Comparison of the modified Masood's scoring index versus international academy of cytology Yokohama system in the categorization of breast fine needle aspirates.

CONTEXT: The Modified Masood Scoring Index (MMSI) categorizes breast fine needle aspirates into four categories non-proliferative breast diseases (PBD), PBD without atypia, PBD with atypia and carcinoma in situ/carcinoma. The International Academy of Cytology Yokohama System classifies the aspirates into five categories - inadequate, benign, atypical, suspicious, and malignant. Very few studies have been conducted so far to compare the diagnostic accuracy of this system. AIMS: The objectives of the study were to classify breast fine needle aspirates according to the MMSI and IAC Yokohama and assess their risk of malignancy (ROM) and performance parameters. MATERIALS AND METHODS: All breast FNAs received from June 2020 to May 2023 were classified according to the MMSI and IAC Yokohama. Using histopathological diagnosis as the gold standard, ROM and performance parameters were calculated. RESULTS: Out of the 559 breast fine needle aspirates, the histopathological correlation was available for 337 cases. The ROM for non-PBD, PBD without atypia, PBD with atypia and carcinoma in situ/carcinoma categories were 0%, 1.2%, 9.1% and 93%, respectively. The ROM for each of the categories of Yokohama system was 16.6%, 1.1%, 4.3%, 86.2% and 97.6%, respectively. The values for the sensitivity, specificity, PPV, NPV and diagnostic accuracy were slightly higher for IAC Yokohama (97.3%, 97.2%, 94.7%, 98.6% and 97.2%, respectively) than the MMSI (96.4%, 96.2%, 93%, 98.1% and 96.3%, respectively). Furthermore, another shortfall of MMSI is the inability to compare the Inadequate category of the Yokohama system. CONCLUSION: Overall Yokohama system proved to be a better system for categorizing breast lesions on FNAB as the scoring system provides more objective categorization and minimizes false positive and false negative cases.

Synchronous ipsilateral adrenal cortical adenoma and ganglioneuroma: A case report.

Synchronous tumors comprising of cortical as well as medullary differentiation are rare in the adrenal gland. Collision tumors comprise of two independent neoplasms arising from the cortex and the medulla without any histological admixture. Adrenal cortico-medullary mixed tumors are rare tumors comprising of adrenal cortical and chromaffin cells intermixed with each other. Ganglioneuroma is a rare benign tumor originating from the paravertebral sympathetic ganglia and is rarely seen in the adrenal medulla. The presence of a synchronous ganglioneuroma with an adrenal cortical adenoma in the ipsilateral adrenal gland is exceedingly rare. We report a collision tumor comprising of an adrenal cortical adenoma and a ganglioneuroma detected as an incidental finding in a pediatric patient who presented with hypertension and palpitations.

Spinal cord injury without radiographic abnormality (SCIWORA) in adults: A report of two cases.

Spinal cord injury without any radiographic abnormality (SCIWORA) is rare in adults. We describe here two case reports of adult patients, who presented to us with quadriplegia, following a road traffic accident. Plain radiography and computed tomography (CT) of cervical spine were normal. Hence the patients were diagnosed as cases of adult SCIWORA. However, subsequent magnetic resonance imaging (MRI) of the two patients revealed cervical cord injury in the form of cord contusion and disc protrusion, respectively. Patient with cord contusion was managed medically, whereas the patient with disc lesion was treated with discectomy. Patient treated with discectomy showed marked improvement. Therefore, patients having no osseous injury on X ray and CT scan should have an MRI study done to look for surgically correctable pathology. As in such rare patients of SCIOWRA an early diagnosis and timely intervention is crucial; with MRI playing a pivotal role.

LYMPHOCYTIC HYPOPHYSITIS: A RARE AUTOIMMUNE DISORDER PRESENT IN A LARGE SUPRA SELLAR MASS HAVING COMPLETE RESOLUTION WITH STEROIDS.

