytology as Compared to Histopathology in Parotid Gland Swelling.

BACKGROUND: The diagnosis of parotid swelling is challenging and investigations like imaging and needle aspiration cytology are helpful. The objective of this study was to determine the diagnostic accuracy of fine needle aspiration cytology (FNAC) as compared to the histopathology in parotid gland swelling. METHODS: It was a descriptive cross sectional study carried out in the Department of ENT-Head and Neck Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu by reviewing the medical record charts of the patients who had undergone surgery for parotid lesions during the study period of seven and half years. All patients whose fine needle aspiration cytology and histopathology reports were available were included in the study. The data were presented as mean, standard deviation, ratio and percentages. Microsoft excel was used for data analysis. RESULTS: There were 75 patients included in the study. The age ranged from nine years to 78 years and the mean age being 38.3 17.42 years. The male to female ratio was 1:1.78. The concordance rate between fine needle aspiration cytology and histopathology was 82.7%. The sensitivity and specificity of the fine needle aspiration cytology were 80% and 95% respectively. Similarly, the positive predictive and negative predictive values were 84% and 93% respectively. The diagnostic accuracy of the fine needle aspiration cytology was 91% for the parotid swelling in our study. CONCLUSIONS: The diagnostic accuracy of fine needle aspiration cytology for parotid swellings in our study was excellent. The result of fine needle aspiration cytology is helpful in deciding management plan for parotid lesions.

Pancreatic solid pseudopapillary neoplasm with concomitant left unilateral renal agenesis and bicornuate uterus: a case report.

A solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor of the pancreas. Concomitant SPN with urogenital anomalies is a very rare presentation. Case Presentation: A 16-year-old female presented with a chief complaint of abdominal pain 30 days back. Solid pseudopapillary neoplasm (SPN) of the pancreas was diagnosed with the aid of ultrasonography and contrast-enhanced computed tomography of the abdomen and pelvis. Incidentally, concomitant left unilateral renal agenesis and bicornuate uterus were also detected in radiological findings. The patient underwent spleen-preserving distal pancreatectomy, and SPN was confirmed with the histopathological report. Discussion: Symptomatic SPN patients present with an abdominal mass and pain or very rarely jaundice. Most of the SPNs are benign. Complete surgical excision results in more than 95% cure. SPN with concomitant urogenital anomalies is extremely rare, and their concurrent occurrence can be better attributed to Wnt signaling pathway owing to their similar pathogenic mechanism. Conclusion: The solid pseudopapillary tumor has an excellent prognosis if timely resected. Proper evaluation of the patient with imaging is necessary to suspect and diagnose SPN who has urogenital anomalies and vice versa.

Renal Mucormycosis: Post-COVID-19 Infection Presenting as Unilateral Hydronephrosis in a Young Immunocompetent Male.

Mucormycosis is a rare invasive fungal infection with a high mortality rate caused by members of the family Mucoraceae. It mainly affects immunocompromised hosts such as poorly controlled diabetes mellitus, previous solid organ transplant, high-dose steroids, and hematologic malignancy. The most common sites of the disease are rhinocerebral, the skin, the lungs, and the gastrointestinal tract. In this era of COVID-19 infection, there has been a significant rise in invasive mucormycosis predominantly reported from southeast. We present a case of isolated renal mucormycosis in an apparently healthy individual with post-COVID-19 infection presenting as unilateral hydronephrosis. Timely identifying at-risk populations and having a high degree of suspicion with involvement of multidisciplinary teams are of utmost importance to diagnose and treat a rare and fatal infection. Even if there is a long history, antifungal drugs and removal of the source can result in a good outcome.

Calciphylaxis and Ulcerative Lesions of Bilateral Nipple-Areolar Complex Due to Alcoholic Liver Disease.

