Categorisation of peritoneal serous effusions using the International System for Reporting Serous Fluid Cytopathology-A study on gynaecological samples.

BACKGROUND: Cytology of serous effusions is an indispensable diagnostic tool for the diagnosis of non-neoplastic as well as neoplastic effusions, aiding in the categorisation, staging, and prognostication of the patient. This study focuses on reclassifying cases of peritoneal fluid cytology following the International System for Reporting Serous Fluid Cytopathology (TIS), highlighting various challenges encountered and adding to the body of data regarding the risk of malignancy (ROM), focussing on peritoneal effusions due to gynaecological causes. METHODS: Peritoneal effusion samples were retrieved from our department's archives and reclassified according to the TIS. The ROM for each category was calculated based on available surgical follow-up. RESULTS: A total of 818 peritoneal effusions were studied. Following the definitions and guidelines of the TIS, the cases were reclassified with 125 (15.2%) in the category of non-diagnostic (ND), 595 (72.7%) as negative for malignancy (NFM), 26 (3.2%) as atypia of undetermined significance (AUS), 12 (1.5%) as suspicious for malignancy (SFM), and 60 (7.3%) as malignant (MAL). The respective ROM values for each category were 16.9%, 12.1%, 50%, 80%, and 100%, respectively. By considering the MAL and SFM groups as positive, and the ND, NFM, and AUS groups as negative, the diagnostic accuracy, sensitivity, specificity, and positive and negative predictive values were determined as 85.2%, 36.7%, 99.1%, 91.7%, and 84.5%, respectively. CONCLUSIONS: Peritoneal cytology categorisation following the proposed TIS offered a practical approach for categorisation of the fluids received. The ROMs reported in our study were mostly concordant with those published according to the TIS.

Placental findings in singleton stillbirths: a case-control study from a tertiary-care center in India.

OBJECTIVES: Placental examination in a case of stillbirth can provide insight into causative/associated factors with fetal demise. The aim of this study was to compare placental and umbilical cord pathologies in singleton stillbirth and livebirth placentas, and to find prevalence of various associated maternal and fetal clinical factors. METHODS: This case-control study was conducted at a tertiary-care center in India over a period of 20 months. About 250 women who delivered stillborn fetus ≥28 weeks' gestation and 250 maternal-age-matched controls were recruited. Sociodemographic and clinical details were noted and placental gross and microscopic examination was done. Placental findings were compared between stillbirth and livebirth (overall), preterm stillbirth and preterm livebirth as well as term stillbirth and term livebirth in six categories - placenta gross, cord gross, membranes gross, maternal vascular malperfusion, fetal vascular malperfusion and inflammatory response. Prevalence of 11 maternal and fetal factors were studied in all categories of placental findings in both livebirth and stillbirth. RESULTS: Placental findings in all six categories were significantly associated with stillbirths (p<0.05). The placental findings associated with stillbirth with highest odds included placental hypoplasia (OR 9.77, 95% CI 5.46-17.46), necrotizing chorioamnionitis (OR 9.30, 95% CI 1.17-73.96) and avascular villi (OR 8.45, 95% CI 3.53-20.25). More than half of the women with stillbirths had medical disorders (n=130, 52.0%) and the most prevalent was hypertensive disorder (n=45, 18.0%). CONCLUSIONS: Changes in placenta are associated with development of stillbirth. Therefore, antenatal investigations to identify placental dysfunction should be investigated to determine whether these reduce stillbirth. Also, placental examination in a case of stillbirth can detect/diagnose many maternal/fetal conditions and thereby can help in preventing future stillbirths.

DLBCL of bilateral submandibular glands and MALToma of thyroid-A rare coexistence.

Involvement of the bilateral submandibular glands and thyroid by the same lymphoma simultaneously has been reported in the literature. However, two different types of lymphomas presenting simultaneously at different sites have never been reported. This case report highlights this rare occurrence. A 65-year-old female, a known case of Hashimoto's thyroiditis with raised anti-TPO antibodies, presented with thyroid swelling for 1 year and bilateral submandibular swelling for 3 years. FNAC and flow cytometry showed features of mucosa-associated lymphoid tissue lymphoma in the thyroid gland, whereas the bilateral submandibular glands showed features of diffuse large B cell lymphoma. Histopathology and immunohistochemistry from the submandibular swelling led to similar diagnoses as the flow cytometry.

