Deeper Sections: Its Frequency and Diagnostic Utility in Histopathology of Noncutaneous Small Biopsy Specimen in a Tertiary Hospital in Nepal.

BACKGROUND: Biopsy is an important tool for accurate diagnosis of disease in histopathology which can be examined at multiple levels during microscopic examination. The initial sections may not be representative of the entire biopsy, which leads to frequent request for deeper sections. This study assessed the frequency and diagnostic utility of deeper sections in noncutaneous small biopsy specimens at a tertiary hospital. Material and Methods. All the formalin fixed noncutaneous small biopsy specimens received were processed for grossing followed by tissue processing and embedding. The paraffin-embedded blocks were cut into 3-5 µm sections, fixed in a glass slide, deparaffinised, and then stained with hematoxylin and eosin (H&E) stain as per the standard protocol. Deeper sections were instructed based on microscopic findings of initial slides. The overall frequency of deeper section, its levels of cutting, tissue survival, and outcome were assessed and interpreted for the final diagnosis. RESULTS: A total of 125 cases (26.9%) from 464 samples received were requested for deeper sections. The most frequent deeper sections were from cervix (72 cases) followed by stomach (18 cases) and endometrium (17 cases). The deeper sections were performed most frequently at 4 levels (17.8%) followed by 5 levels (14.8%) and 6 levels (13.3%). Deeper sections revealed nondiagnostic additional features in 28.2%, while 2.2% showed additional diagnostic features. Likewise, 2.2% had tissue segment loss. The overall mean level showing additional features was 6 levels. Tissue survival increased in 13% cases and 1.5% had decreased survival. The most common reason for requesting deeper section was to enhance sensitivity and diagnostic accuracy of disease. CONCLUSIONS: Deeper sections often contribute to final diagnosis. Therefore, deeper sections on biopsies that cannot readily be diagnosed on routine levels are recommended regardless of size of the lesion and there should be uniformity in the practice of deeper sections across the globe.

Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis.

INTRODUCTION: Ductal carcinoma in situ with microinvasion (DCISM); arguably a more aggressive subtype of DCIS, currently has variable recommendations governing its staging and management in the UK. As a result, there is ongoing controversy surrounding the most appropriate management of DCISM, in particular the need of axillary staging. METHOD: A search was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, "ductal carcinoma in situ with microinvasion", sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of metastasis of lymph node; secondary outcome looked at characteristics of DCISM that may affect node positivity. RESULTS: A total of 2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I2 = 61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033). CONCLUSION: Although histologically more advanced than DCIS, DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management, thus may only be an unnecessary and inconvenient additional intervention considering the majority of DCISM diagnoses are made from post-operative pathology samples. A multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.

Simple Bone Cyst of Rib.

Simple bone cyst is a benign lytic lesion usually encountered in children and adolescents. It is a cystic, fluid-filled lesion that usually involves the metaphysis of the long bones. Simple bone cyst of the rib is very rare, with few cases reported in the literature. Here we describe an interesting case of a simple bone cyst of the sixth rib in a 15-year-old girl that was managed successfully with surgical excision.

Blood Component Separation Service: A New Experience in an Institution.

INTRODUCTION: Blood component separation facility began dispatching its blood component units from 21st April 2013 at the new blood component separation service complex at B.P. Koirala Institute of Health Sciences. With the supply of blood components being finite and with the added recognition of a high rate of inappropriate use of blood component services around the world, there is a need to monitor and regulate these services. Our study was conducted to identify blood component utilization pattern in institute and to know about different blood components demand for future preparedness. METHODS: This retrospective study was conducted at B.P. Koirala Institue of Helath Sciences, Dharan, Nepal for blood component dispatched from 21st April, 2013- 12th February, 2014. Blood components requisitions from all clinical department were reviewed regarding the specific component requested, blood group and socio-demographic profile. RESULTS: Among 3054 transfusion units dispatched, 1552 were males, 1498 females and 4 unspecified. Likewise, 1722 were pack cell volume, 808 platelet rich plasma, 523 fresh frozen plasma and 1 cryoprecipitate disptached respectively with majority of A positive blood group demanded from Neonatal and Paediatric Intensive Care Unit ward for Packed Cell Volume was 201 and Fresh Frozen Plasma was 300 followed by emergency ward for Platelet Rich Plasma. About 197 (6.45%) requistions forms lacked the details of requesting department, while some even reveal multiple demands. CONCLUSIONS: Packed Cell Volume of A positive blood group being the predominant blood component requested from Neonatal Intensive Care Unit/Pediatrics Intensive Care Unit ward at the institute making most requests. Finally, these results could be useful for estimating the requirements for our newly establish blood bank to meet the demand in future.

