The 1000 Mitoses Project: A Consensus-Based International Collaborative Study on Mitotic Figures Classification.

Introduction. The identification of mitotic figures is essential for the diagnosis, grading, and classification of various different tumors. Despite its importance, there is a paucity of literature reporting the consistency in interpreting mitotic figures among pathologists. This study leverages publicly accessible datasets and social media to recruit an international group of pathologists to score an image database of more than 1000 mitotic figures collectively. Materials and Methods. Pathologists were instructed to randomly select a digital slide from The Cancer Genome Atlas (TCGA) datasets and annotate 10-20 mitotic figures within a 2 mm2 area. The first 1010 submitted mitotic figures were used to create an image dataset, with each figure transformed into an individual tile at 40x magnification. The dataset was redistributed to all pathologists to review and determine whether each tile constituted a mitotic figure. Results. Overall pathologists had a median agreement rate of 80.2% (range 42.0%-95.7%). Individual mitotic figure tiles had a median agreement rate of 87.1% and a fair inter-rater agreement across all tiles (kappa = 0.284). Mitotic figures in prometaphase had lower percentage agreement rates compared to other phases of mitosis. Conclusion. This dataset stands as the largest international consensus study for mitotic figures to date and can be utilized as a training set for future studies. The agreement range reflects a spectrum of criteria that pathologists use to decide what constitutes a mitotic figure, which may have potential implications in tumor diagnostics and clinical management.

p16 expression in urothelial carcinoma: Experience from a tertiary care center in coastal South India.

Background: Urothelial carcinomas (UC) account for 6 and 2% of all cancers in men and women, respectively. Human papillomavirus (HPV) is one of the causative agents in cancers of the uterine cervix and head and neck. The role of HPV is also being studied in cancers of the urinary bladder, penis, and prostate. As p16-INK4a is a surrogate marker for high-risk HPVE7 oncoprotein, this study aims to highlight the utility of p16 immunohistochemistry (IHC) in the evaluation of HPV-associated UC. Materials and Methods: A retrospective study was conducted on UC of the bladder received in the Pathology department between January 2013 and December 2018. Bladder biopsies from non-neoplastic lesions served as controls. IHC was done for the detection of the p16 antigen. The p16 staining was recorded as positive, when there was strong staining in >50% of tumor nuclei. The p16 positive and negative tumors were compared based on age, gender, tumor size, grade, and muscle invasion. P value <0.05 was considered statistically significant. Results: The expression of p16 was analyzed in 72 UC and compared with 20 non-neoplastic cases, of which 26.4% of the cases showed p16 expression. The p16 expression was absent in the non-neoplastic lesions. While the majority (87.5%) of the low-grade tumors were negative for p16 expression, 43.8% high-grade tumors were positive. Similarly, a larger proportion of invasive carcinomas (38.8%) expressed p16 as compared to non-invasive carcinomas (13.8%). Thus, p16 expression showed a significant association with grade and stage in these malignancies (P < 0.05). Conclusion: The p16 expression was associated with high-grade and muscle-invasive UC. The p16 was absent in all non-neoplastic and precursor lesions. Thus, it can provide essential information not only about HPV association but also on the prognostic implications for the patients.

Primary Ovarian Non-Hodgkin's Lymphoma: An 18-year Retrospective Institutional Study and Review of Literature from India.

BACKGROUND: Primary lymphomas of the female reproductive tract are rare and the ovarian extranodal presentation of non-Hodgkin's lymphoma (NHL) accounts for only 0.5% of all NHLs and 1.5% of all ovarian malignancies. METHODS: We retrospectively reviewed the institutional medical oncology database for newly diagnosed NHL cases between 1999 and 2017. We aimed to study the clinical characteristics, pathology, and outcome of primary ovarian non-Hodgkin's lymphoma (NHL) cases presented to our institution. RESULTS: We identified three patients (3.7% of extranodal NHLs and 0.85% of all NHL patients) with primary ovarian NHL from 350 NHL patient records. They underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by six to eight cycles of (rituximab, adriamycin, cyclophosphamide, vincristine, prednisolone (R-CHOP/CHOP), and they attained complete remission. CONCLUSION: Given the heterogeneity of cancer incidence in India and the absence of state-wise cancer registries, our study argues a pressing need to develop a national representative registry for NHL for accurate incidence, mortality, and survival data. Additionally, fertility preservation is an important issue that must be discussed with women of fertile age and the parents of children.

Automated Molecular Subtyping of Breast Carcinoma Using Deep Learning Techniques.

