Current practice in handling and reporting needle biopsies: A hospital-based survey.

CONTEXT: Core-needle biopsy (CNB) is a minimally invasive screening and diagnostic tool which provides intact tissue fragments for histopathological examination. AIMS: This study was conducted to review the current practices of handling and reporting CNBs performed for core-needle biopsies from four organ systems which are frequently encountered in our institution. These include breast, prostate, soft tissues, and lymph nodes. SETTINGS AND DESIGN: This was a retrospective study conducted at a tertiary care hospital. MATERIALS AND METHODS: CNB reports of breast, prostate, soft tissue, and lymph nodes were accessed and categorized based on the site of biopsy, number, and average length of the cores. The CNB reports were categorized into diagnostic or nondiagnostic. In case of diagnosis of malignancy, reports were recorded as structured or nonstructured reports. STATISTICAL ANALYSIS USED: Fisher's exact test and Chi-square tests were applied to check the significance of the results obtained on comparing the number of cores and size of cores with the outcome of report. RESULTS: Out of 16,300 surgical pathology specimens received, 400 were CNBs comprising breast (n = 211), prostate (n = 108), soft tissue (n = 50), and lymph node (n = 31). Majority of the CNBs had 2-5 cores and the size of the core was ≥0.5 cm, which accounted for most of the reports which were diagnostic. There was a lack of clinical and radiological detail in many of the cases. Out of the malignant cases diagnosed, structured reports were given in 30% of breast, 79.3% of prostate, 41.7% soft tissue, and 60% of lymph node needle biopsies. CONCLUSIONS: The audit helped to identify areas of improvement in CNB services.

Intestinal GIST masquerading as an ovarian mass: Diagnosed on FNAC.

The preoperative diagnosis of metastatic intestinal gastrointestinal stromal tumors (GIST) on cytology can be quite difficult at times. The present case characterizes the cytomorphological and immunocytochemical features of GIST, emphasizing the utility of fine-needle aspiration cytology (FNAC) in the evaluation of spindle cell tumors of gastrointestinal tract. An accurate and early diagnosis of GIST affects the treatment, primarily allowing the use of tyrosine kinase inhibitors in unresectable or metastatic cases. Presence of highly cellular fragments of spindle-to-oval cells with variable degree of pleomorphism, atypia, and necrosis supplemented by immunocytochemistry can render a cytological diagnosis of GIST in dilemmatic clinical situations. Our case highlights the diagnostic role of FNAC in the evaluation of a pelvic mass, which was clinicoradiologically misdiagnosed as ovarian carcinoma.

Fine needle aspiration biopsy: An entrustable professional activity in cytopathology postgraduate training.

CONTEXT: In the context of competency-based medical education being advocated worldwide, fine needle aspiration biopsy (FNAB) is considered as an entrustable professional activity (EPA). There is no information regarding how much time and training are required to achieve a "competent level" for performing and documenting FNAB in the Indian context. AIM: To determine the time taken by an average postgraduate pathology trainee to become competent in performing FNAB with respect to history taking, clinical examination, and fine needle aspirate adequacy. SETTINGS AND DESIGN: A descriptive, retrospective, chart-based audit was conducted in the Department of Pathology. MATERIALS AND METHODS: FNAB chart records documented during 3 years of postgraduate training by a cohort of 13 postgraduate (PG) resident trainees admitted in 2010 were included in the study. Adequacy rates and criteria for adequacy were defined for the purpose of the study. STATISTICAL ANALYSIS: Data was entered in MS Excel and analyzed using the Statistical Package for the Social Sciences version 20.0. The adequacy rates are presented as percentages and time taken to achieve adequacy rates as median values. RESULTS: A total of 3272 charts were audited. Median time taken to achieve 85% adequacy rate for history taking, for clinical examination by the first and the second criteria, and for FNAB were 1 month, 1 month and 3.5 months, and 1 month, respectively. CONCLUSIONS: Although the mean time taken to achieve 85% adequacy rates for FNAB was 1 month, there was wide variation in the time durations between the residents to achieve this level.

Multifocal Tuberculosis Verrucosa Cutis: A Manifestation Extraordinary of Reactivation Secondary Tuberculosis.

