Myoid hamartoma of breast: a rare case report with review of literature

Myoid hamartomas of breast are extremely rare lesions with poorly defined pathogenesis. They are composed of differentiated mammary glandular and stromal structures with areas of smooth muscle differentiation. They are postulated to arise from walls of the blood vessels and/or muscularis mammillae of the areolae. They usual present as a well demarcated lump and it is difficult to diagnose them on clinical and radiological basis. Diagnosis requires demonstration of smooth muscle phenotype using immunohistochemistry by smooth muscle actin and desmin. Surgical resection is the curative treatment. We reported a case of myoid hamartoma in a 50-year-old postmenopausal lady with its clinical, radiological and histopathological discussion. The lesion presented as a painless lump and was initially reported as BIRADS 4a on mammography. Apart from the stroma showing spindle cell component with smooth muscle differentiation, the histopathology also showed epithelial changes including epithelial hyperplasia and columnar cell change.

Role of CD44 as cancer stem cell marker in triple-negative breast cancer and its association with histological grade and angiogenesis

Introduction: Cancer stem cells (CSC) within the tumors play a central role in tumorigenesis. It is, thus, of utmost importance to identify these cells to develop effective cancer therapy. Triple-Negative Breast Cancer (TNBC) is an aggressive molecular subtype of breast cancer associated with poor patient outcomes. The role of CD44 immunohistochemistry (IHC) as a putative CSC in breast carcinomas, particularly of the TNBC-subtype is ambiguous, with equivocal results. Aims and Objectives: The present study aims to assess the role of CSC in breast carcinoma by immunohistochemical analysis of CD44 expression in TNBC. The association of TNBC expressing CSC with histological grade as well as with angiogenesis (using CD34 IHC) has been studied. Materials and Methods: Biopsy samples from 58 patients with infiltrating ductal carcinoma, NST were studied. The histology of the tumor was sub-classified into grades 1–3. Based on immunohistochemical analysis (ER, PR, HER2/Neu), the cases were divided into TNBC and NTNBC groups. The tissue sections were also subjected to analysis for CD44 to identify the CSC-phenotype and CD34 to evaluate angiogenesis, to determine the microvascular density (MVD). Results: Out of the 58 cases in the study, 28 were TNBC and 30 were NTNBC. CSC phenotype (CD44 positive) was expressed significantly higher in the TNBC (78%) versus the NTNBC (53%) (p-value 0.043). The MVD estimated using CD34 IHC was lower in the TNBC group in our study, though the difference was not statistically significant. A larger proportion of cases in TNBC showed a higher histological grade (35%) in comparison to NTNBC (27%). However, statistically, it was not significant. Conclusion: Our study demonstrated that CD44 as a CSC marker is seen significantly more in the TNBC category of invasive ductal carcinomas. Further large-scale studies, to confirm these findings, will be of potential therapeutic and prognostic value.

Anaplasia in childhood rhabdomyosarcoma: An under reported entity

Background: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. Anaplasia is a rare phenomenon seen in childhood RMS. The most common histologic subtype was Embryonal followed by Alveolar and spindle subtype. Design: A total of 11 cases of pediatric RMS were selected from January 2017 to June 2019 presenting at various sites. Out of 11 cases, 2 were further diagnosed as Embryonal, 2 as Alveolar, 2 as Pleomorphic, 1 as Spindle subtype and rest 4 as RMS-NOS based on morphology. All cases were positive for Desmin. The presence of cells with lobated, hyperchromatic nuclei at least three times larger than the tumor cell (anaplastic cells) was selected as the main criterion to diagnose Anaplasia. Results: Out of the total 11 cases, anaplasia was seen in 7 cases. Out of these seven, five cases showed Focal Anaplasia (FA) (71.4%) and 2 cases showed Diffuse Anaplasia (DA) (28.6%). Out of 2 cases of Embryonal RMS one exhibited focal anaplasia (50%). One case of Spindle RMS showed diffuse anaplasia, 2 cases of pleomorphic RMS showed focal anaplasia. Out of 3 cases of RMS- NOS, 2 exhibited focal anaplaisa and one displayed Diffuse anaplasia. Both Alveolar RMS had no features of anaplasia. Conclusion: Presence of Anaplasia is a frequent observation in pediatric RMS. Anaplasia is often under reported in pediatric RMS. Pathologist should be more aware of this rare phenomenon.