When faced with eczematous lesions involving the nipple-areolar complex (NAC), Paget's disease is assumed to be the diagnosis, anything else being considered a "Zebra" necessitating its exclusion on pathology. A middle-aged lady presented with synchronous asymmetrical ulceration of bilateral NAC with pleomorphic calcifications on mammography and simultaneous extensive vascular calcification in bilateral breasts that suggested systemic cause. Calciphylaxis is a rare diagnosis occurring usually due to underlying end-stage renal disease or hyperparathyroidism. There are very few case reports of calciphylaxis due to alcoholic liver disease and no cases to the best of our knowledge involving NAC. We report an extremely rare case of breast and NAC calciphylaxis due to alcoholic liver disease, highlighting need to consider benign etiology when bilateral involvement is present.

The Bethesda System for Reporting Thyroid Cytopathology: Validating at Tribhuvan University Teaching Hospital

Abstract Introduction Fine needle aspiration cytopathology (FNAC) is widely used for the stratification of thyroid nodules. Objective The objective of the present study is to validate FNAC reporting based on The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) at our institution and to calculate the risk of malignancy in each category. Methods This was a descriptive cross-sectional study conducted jointly at the Department of Ear, Nose and Throat and at the Department of Pathology for a period of 1.5 years (May 2018 to November 2018). All cases presenting with thyroid swelling in the outpatient department were investigated with ultrasonography (USG) of the neck, thyroid function test, and FNAC. All FNAC reporting was done according to TBSRTC. Results A total of 134 thyroidectomies were performed during the study period. The female to male ratio was 5.3:1. The age ranged from 11 to 74 years old. with a mean age of 51 years old. The FNAC has a specificity of 84.9%, a sensitivity of 89.4%, a positive predictive value of 86.4%, a negative predictive value of 88.2%, and an accuracy of 87.3% in detecting thyroid cancer. The implied risk of malignancy (ROM) in Bethesda II, III, IV, V and VI is 11.7%, 25%,40%,76.6% & 96%, respectively. Conclusion The four studied categories had a ROM comparable to other studies, except for the Bethesda III category. Further studies with larger sample sizes and with the use of USG guidance for the aspiration from the thyroid swelling may give better results by reducing the number of false negative and false positive cases.

The Bethesda System for Reporting Thyroid Cytopathology: Validating at Tribhuvan University Teaching Hospital.

Introduction Fine needle aspiration cytopathology (FNAC) is widely used for the stratification of thyroid nodules. Objective The objective of the present study is to validate FNAC reporting based on The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) at our institution and to calculate the risk of malignancy in each category. Methods This was a descriptive cross-sectional study conducted jointly at the Department of Ear, Nose and Throat and at the Department of Pathology for a period of 1.5 years (May 2018 to November 2018). All cases presenting with thyroid swelling in the outpatient department were investigated with ultrasonography (USG) of the neck, thyroid function test, and FNAC. All FNAC reporting was done according to TBSRTC. Results A total of 134 thyroidectomies were performed during the study period. The female to male ratio was 5.3:1. The age ranged from 11 to 74 years old. with a mean age of 51 years old. The FNAC has a specificity of 84.9%, a sensitivity of 89.4%, a positive predictive value of 86.4%, a negative predictive value of 88.2%, and an accuracy of 87.3% in detecting thyroid cancer. The implied risk of malignancy (ROM) in Bethesda II, III, IV, V and VI is 11.7%, 25%,40%,76.6% & 96%, respectively. Conclusion The four studied categories had a ROM comparable to other studies, except for the Bethesda III category. Further studies with larger sample sizes and with the use of USG guidance for the aspiration from the thyroid swelling may give better results by reducing the number of false negative and false positive cases.

Extra-adrenal paraganglioma of a urinary bladder in an adolescent male: A rare case report.