A BCG (Bacillus Calmette-Guérin)-vaccinated 78-year-old man, a native Indian, reported with numerous asymptomatic, peanut-sized, dirty gray, elevated eruptions of 1 year's duration appearing over apparently normal skin on the upper and lower extremities (Figure 1). The onset of the eruptions had been sudden, but they had progressed slowly. A history of cough and/or expectoration, evening rise of temperature, night sweats, or loss of appetite and weight was denied.

Clinical audit of ultrasound guided fine needle aspiration in a general cytopathology service.

BACKGROUND: Studies on ultrasonography (USG) guided fine needle aspiration cytology (FNAC) have been conducted in specialized settings such as thyroid, breast, and intra-abdominal aspirates. There is a paucity of literature on the practices of guided FNAC in a general cytopathology service. AIM: The aim was to determine prevailing practices of USG guided FNAC in a general cytopathology service of a teaching hospital. SETTINGS AND DESIGN: Metropolitan hospital, clinical audit. MATERIALS AND METHODS: Audit of 112 USG guided percutaneous FNAC done over 12 months. STATISTICAL ANALYSIS: Data were coded, entered in an excel spreadsheet and analyzed by translating into percentages and proportions. RESULTS: The 112 guided FNACs included constituted 36 thyroid (32.14%), 45 intra-abdominal (40.17%), 11 breast (9.82%), 10 superficial lymph node (8.92%) and 10 soft tissue and miscellaneous (8.92%) lesions. Previous freehand FNAC was documented on the requisition forms in 14 cases. The reports were: Inadequate 33 (29.46%), nondiagnostic descriptive 35 (31.25%) or diagnostic 44 (39.28%). Inadequacy rates of aspirates from thyroid were 11 (30.56%) breast were 2 (18.18%), and intra-abdominal lesions were 13 (28.88%). Majority of the reports were nonstructured: 108 (96.42%) and nonrecommendatory: 101 (90.17%). CONCLUSIONS: Reporting practices varied and did not conform to a uniform structure. The inadequacy rates of breast and thyroid aspirates were comparable to the rates in the literature. Comparable studies were not available for intra-abdominal aspirates.

Is it Askin Tumour? A Question You Must Ask Even in Elderly.

Primitive neuroectodermal tumour of chest wall has been given the name Askin tumour after FB Askin who first reported this distinctive clinicopathologic entity in 1979. Most of the patients are either children or adolescents, however, rarely it may affect older patients. This case report emphasizes on the diagnostic approach to this rare tumour and underlines the importance of keeping it in the differential diagnosis even in elderly patients. Since it is an aggressive tumour, a high index of suspicion is required to make a timely diagnosis.

Implementation of the bethesda system for reporting thyroid cytopathology: interobserver concordance and reclassification of previously inconclusive aspirates.

Standardized diagnostic terminology was introduced by the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) in an effort to bring uniformity to the reporting of thyroid cytopathology, provide more defined categories to enable clinical management, and minimize the number of inconclusive cases. Previous studies indicate that the BSRTC is a reliable and valid reporting system for thyroid cytology. This study was conducted to compare the concordance between observers with varying cytopathology experience when using the BSRTC, and to assess the impact on the number of inconclusive reports. A retrospective study was conducted in two parts. In the first part 415 thyroid aspirates were reviewed independently by three observers with different experience levels. The aspirates were reclassified according to BSRTC and agreement scores were calculated using kappa statistics. In the second part 39 inconclusive aspirates signed out previously, were recategorized according to BSRTC. Agreement level between the three observers using the BSRTC was strong (Fleiss' kappa score = 0.6561). Inconclusive cases could be categorized further with BSRTC; there was significant reduction in the number of inconclusive diagnoses (P < 0.001). Strong interobserver agreement with BSRTC indicates the ease with which the new system can be applied in regular reporting. Significant reduction in the number of inconclusive diagnoses results in better communication with the clinician and improved risk assessment for thyroid aspirates.

Immunocytochemical detection of mycobacterial antigen in extrapulmonary tuberculosis.

