Biphasic synovial sarcoma with epithelial predominance reminiscent of adenocarcinoma: a diagnostic challenge.

Synovial sarcoma (SS) is a rare tumour of unknown origin with peak incidence between 10 and 35 years. Although it arises in juxta-articular location, SS is a misnomer and has no true relationship with synovium. In this case report, we present an elderly female patient with a long-standing history of thigh mass which was initially misdiagnosed as metastatic adenocarcinoma deposits on fine needle aspiration cytology, and again misdiagnosed as malignant adnexal skin tumour on core needle biopsy and referred for further management. Here, we discuss the challenges faced in the diagnosis of SS on a small biopsy and ways to differentiate it from other morphological mimickers. Therefore, we aim to increase the awareness of soft tissue tumours that microscopically appear like adenocarcinoma, which is a potential diagnostic pitfall. We also highlight the importance of morphological diagnosis and the utility of molecular testing using fluorescence in situ hybridisation, to arrive at the correct diagnosis of SS.

Double Whammy Due to Coronavirus Disease-2019: Invasive Small Bowel Mucormycosis with Recent-Onset Diabetic Ketoacidosis Presenting as Diffuse Fecal Peritonitis in a 12-Year-Old Girl.

Mucormycosis is a fatal fungal infection occurring in immunocompromised patients. Small bowel mucormycosis is extremely rare with a high mortality rate. We report the case of a 12-year-old girl with postcoronavirus disease (COVID) recent-onset diabetic ketoacidosis, who presented with acute abdomen with fecal peritonitis. She was diagnosed with intestinal mucormycosis (post-COVID) and was treated successfully with surgical and antifungal management.

Differential expression pattern of annexin A2 during nephrogenesis and kidney carcinoma.

The creation of a cancer cell could be due to reactivation of repressed gene in the process of normal embryonic development. The differences in embryonic origins and functions of various components of nephron may contribute to the diversity of morphological patterns, molecular and immunohistochemical phenotypes of common renal neoplasms. Renal cell carcinomas (RCCs) are the most common amongst the genitourinary cancers. Annexin A2 (AnxA2) is a multifunctional calcium-regulated phospholipids-binding protein found in a subset of renal neoplasms. Since the tumor cells usually recapitulate embryonic cells, we studied the ontogeny of AnxA2 in developing renal tissues and compared it with those of normal adult RCCs, to better understand their role in renal development and tumorigenesis. AnxA2 immunoexpression was evaluated by immunohistochemistry from various autopsied fetuses, mature kidney and renal cancer tissue specimens. The study showed moderate membranous AnxA2 immunoexpression in the ureteric buds and collecting tubules of fetal kidneys (in all gestational ages) and in the collecting ducts of adult normal renal tissues. It is not often expressed in the proximal convoluted tubules of normal adult kidney; however, younger fetal kidneys show moderate AnxA2 immunoexpression in the proximal convoluted tubules (thought to be the origin of RCC) and the reappearance of strong membranous AnxA2 immunoexpression in the clear cell carcinoma is suggesting a deregulation of the gene during tumorigenesis. The understanding of the AnxA2 molecular immunoexpression pattern during development, its specific function and deregulated immunoexpression in different renal carcinoma types indicates the decisive role of AnxA2 in the cancer progression.

Immuno-Histochemical Assessment of HER2NEU Expression in Gastric Adenocarcinoma in North Karnataka, India

Background and Objectives: Gastric cancer is the fourth most common cancer worldwide and ranks fifth in India. Surgical resection is curative in early stage gastric cancers. Most of the gastric cancers are diagnosed at an advanced stage necessitating multimodality treatment strategies. Based on the ToGA trial, the international regulatory agencies have recently approved trastuzumab in locally advanced and metastatic gastric and gastroesophageal adenocarcinomas expressing HER2. Since there are limited studies from India and no published data available from this part of North Karnataka, we undertook this study to evaluate the frequency of expression of HER2 in gastric and gastroesophageal adenocarcinomas and to correlate it with various clinicopathological variables. Methodology: The study was conducted in the Department of Pathology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka from May 2012 to January 2016. The samples included both endoscopic biopsies and gastrectomies. Histopathological slides from 70 cases were reviewed. Immunohistochemical staining for HER2 was performed in all the cases and Hoffman's gastric cancer scoring system was employed. The results of HER2 expression was correlated with various clinicopathological parameters. Results: HER2 positivity was seen in 16/70 cases (23%). 6 cases (8.5%) were equivocal and 48/70 cases (68.5%) were HER2 negative. HER2 positivity was more common in GEJ cancers and intestinal type of adenocarcinoma. However, it did not correlate with age, gender, grade and stage. Conclusion: HER2 positivity was noted in 23% of the cases. 23.4% of intestinal type and 21.7% of diffuse type were HER2 positive. HER2 positivity did not significantly depend on age, gender, tumour type, grade and stage. Hence, HER2 remains as an independent biomarker and should be tested in all patients of gastric cancer regardless of the clinicopathological findings for offering a personalized treatment.