Significant proportion of sellar masses is seen in clinical practice. They range from most common pituitary adenomas to rare inflammatory lesions. Presentation can vary and depends if it secretes any hormone or imparts a pressure effect upon the surrounding vital structures. Radiological imaging coupled with histopathology is important tools of diagnosis. Management options depend upon type of disease.

EXPERIENCE AND OUTCOME OF VENTRICULAR-ATRIAL SHUNT: A MULTI CENTRE STUDY.

BACKGROUND: Ventriculoperitoneal (VP) shunt has been widely utilized in the treatment of hydrocephalus as a safe option but there is recent literature evidence that ventricularatrial (VA) shunt is not as notorious for its complications as proclaimed, to analyse and report our success with this procedure we conducted our study. METHODS: A total of 64 patients undergoing VA shunting were included in this case series study conducted at RMC and Allied hospital Rawalpindi. The data was collected over a period of 4 years from, 1st June 2010 to 1st June 2015. RESULT: Our study included 64 patients who underwent a VA shunt for hydrocephalus. Their age ranged from 25 to 75 years. Most of the patients were females (60%). The following complications were observed with 2 (3.12%) patients having blockage of the shunt at the neck, 3 (4.68%) suffered from glomerulonephritis, 2 (3.1%) had post-operative neck hematoma, 4 (6.25%) had wound infection, short lower end of the tube was found in 3 (4.68%), migrated lower end (into the subclavian) was seen in 1 (1.56%). Mortality was 1 (1.56%). These results were comparable to other studies. CONCLUSION: Neurosurgeons have been doing a VA shunt as a second procedure, after a VP shunt when the need due to a complication was encountered. We however share our experience regarding ventriculo-atrial shunting, as first choice procedure, because of its low incidence of shunt blockage unlike VP shunt, which has high rate of shunt blockage and therefore warrants repeated surgeries.

Cytomorphological Insights into Embryonal Rhabdomyosarcoma: A Rare Case in the Middle Ear.

INTRODUCTION: Rhabdomyosarcoma, though rare in the middle ear, necessitates prompt recognition for optimal management. They are malignant mesenchymal neoplasms arising from the embryonic mesenchymal cells of striated skeletal muscles. CASE PRESENTATION: We present a case of a 5-year-old child with massive right mastoid swelling and bloody ear discharge. Cytological examination via fine needle aspiration biopsy revealed features suggestive of a malignant mesenchymal tumor, confirmed on imaging and subsequent histopathology as embryonal rhabdomyosarcoma (ERMS) FNCLCC grade 2. Characteristic cytological findings included spindle-shaped cells in a myxoid stroma with tigroid background, aiding in early diagnosis. Despite radical mastoidectomy and adjuvant chemotherapy, ERMS in the middle ear remains challenging due to its aggressive nature and potential complications. CONCLUSION: This case underscores the importance of cytological evaluation in identifying rare soft tissue tumors like ERMS, facilitating timely intervention and improved outcomes. Early recognition and multidisciplinary management are crucial in addressing the complexities of ERMS in uncommon sites like the middle ear.

Understanding the spectrum of HER2 status in breast cancer: From HER2-positive to ultra-low HER2.

HER2 (human epidermal growth factor receptor 2) status in breast cancer spans a spectrum from HER2-positive to ultra-low HER2, each category influencing prognosis and treatment decisions differently. Approximately 20 % of breast cancers overexpress HER2, correlating with aggressive disease and poorer outcomes without targeted therapy. HER2 status is determined through immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), guiding therapeutic strategies. HER2-positive breast cancer exhibits HER2 protein overexpression or gene amplification, benefiting from HER2-targeted therapies like trastuzumab and pertuzumab. In contrast, HER2-negative breast cancer lacks HER2 overexpression and amplification, treated based on hormone receptor status. HER2-low breast cancer represents a newly recognized category with low HER2 expression, potentially benefiting from evolving therapies. Ultra-low HER2 cancers, characterized by minimal expression without gene amplification, challenge conventional classifications and treatment paradigms. Their distinct molecular profiles and clinical behaviors suggest unique therapeutic approaches. Recent diagnostic guideline updates refine HER2 assessment, enhancing precision in identifying patients for targeted therapies. Challenges remain in accurately classifying HER2-low tumors and optimizing treatment efficacy, necessitating ongoing research and innovative diagnostic methods. Understanding the heterogeneity and evolving landscape of HER2 status in breast cancer is crucial for advancing personalized treatment strategies and improving patient outcomes.