The aim of the study is to determine whether immunostaining for mycobacterial antigen can contribute to the cytological diagnosis of extrapulmonary tuberculosis (EPTB). The study was carried out on aspirated material of lymph nodes, and other accessible sites, from 65 patients with clinical diagnosis of tuberculosis (TB). Twenty patients, diagnosed by fine-needle aspiration, with non-tuberculous granulomas served as controls. The diagnosis of TB was based on the demonstration of acid-fast bacilli (AFB), culture positivity for Mycobacterium tuberculosis (M. tuberculosis), or response to treatment with standard anti-tubercular therapy. Immunostaining was done using polyclonal antibody to mycobacteria. AFB positivity by Ziehl Neelsen (ZN) staining was 21%, 65.38%, and 68% respectively in Pattern 1 (granulomas alone), in Pattern 2 (granulomas with necrosis), and in Pattern 3 (necrosis alone). Overall AFB positivity was 56.92%. Twenty-eight of 65 cases were negative for AFB on direct smear. Culture was positive in 46% (13/28). Sensitivity and specificity of immunostaining were 96.92% (63/65) and 95%, respectively. Immunoreactivity was seen in 26 (92.8%) of 28 cases which were negative by ZN staining. Except in the case of leprosy, in which cross reactivity was seen, there was no immunoreactivity in the control group. Immunocytochemistry (ICC) had high sensitivity (96.2%) and specificity (95%) in the diagnosis of EPTB. ICC may be a useful adjunct to evaluation of cytomorphology and ZN staining.

Cytokeratin-20 immunocytochemistry in voided urine cytology and its comparison with nuclear matrix protein-22 and urine cytology in the detection of urothelial carcinoma.

This study was done on 59 subjects (42 urinary bladder carcinoma patients and 17 non-neoplastic controls). Urine cytology and bladder chek NMP22 test was done on all cases. CK20 immunostaining was performed on archived papanicolaou stained urine cytology smears in 34 cases (27 bladder carcinoma and 7 negative controls). Results of all three tests (cytology, NMP22, and CK20 immunostaining) were compared with histopathology to evaluate the accuracy of individual test. The combination of cytology and NMP22 was compared with combination of cytology and CK20 immunostaining for detection of bladder carcinoma. NMP22 had sensitivity of 92.9% and specificity of 70.6%, as compared with voided urine cytology (sensitivity of 76.2% and specificity of 76.5%) and CK20 immunostaining (sensitivity of 70.4% and specificity of 71.4%). Combination of cytology and NMP22 gave better results (sensitivity of 88.1% and specificity of 88.2%) than combination of cytology and CK20 immunostaining or any other test in isolation.

Exclusive plaque psoriasis of the lips: efficacy of combination therapy of topical tacrolimus, calcipotriol, and betamethasone dipropionate.

A 16-year-old unmarried woman presented with recurrent cracking of the lips indicated by the appearance of grayish white flakes since October 2004, which, in due course, shed off leaving behind an apparently normal mucous membrane. Chewing roasted corn treated with salt and lemon (bhutta) initially caused the lesions. Ever since, it has been a cause of its exacerbation. She never had any relief with either systemic or topical treatment. In fact, an obsession had overtaken her, resulting in a psychological setback. She denied regular drug use for any other ailment. Her menstrual cycle was normal. There was a positive history of psoriasis in her mother. Examination of the lips was conspicuous. It was marked by the presence of a well-circumscribed, moist, raised plaque (Figure 1). Its surface was irregular, with elevation and depression. It was made up of thick, grayish white scales, which were arranged in layers; however, Grattage/Auspitz sign could not be elicited. Fissuring was prominent but the buccal mucosa, surface of the tongue, gingiva, and palate were normal. The clinical examination did not reveal any evidence of skin and/or nail psoriasis/psoriatic arthropathy or any other systemic abnormality. Blood examination including total and differential leukocyte count, complete hemogram, and liver and renal function tests were normal. Biopsy of the representative lesion was subjected to serial sections. They were stained with hematoxylin-eosin to work up microscopic pathology. It revealed the presence of mounds of parakeratosis with numerous neutrophilic Munro microabscesses (Figure 2). Submucosal vessels were dilated and congested. Periodic-acid-Schiff (PAS) stain revealed fungal hyphae and spores within the parakeratotic layer. Colonies of Gram-positive cocci were also demonstrated on the surface of the mucosa. She was administered combination therapy, comprising topical tacrolimus (0.1%) ointment and calcipotirol hydrate (50 microg/g) plus betmethasone dipropionate (0.5 mg/g) twice a day for 7 days. A single bolus dose of fluconazole 450 mg orally was also administered. The response to treatment was favorable and the lesions showed regression (Figure 3).

