Modification of Rapid Papanicolaou Stain with Phloxine: A Study Assessing the Utility in Gynecological Smears.

Background: Rapidity and reliability are the major advantages of cytopathology in tumor diagnosis. The need for minimal turnaround time for assessing cytological smears has encouraged innovations in staining techniques that require lesser staining time with unequivocal cell morphology. Rapid Pap staining was introduced as a hybrid to conventional Pap stain. It improves staining quality, gets over the staining time in restriction, and is a more efficient technique financially. In the present study, a modified staining technique was adopted where phloxine is added as one of the cytoplasmic stain components in rapid Pap stain kits. Objective: The aim of this study was to assess whether the modification of the existing procedure by adding phloxine as one of the components of the cytoplasmic stain intensifies the cytoplasmic differentiation and cytoplasmic staining in gynecological smears. Materials and Methods: This was a prospective study done on 50 cases of gynecological smears. Two smears were collected from each patient and fixed in 100% propanol and stained with the rapid Pap stain kit procedure and modified rapid Pap stain with phloxine. Slides were then analyzed by two pathologists blinded to the staining method used. Five parameters were considered and scored (background, cell morphology, nuclear staining, cytoplasmic differentiation, and cytoplasmic staining). The quality index for each method was calculated by finding out the ratio of the actual score obtained to the maximum score possible. Results: Both the staining methods had comparable results. For both pathologists, the quality index calculated for modified Pap stain was found to be marginally higher than the quality index for rapid Pap. The mean quality index was comparable for modified Pap (0.91) and rapid Pap (0.89). Conclusions: The efficacy of modified Pap stain with phloxine to distinctly stain the cytoplasm is comparable with that of rapid Pap stain. In addition, the intensity of staining can be enhanced with little cost outlay, and this can be especially beneficial in low-resource settings.

A Clinicopathological Analysis of Molecular Subtypes of Breast Cancer using Immunohistochemical Surrogates: A 6-Year Institutional Experience from a Tertiary Cancer Center in North India.

Puneet Kaur SomalObjective Classification of breast cancer into different molecular subtypes has important prognostic and therapeutic implications. The immunohistochemistry surrogate classification has been advocated for this purpose. The primary objective of the present study was to assess the prevalence of the different molecular subtypes of invasive breast carcinoma and study the clinicopathological parameters in a tertiary care cancer center in rural North India. Materials and Methods All female patients diagnosed with invasive breast cancer and registered between January 1, 2015, and December 31, 2020, were included. Patients with bilateral cancer, missing information on HER2/ER/PR receptor status, absence of reflex FISH testing after an equivocal score on Her 2 IHC were excluded. The tumors were classified into different molecular subtypes based on IHC expression as follows-luminal A-like (ER- and PR-positive, Her2-negative, Ki67 < 20%), luminal B-like Her2-negative (ER-positive, Her2-negative and any one of the following Ki67% ≥ 20% or PR-negative/low, luminal B-like Her2-positive (ER- and HER2-positive, any Ki67, any PR), Her2-positive (ER- and PR-negative, Her2-positive) and TNBC (ER, PR, Her2-negative). Chi square test was used to compare the clinicopathological parameters between these subtypes. Results A total of 1,625 cases were included. Luminal B-like subtype was the most common (41.72%). The proportion of each subtype was luminal A (15.69%), luminal B Her2-negative (23.93%), luminal B Her2-positive (17.78%), Her2-positive (15.26%), TNBC (27.32%). Majority of the tumors were Grade 3 (75.81%). Nodal metastases were present in 59%. On subanalysis of the luminal type tumors without Her2 expression (luminal A-like and luminal B-like (Her2-negative), luminal A-like tumors presented significantly with a lower grade ( p < 0.001) and more frequent node-negative disease in comparison to luminal B-like (Her2-negative) tumors. In comparison to other subtypes, TNBC tumors were more frequently seen in the premenopausal age group ( p < 0.001) and presented with node-negative disease ( p < 0.001). Conclusion This is one of the largest studies that enumerates the prevalence of various molecular subtypes of breast cancer in North India. Luminal B-like tumors were the most common followed by TNBC. TNBC tumors presented more commonly in premenopausal age group and with node negative disease in comparison to other subtypes.

Aliens in the thyroid gland: The secondary lesions.