Melanosis tubae et ovarii: An overlooked entity?

Melanosis is a rare benign entity defined by the deposition of brownish-black pigment in a wide variety of organs especially the gastrointestinal tract, peritoneum, fallopian tubes and ovaries. Melanosis of the fallopian tube is widely known as pigmentosis tubae. Literature has mentioned ovarian teratomas and serous cystadenomas to be associated with the ovarian and peritoneal melanosis. We report five such cases of tubo-ovarian melanosis. The cases include mature teratoma and serous cystadenoma as well as melanosis of the fallopian tubes with otherwise normal ovarian histology. The importance of recognising this entity lies in its differential diagnosis.

Primary breast sarcoma: A case series

Background: Primary Breast Sarcomas (PBS) are rare malignancies and seen in less than <1 % of all breast malignancies. PBS are non epithelial, composed of mesenchymal mammary tissue and are difficult to diagnose from other sarcomas arising in breast. Materials and Methods: A retrospective study was conducted in the Department of Pathology and slides of breast malignancies over a period of 5 years were reviewed. Out of total 1570 breast malignancies, 5 cases were reported as PBS. Diagnosis was made on the basis of Histopathology and IHC findings. Results: Out of total 1570 cases, 5 cases were diagnosed as PBS (i.e. 0.32% of all cases). 3 out of 5 cases were males comprising of 60% of cases and 2 cases were females accounting for 40% of cases. The age group of presentation was 32-65 years with mean age being 48.5 years. A diagnosis of MPNST was rendered in two cases ( 1=M, 1=F), one each was diagnosed as DFSP ( with fibrosarcoma), Leiomyosarcoma and Fibrosarcoma. Conclusion: PBS is an extremely rare entity and locally aggressive. It requires diagnosis as its treatment protocol is different.

Does tumor stroma ratio of breast cancer trucut biopsy determine response to neoadjuvant therapy?

Aims and Objectives: We examined the prognostic value of Tumor stroma ratio (TSR) in breast tumor core biopsy (TCB) specimen to determine response to neoadjuvant therapy (NAT) prior to modified radical mastectomy (MRM). Methods: This was a retrospective analysis of patients with breast cancer who underwent TCB before NAT between August 2016 and July 2018. TSR in TCB was studied independently by 2 pathologists ( VM, VS) defined as stroma rich (TSR?50%) or stroma poor (TSR>50%). MRM specimen of these patients were subsequently studied .Residual cancer burden (RCB) was calculated using the MD Anderson RCB calculator, categorized as complete (0), good (1) Partial (2) and no response (3). Statistical analysis was done to assess correlation of TSR to RCB. Results: A total of 62 patients were analyzed. Mean(SD) age was 48(11) years.Twenty eight (45%) and 34 (55%) patients were stroma rich and stroma poor respectively. Twenty six (42%) patients were responders and 36 (58%) non-responders to NAT. Among stroma rich patients, only 3 (10%) were responders (Class 0 &1)and 25 (90%) non-responders(Class2&3)to NAT, among stroma poor patients 23 (68%) responded well and 11 (32%) did not.TSR had a moderate negative correlation with RCB (-0.6). On univariate analysis, only TSR had a significant effect on RCB class (<0.001). Conclusions: TSR on TCB is a useful prognostic factor to determine response of breast carcinoma patients to neoadjuvant therapy.It is cost effective, simple and quick. Larger multi-centric studies would be useful to study its clinical implications.

Tumor budding in infiltrating breast carcinoma: Correlation with known clinicopathological parameters and hormone receptor status