Unicentric Castleman disease masquerading as a gluteal mass: A diagnostic challenge.

Castleman disease, a rare lymphoproliferative disorder characterized by non-neoplastic lymph node enlargement, typically presents as nodal involvement, while extranodal manifestations are uncommon. We present a unique case of unicentric Castleman disease localized to the gluteal region in a 27-year-old female. Initially mistaken for a neurogenic or vascular tumour, fine needle aspiration cytology (FNAC) revealed a polymorphous population of lymphoid cells with numerous traversing capillaries suggestive of reactive hyperplasia, possibly Castleman disease, which was later confirmed by histopathology. This case highlights the diagnostic challenges posed by rare extranodal presentations of Castleman disease and underscores the importance of interdisciplinary collaboration in accurate diagnosis and management.

Clinical and histopathological spectrum of congenital pulmonary airway malformations: A case series.

BACKGROUND: Congenital pulmonary airway malformations (CPAM) are a spectrum of cystic and non-cystic anomalies arising from abnormal airway development in utero, with an incidence of 1 in 25,000 to 35,000 births. CPAM can present prenatally or postnatally with respiratory distress, recurrent infections, or occasionally as an incidental finding. This case series aims to highlight the clinical, radiological, and histopathological characteristics of CPAM through three pediatric cases, which include types 1, 2, and 3 CPAM. CASE PRESENTATION: Case 1: A four-month-old male presented with cough, cold, and respiratory distress. Imaging revealed hypoattenuation and overinflation of the left upper lobe with mediastinal shift. Left upper lobectomy confirmed CPAM type 2. Case 2: A one-month-old female presented with recurrent respiratory distress and infections. Imaging showed a large cystic lesion in the right middle lobe. Right middle lobectomy confirmed CPAM type 3. Case 3: A two-month-old male presented with dyspnea. Imaging showed a large bullae in the right chest with mediastinal shift. Right upper lobectomy confirmed CPAM type 1. CLINICAL DISCUSSION: CPAM is a rare congenital lung malformation characterized by abnormal bronchial development and localized glandular overgrowth. Management involves surgical resection, with the timing of surgery dependent on symptomatology. Early identification and intervention are crucial for preventing complications such as pulmonary hypoplasia and recurrent infections. Histopathological examination post-resection is essential for accurate classification and management of CPAM. CONCLUSION: This case series provides valuable insights into the clinical, radiological, and histopathological features of CPAM, including the types encountered in each case. It underscores the importance of early diagnosis and timely surgical intervention, advocating for routine prenatal and postnatal screenings to effectively identify and manage CPAM.

Assessment of stromal tumor-infiltrating lymphocytes in neoadjuvant chemotherapy for invasive breast carcinoma: Predictive insights across molecular subtypes.

BACKGROUND AND AIMS: Breast cancer, a leading cause of female mortality, has prompted the widespread adoption of Neoadjuvant chemotherapy (NAC) for its potential to minimize metastasis risk and downstaging tumors. Tumor Infiltrating Lymphocytes (TILs) have emerged as key immunological biomarkers, particularly in breast cancer research. This study focuses on evaluating Stromal TILs (sTILs) in pre-NAC core needle biopsies of Invasive Breast Carcinoma, No Special Type (IBC, NST) and correlating it with NAC response. MATERIALS AND METHODS: A retrospective study spanning three years (October 2020 to September 2023) was conducted in a tertiary care hospital, involving 73 patients meeting specific inclusion criteria. Pathological assessments, including hormone receptor status, molecular subtyping, and TILs evaluation, were performed. Logistic regression and statistical analyses were conducted to determine associations between TILs, clinicopathological parameters, and complete response. RESULTS: The study demonstrated excellent discriminatory power of TILs (>10 %) in predicting complete response. Univariate and multivariate logistic regression underscored the independent predictive value of TILs, emphasizing their significance across diverse molecular subtypes. CONCLUSION: This study provides crucial insights into immune response assessment, particularly sTILs, in optimizing breast cancer treatment strategies and patient outcomes during NAC, contributing to the evolving landscape of personalized emphasising oncology.