Prevalence of Different Types of Apical Root Canal Morphology and their Treatment Recommendations in an Institute.

INTRODUCTION: Canals can be of different shapes in cross section including round canals, oval canals, long oval canals or ribbon shaped canals. Recesses of nonround canals may not be included in the round preparation created by rotary instruments and thus they remain unprepared. The aim of this study included determination of shape and taper of the apical root canal based on diameter at different levels. Measurement of the diameter of the root canal at one, two and three mm cross sections from the apex of the tooth were done such that apical instrumentation in root canal treatment could be modified based on the results obtained. METHODS: This was a cross sectional study which used convenient sampling technique to determine the sample size. Seventy extracted teeth were sectioned horizontally at one, two and three millimeter from the apex using the diamond disc which was observed under trinocular research microscope for the determination of diameter of root canal under 10x magnification. Digital images of the sections were taken by a camera attached to the research microscope and analysis done using DigiPro 4.0 software. RESULTS: The most common canal configuration was oval. The taper of the canals was 25% in mesial root and 20% in distal in bucco-lingual orientation and 14% in mesial root and 15% in distal in mesio-distal orientation. CONCLUSIONS: The most prevalent canal configuration in this study was non round, however, most of the rotary instruments tend to prepare root canals into round shape making their use questionable. The taper of the root canals was found to be higher in our study than what most of the shaping instruments have to offer. So it would be advisable to consider this fact while selecting instruments and preparing these non-round canals as far as the Nepalese subpopulation is considered.

Accuracy of Frozen Section with Histopathological Report in an Institute.

INTRODUCTION: Frozen section helps in rapid intra-operative diagnosis. It is commonly used during surgical procedures to detect malignancy so that modifications of surgery can be decided at the time of surgery on the table. Frozen section is also performed for evaluation of surgical margins and detection of lymph node metastasis. In addition it is applied for detection of unknown pathological processes.The objective of this study was to assess the accuracy of frozen section diagnosis in comparison to gold standard histopathological diagnosis and to find concordance and discordance rate of frozen section with histopathological report. METHODS: This was a cross sectional study of 41 frozen section samples done in the department of pathology of BP Koirala Institute of Health Sciences from September 2014 to August 2015. All frozen section samples with their permanent tissue samples sent for final histopathological evaluation were included in the study. RESULTS: The overall accuracy of frozen section diagnosis was 97%. The sensitivity was 94%, specificity was 87%, positive predictive value was 90% and negative predictive value was 93%. The concordance rate was 90.2% and the discordance rate was 9.8%. CONCLUSIONS: The results of frozen section varied in different organ systems and the common cause of discrepancy in our study were the gross sampling error and the interpretational error.

Is fine needle aspiration cytology (FNAC) useful in skin adnexal masses? A study on 5 cases of pilomatixoma.