Introduction: Tumor budding (TB) is proposed as an essential step in the invasion and metastasis of various tumors. However, there is limited information about its role in breast cancer. This study was designed to assess the prognostic significance of TB in clinical practice. Objectives: To study and grade TB in patients with invasive breast cancer and to correlate it with known prognostic parameters. Materials and Methods: In this prospective study, 40 cases of invasive breast cancer were studied over a period of 1.5 years. Tumor buds were defined as comprising five tumor cells or less at the invasive front of the tumor. Cases were separated into two groups according to TB density as low grade and high grade. Significance and correlation between TB with established clinicopathological parameters and hormone receptor status were studied by Chi-square test. P value <0.05 was considered significant. Results: All 40 cases in this study were newly diagnosed cases, who did not receive any therapy. The majority of patients were premenopausal (55%), had small tumor size ?5 cm (67.5%), had negative lymph nodes (67.5%), had grades 2 and 3 (75%), and presented in stages 1 and 2 pathological stage (62.5%). The majority were estrogen-receptor-negative (62.5%), progesterone-receptor-negative (65%), and human epidermal growth factor receptor-2-positive (52.5%). Higher grade TB was observed in larger tumor (P = 0.03), in higher stage (P = 0.046), and in tumor having lymphovascular emboli (P = 0.03) when compared with small size, lower stage, and tumor with no lymphovascular emboli, respectively. Conclusion: As higher grade TB was associated with larger, higher stage tumor, and in tumor having lymphovascular emboli, it can be recognized as an easily identifiable prognostic factor.

Xylene-free staining: Is it possible and practical?

Good paraffin sections are key to correct histopathological diagnosis. Xylene is hazardous to health, expensive, and difficult to dispose. Various substitutes have been tried without success. We aimed to examine if 1.7% dishwasher soap (DWS) aqueous solution and refined mineral oil (RMO) for deparaffinization can replace xylene. Fifty tissue blocks consisting of benign and malignant lesions were processed using xylene (A), 1.7% DWS (B), and RMO (C). Each section was evaluated, scored as 0 (inadequate) and 1 (adequate) by two independent pathologists who were blinded to agent used. Following criteria were considered: nuclear staining, cytoplasmic staining, clarity, crispness, and uniformity. Total score of <2 was graded as inadequate for diagnosis and 3–5 as adequate. Statistical analysis was done using the SPSS software by applying chi-square test. Among three methods, B had the best scores in adequacy for cytoplasmic staining (P = 0.001), clarity (P = 0.004), and crispness (P = 0.003). About 1.7% DWS and RMO were found to be effective methods for deparaffinization and can replace xylene.

Cytological evaluation of pericardial fluids: A 5 years experience in tertiary care center

Background: Cytological examination of pericardial effusion fluids is important in diagnosing the etiology of underlying disease, staging, and prognosis of cancer. Aims and Objectives: (1) To study cytological evaluation of pericardial effusions in various pathological conditions in a tertiary care center. (2) To analyze their frequency and clincopathological correlation of the diagnosis. Materials and Methods: Our study was a retrospective study performed in the Department of Pathology from 1st January 2012 to 31st December 2016. The study sample included all the pericardial effusions submitted in the pathology department for cytological evaluation. Clinical details and relevant parameters correlated with clinical findings. Each fluid underwent cytospin and cytocentrifuge along with preparation of conventional smears. Results: Of 120 cases, 80% were of benign effusion and 20% were of malignant effusion. Male-to-female ratio was 1.44:1 with patient age ranging from 3 to 90 years. Conclusion: Benign effusions can been seen in younger age group and malignant ones in the older age group. The preliminary pericardial fluid analysis in resource-limited settings is the most convenient and cost-effective method for accurate diagnosis. It reduces the demand of invasive investigations and its complications. At times, it is the first test to point toward underlying malignant process thereby affecting the prognosis, survival, and treatment outcome of the patient.

Direct immunofluorescence findings in cicatricial alopecia: A retrospective study of 155 cases