BACKGROUND: A secondary lesion in the thyroid gland is a rare clinical scenario diagnosed preoperatively during the evaluation of a neck mass, postoperatively in a thyroidectomy specimen or in autopsy studies. Even though the thyroid gland is highly vascular, secondary malignant lesions are rare accounting for 0.2% of all thyroid malignancies. Thyroid gland secondary lesions are often metachronous in presentation as they are seldom evaluated in the initial diagnostic workup of the primary lesion. Fine-needle aspiration cytology (FNAC) is a useful modality for the diagnosis of secondary thyroid lesions. MATERIALS AND METHODS: A 6-year retrospective review (2016-2021) was carried out to assess the secondary lesions in the thyroid gland. Papanicolaou and field-stained FNAC smears of secondary thyroid lesions were reviewed. Ancillary techniques were performed on the cell block for differentiating from the primary thyroid gland lesions. RESULTS: There were 383 patients in our archives. There were only 18 cases (4.7%) that presented with secondary neoplastic lesions in the thyroid gland either by direct extension, metastases or as a hematolymphoid malignancy. There were 14 (77.7%) cases that presented with non-hematolymphoid secondary lesions while 4 (22.3%) cases presented with hematolymphoid malignancies. Thyroid secondaries were predominantly seen in female patients (female: male ratio of 1.5:1). Most of the cases presented with a synchronous secondary lesion (n = 14, 77.7%) and few metachronous secondary lesions were also noted (n = 4, 22.3%). CONCLUSION: Although exceedingly rare, the detection of secondary thyroid gland lesions is important for staging and planning treatment.

Challenges Encountered and Pattern-Based Analysis of Bone Marrow Biopsy in Lymphomas: An Institutional Experience.

Objective The evaluation of bone marrow (BM) status is an integral part of the initial workup of patients diagnosed with lymphoma as it plays an important role in staging and predicting prognosis in these patients. This article determines the incidence and pattern of BM involvement in lymphoma cases and distinguishes benign from malignant lymphoid aggregates in BM biopsies. Materials and Methods The study group included 121 cases of Hodgkin and non-Hodgkin lymphomas for which BM biopsies were performed, fixed in acetic acid-zinc formalin solution, decalcified using 10% formic acid, and subjected to hematoxylin and eosin and immunohistochemistry. Results The overall incidence of BM biopsy involvement in our study was 31.4% (37/118), including 34.7% (35/101) in cases of B cell lymphomas, 25% (2/8) in cases of T cell lymphomas, and no involvement in Hodgkin lymphoma. The predominant histological pattern of BM involvement was diffused (14/37; 37.8%), followed by interstitial (10/37; 27.1%). Five cases revealed benign nonparatrabecular lymphoid aggregates which could be confused with lymphomatous involvement, especially in low grade lymphomas. Conclusion A careful examination of the BM biopsies along with clinical history, peripheral blood examination, flow cytometry, and immunohistochemistry will help in arriving at the correct diagnosis.

Immunohistochemistry on cell blocks for diagnosis of malignancy in abdomino-pelvic lesions and ascitic fluid cytology at a rural cancer center: A paradigm shift in cancer management.

Background: Cell block preparation is routine practice in cytopathology these days because of its pivotal role in increasing diagnostic yield and ancillary studies. In the present era of personalized medicine in oncology, ancillary techniques such as immunohistochemistry (IHC) and molecular analysis are gaining more importance. Methods: A retrospective study was conducted in the Department of Pathology, over 6 months, which included 144 cases of Fine Needle Aspiration Cytology (FNAC) of abdominopelvic masses and 105 cases of ascitic fluids. Cell blocks and conventional smears were prepared simultaneously in all cases. IHC was applied on cell blocks and analyzed. Results: IHC was performed on cell blocks in 76 cases of FNA and 53 cases of ascitic fluids. Based on IHC, liver lesions (50 cases) were categorized into metastatic carcinomas with a suggested primary site (45.0%), hepatocellular carcinoma (12.2%), neuroendocrine tumors (16.3%), and malignant melanoma (2%). Using MOC-31 and WT-1, ascitic fluid samples were categorized into benign and malignant. Forty-one out of 53 cases of fluids were diagnosed as metastatic adenocarcinomas with the ovary as the most common primary site. Conclusion: A panel of IHC markers, though not specific alone when applied to cell blocks in a careful clinical and morphological context leads to a rapid and accurate diagnosis. This in turn obviates the need for biopsy in severely ill patients. An astute pathologist can provide accurate results with judicious use of IHC on cell blocks and may bring a sigh of relief for many cancer patients by averting the need for biopsy.

Ectopic Prostate Tissue Presenting as Urinary Bladder Tumor: The Imitation Game!

Ectopic prostate tissue is a rare phenomenon. Histologically and immunohistochemically it is indistinguishable from normal prostatic tissue but it is difficult to recognize and may be confused with malignancy when presenting as ectopic lesion in the urinary system. Therefore, awareness of this entity is essential for both urologists and pathologists to prevent misdiagnosis.

Adequacy of Histopathology Reports Representing Oncologic Resection Specimens: An Experience of Reporting Practice in Rural India.