Pap Smears in Endometrial Adenocarcinoma: Does It Have a Role?

Background: Historically the conventional Pap smear has been an effective screening tool for Carcinoma cervix. However the reporting of benign and malignant endometrial cells on Pap smear has remained controversial. There are very few studies addressing the utility of Pap smears in diagnosing endometrial carcinomas. Objective: To rescreen the Pap smears of patients with endometrial adenocarcinoma for the detection of normal/ atypical endometrial cells and to correlate with clinico-pathological parameters. Methods: The present study was carried out at SDM College of Medical Sciences, Dharwad, Karnataka, India for a period of 7 years. Of the 89 endometrial cancers diagnosed, Pap smear slides were available in 32 patients, which were reviewed and classified as normal cells/ atypical cells. Corresponding biopsy slides were reviewed for tumour type, nuclear grade, myometrial invasion and stage. Statistical tests of independence were applied for selected clinico-pathological parameters. Results: Cervical cytology was normal in nine patients (28.1%) and atypical in 23 patients ( 71.2%). The most common histological type was endometrioid carcinoma in 27 cases (84%). 13 cases(40.5%) had nuclear grade 1 whereas 9 cases(28%) and 10 cases(31.2%) had grades 2 and 3, respectively. Of the 22 cases assessed for invasion and stage, 12 cases had <1/2 of invasion (41.2%) and remaining 10 cases had >1/2 of invasion (58.8%). Early stages (I and II) had 17 cases (77.27%) and advanced stage (III and IV )had 5 cases (23.5 %). Significant correlation was found between post-menopausal status and higher nuclear grades (p<0.05).Conclusion: Pap smear is primarily a screening test for squamous cell carcinoma cervix. If atypical glandular cells are seen, further investigations are required to rule out neoplasia. All women with atypical endometrial cells on Pap tests need endometrial sampling irrespective of age/menstrual status.

Opportunistic screening for cervical cancer in a tertiary hospital in Karnataka, India.

The incidence and mortality of cervical cancer remains high in India even after sixty years of introduction of the Pap smear (cervical cytology) which is an effective means of identifying preinvasive lesions of carcinoma cervix. The morbidity and mortality due to cervical cancer has come down drastically in countries with well established screening programmes at national level. This study aims at screening women for cervical cancer opportunistically during their visit to hospital and to study various types of neoplastic and non-neoplastic lesions of the cervix by cervical smear study (Pap smear study). In the present study, a total of 350 cervical smears were studied. The age of patients ranged from 19 years to 80 years with mean age being 37.5 years. Out of 350 cases, the diagnosis of neoplasia was given in 43 cases and 258 cases were diagnosed as inflammatory smears. Forty-cases were normal and 9 cases were inadequate to evaluate. Forty-three patients who were found to have neoplastic lesions on cytology were referred for further investigations like colposcopy and biopsy to confirm the diagnosis and avail proper treatment. Limitation of the present study was small sample size as all female patients aged between 20 and 60 years visiting hospital were not included in the screening, other screening tests like VIA (visual inspection with acetic acid test) and HPV DNA (human papilloma virus) tests were not done. Until the time centrally organised screening programmes for cervical cancer are established in India, arrangements should be made for hospital based opportunistic screening for all women attending hospital. The cost effectiveness of different screening tests for cervical cancer should be evaluated.

Chiari III Malformation: a rare case with review of literature.

The Chiari Malformation is a neural tube defect involving the posterior cranial fossa and the hind brain, characterized by herniation of the posterior fossa contents below the level of the foramen magnum. Four types were described by Hans Chiari in the late 19th century. Of these, Type III is exceedingly rare. We report the case of Chiari III malformation in a 24-week fetus by the integration of radiologic and autopsy findings which was conspicuous by the absence of high cervical spina bifida and the presence of occipital squama defect.

Idiopathic infantile arterial calcification with thrombotic microangiopathy--a unique case.

Idiopathic Infantile Arterial Calcification (IIAC) is a rare syndrome of unknown cause characterized by disruption and calcification of the internal elastic laminae of fetal arteries with calcium deposits leading to fibrosis and occlusion of the arteries. The diagnosis is often made at post-mortem examination. However, in a few cases it has been detected prenatally as in this case. Fewer than 10 cases of antenatal detection of this condition have been reported in the literature. In our case, thrombotic microangiopathy was an added feature, which has not been reported thus far in the literature to the best of our knowledge.

Intestinal lymphangiectasia - a report of two cases.

Intestinal lymphangiectasia is a rare benign disease characterised by focal or diffuse dilation of the mucosal, submucosal and subserosal lymphatics. Clinically, the patients may present with protein losing enteropathy (PLE), hypoproteinemic oedema, chylous ascites, pleural effusion, acute appendicitis and intestinal obstruction.