Anaplastic large cell lymphoma and lepromatous leprosy: a rare coexistence.

Lepromatous leprosy (LL) has been reported in the literature with Non Hodgkin Lymphoma and rarely with Hodgkin Lymphoma. However, an extensive search of the literature shows no case report describing anaplastic large cell lymphoma (ALCL) in association with LL. We report a case of a young male with LL who was found to have ALCL. This is an interesting case of coexistence of an endemic infectious disease and a rare lymphoma involving the same lymph node, with a brief review of the literature.

Fine needle aspiration cytology of primary thyroid non-hodgkins lymphoma: Experience from a tertiary care center of North India.

Presentation: Twelve cases of Primary Thyroid Non-Hodgkin's Lymphoma (PT-NHL) were retrieved from the records suspected or diagnosed as NHL on fine needle aspiration cytology (FNAC) over a period of nine years from 2010-2018. During this period 5236 patients underwent thyroid FNAC;of these 685 cases were diagnosed under Bethesda Caregory V and VI. Thyroid NHL constituted 0.23 % of all thyroid FNA (12/5236 cases)and 1.7% (12/685) of all thyroid malignancies. Patients ranged in age from 40-61 years with Female:Male 7:5. All patients presented with thyroid enlargement (5-14 cms), and were of two months to five years duration. Patients had history of tobacco intake (smoking/chewing)in nine cases (75%). Thyroid function tests showed hypothyroidism in four (33%), positive antithyroid antibodies in three (25%) and; two cases(16.7%) were known cases of Hashimotos thyroiditis with follow up. Cytological Findings: Eight cases (66.7%) had monomorphic large cell morphology,other four had mostly intermediate cell types (33.3%). A panel of immunocyto/ histochemistry (ICC/ IHC) showed CD 19 and CD 20 positivity in all cases;sixof these could be correlated on Flow cytometry (FC) with expression of FMC7, CD20, CD19 with kappa light chain restriction (5) and Lambda (1). FC findings corroborated completely with IHC on biopsy sections. The final diagnosis were Diffuse large B cell Lymphoma (DLBCL,8) and MALT- Lymphoma(4). The follow up was available in DLBCL (4) and MALT- Lymphoma (1). CHOP therapy were given in all patients followed by radiotherapy in DLBCL; one patient of DLBCL died following pulmonary complications, rest are well and alive on follow-up. Discussion: PT-NHL is rare in India. DLBCL is the commonest histological type reported. In the present study, tobacco exposure has shown strong association. Combined FNAC-FC provide definitive diagnosis and thus can replace histopathology reducing turn around time. Conclusion: FNAC -FC provides a definitive diagnosis and thus can reduce turnaround time.

Primary ALK-Positive Large B Cell Lymphoma of Pancreas.

INTRODUCTION: Primary pancreatic B-cell lymphoma is rare with most common type being Diffuse Large B-cell lymphoma (DLBCL). Anaplastic lymphoma kinase-positive large B-cell lymphoma (ALK+ LBCL) represents less than 1% of all DLBCL. Extra-nodal presentation is rare with presentation as a primary pancreatic mass being exceptional. CASE REPORT: A 42 years female presented with lump in central upper abdomen for one month with evidence of icterus. Lab Investigations showed deranged Total Bilirubin/Direct Bilirubin, AST, ALT, ALP, Amylase, Lipase, CEA, CA 19-9 and CA-125 levels. CECT scan showed large solid mass in pancreas with necrotic areas within. Biopsy revealed a lymphoma with strong expression of ALK (granular cytoplasmic), CD138, MUM1, kappa, moderate expression of CD45 and focal expression of CD20, CD79a and PAX5 and lack of expression of CD5, CD3, CD45RO, BCL6, CD10 and EMA. FNAC and Flow Cytometry was also performed. A final diagnosis of ALK positive LBCL was made with pancreas as primary. CONCLUSION: Present case is the first case of ALK positive LBCL reported in pancreas. Expression of mature B-cell markers such as CD20, CD79a and light chain restriction may be seen unlike previous claims.

USG Guided Fine Needle Aspiration Cytology along with Immunocytochemistry to Diagnose Primary Malignant Mixed Mullerian Tumors: A Three-Year Study from a Tertiary Care Center.