INTRODUCTION AND IMPORTANCE: Paraganglioma of the urinary bladder is unusual and reported rarely. The patient usually presents with the complaint of hematuria and fluctuating blood pressure. CASE PRESENTATION: We discuss the case of a 21-year old male, who had been experiencing gross hematuria, was found to have a mass on ultrasonography. Further evaluation with contrast-enhanced computerized tomography (CECT) revealed an irregular soft tissue density of endophytic mass arising from the left posterior wall of the urinary bladder. The histopathological examination of the excised mass was suggestive of a tumor of neural origin, which was further confirmed as paraganglioma by immunohistochemistry. CLINICAL DISCUSSION: Imaging prior to the surgery must be done for a provisional diagnosis of paraganglioma to avoid fluctuating blood pressure during elective surgery. On histopathological examination tumor cells are arranged in the nest like fashion forming a specific 'Zellballen' pattern. Positive staining for synaptophysin and chromogranin in immunohistochemistry confirms the diagnosis. CONCLUSION: It is difficult to diagnose paraganglioma of the urinary bladder with the aid of imaging only, particularly if the patient presents without specific symptoms of fluctuating blood pressure. So, a multidisciplinary approach is essential for the diagnosis and proper therapy of this entity. However, prompt surgical resection is the mainstay of treatment.

A rare case of myxoid pleomorphic liposarcoma in an infant: A report.

INTRODUCTION AND IMPORTANCE: MPL (myxoid pleomorphic liposarcoma) is an uncommon type of liposarcoma that affects mostly children and infants. Its aggressive behavior and tendency to recur warrant complete excision despite the challenges of troublesome locations. CASE PRESENTATION: A 12-month-old infant presented with an insidious onset of noisy breathing and respiratory distress not relieved by supplemental oxygen via face mask. Examination revealed dullness and decreased air entry on the left chest. Computed Tomographic (CT) scan showed a large solid mass occupying the left hemithorax and displacing the mediastinum to the right. Intraoperatively, a large solid mass arising from the left chest wall and attached to the fifth rib was seen. Histopathology of the resected mass showed myxoid pleomorphic liposarcoma which is non-reactive for MDM2 immunostain. CLINICAL DISCUSSION: Unlike other liposarcomas, myxoid pleomorphic liposarcoma occurs in children, commonly in the chest. CT scan is the preferred imaging modality. Treatment is by complete excision where possible. Molecular studies like Fluorescent in-situ Hybridization (FISH) and Immunohistochemistry (IHC) is used for confirmation. It has a high propensity to metastasize and recurrence is expected. Chemotherapy and irradiation following complete resection decrease the disease recurrence. CONCLUSION: Soft tissue malignancy must be considered in the differential diagnosis of a large intrathoracic tumor in an infant. FISH and IHC are essential for confirmation.

Paragonimiasis: A missed diagnosis from Nepal.

Paragonimiasis, or Oriental lung fluke is a parasitic infestation seen in Asia, Africa and South America which is spread by the consumption of crabs and crayfish. To date four cases have been reported from Nepal. Here, we report a case of paragonimiasis in a young male from Kathmandu valley who presented with symptoms of fever, on and off for 1 month, shortness of breath and cough. He was found to have pleural effusion. Sputum examination did not reveal acid fast bacilli, However, based on clinical features, he was started on antitubercular treatment. There was initial improvement, but later, he continued to have cough and hemoptysis over the next 2 years and on subsequent High-Resolution Computerized Tomography (HRCT) he was found to have a cavitary lung lesion in the superior segment of lower lobe of left lung. A possibility of aspergillosis was considered for which he underwent a lobectomy. The gross examination of the lung showed a small cavity measuring 5 mm which revealed on histology a parasitic structure with serous glands within it. In addition, there were many foreign body granulomas with ova within them. A diagnosis of paragonimiasis was made and the patient was started on Praziquantal. He recovered well and is currently asymptomatic. We can learn from this case that the signs and symptoms of paragonimiasis mimic that of tuberculosis and the mistaken diagnosis can lead to unnecessary treatment, prolonged morbidity and loss of time and resources.

Giant cell glioblastoma in 6-year-old kid: Report of an unusual case.

Pediatric giant cell glioblastoma, a highly malignant and lethal tumor, can only be distinguished from glioblastoma multiforme histologically. Though it is said to have a better prognosis, adequate evidence in favor is lacking. Early diagnosis with gross total resection and adjuvant chemotherapy might increase the survival period.

Tumour angiogenesis and c-Met pathway activation - implications in breast cancer.