Superficial cutaneous/subcutaneous nodules, caused by a variety of inflammatory, benign and malignant pathology of diverse origin, are tempting lesion for fine needle aspiration cytology (FNAC). Amongst these, adnexal tumor show considerable overlap, both in clinical manifestation as well as in histopathology. Archieval records of clinical findings, FNAC smears and reports pertaining to 5 histologically proved cases of pilomatricoma (PMX) were analyzed. Different cytological findings were graded + to +++. Pre FNAC clinical diagnoses were sebaceous cyst, tuberculous lymphadenopathy, dermatofibroma, reactive lymphadenopathy and lipoma. PMX was diagnosed on FNAC in 3 cases on finding groups of basaloid cells, ghost epithelial cells, pink fibrillary material and calcium deposits. Other cases were diagnosed as epidermal inclusion cyst with the differential diagnosis of well differentiated squamous cell carcinoma and skin appendageal tumor of undetermined origin in one case each. In all the cases, FNAC established epithelial nature of the lesion, excluding clinically mimicking inflammatory/neoplastic lesions of other origin. FNAC should be followed by excision biopsy to accurately type the epithelial neoplasm.

An unusual culprit: simple angioplasty for a complex disease.

We present the case of an atypical presentation of myelofibrosis presenting with acute inferior-wall ST-elevation myocardial infarction. Besides cigarette smoking, the patient had no known traditional cardiovascular risk factors like diabetes, hypertension, or a sedentary lifestyle. He, however, had a hypercoagulable state due to a myeloproliferative neoplasm. This demonstrates that the typical presentation of a common emergency condition may involve more complex underlying illness, which when identified, may change the approach to the management of the patient for a more optimal outcome.

Clinicopathological features and complications of thyroid operations: a single centre experience.

Thyroid surgery evolution is important with a lots of hurdles faced by many surgeons to reach the present stage. The complications from the olden days reduced with improvement in understanding the disease process, development of antibiotics, anaesthesia and now restricted mainly to hypoparathyroidism and recurrent laryngeal nerve injuries. A retrospective analysis of thyroid surgeries performed at BP Koirala Institute of Health Sciences centre from 2007 to 2011 Clinicopathological features and complications were analyzed. Among 203 patients who underwent surgery for thyroid operations, 53 were malignant and 150 were benign cases. Hemithyroidectomy was the most common procedure performed (118 cases). Papillary thyroid cancer was the most common malignant lesion and colloid goiter the most common benign lesion. Postoperative complications occurred in 12 patients-infection in two patients, bleeding requiring reexploration in one patient, hypocalcemia in 6 (5-transient and 1-permanent) and hoarseness of voice in three patients (2-temporary and 1-permanent). FNAC is an easy, cost effective, reliable investigation in experienced hands. Reoperation, primary stage of the tumor and central node dissection are associated with increased complication rates.

Role of fine needle aspiration cytology in diagnosis of filarial infestation.

Filariasis is a tropical disease transmitted by the Culex mosquitoes. The diagnosis of it is conventionally made by demonstrating microfilariae in the peripheral blood smear. However; microfilariae and adult filarial worm have been incidentally detected in fine needle aspirates of various lesions in clinically unsuspected cases. The cases of filariasis diagnosed by fine needle aspiration cytology (FNAC) were retrieved from the archives of the Cytopathology laboratory between the periods of January 1998 to February 2009. Both Papanicolaou- and May-Grunwald-Giemsa-stained smears were available in all the cases. A total of 26 diagnosed cases of filariasis were found, of which 19 were related to funiculo-epididymitis, four presented with breast lump, and three cases with lymphadenopathy. Smears revealed fragments of adult worm in 12 cases including 10 gravid female worm containing eggs and microfilariae and two male adult worm; whereas in remaining 14 cases only microfilariae or eggs were seen. Unfertilized eggs were seen in three cases and fertilized eggs were seen in five cases. Tissue response in the form of eosinophils in 16 cases, acute inflammatory exudate in five cases, macrophages in 22 cases, epitheloid cell granulomas in five cases, giant cells in four cases, lymphocytes in 10 cases, and plasma cells in three cases were seen. Adherence of polymorphonuclear leukocytes, eosinophils, and epithelioid cells were observed in four cases. On conclusion, filaria may affect the epididymis, spermatic cord, breast, and lymph node, and the accurate diagnosis can be easily and conveniently achieved by FNAC without any requirement of biopsy.