Aims and Objectives: To study the diagnostic utility of fine-needle aspiration cytology (FNAC) and immunocytochemistry in diagnosing primary malignant mixed Mullerian tumors (MMMT). Materials and Methods: A 3-year retrospective study carried out in a tertiary care hospital, which included all the gynecological patients who underwent USG-guided FNAC of their abdominopelvic masses. Observations and Results: Out of the 324 total cases, 05 (1.5%) were reported as primary malignant mixed Mullerian tumors. Out of these 05 cases, 03 were ovarian, 01 was uterine, and 01 involved both uterus and one-sided adnexa. The FNA smears from the masses revealed cytomorphological features of a biphasic neoplasm with elongated pleomorphic spindle cells and dispersed, focal attempted acinar pattern, thus indicating the possibility of MMMT. Immunocytochemistry was further carried out which showed both vimentin and cytokeratin positivity. The diagnosis was confirmed on subsequent biopsy and immunohistochemistry (without any histopathological-cytological discrepancy). Conclusion: Though the literature is replete in establishing a histo-pathological diagnosis of MMMT, the diagnosis on USG-guided FNAC has been rarely described. Emphasis should be made on the careful examination of small sarcomatous elements in smears. Utilization of cell block and immunocytochemistry with histopathological correlation should be done to avoid misdiagnosis.

Transformation of diffuse large B-cell lymphoma to lymphoblastic lymphoma.

Transformations in diffuse large B-cell lymphoma (DLBCL) are extremely rare. Here, we are presenting a very rare case of DLBCL transforming into lymphoblastic lymphoma (LBL) diagnosed by fine-needle aspiration cytology (FNAC) and flow cytometry. A 31-year old male on antiretroviral therapy and a known case of diffuse large B-cell lymphoma diagnosed 1 year back on cervical lymphadenopathy, presented with left axillary swelling for 3 months. FNAC and Flow cytometry were performed from the left axillary swelling which confirmed the diagnosis of LBL.

Cytological Diagnosis of Malignant Mesothelioma: A Case Series.

Background: Mesotheliomas are neoplasms of the serosal lining of the body cavities. Diagnosis requires a multimodal approach of clinical findings, cytology, and histopathology with immunohistochemistry (IHC). The published sensitivity of cytology for diagnosing mesothelioma ranges from 30% to 75%. Aim and Objectives: This study aimed to calculate the incidence of malignant mesothelioma (MM) at our institute and to study the cytological features of MM. Materials and Methods: A retrospective study of pleural, peritoneal, and pericardial fluids submitted at our institute was done. The duration of the study was 8 years (2011-2019). Apart from examining Giemsa smears, a panel of immunocytochemical (ICC) and cell block immunohistochemical (IHC) markers was applied to achieve the diagnosis. These included calretinin, mesothelin, CK5/6, Hector Battifora mesothelial cell antibody (HBME), WT1, MOC31, CK7 and CK20. Histopathological correlation was done wherever possible. Result: In the present study, we compiled four cases of MM over 8 years diagnosed on serous effusion cytology and confirmed by immunocytochemistry (ICC)/cell block immunohistochemistry (IHC)/biopsy. This indicates a rare incidence of MM. The Cytological features of MM were studied. Conclusion: The diagnosis of MM is difficult, especially cytologically. It was found to be a rare entity in the malignant cases diagnosed on effusion cytology.

Evaluation of immunocytochemistry on destained giemsa stained smears as an alternative to conventional technique.

Introduction: Protocol for immunocytochemical (ICC) staining in May-Grünwald Giemsa (MGG)-stained smears has been difficult to establish. It is the need of the hour to be able to use prestained slides for ICC in specific cases to deliver timely diagnoses and reduce inconvenience to patients. Aims and Objectives: To evaluate and compare the use of MGG-stained smears for the purpose of ICC, after de-staining and saline rehydration to that of routine standard ICC. Materials and Methods: A prospective study was conducted on 40 FNAC samples: 25 cases of breast disease and 15 cases of reactive lymphoid hyperplasia known to express pancytokeratin and leukocyte common antigen (LCA)/CD45, respectively. Air-dried smears of each case were stained by standard MGG stain and after the report was dispatched, one smear was selected and sent for ICC. The smears were analyzed to determine the overall result and grade each smear semi-quantitatively with respect to staining-intensity, stain-localization, staining-uniformity, counter-staining, and background-staining. Observations and Results: The proposed protocol was inferior to conventional ICC in all the parameters, more pronounced in pancytokeratin than LCA/CD45. Only 8% of air-dried smears stained for pancytokeratin showed optimal stain intensity (as opposed to 44% of wet-fixed smears), whereas only 14.3% of air-dried smears were optimally stained for LCA (as opposed to 85.7% of wet-fixed smears). Conclusion: The proposed protocol of de-stained Giemsa smears as an alternative to conventional technique for ICC was unsuccessful in giving satisfactory results.