Breast cancer is a heterogeneous disease with wide range of clinical behaviour. Tumour angiogenesis and metastasis have been considered as prognostic markers of the breast carcinoma, and c-Met, a transmembrane receptor tyrosine kinase has been implicated in both these processes of tumour progression. This study was conducted to elucidate c-Met and downstream signalling pathways in breast cancer and correlate with angiogenesis as assessed by microvessel density (MVD) and other prognostic parameters including lymph node metastases. Microvessel density (MVD) was assessed by endothelial cell (CD34) marker in breast cancers. c-Met was evaluated by immunohistochemistry for protein expression and by copy number assay for amplification at gene level. PCR array for gene expression related to c-Met, RAS-MAPK, PI3K-AKT and angiogenesis pathway was performed by real-time PCR. c-Met protein, copy number and mRNA expression did not differ significantly with the lymph node status or MVD. However, Her-2 overexpressing group showed c-Met protein overexpression and amplification. c-Met protein overexpression was also noted in the Luminal B subtype though no amplification was noted. Thus, the c-Met immunohistochemistry score and the c-MET copy numbers did not correlate with each other. c-Met downstream pathway genes (RAS-MAPK, PI3K-AKT and angiogenesis pathway) showed significant upregulation in Luminal B molecular subtype, lymph node-positive cases and cases with high MVD. The downstream signalling pathways (angiogenesis, RAS-MAPK and PI3K-AKT) were associated high MVD, lymph node metastases, and Her-2 and Luminal B subtype. Since inhibitors of these pathways are commercially available, these can be of therapeutic significance.

Tungiasis: A Rare Parasitic Infestation in Genitals of a Native Male from Kathmandu.

Tungiasis is a common parasitic infection inmany parts of the world, including South and Central America and parts of Africa. It is rare in other places, such as in India and Pakistan and imported cases have been reported in Taiwan, Italy, the United States of America, etc. Our diagnosis was made based on histopathologiocal features of the parasite, which corresponds too ther reports and description of tungiasis.1-3 It was treated by surgical excision alone. The fact that the disease has never been reported in Nepal makes it difficult to diagnose clinically, but should be considered in the future. Histopathology can aid in diagnosingthis rare condition.

Unusual clinical presentation of spinal echinococcal cyst imitating a malignant tumour.

Spinal echinococcal cyst is very uncommon and may have variable clinical presentations. We describe an exceptional case of intradural and extramedullary spinal echinococcal cyst, misguided as a spinal tumour on radiological examination and was diagnosed as echinococcal cyst on fine needle aspiration biopsy smears and subsequently on histopathological examination.

Tumor Angiogenesis in Breast Cancer: Pericytes and Maturation Does Not Correlate With Lymph Node Metastasis and Molecular Subtypes.

BACKGROUND: Angiogenesis, traditionally assessed by microvessel density (MVD), does not give an indication of the functional status of the tumor neovasculature. The structural and functional stability of the tumor vasculature and its potential clinical relevance in breast cancer was evaluated. MATERIALS AND METHODS: In invasive breast cancer, immunostaining of endothelial cells and pericytes was performed using anti-CD34 and anti-platelet-derived growth factor receptor-ß antibody, respectively. Double immunostaining for the proliferating capillary index (PCI) and microvessel pericyte coverage index (MPI) was performed with CD34/Ki-67 and CD34/smooth muscle actin. RESULTS: The mean MVD of 145 vessels/mm(2) was significantly greater in grade 3 tumors (P = .018) and in necrotic tumors (P = .022). The PCI ranged from 0% to 17.14% (mean, 4.37%) and was associated with a high proliferative index in tumor tissue (P = .044). The MPI ranged from 13.09% to 88.18% (mean, 41.35%), indicating the stability of the tumor vasculature. However, it was not significantly associated with the tumor size, tumor grade, lymph node metastasis, proliferative index, or molecular subtypes. CONCLUSION: MVD remains the angiogenesis-related parameter associated with tumor grade and necrosis. The PCI was the only functional parameter of angiogenesis associated with a poor prognostic indicator. The MPI did not show any correlation with the known prognostic and predictive factors.