OBJECTIVE: Molecular subtyping is an important procedure for prognosis and targeted therapy of breast carcinoma, the most common type of malignancy affecting women. Immunohistochemistry (IHC) analysis is the widely accepted method for molecular subtyping. It involves the assessment of the four molecular biomarkers namely estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and antigen Ki67 using appropriate antibody reagents. Conventionally, these biomarkers are assessed manually by a pathologist, who finally combines individual results to identify the molecular subtype. Molecular subtyping necessitates the status of all the four biomarkers together, and to the best of our knowledge, no such automated method exists. This paper proposes a novel deep learning framework for automatic molecular subtyping of breast cancer from IHC images. METHODS AND PROCEDURES: A modified LadderNet architecture is proposed to segment the immunopositive elements from ER, PR, HER2, and Ki67 biomarker slides. This architecture uses long skip connections to pass encoder feature space from different semantic levels to the decoder layers, allowing concurrent learning with multi-scale features. The entire architecture is an ensemble of multiple fully convolutional neural networks, and learning pathways are chosen adaptively based on input data. The segmentation stage is followed by a post-processing stage to quantify the extent of immunopositive elements to predict the final status for each biomarker. RESULTS: The performance of segmentation models for each IHC biomarker is evaluated qualitatively and quantitatively. Furthermore, the biomarker prediction results are also evaluated. The results obtained by our method are highly in concordance with manual assessment by pathologists. CLINICAL IMPACT: Accurate automated molecular subtyping can speed up this pathology procedure, reduce pathologists' workload and associated costs, and facilitate targeted treatment to obtain better outcomes.

Study of pre-operative neutrophil-lymphocyte ratio in urothelial carcinoma.

OBJECTIVES: Neutrophil-lymphocyte ratio (NLR), as an indicator of heightened systemic inflammatory response, predicts increased disease burden and poor oncological outcomes in urothelial carcinoma (UC). The study was undertaken with an aim to evaluate the association of NLR with clinicopathological variables and survival outcomes. METHODS: A total of 80 patients of UC were enrolled in the current retrospective study. Pre-operative NLR (within one month prior to the procedure), patient age, sex, tumour grade, pathological stage, recurrence free survival (RFS), progression free survival (PFS) and cancer specific survival (CSS) were recorded. We chose a cut-off value of 2.7 for NLR and patients were divide into two groups (NLR <2.7 and ≥2.7). RESULTS: NLR ≥2.7 was significantly associated with advanced tumour stage (p=0.001), but not with tumour grade (p=0.116). Progression (p=0.032) and death rates (p=0.026) were high in patients with NLR ≥2.7. Mean RFS (p=0.03), PFS (p=0.04) and CSS (p=0.04) were reduced in patients with NLR ≥2.7. On univariate analysis, NLR ≥2.7 predicted worse RFS (HR=2.928, p=0.007), PFS (HR=3.180, p=0.006) and CSS (HR=3.109, p=0.016). However, it was not an independent predictor of outcomes on multivariate analysis. CONCLUSIONS: Tumour stage and grade are the only independent predictors of RFS, PFS and CSS. High NLR at a cut-off value of ≥2.7 is associated with advanced pathological stage, but does not have an independent predictive value for RFS, PFS and CSS.

Heat exertion precipitating shock and death in a case of previously undiagnosed sickle-cell disease.

Sickle cell disease (SCD) is an autosomal recessive genetic condition characterized by the presence of a mutated form of haemoglobin (HbS). HbS polymerises into long needle-like fibres under low oxygen conditions, leading to the erythrocytes forming sickle shaped red blood cells. With repeated sickling, the red blood cells become irreversibly sickled and trapped within the circulation, and this leads to vaso-occlusive crisis. The patient, a 25-year-old female, previously undiagnosed with SCD, presented with high grade fever, splenomegaly and succumbed due to heat exertion precipitating sickling crisis, multiorgan failure and shock.

Spindle cell carcinoma masquerading as a benign polyp of the soft palate.

Spindle cell carcinoma of the head and neck is a rare biphasic neoplasm. The presentation mimics other head-and-neck malignancies and hence the diagnosis hinges upon histopathological confirmation along with positive immunohistochemistry (IHC) markers denoting the presence of both epithelial and mesenchymal components. At present, there are no standard management criteria for these tumors with the options varying from surgery alone to surgery combined with adjuvant radiotherapy. We discuss here the case of a patient presenting with an oropharyngeal mass that had benign clinical features and the final diagnosis of spindle cell carcinoma could only be established after histopathology with IHC typing.

p63-positive prostate carcinoma-A very rare presentation.