Secondary malignant fibrous histiocytoma of thigh with surface ulceration following radiotherapy for carcinoma cervix.

INTRODUCTION: Radiotherapy is known to cause rarely various malignancies including leukemia, sarcoma, and thyroid and lung carcinoma. Post-radiation sarcomas account for 0.5-5.5% of all sarcomas; and include extra skeletal osteosarcoma, fibrosarcoma leiomyosarcoma, and malignant fibrous histiocytoma. Reports on post radiotherapy malignant fibrous histiocytoma in cervical cancer patients are rare. CASE REPORT: We present a case of 45-years-old female diagnosed with squamous cell carcinoma of the uterine cervix stage IIB; she underwent a radical hysterectomy with pelvic lymphadenectomy and postoperative radiotherapy and chemotherapy. Five years later, she presented with ulcerated nodular masses in right and left medial aspect of thigh. Cytological and histological diagnosis of the masses was malignant fibrous histiocytoma which was further confirmed by immunohistochemistry. CONCLUSION: Post-irradiation sarcoma must be considered in patients of carcinoma cervix treated with radiotherapy, when soft tissue mass is seen in the previously irradiated area. It should be differentiated from metastasis from primary tumor with the help of appropriate markers as it has a grave prognosis.

Cytological clues to Alternaria alternata.

Alternaria alternata is dematiaceous fungi affecting mainly immunocompromised host. It generally causes cutaneous infection in humans, but can cause fatal disease. Fine needle aspiration cytology (FNAC) has not been used widely for the diagnosis of dematiaceous fungi. Here, we present a case of Alternaria alternata in an immunocompetent patient diagnosed on cytology and culture.

Acinic cell carcinoma of the parotid gland with neuroendocrine differentiation.

Acinic cell carcinoma (ACC) is a malignant salivary gland tumor characterized by tumor cells displaying acinar features. Usually presenting as a slow-growing tumor, ACC, however, may show dedifferentiation to a higher grade including neuroendocrine carcinoma. In addition, ACC may rarely show focal neuroendocrine differentiation without any frank evidence of neuroendocrine carcinoma. We describe such a case of ACC of the parotid gland in a 65-year-old female, which showed neuroendocrine differentiation. The diagnostic clues, immunohistochemistry panel, and prognostic and treatment aspects are also presented.

Neuroendocrine carcinoma of prostate presenting with ascites.

Prostate cancer is a very common cause of morbidity and mortality in India. The commonest type of prostate carcinoma is adenocarcinoma, most of them are confined to prostate at the time of presentation. Bone is the preferred site for metastasis. The following is a case of neuroendocrine carcinoma of prostate arising in a 36 years old male who presented with ascitis and jaundice to the emergency department. The ascitic tap was positive for malignant cells. CECT done to detect primary showed osteoblastic secondaries in the spine along with lesions in the liver. DRE revealed grade 2 prostatomegaly. A TRUS guided biopsy showed neuroendocrine carcinoma of the prostate. Neuroendocrine carcinoma is a very rare type of prostatic carcinoma, with presentation of the same as ascitis is very uncommon. The following case is presented due to its rarity.

Localized cutaneous infection caused by Scedosporium apiospermum: Report of a case diagnosed on cytology.

Scedosporium apiospermum (also known as Pseudallescheria boydii) is a ubiquitous filamentous fungus. This fungus is known as a cause of mycetoma, which may occur in a normal immune host following trauma and nonmycetoma-localized skin infections without grain production which are much rarer. However, in an immunocompromised host, S. apiospermum may cause a life-threatening infection. We describe a case of S. apiospermum infection of the left middle finger in an immunocompetent patient, which was diagnosed on cytology and later confirmed on culture.

Utility of fine needle aspiration cytology to diagnose intraoral lymphoma: 7 years study from a tertiary care center.

