Inguinal Lymphadenopathy: A Rare Initial Site of Metastatic Lung Carcinoma.

Solid-organ tumors involving inguinal lymph nodes commonly originate from genitourinary tract, skin, ano-rectum, or the urinary bladder. Thus, solitary metastatic involvement of inguinal lymph nodes from extra-abdominal primary malignancies is extremely rare. However, involvement of nonregional lymph nodes upstages the disease to M1b with poor prognosis. Identification of the site of metastases is extremely crucial for deciding the management of patients. This is the first ever case reported of de-novo or synchronous oligometastatic disease of carcinoma lung with inguinal lymph node involvement. In addition, it highlights the importance of 18 FDG PET-CT to diagnose the involvement of inguinal lymph node that was further proved on fine needle aspiration cytology. Only two such cases of lung cancer have been reported, but both of them had inguinal lymph node during the follow-up and none was present at initial presentation.

Microvillous Inclusion Disease as a Cause of Protracted Diarrhea.

Microvillous inclusion disease (MVID), also known as congenital microvillus atrophy, was first described by Davidson et al. in 1978. Till date, only a handful of cases with MVID have been described in English literature. It is an autosomal recessive disorder with no sex predisposition and more commonly noted in countries with prevalent consanguineous marriages. These patients usually present with intractable secretory diarrhea in early days of life. The pathognomonic findings of MVID are villous atrophy along with the formation of intracellular microvillous inclusions on electron microscopy. Till date, no curative therapy exists, and prognosis mainly depends upon parenteral nutrition. Small bowel transplantation is one of the treatment options. Clinician and pathologist should consider the possibility of MVID in the differential diagnosis of chronic intractable diarrhea in an infant. Herein, authors are describing a case of intractable diarrhea with MVID phenotype diagnosed in a 3-mo-old male child who presented with intractable diarrhea in an outside hospital, and the diagnostic workup was performed by the authors on endoscopic biopsy sample.

Histological assessment & use of immunohistochemical markers for detection of dysplasia in Barrett's esophageal mucosa.

BACKGROUND: Histological assessment of dysplasia in Barrett's esophagus (BE) has high inter-observer variability. Hence, use of ancillary markers for early detection of dysplasia in BE is an important clinical question. METHODS: In this retrospective study consecutive cases of BE (n = 59), over a period of 4 years were included. Hematoxylin and eosin stained sections were reviewed independently by 3 senior qualified pathologists, who graded the dysplasia according to the Vienna Classification system and inter-observer agreement was analysed using the Kappa statistics. Subsequently Alpha-Methyl Acyl-CoA Racemase (AMACR), p53, CyclinD1, ß-catenin, H2AX and M30 immunohistochemical (IHC) stains were examined on the following disease categories: BE with no dysplasia [NFD] (45), BE with indefinite for dysplasia (IFD) (4), low grade dysplasia (LGD) (3), high grade dysplasia (HGD) (2) and in adenocarcinomas (5). H score was calculated by adding up products of different grades of stain distribution and stain intensities (range of scores 0-300). RESULTS: Among the 3 pathologists, overall agreement was poor (k 0.06; 95% CI -0.089 to 0.145), with highest disagreement noted for differentiating the LGD and IFDs (k = 0.21). After revising the histological criteria, the kappa improved to 0.53. Among the IHC stains performed, p53, ß-catenin, H2AX and M30 stains were significantly useful to differentiate between IFD and LGD (P values: 0.04, 0.004, 0.05 & 0.04, respectively). AMACR and ß-catenin stains though were up-regulated in HGD/adenocarcinomas than in other categories, their expression were not statistically different between the IFD and LGDs. CONCLUSIONS: A detail histological scoring system may bring uniformity in histological interpretation of dysplasia in BE. Using a combined panel of IHC stains seems helpful in detection of dysplasia in BE, especially to differentiate the IFD and LGD changes in BE.

Immunohistochemical Expression of Antitissue Transglutaminase 2 in Tissue Injuries: An Interpretation Beyond Celiac Disease.