Prostate cancer being the world's leading cause of cancer and also the second most common cancer in men is posing challenges in its diagnosis. Immunohistochemistry with markers like high molecular weight cytokeratin, p63 aid in the diagnosis. The absence of p63 and high molecular weight cytokeratin and presence of p504s in the biopsies indicate malignant lesions. Yet, there is a loophole to this too. A rare case of p63-positive prostatic adenocarcinoma in an 87-year-old patient, with immunohistochemistry results showing overexpression of p63 in the nuclei of the malignant glands. This tumor shows high molecular weight cytokeratin negativity, and p504s positivity. Prognosis of this variant of the tumor is mostly favorable. Prompt treatment will halt the progression of this tumor and prevent paraplegia. Radical prostatectomy could be avoided by treatment modalities like androgen blockade and brachytherapy, as morbidity is very high with radical prostatectomy surgery.

In pursuit of the primary.

Extraovarian primary peritoneal carcinoma (EOPPC) is a rare tumour of the peritoneum that shares many features with serous ovarian carcinoma because of a common embryological origin. We report a case of EOPPC presenting with a malignant pleural effusion. https://bit.ly/3GMuKgL.

Genetic diversity of Indian Plasmodium vivax isolates based on the analysis of PvMSP3ß polymorphic marker.

BACKGROUND: Malaria is one of the major communicable diseases in India and worldwide. PvMSP3ß is a highly polymorphic gene due to its large insertions and deletions in the central alanine-rich region, which, in turn, makes it a valuable marker for population genetic analysis. Very few studies are available from India about the genetic diversity of Plasmodium vivax based on PvMSP3ß gene, and hence, this study was designed to understand the molecular diversity of the P. vivax malaria parasite. The accumulating epidemiological data provide insights into the circulating genetic variants of P. vivax in India, and ultimately benefits the vaccine development. MATERIALS AND METHODS: A total of 268 samples confirmed to be positive by microscopy, rapid diagnostic test, and quantitative buffy coat test were collected from four different regions of India (Puducherry, Mangaluru, Jodhpur, and Cuttack) in the present study. Polymerase chain reaction (PCR)-based diagnosis was carried out to confirm the P. vivax monoinfection, and only the mono-infected samples were subjected to PvMSP3ß gene amplification and further restriction fragment length polymorphism (RFLP) to determine suballeles. RESULTS: Based on the size of the amplified fragment, the PvMSP3ß gene was apportioned into two major types, namely Type A genotype (1.6-2 Kb) was predominantly present in 148 isolates and Type B (1-1.5 Kb) was observed in 110 isolates. The percentage of mixed infections by PCR was 3.73%. All the PCR products were subjected to RFLP to categorize into suballeles and we detected 39 suballeles (A1-A39) in Type A, and 23 suballeles (B1-B23) in Type B genotype. A high degree of diversity was observed among the isolates collected from Mangaluru region when compared to isolates collected from other regions. CONCLUSION: The present study showed a high degree of genetic diversity of PvMSP3ß gene among the isolates collected from various parts of India. High polymorphism in PvMSP3ß gene makes it a promising marker for epidemiological and vaccine development studies.

Utility of fine-needle aspiration cytology in the diagnosis of HIV lymphadenopathy.

BACKGROUND: India, being a developing country, harbors the third largest human immunodeficiency virus (HIV)-infected population in the world, and HIV-associated lymphadenopathy is commonly encountered. HIV lymphadenopathy is more commonly generalized and pathology ranges from reactive lymphoid hyperplasia to infections like tuberculosis to neoplasms such as lymphoma and Kaposi sarcoma. The study intended to assess the utility of fine-needle aspiration (FNA) cytology in HIV lymphadenopathy. MATERIALS AND METHODS: A retrospective FNA slide review of HIV-infected cases with lymphadenopathy received over a period of 2 years in the cytopathology department was performed. The clinicopathological characteristics, absolute lymphocyte count (ALC), and CD4 counts were analyzed. RESULTS: Seventy-nine lymph node aspirates were received from HIV patients over 2 years. The mean age at presentation was 39 years with a male:female ratio of 2.4:1. Cervical lymph nodes (62%) were more commonly affected. Tuberculous lymphadenitis was the commonest lesion (41.8%), followed by reactive lymphadenitis (24%), nonspecific granulomatous lymphadenitis (14%), suppurative lymphadenitis (8%), cryptococcal lymphadenitis (2%), lymphoma (9%), and metastasis (1%). CONCLUSION: Lymph node FNA in HIV/AIDS is not only useful in identifying those cases that require further evaluation, but also aids in categorizing various etiologies such as opportunistic infections, non-neoplastic, and neoplastic lesions. FNA is a less expensive, expeditious minimally invasive method for an early diagnosis that abets in deciding the treatment strategy, thus curtailing the associated morbidity and mortality.