Clinical features and histological patterns of lupus nephritis in Eastern Nepal.

To determine the clinical profile and patterns of lupus nephritis patients in Eastern Nepal, we studied 38 patients fulfilling the 1982 revised criteria of American College of Rheumatology for systemic lupus erythematous (SLE), followed up from January 2004 to January 2008. Arthritis was a common initial feature in addition to variable cutaneous, cardiac, pulmonary and neuropsychiatric manifestations. Renal biopsy showed grade 1 changes in 5 (13.5%) patients, grade 2 changes in 13 (35.1%) patients, grade 3 changes in 9 (24.3%) patients, grade 4 changes in 7 (18.9%) patients, grade 5 changes in 2 (5.4%) patients, and grade 6 changes in 2.7% patients. Antinuclear antibody (ANA) assay and anti-ds DNA were positive in 78.4 and 81.1%, respectively. We conclude that mesangial proliferative glomerulonephritis (grade 2) was the most common pattern of lupus nephritis encountered in our study. Timely diagnosis and treatment may improve the overall patients' survival.

Benign cystic mesothelioma of the peritoneum in a child-case report and review of the literature.

A 4-year old female child presented with clinical features of ascites that, on computed tomography, showed a huge thin-walled cystic lesion in the peritoneum. Laparotomy confirmed a unilocular cyst in the peritoneum adhered to the parietal wall and bowel but not originating from any internal organs. Histopathologic examination of the cyst wall was consistent with the diagnosis of benign mesothelioma. Benign cystic mesothelioma of the peritoneum has rarely been reported in children.

Primary laryngeal leishmaniasis: a rare case report.

Laryngeal leishmaniasis is extremely rare. We report a case of primary laryngeal leishmaniasis in a 70-year-old male who was admitted with complaints of gradual progressive hoarseness of the voice, dyspnea, cough for the past 3 months and noisy breathing for the past 5 days. An X-ray of the soft tissue of the neck showed a prevertebral soft tissue mass causing narrowing of the airway at the C6-C7 vertebral level. A computerized tomography (CT) scan showed a soft tissue mass in the subglottic region causing significant narrowing of the airway. A direct laryngoscopy showed a pinkish-white, friable mass involving the subglottic region and the anterior half of the vocal cords. With the clinical suspicion of malignancy, an endoscopic biopsy was done. A histopathological examination showed diffuse mixed inflammatory cell infiltrate in subepithelium with numerous Leishmania donovani bodies in the cytoplasm of histiocytes.

Crohn disease in Nepal: true rarity or gross underdiagnosis?

Gross and histopathological examination of a resected segment of ileum in a 72-year-old man with the preoperative diagnosis of small intestinal perforation peritonitis revealed the first-ever diagnosed case of Crohn Disease (CD) at the B P Koirala Institute of Health Sciences, Dharan, Nepal. In view of the recent reports on rising incidence of CD in neighbouring Asian countries, it was decided to perform an exhaustive literature search to find out the documented prevalence of CD in Nepal. It was surprising to find only a single case of CD from Nepal, occurring in the year 1980, to be documented in English literature. Further, the index case of CD presenting with acute abdomen is of interest since only about 100 cases of CD with small intestinal perforation have been so far reported worldwide.

Diagnosis of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) by fine needle aspiration cytology.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a rare benign disease of unknown etiology presenting with massive lymphadenopathy. We report four cases of this disease retrieved from the archives of cytopathology laboratory, BPKIHS, Dharan, Nepal, during the period of January 2002 to October 2007. The cytologic morphology revealed lymphocytes, plasma cells, and single to multinucleated histiocytes with well preserved lymphocytes in their cytoplasm (emperipolesis or lymphophagocytosis). It is concluded that FNAC is a useful and reliable tool for the diagnosis of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) and biopsy can be avoided in these patients, thereby reducing patient inconvenience and health care cost.