Tissue transglutaminase 2 enzyme plays a diverse role in intracellular and extracellular functioning. Aberrant expression of anti-TG2 antibody has recently been proposed for extraintestinal identification of celiac disease (CeD), but its utility is questionable. To examine whether anti-TG2 immunohistochemical (IHC) staining can be of diagnostic value in identifying extraintestinal involvement in CeD, tissue blocks of patients with IgA nephropathies (IgAN), minimal change disease, membranous glomerulonephritis, membrano-proliferative glomerulonephritis, normal kidney, intestinal biopsies from CeD, tropical sprue, nonspecific duodenitis, and inflammatory bowel disease; liver biopsies from patients with chronic hepatitis B and C, acute liver failure (ALF), and CeD-associated liver diseases were retrieved and subjected to IHC staining for anti-tissue transglutaminase 2 enzyme. H-score was calculated by multiplying the area of positivity and stain intensity. Anti-TG2 stain H-scores were almost similar in IgAN and non-IgANs (H-score 6.31±3 vs. 7.03±2.7); however, H-scores in both of these groups were significantly higher than in normal renal parenchyma (1.6±1.5). Only 6.2% patients with IgAN with anti-TG2 immunostain positivity showed a positive anti-tTG antibody serology and villous abnormalities, suggestive of CeD. Intestinal biopsies from patients with CeD, tropical sprue, nonspecific duodenitis, and inflammatory bowel disease also showed high anti-TG2 H-scores, with no statistically significant differences. Liver biopsies from patients with both ALF, as well as chronic liver diseases showed high anti-TG2 H-scores; with highest stain expression in ALF. In conclusion, IHC expression of anti-TG2 stain correlates with both acute and chronic tissue injuries, irrespective of etiology and organ involvement. It is not a reliable marker for diagnosis of CeD.

Patients with mild enteropathy have apoptotic injury of enterocytes similar to that in advanced enteropathy in celiac disease.

BACKGROUND: Severity of villous atrophy in celiac disease (CeD) is the cumulative effect of enterocyte loss and cell regeneration. Gluten-free diet has been shown to benefit even in patients having a positive anti-tissue transglutaminase (tTG) antibody titre and mild enteropathy. AIM: We explored the balance between mucosal apoptotic enterocyte loss and cell regeneration in mild and advanced enteropathies. METHODS: Duodenal biopsies from patients with mild enteropathy (Marsh grade 0 and 1) (n=26), advanced enteropathy (Marsh grade ≥2) (n=41) and control biopsies (n=12) were subjected to immunohistochemical staining for end-apoptotic markers (M30, H2AX); markers of cell death (perforin, annexin V); and cell proliferation (Ki67). Composite H-scores based on the intensity and distribution of markers were compared. RESULTS: End-apoptotic markers and marker of cell death (perforin) were significantly up-regulated in both mild and advanced enteropathies, in comparison to controls; without any difference between mild and advanced enteropathies. Ki67 labelling index was significantly higher in crypts of mild enteropathy, in comparison to controls, suggesting maintained regenerative activity in the former. CONCLUSIONS: Even in patients with mild enteropathy, the rate of apoptosis is similar to those with advanced enteropathy. These findings suggest the necessity of reviewing the existing practice of not treating patients with mild enteropathy.

Small cell osteosarcoma of the parietal region: a unique case at an unusual site.

Small cell osteosarcoma is a rare tumour that histologically mimics Ewing sarcoma, mesenchymal chondrosarcoma and lymphoma, the presence of osteoid being diagnostic. This variant needs different management protocol, being non-radiosensitive and behaving more aggressively than conventional osteosarcoma. The aim of this article is to highlight such an entity at an unusual site--the parietal region--with unique diagnostic, treatment and prognostic considerations in a 16-year-old girl.

Interpretation of ileal biopsies.

The ileum is one of the most common sites of intestine to undergo endoscopic biopsy. However, even with the experienced histopathologists, a definite diagnosis can be achieved only in 18% cases. Lack of knowledge about proper tissue handling, tissue orientation, overlapping histological findings, and lack of a standard algorithm based approach results in this low diagnostic yield. In this review article, we have tried to discuss these aspects and give a clear picture how to approach the ileal lesions. It would help the surgical pathologists in effectively interpreting the lesions and to identify the common pitfalls.