Polymorphisms in genes associated with drug resistance of Plasmodium vivax in India.

Malaria is a sterning public health concern in India and contribute to a major part of malaria burden in Southeast Asia. Being more populated and diverse geographic conditions makes more suitable place for sustaining malaria parasite in India. Anti-malarial resistance is a major concern in the battle against malaria, and the identified molecular markers will aid us to monitor the drug resistance in endemic areas. The aim of the current study is to determine the genotype of drug resistance associated genes pvmdr-1 and pvcrt-o from four different regions of India. Especially from Puducherry and Jodhpur, there were no prior studies focused on screening of drug resistance genes in P. vivax parasite. A total of 240 positive P. vivax infected patient samples were collected from four tertiary care hospitals from four different regions of India, namely, Puducherry (PDY), Mangaluru (MAQ), Cuttack (CTC), Jodhpur (JDH). All samples were screened by microscopy, RDT, QBC, and further DNA was extracted and vivax mono-infection was confirmed by nested PCR. Randomly selected amplicons were further subjected to nucleotide sequencing. The prevalence of K10 insertion in pvcrt-o gene was detected with 18.8% in PDY, 12.5% in MAQ and 6.3% in CTC P. vivax isolates, whereas no change in nucleotide was identified in P. vivax isolates collected from JDH region. Based on the F1076L mutation in pvmdr-1 gene, resistant P. vivax isolates was highly predominant in both the regions, JDH and CTC, with 100%, followed by MAQ with 93.3% and PDY with 73.3%. This study showed less frequency of pvcrt-o and high frequency of pvmdr-1 gene variants associated with CQ resistance, which act as an indicator and the onset of P. vivax drug resistance trend in four different regions of India. Due to the poor phenotypic studies available for P. vivax parasite, the present study data for CQ resistance based on pvcrt-o and pvmdr-1 markers should assist by providing base-line data for future monitoring of drug resistance.

Lipofibromatous Hamartoma of the Median Nerve in Association with or without Macrodactyly.

Lipofibromatous hamartoma is a rare tumour-like condition involving the peripheral nerves, particularly the median nerve. It commonly affects the volar aspect of the hands, wrists and forearms of young adults. Most patients present either early with macrodactyly or later with a forearm mass lesion or symptoms consistent with compressive neuropathy of the involved nerve. The clinical and histomorphological findings of five patients with lipofibromatous hamartoma of the median nerve are analysed. The presentation, pathological features and differential diagnosis of neural lipofibromas are discussed along with a brief review of the literature. Of the five cases of lipofibromatous hamartoma, all were seen to involve the median nerve, occurring in four women and one man. Three of these cases had associated macrodactyly which was congenital in two and was seen from childhood in one. Microscopic examination showed fibrofatty tissue surrounding and infiltrating along the epineurium and perineurium. The nerve bundles were splayed apart by the infiltrating adipose tissue. Neural fibrolipomatous hamartoma is a benign condition. Most respond to conservative management with surgical exploration, biopsy and carpal tunnel release to decompress the nerve. Correct diagnosis of this uncommon lesion is important as surgical excision of the lesion may lead to loss of neurological function.

Fungal spores and fruiting bodies in cervicovaginal smears: Contaminant or infection?

BACKGROUND: Contaminants from various sources are curious findings in cervicovaginal smears and pose diagnostic challenges especially when they need to be distinguished from pathogens. Candidiasis is the most frequently encountered fungal infection but fungal contaminants are relatively common. Detection of fruiting bodies and spores of Aspergillus species is uncommon and may represent either a true infection or contamination. This study was undertaken to evaluate the presence of fungal spores, hyphae, and fruiting bodies in routine cervical smears and distinguish a true infection from contamination. METHODS: Conventional cervicovaginal smears collected from women were incidentally found to have fungal fruiting bodies and spores. All smears received in the Cytology Department during that one month were reviewed for the presence of these elements. RESULTS: Five out of the 120 smears, received from the outpatient department over a period of three consecutive days, showed evidence of fungal organisms. The patients were 28-59 years of age. While four patients were asymptomatic, only one patient complained of minimal vaginal discharge. All were immunocompetent. Cervicovaginal smears were prepared as part of routine screening. Fungal fruiting bodies, branching hyphae and numerous spores were seen in otherwise normal smears. Culture of scrapings from the surface of the wooden spatulas grew Aspergillus niger. CONCLUSIONS: Contamination of Pap smears by fungus must be distinguished from true infection, the latter being supported by positive clinical findings and the presence of significant inflammation in the smears. Literature review was done to see the range of contaminants detected in Pap smears. Diagn. Cytopathol. 2017;45:191-194. © 2016 Wiley Periodicals, Inc.