Cutaneous tuberculosis: a diagnostic dilemma--laboratory inputs.

Bacterial cultures are the gold standard for diagnosing cutaneous tuberculosis, but there are limitations, despite the advances embracing the innovative technologies, including interferon yrelease assays, enzyme-linked immunoabsorbant assay, and molecular diagnostics, in addition to conventional skin tests and microscopic pathology. The results and their interpretation of cultures are reviewed for use in day-to-day practice.

A cytomorphological study of secretions in breast cancer.

BACKGROUND: Secretions are seen in a range of breast cancer that includes invasive ductal carcinoma, mucinous carcinoma and secretory carcinoma. Evaluation of the quantity and location of secretions and the contours of the cell clusters complement cell morphology could improve diagnostic cytopathological criteria. AIM: To identify the range of breast carcinomas with secretions on fine-needle aspiration. MATERIALS AND METHODS: A retrospective study of 160 patients with breast carcinoma was carried out. The tumors were typed by evaluating the quantity and location of secretions, cellularity and nuclear grade. RESULTS: Secretions were seen in 16 of 160 breast carcinomas. Eleven were invasive ductal carcinoma (IDC), three were mucinous and two were secretory carcinomas. In IDC, minimal intracytoplasmic secretions were seen in 10, nuclear grades of 2 and 3 in 9, cell clusters with irregular margins in 6, and necrosis in 4. All mucinous and secretory carcinomas were nuclear grade 1. Extensive extracellular secretions and cell clusters with rounded contours were seen in mucinous carcinomas. In secretory carcinomas, the secretions were predominantly intracellular; stringy vasculature was a unique feature. CONCLUSION: Secretions in breast cancer are seen in a range of lesions that include IDC, mucinous, and secretory carcinomas. The quantity and location of secretions in breast cancer offer clues to differentiating these.

Mid-arm and epitrochlear lymphadenopathy: a clinico-radiological surprise.

An 18-year-old man presented with multiple subcutaneous nodules over the anteromedial aspect of his right lower arm. Based on findings of sonography, histopathology, circulating filarial antigen test, and therapeutic response to diethylcarbazine, a diagnosis of filarial lymphadenopathy affecting mid-arm nodes and epitrochlear lymph nodes was made.

Usefulness of NMP22 as an adjunct to a typical urine cytology and low-grade urothelial carcinoma.

The usefulness of urine cytology combined with NMP22 was evaluated for the primary diagnosis of urothelial carcinoma. Of 53 clinically suspected patients, histopathological diagnoses were low-grade urothelial carcinoma (25), high-grade urothelial carcinoma (13), and inflammatory lesions (15). Cytology was positive in 25 and negative in 14 patients. Fourteen of 25 low-grade urothelial carcinoma and 11/13 high-grade urothelial carcinoma were diagnosed correctly on urine cytology. Atypical cells seen in 14 patients were categorized as inconclusive for malignancy. The overall sensitivity of urine cytology was 65.8%, whereas specificity was 100%. NMP22 was positive in 33 patients. Of these 30, 18 low-grade and 12 high-grade lesions were true positive. Of the 20 NMP22, eight negative cases were false-negative. Ten of 15 with negative histopathology were also negative for NMP22, three were false-positive, and two showed erratic results. Nine of 14 cases with atypical urine cytology were positive for NMP22. Eight of these showed low-grade carcinoma on histopathology. The sensitivity of BladderChek NMP22 test was 79%, whereas specificity was 80%. NMP22 BladderChek test is a useful adjunct to urine cytology in atypical and low-grade carcinoma.

Chondrodermatitis nodularis.

Chondrodermatitis nodularis is a common condition in clinical practice but rarely discussed or reported in the literature. It most often affects the helices and antihelices of the ear. It is either uni- or bilateral. Injury usually initiates or triggers the disease. Microscopic pathology supplements the clinical diagnosis. Its etiopathogenesis points to this being a transepidermal elimination or perforating dermatoses.