Objectives: To study the direct immunofluorescence (DIF) in cicatricial alopecia (CA) patients. Materials and Methods: Approximately, 155 skin biopsies from CA patients examined over 7 years (2009–2015). Special stains and Hematoxylin and Eosin were performed, and final histopathological diagnosis was made. DIF (against anti-IgG, IgM, C3, IgA, and fibrinogen) on all these cases and patterns were noted. The descriptive statistics were applied along with ANOVA test. Results: Approximately, 155 patients with Male: Female = 1.24:1, age 7–65 years. In total, 57 cases were of Lichen planopilaris (LPP; 36.7%), 22 Lichen planus (LP; 14.2%), 22 Psuedopalade of Brocq (PPB; 14.2%),16 discoid lupus erythematosus (DLE; 10.3%), 8 end-stage scarring alopecia (ESSA; 5.2%), 2 cases each of Fungal folliculitis (FF), and Folliculitis decalvans (FD; 1.3% each), and in 26 cases, no specific diagnosis could be reached were collectively kept in the category of non-specific findings (NSP; 16.7%). On DIF: LPP positive for IgG = 4 cases (7%), IgM = 26 (45%), IgA = 11 (19.3%), C3 = 16 (28.1%), and fibrinogen = 11 (19.3%). LP positive for IgG = 2 (9%), IgM = 18 (81%), IgA = 2 (9.1%), C3 = 10 (45%), and fibrinogen = 1 (4.5%). DLE positive for IgG = 6 (37%), IgM = 8 (50%), IgA = 1 (6.3%), C3 = 9 (56%), and fibrinogen = 1 (4.5%). Limitations: Because this was a retrospective study, clinical follow-up and treatment history of the patient could not be retrieved. Conclusions: IgG positivity helps significantly in differentiating LPP from DLE (P 0.004) and NSP from DLE (P 0.005). IgM positivity helps significantly in differentiating LPP from LP (P 0.04), LP from PPB (P 0.00) and NSP (P 0.00). C3 positivity helps significantly in differentiating PPB from DLE (P 0.02).

Extensive trophoblastic differentiation in case of an endometrial carcinoma

Trophoblastic differentiation of endometrial carcinoma is extremely rare, till date 18 cases reports are there in the literature. A 68-year-old postmenopausal female presented with abnormal vaginal bleeding. Histopathologically, there were areas of serous carcinoma with trophoblastic differentiation (~90%). On immunohistochemistry, the trophoblastic component was positive for ?-human chorionic gonadotropin (hCG), HPL and EMA. IHC confirmed the diagnosis of serous carcinoma with trophoblastic differentiation. The clinicopathological features of 18 previously reported cases of trophoblastic differentiation in the uterine tumor were analyzed in addition to the present case.

Synovial hemangiomas of wrist and ankle joint: A report of two rare cases

Synovial hemangioma is a rare, benign, vascular tumor of synovium leading to joint pain and swelling. The most common site is the knee joint, but rare cases involving other sites have also been reported. We report two rare cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint. Histopathology is the gold standard for diagnosis of these cases. Early treatment is warranted to prevent the risk of permanent joint damage.

Adrenal medullary hyperplasia with coexistent cerebral angiomas

Sporadic adrenal medullary hyperplasia (AMH) is a rare entity and mimics pheochromocytoma clinically as well as pharmacologically. It is characterized by increase in adrenal medullary cells with the expansion of cells into areas normally not seen. A 59-year-old male presented with chronic hypertension and raised 24-h urinary normetanephrine levels. Radiological and clinical possibility of pheochromocytoma led to left transperitoneal laparoscopic adrenalectomy. Histopathology, however, showed increase in adrenal medullary to cortical ratio, further confirmed by immunohistochemistry. The absence of any well-defined lesion led to the diagnosis of AMH. Furthermore, on routine imaging, two asymptomatic cavernous hemangiomas were seen. We present this case to reiterate that AMH is an entity which should be considered as a differential for pheochromocytoma. Furthermore, the presence of asymptomatic cavernous hemangiomas in the cerebrum, in this case, makes it rarer since this sporadic association is seldom seen.

Dedifferentiation of oncocytic epithelial–myoepithelial carcinoma to mucoepidermoid carcinoma in parotid gland: A rare case report

Epithelial–myoepithelial carcinomas (EMCs) account for <1% of all salivary gland malignancies. Till now, 23 cases of dedifferentiated EMC have been reported to the best of our knowledge. However, dedifferentiation of oncocytic EMC to mucoepidermoid carcinoma is extremely rare. A 38-year-old female presented with right post aural swelling 4 cm × 2 cm in size for 6 months. Surgical excision was carried out, and we received partly skin-covered tissue 5 cm × 2 cm in size. Sections examined showed features of oncocytic EMC dedifferentiating into mucoepidermoid carcinoma. Myoepithelial component showed oncocytic change which was highlighted by p63.

A retrospective study of 18 cases of adenoid cystic cancer at a tertiary care centre in Delhi.