Intraparotid plexiform neurofibroma: A rare diagnostic challenge.

Isolated intraparotid neurofibromas are exceptionally rare and often associated with neurofibromatosis type 1 (NF1). Diagnosing these tumors proves challenging because of the clinical resemblance to primary salivary gland masses. This case report details an 18-year-old with a painful, enlarging parotid mass, diagnosed through fine needle aspiration biopsy (FNAB) revealing myxoid stroma and spindle cells. Magnetic resonance imaging confirmed a plexiform neurofibroma involving the parotid gland and facial nerve. Histopathology validated the diagnosis, emphasizing the importance of cytological and radiological correlation. Notably, the absent NF1 association makes this case unique. Surgical excision with facial nerve reconstruction was performed, highlighting the complexity of managing such rare intraparotid neurofibromas. Awareness of this entity is crucial for accurate diagnosis and appropriate management.

A rare Encounter with Pediatric Malignant Peripheral Nerve Sheath Tumor in Nasal Sinuses and Orbit.

This case report explores a rare and aggressive Malignant Peripheral Nerve Sheath Tumor (MPNST) in a 7-year-old child affecting nasal sinuses, maxilla, and orbit, an exceptionally uncommon pediatric manifestation unrelated to Neurofibromatosis 1. The child presented with alarming symptoms-nasal obstruction, snoring, epistaxis, and difficulty swallowing-underscoring the case's urgency. Non-contrast computed tomography revealed an extensive mass infiltrating nasopharynx, nasal cavity, maxillary sinus, ethmoid sinuses, and orbit, causing destructive consequences. Histopathology confirmed a high-grade MPNST, marked by rapid growth and early metastasis, highlighting management challenges. The rarity of pediatric MPNST in the nasal cavity is discussed, emphasizing the need for a broad differential diagnosis. Treatment involves surgical resection and adjuvant chemoradiation with a grim prognosis due to diagnostic complexities and morphological mimicry in young patients.

Association of tumor budding and tumor infiltrating lymphocytes with clinicopathological parameters in gallbladder carcinoma.

PURPOSE: Gallbladder carcinoma (GBC) poses significant challenges in oncology due to its aggressive nature and limited treatment options. The lack of effective biomarkers for early detection and prognosis exacerbates the prognosis for GBC patients. Tumor budding (TB) and tumor infiltrating lymphocytes (TILs) have emerged as potential prognostic indicators in various cancers, reflecting tumor-host immune interactions and tumor aggressiveness. The study of TB and TILs in GBC is particularly important due to the limited literature available. METHODS: This retrospective observational study aimed to evaluate the association of TB and TILs with clinicopathological parameters in GBC patients. Clinicopathological data were collected from patients with histologically confirmed GBC who underwent surgical resection. The sections were evaluated for TB and TILs using standardized methods. Statistical analysis was performed to assess associations between these parameters and clinicopathological variables. RESULTS: Tumor stage and grade showed significant associations with TB and TILs, indicating their potential as prognostic markers. High TB correlated with advanced tumor stage and higher grade, while high TIL infiltration was associated with early tumor stage and lower grade. Additionally, TILs exhibited a significant association with lymphovascular invasion. Interestingly, an inverse association was observed between TB and TILs, highlighting the dynamic interplay between tumor aggressiveness and host immune response. CONCLUSION: TB and TILs hold prognostic significance in GBC, offering insights into its pathogenesis and potential therapeutic targets. Future research exploring the mechanistic underpinnings of tumor-host immune interactions in GBC is crucial for translating these findings into clinical applications and improving outcomes for patients.