Histoid leprosy: histopathological connotations' relevance in contemporary context.

A reappraisal of histoid leprosy in the contemporary postglobal leprosy elimination era, a fallout of the World Health Organization leprosy elimination program, is succinctly outlined. The cardinal clinical expression, differential clinical diagnosis, the cytodiagnosis, and diagnostic salient histopathological features are highlighted.

Koilocytosis: correlations with high-risk HPV and its comparison on tissue sections and cytology, urothelial carcinoma.

The aim of this study were (1) To correlate koilocytosis with high risk HPV(HrHPV) DNA in urinary bladder carcinoma and (2) To compare detection of koilocytosis on tissue sections and urine cytology. Biopsy and cytologic specimens from 33 patients of urinary bladder carcinoma were analyzed. HPV DNA was detected by PCR on biopsy specimens using consensus primers MY09 and MY11. Koilocytosis was assessed both on tissue sections and urine cytology. HrHPV DNA was found in 14 of 33 bladder carcinoma. Koilocytosis was seen in tissue sections from 13 patients. Eleven of these were HrHPV DNA positive (positive predictive value 84.6%). Koilocytosis was seen in urine cytology in three patients. All three were positive for HrHPV DNA. To conclude koilocytosis is a good morphological marker for HrHPV DNA in the urothelium. Tissue sections are better than cytologic smears for detection of koilocytes.

Abdominal tuberculosis: a histopathological study with special reference to intestinal perforation and mesenteric vasculopathy.

BACKGROUND: Along with the increased incidence of pulmonary tuberculosis in parallel with the increase in population in various parts of the world, in recent years, the incidence of abdominal tuberculosis has also increased. The pathogenetic events in intestinal tuberculosis, which culminate in ulcer formation, perforation, and stricture, still have to be identified. AIM: To correlate the gross and microscopic features in intestinal tuberculosis, in particular tuberculous perforation with changes in mesenteric vasculature. PATIENTS AND METHODS: A one-year prospective study of excised/resected tissues from patients with abdominal tuberculosis requiring surgical intervention was conducted. Tissues from fifty-six patients were included in the study-of which 36 were resected intestinal segments and 20 were intestinal and lymph node biopsies. Hematoxylin and Eosin and Ziehl-Neelsen stains were used for histopathological examination. RESULTS: Tuberculous enteritis was found to be present in 49 of the 56 patients (87.5%) (ileum being the site most commonly affected), while nodal involvement was seen in 39 (69.6%) patients. Perforations were present in 39 out of 49 (79.6%) intestinal tissues; most being solitary and ileum was the commonest site. Typical epithelioid cell granulomas were seen in the intestine and lymph nodes, with caseation being more prevalent in the latter. The mesenteric vasculature was frequently involved by granulomatous inflammation, with intravascular organizing thrombus being present in 30% of the resected specimens with perforation. Acid fast bacilli were demonstrated in the tissue sections of 37.5% of the patients. AFB positivity was higher in caseating granulomas. CONCLUSION: Involvement of mesenteric vasculature by granulomatous inflammation was commonly associated with the ulcerative type with perforation, suggesting that ischemia caused by vascular thrombosis is responsible for tissue breakdown. This implies that vasculitis plays an important role in the natural history of abdominal tuberculosis.

Localized amyloidosis in endometrioid carcinoma of the uterus: a rare association.

BACKGROUND: Amyloidosis is associated with infections, chronic disorders, hematological malignancies and endocrine neoplasms. Only rarely has it been associated with other tumors. Amyloidosis of the endometrium is rare and has only been reported as part of a systemic disease. CASE REPORT: A 65-year-old postmenopausal female presented with irregular vaginal bleeding. Ultrasonography revealed a growth in the uterine cavity and enlarged internal and external iliac lymph nodes. Total hysterectomy with Bilateral salpingo-ophorectomy and dissection of pelvic fascia with external and internal iliac lymph nodes was done. The histologic diagnosis was that of a well-differentiated endometrioid adenocarcinoma: villoglandular type. Additionally, there were intratumoral nodular deposits of amyloid which were positive with Congo red showing apple green birefringence on polarization. CONCLUSION: This is an unusual case of amyloidosis associated with endometrioid carcinoma of the uterus.