OBJECTIVE: Fine needle aspiration (FNA) cytology has been successfully utilized in the preoperative diagnosis of oral masses. Lymphoma involving other sites has also been diagnosed frequently on FNA. Oral cavity lymphoma (OL) is rare and is clinically indistinguishable from other lesions of the mouth. A complete excision of these may be difficult. Our experience with FNA diagnosis of 11 OLs along with histopathological correlation is reported herein in a tertiary health care setting. METHODS: In this retrospective study, clinico pathological characteristics of patients with final diagnosis of non-Hodgkin's lymphoma (NHL) were reviewed over a 7 year period. Routine cytological giemsa staining was performed in all cases along with immunocytochemistry (ICC) wherever possible. The gold standard for diagnosis of NHL was based on: (1) Histopathology and immunohistochemistry and/or (2) Flow cytometry (FC). RESULTS: A total of 11 cases were diagnosed as NHL. All showed B cell immunophenotype. Two of them were diagnosed as follicular lymphoma on histopathology. Male to female ratio was 7:4 and ranged in age from 37 to 70 years. The most common site was tonsillar fossa (N = 5), followed by hard palate (N = 3), soft palate (N = 2), and buccal mucosa (N = 1). Size ranged from 1 to 6 cm. CONCLUSIONS: Diagnosis of OLs may be hampered by its rarity and difficulties in obtaining sufficient cellularity in oral FNA but there is need for immediate and accurate diagnostic procedures, including immunohistochemical analysis to avoid delay in treatment. FNA along with ICC helps in early diagnosis of this rare entity and can also provide sample for FC.

Pleomorphic leiomyosarcoma of gingivoalveolar sulcus: a case report.

BACKGROUND: Leiomyosarcomas are rare tumors in the oral cavity. Oral leiomyosarcomas may arise primarily from bones (maxilla and mandible) or soft tissues. Pleomorphic leiomyosarcoma (PLMS) is a recently described morphologic variant with aggressive clinical behavior and low survival rate; it is exceptionally rare at intraoral sites. CASE: A 21-year-old male presented with a rapidly progressive growth arising from the gingiva. Fine needle aspiration cytology showed pleomorphic polygonal, plasmacytoid and spindled cells. Immunocytochemistry (IC) showed diffuse positivity for vimentin, desmin and cytokeratin, suggestive of high grade sarcoma. The patient underwent surgery, and total extended maxillectomy was performed; the diagnosis was PLMS on histology and IC. Further, detailed clinical and radiologic findings suggested primary high grade soft tissue sarcoma involving the underlying maxillary bone; thus, the final diagnosis was primary PLMS of the gingivoalveolar sulcus. CONCLUSION: Intraoral PLMS arising from gingivoalveolar sulcus in a young patient is an extremely rare lesion with aggressive behavior. Detailed clinicoradiologic findings, its correlation with morphology and IC are mandatory for its final diagnosis and also to exclude metastasis from other sites and primary tumor in bone.

Utility of Fine Needle Aspiration in Diagnosis of Intraoral Minor Salivary Gland Tumors.

OBJECTIVE: To evaluate the utility of intraoral fine-needle aspiration cytology (FNAC) in diagnosis of minor salivary gland neoplasms (MSGN) with application of Milan system of reporting salivary gland cytopathology; keeping histopathology as gold standard and to detail the cytological findings of MSGNs. METHOD: Retrospective study between Jan 2008 and June 2017 (appro × 10 years) on the cytology of the minor salivary gland tumor along with the histopathological correlation. The relevant clinical data was collected from the medical record. RESULT: Sixty-four cases of MSGNs were included in the study. The histodiagnosis of the 41 were available. Twenty-one cases were diagnosed as malignant, while rest 20 cases were reported as benign. The most common tumor diagnosed was pleomorphic adenoma (PA) (50% cases), followed by mucoepidermoid carcinoma (14%) and adenoid cystic carcinoma (12.5%). The most common site of MSGT was found to be hard palate (44%), followed by soft palate (23%), floor of the mouth (12%), lip (11%), buccal mucosa (5%), and tongue (5%) with no gender predilection. Sensitivity of FNAC for detection of malignancy was 81% while specificity 95%. For malignancies, positive predictive value for malignancies was 17/18 (94.4%) and negative predictive value was 19/23 (82.3%). According to Milan system out of 21 cases in category IV B, 4 cases were found malignant (Category VI), while 1/18 case in category VI turned out to be nonneoplastic lesion (Category II). CONCLUSION: FNAC is imperative in early diagnosis and subsequent management of MSGNs.