Unravelling the enigma: A rare case of primary gastric squamous cell carcinoma with aggressive metastasis.

This report details a rare case of squamous cell carcinoma (SCC) in the stomach, a condition accounting for only a fraction of gastric carcinomas. A 46-year-old male patient with dysphagia, abdominal pain, and haematemesis was diagnosed with primary gastric SCC displaying aggressive metastasis, an exceptionally low-incidence condition affecting mainly males in their sixth decade of life. Primary gastric SCC, though clinically similar to adenocarcinoma, involves a bleaker prognosis, lacking standardized treatment protocols. Histopathology and imaging confirmed the diagnosis, highlighting the challenges in managing advanced cases. Palliative chemotherapy showed partial remission but led to severe neuropathy. The case underscores the urgent need for research to understand the pathogenesis, effective management, and therapeutic targets for primary gastric SCC, emphasizing its scarcity and poor prognosis in medical literature. Increased clinical awareness and ongoing research are crucial for improving outcomes in such rare presentations.

Isolated tubercular cholecystitis: A rare diagnostic challenge.

Abdominal tuberculosis, particularly affecting the hepatobiliary system, presents a diagnostic challenge due to its rarity and its tendency to mimic neoplastic conditions. Tuberculosis of the gallbladder, especially in the absence of pulmonary infection, is exceedingly rare. We present a case of isolated tubercular cholecystitis in a 41-year-old female initially suspected to have neoplastic etiology. Radiological imaging revealed thickened gallbladder wall with heterogenous enhancement extending into the subcutaneous plane. Histopathological examination post-cholecystectomy confirmed tubercular etiology with epithelioid cell granulomas and focal necrosis, alongside the presence of acid-fast bacilli. Such cases pose diagnostic dilemmas due to overlapping clinical and radiological features with gallbladder carcinoma. This report emphasizes the importance of considering tuberculosis in differentials, particularly in endemic regions like India, even without pulmonary symptoms. Treatment involves postoperative administration of anti-tubercular drugs, with the preoperative diagnosis being challenging and rarely achieved due to the avoidance of invasive procedures like fine needle aspiration in suspected carcinoma cases. The rarity of isolated gallbladder tuberculosis underscores the necessity for comprehensive diagnostic evaluations and awareness among clinicians in endemic regions.

BCOR Positive Central Nervous System Neuroepithelial Tumor Masquerading as a Meningioma.

The central nervous system tumor with BCL-6 interacting corepressor internal tandem duplication (BCOR-ITD) is a molecularly defined entity with an internal tandem duplication in exon 15 of the BCOR gene. It is histologically characterized by a solid pattern with spindle-shaped cells and a dense capillary network. Very few cases of this rare entity have been reported till date. We present a case of BCOR-positive CNS tumor in a 3-year-old child who presented with scalp swelling. A differential diagnosis of CNS tumor with BCOR expression should be considered whenever high-grade tumors with histopathological features of glial or ependymal tumors do not express the classical glial markers.

Unveiling the Rarity: A Case Report on Solitary Fibrous Tumor of the Thyroid Gland.

Solitary Fibrous Tumor (SFT) rarely manifests within the thyroid gland, an organ predominantly associated with epithelial carcinomas. This case report explores the clinical narrative of a 70-year-old patient presenting with a sizable SFT localized in the left lobe of the thyroid, posing diagnostic challenges uncommon in thyroid nodules. The report delves into the clinical history, radiological findings, pathological assessments, and therapeutic interventions, contributing to the limited literature on thyroidal SFTs. The patient's ultrasound revealed a substantial thyroid mass causing tracheal and vascular displacement, categorized as TIRADS 3. Fine needle aspiration indicated mesenchymal origin, prompting further investigation. Contrast-enhanced computed tomography depicted a well-defined lesion with varied enhancement, compressing surrounding structures. Histopathology confirmed a spindle cell proliferation, prompting immunohistochemistry revealing CD34, STAT6, and Bcl-2 positivity, aligning with SFT characteristics. The rarity of thyroidal SFTs poses diagnostic challenges, necessitating reliance on immunohistochemistry for accurate differentiation from other spindle cell neoplasms. Radiological investigations, including ultrasound and magnetic resonance imaging, contribute to preoperative planning. The case underscores the importance of meticulous pathological examination, emphasizing the utility of immunohistochemistry in confirming SFT diagnosis. The report enhances understanding among clinicians, pathologists, and researchers, guiding improved diagnostic accuracy and tailored treatment strategies for future occurrences of thyroidal SFTs.