Context: Adenoid cystic carcinoma (ACC) is a rare neoplasm that usually arises from the salivary, lacrimal, or other exocrine glands. It is characteristically locally infiltrative in nature and has a tendency toward local recurrence, high propensity for perineural invasion, and prolonged clinical course. Aim: To analyze the presentation and natural history of cases of adenoid cystic tumors of salivary glands in our institution; and to compare with the existing literature. Design and Setting: Retrospective study at the Department of Radiotherapy. Materials and Methods: Data on 18 patients of ACC of the salivary glands treated between 2004 and 2008 were reviewed with respect to clinical presentation, stage, and histology. Results: There were 8 cases of major salivary gland tumors (47%), of which 2 were in the submandibular and 6 were involving the parotid. Ten patients (53%) had minor salivary gland involvement. Two patients had metastasis at the time of presentation. All patients underwent surgery. Radiotherapy was delivered to 16 patients and chemotherapy to 6 patients (concurrent, n = 3 and adjuvant, n = 3) and no adjuvant therapy was given to 2 patients. All patients were alive at a median follow-up of 3 years. No patient developed local or distant failure during the study duration. Conclusion: ACC has locally aggressive behavior. Radiotherapy adjuvant to surgery improves local control in locally advanced disease. Longer follow-up is mandatory in view of incidence of late metastasis.

Histopathology for the diagnosis of infectious diseases.

Histopathological examination of tissue biopsies for the identification of infectious organisms is a very important diagnostic tool. Conventional culture confirmation of tissue biopsies often fail to identify any pathogen as, first of all, invariably most of the tissue samples that are collected and sent for culture isolation are inappropriately collected in formalin, which prevents pathogen growth in culture media. Inadequate processing like grinding, etc. further hinders isolation. Presence of inhibitors like dead tissue debris, fibers, etc. also delays isolation. Microbiologists often lack expertise in identifying infectious pathogens directly from tissue biopsies by microscopic visualization. This review therefore acquaints microbiologists with the various methods available for detecting infectious agents by using histological stains. On histopathological examination of the tissue biopsy once, it is determined that a disease is likely to be due to an infection and has characterized the inflammatory response and hence associated microorganisms should be thoroughly looked for. Although some microorganisms or their cytopathic effects may be clearly visible on routine haematoxylin- and eosin-stained sections, additional histochemical stains are often needed for their complete characterization. Highly specific molecular techniques, such as immunohistochemistry, in situ hybridization and nucleic acid amplification, may be needed in certain instances to establish the diagnosis of infection. Through appropriate morphologic diagnoses and interlaboratory communication and collaboration, direct microscopic visualization of tissue samples can thus be very helpful in reaching a correct and rapid diagnosis.

Primitive neuroectodermal tumor of prostate.

Primitive neuroectodermal tumors (PNETs) are malignant proliferations of small, undifferentiated neuroectodermal cells occurring mainly in children and share the same reciprocal translocation between chromosomes 11 and 22 and the same patterns of biochemical and oncogene expression as osseus and extraosseus Ewing's sarcoma. Some PNETs occur in the brain, while others (the peripheral PNETs) occur in sites outside the brain, such as in the extremities, pelvis and the chest wall. They mostly originate in the chest, pelvis and retroperitoneum; in rare cases, occurrence in the head and neck area has also been seen. We present a rare case of primitive neuroectodermal tumor arising in the prostate gland in a 25-year-old male. To the best of our knowledge, this is the first documentation of a primary peripheral primitive neuroectodermal tumor in the prostate gland of any patient from India and rarely reported in English literature.

Primary chondrosarcoma of the breast.

Mammary sarcomas are uncommon tumours. Of these, pure chondrosarcoma without any other area of epithelial or mesenchymal differentiation feature is even rarer. This excludes tumours like malignant cystosarcoma phylloides and metaplastic carcinoma where malignant cartilaginous areas may be present. Further, primary chondrosarcoma arises from breast stroma and not from underlying bone or cartilage. Here is this case, a 46-year-old female was presented with a huge lump in her left breast. FNAC reported it to be a case of infiltrating duct carcinoma. Microscopically a well differentiated chondrosarcoma was identified. The case is presented because of its rarity.