Value of bone marrow examination in Hodgkin lymphoma: report of three cases with review of literature.

Bone marrow involvement by Hodgkin lymphoma is rare with an average incidence of 10%. However, the incidence of bone marrow involvement has been shown to be less than 1% in patients with clinical stage IA or IIA disease. The involvement of the marrow in a patient with Hodgkin lymphoma represents stage IV disease. We report our experience wherein three cases of marrow involvement were picked up on bone marrow aspirates/ -imprints and confirmed on trephine biopsy. In this paper we wish to highlight the significance of bone marrow examination in the initial diagnosis and staging of even clinically early stage Hodgkin lymphoma. Staging investigations performed at the time of diagnosis for patients with Hodgkin lymphoma are vital for determining the appropriate treatment and prognosis.

Spectrum of paranasal sinus mycoses in coastal India.

Fungal infections of the nose and paranasal sinuses are uncommon, and the disease they cause can be identified from their histopathologic appearance. The aim of this study was to assess the incidence of fungal infection and histopathologic changes in specimens sent for evaluation of chronic sinusitis and correlate with culture findings wherever possible. The records of 200 consecutive cases coded as paranasal sinuses over a period of 3 years were retrieved from the Department of Pathology, Kasturba Medical College, Mangalore, India. Twenty nine out of a total of 200 specimens (14.5%) were positive for fungal elements on histopathologic examination. The most common etiologic agents in our study were Aspergillus spp (37.9%); only 1 culture (3.4%) was positive for a Candida species. Eight of 29 patients with fungal sinusitis (27.6%) had diabetes, and 1 patient was being treated for rheumatoid arthritis. Eight of the 29 patients had allergic fungal sinusitis, 8 had chronic granulomatous sinusitis, and 1 had acute fulminant invasive sinusitis. Fungi have been increasingly recognized as an important pathogen in chronic sinusitis. It is imperative for patient management not only that paranasal sinus mycoses be diagnosed but also that the specific histologic category be identified.

Fine-needle aspiration cytology in the diagnosis of malignant proliferating trichilemmal tumor: Report of a case and review of the literature.

Malignant proliferating trichilemmal tumor is a rare cutaneous neoplasm derived from the outer root sheath of the hair follicle. Fine-needle aspiration cytology is being increasingly used in the investigation of primary and metastatic cutaneous tumors. However, there are few reports on the cytology of trichilemmal tumors in the literature. We describe the cytological features of this uncommon adnexal tumor presenting as a scalp mass in a 58-year-old woman. In view of its aggressive biological behavior, it is crucial for cytologists to be aware of this rare lesion and distinguish it from primary cutaneous squamous-cell carcinoma. The differences on fine-needle aspiration cytology can be subtle and pose problems in diagnosis.

Imprint cytology of pancreatoblastoma: a case report and review of the literature.

Pancreatoblastoma is a rare tumor with approximately 60 cases described in the English literature and only five case reports illustrating the cytologic findings, four by fine-needle aspiration cytology and one by imprint cytology. We herein report the sixth case diagnosed by imprint cytology. Both the cytologic and histopathologic literatures are reviewed, and the pathologic variations observed in our case are also documented.

Orbital melanocytoma.

PURPOSE: To report a case of intermediate grade meningeal melanocytoma presenting as a recurrent orbital mass. INTRODUCTION: Melanocytomas are rare, primary, pigmented tumors of the central nervous system, usually presenting as well-circumscribed, encapsulated, solid masses in the posterior cranial fossa and at the spinal region, often attached to the underlying dura. Orbital manifestation is rarely encountered. METHODS: Case report with computed tomography scan, magnetic resonance imaging, histology, and immunohistochemistry. RESULTS: A 40-year-old man presented with a recurrent orbital mass manifesting as progressive proptosis of the right eye of 4 years duration. The computed tomography scan and magnetic resonance imaging revealed an intraconal mass in the superior quadrant of the orbit. Histological analysis of the excision biopsy of the mass showed a highly cellular, locally infiltrating melanocytic neoplasm suggestive of an intermediate grade meningeal melanocytoma. Immunohistochemical staining for S-100 protein and HMB-45 monoclonal antibody confirmed the diagnosis. CONCLUSIONS: Recurrent intermediate grade orbital melanocytomas are rarely encountered and have to be distinguished from other topographically similar primary melanotic tumors. They have to be managed more aggressively if intracranial extension is present due to its close relation to the visual pathways.