Desmoplastic Melanoma of the Chest Wall: a Diagnostic Dilemma.

Desmoplastic melanoma is an extremely rare subtype of malignant melanoma comprising only 1% of all the cutaneous melanomas. Being amelanotic and owing to its histopathological features of spindle cells lying in a collagenized stroma, it is often misdiagnosed as a dermatofibroma or scar tissue. The present case study describes a case of desmoplastic melanoma of the chest wall where the final diagnosis could be arrived at only after an extensive immunohistochemical panel to exclude other spindle cell proliferations.

Epithelioid Hemangioma of the Nasal Cavity: a Diagnostic Challenge.

Epithelioid hemangioma also known as angio-lymphoid hyperplasia with eosinophilia is a rare benign vascular neoplasm of unknown etiology. It very rarely involves the nasal cavity. It always poses a diagnostic challenge for clinicians and is usually misdiagnosed as Kimura's, IgG4-related disease, or malignant vascular tumors. The present case report describes an extremely rare presentation of epithelioid hemangioma inside the left nasal cavity causing complete obstruction and nasal septal deviation towards the right side in a young male. Hematoxylin and eosin-stained sections depicted a lobular proliferation of small capillary-sized vessels lined by plump epithelioid endothelial cells surrounding central vessels and scattered around them. These cells had abundant eosinophilic to amphophilic cytoplasm and enlarged nuclei with fine chromatin and central nucleoli. On immunohistochemistry, CD34 and CD31 highlighted the vascular proliferation and epithelioid endothelial cells. Erythroblast transformation-specific (ETS)-related gene (ERG) showed strong nuclear positivity in neoplastic plump epithelioid endothelial cells. EH is a benign vascular proliferation, but a high chance of recurrence is seen if complete resection is not done. As a result, the treatment of choice is complete surgical excision with clear margins. The case highlights a non-conventional presentation of epithelioid hemangioma and the importance of histomorphological features in diagnosing this entity.

Germ Cell Tumor Presenting as a Mesenteric Cyst: a Case Report and Literature Review.

Mesenteric cysts, typically benign and asymptomatic, are incidental findings during abdominal investigations for nonspecific symptoms. Their origin is commonly in the mesentery of the small bowel, mesocolon, or retroperitoneum. This paper reports a rare case of a 22-year-old male with a mesenteric cyst presenting as a right lower abdominal mass. Ultrasonography revealed a heterogenous collection, leading to surgical excision. Histopathology unexpectedly revealed an extragonadal yolk sac tumor (YST) originating in the mesentery, a rarity often misdiagnosed as a cyst. YST, primarily found in gonads, is infrequently reported extragonadally. This study contributes to the limited literature on primary peritoneal YST, discussing clinicopathological parameters and presenting a detailed case. The pathogenesis of extragonadal germ cell tumors, including YST, remains debated, with migration and stagnation of germ cells during embryonic development proposed as a prevalent theory. Histopathological examination of extragonadal YST mirrors gonadal YST, featuring various patterns. Immunohistochemistry, crucial for diagnosis, reveals positive expression for SALL-4, glypican-3, PLAP, AFP, and panCK. SALL-4 emerges as the most sensitive marker for extragonadal YST. This case underscores the importance of accurate postoperative histopathology and immunohistochemistry in distinguishing mesenteric YST from cysts, as misdiagnosis can impact prognosis. The rarity of extragonadal YST emphasizes the need for comprehensive understanding and recognition in clinical practice. The study contributes valuable insights into diagnosis and management, shedding light on a challenging aspect of surgical pathology.