CONTEXT.­: The histopathology reporting practice in rural areas is largely variable. To ensure the adequacy of histopathology reports (HPRs), the College of American Pathologists (CAP) has developed cancer reporting checklists. OBJECTIVE.­: To assess the adequacy of resection specimen HPRs received from outside centers for a second opinion. Further, the adequacy of breast resection HPRs from these centers was compared with that of our center. Additionally, the reports representing endometrial carcinoma were assessed for impact on the treatment decision. DESIGN.­: This was a retrospective study conducted from June 2015 to December 2019. HPRs from outside centers and our institute were analyzed for mandatory reporting elements as per CAP 2013 checklists. RESULTS.­: A total of 730 HPRs (558 outside HPRs and 172 in-house breast HPRs) were reviewed for completeness. The outside HPRs were complete in 42 of 558 cases (7.5%). Only 11 of 143 reports (7.7%) from the academic centers were complete. Seventeen of 249 outside breast HPRs (6.8%) were complete, whereas predominant (n = 123 of 172; 71.5%) in-house breast HPRs were adequate. Most outside endometrial carcinoma reports (60.8%; n = 28 of 46) were inadequate with potential impact on the adjuvant treatment, whereas 10 of 46 reports (21.7%) were inadequate and had an actual impact on the adjuvant treatment decision. CONCLUSIONS.­: Minimal data set reporting using checklists is not yet widely operational in most rural laboratories. We call for continuous education and sensitization of the practicing pathologists, oncopathology education of the trainees, and regulatory standards for signing out an oncopathology report.

Strategies to ensure efficient laboratory functioning while navigating through the COVID-19 crisis in developing countries: An early experience from a tertiary care centre in India.

BACKGROUND: The coronavirus disease 2019 (COVID 19) is a zoonotic viral infection that originated in Wuhan, China, in December 2019. It was declared a pandemic by the World Health Organization shortly thereafter. This pandemic is going to have a lasting impact on the functioning of pathology laboratories due to the frequent handling of potentially infectious samples by the laboratory personnel. To deal with this unprecedented situation, various national and international guidelines have been put forward outlining the precautions to be taken during sample processing from a potentially infectious patient. PURPOSE: Most of these guidelines are centered around laboratories that are a part of designated COVID 19 hospitals. However, proper protocols need to be in place in all laboratories, irrespective of whether they are a part of COVID 19 hospital or not as this would greatly reduce the risk of exposure of laboratory/hospital personnel. As part of a laboratory associated with a rural cancer hospital which is not a dedicated COVID 19 hospital, we aim to present our institute's experience in handling pathology specimens during the COVID 19 era. CONCLUSION: We hope this will address the concerns of small to medium sized laboratories and help them build an effective strategy required for protecting the laboratory personnel from risk of exposure and also ensure smooth and optimum functioning of the laboratory services.

Mullerianosis of urinary bladder: The great impersonator.

Müllerianosis of the urinary bladder is a rare entity with less than 30 cases reported. It encompasses a mixture of different types of Mullerian lesions like endometriosis, endocervicosis, and endosalpingiosis. It typically affects the women of reproductive age group. The symptoms vary from hematuria and dysuria, to pelvic pain, which may be associated with menstruation. It can mimic a malignant tumor clinically and radiologically; hence, it is important that a correct diagnosis is rendered in these cases to avoid unnecessary radical procedures. Herein we report a case of mullerianosis of the urinary bladder in a young female and discuss the important differential diagnosis and various treatment modalities.

Anaplastic thyroid carcinoma with rhabdoid phenotype: An unusual case and a comprehensive review.

Anaplastic thyroid carcinoma (ATC) is a highly aggressive thyroid malignancy predominantly affecting the elderly with a fatal outcome. ATC with rhabdoid phenotype is a rare variant, with only a few cases reported in the literature to date. We herein report a case of a 44-year old female diagnosed as ATC with rhabdoid phenotype. She had a slow-growing neck mass with no gross extrathyroidal extension (ETE) or nodal/distant metastasis at presentation. Computed tomography of the neck showed a well-defined heterogeneously hypodense nodule in the right lobe of the thyroid. On cytology, a diagnosis of papillary thyroid carcinoma (PTC) with possible anaplastic transformation was made based on the presence of vague papillae with focal nuclear features of PTC and atypical pleomorphic/rhabdoid cells. The total thyroidectomy specimen showed a relatively circumscribed lesion with no gross ETE. Histopathological examination revealed sheets of rhabdoid cells with a focus of poorly differentiated thyroid carcinoma. On immunohistochemistry, rhabdoid cells were positive for AE1/AE3, focally positive for PAX8 and were negative for TTF-1, synaptophysin, desmin, myogenin, S100P, and SMA. The neck lymph nodes were non-metastatic. The patient was further treated with adjuvant radioactive iodine. Four-months post-operatively, the patient developed pulmonary metastasis which on biopsy examination revealed metastatic ATC. Apart from being a rare tumor type, this case is unusual with its presentation too; wherein, unlike described earlier in the literature the patient had a relatively mitigated clinical course with no gross ETE or nodal/distant metastatic disease. We also review the relevant literature along with this case.

Uterine lipoleiomyoma: A case report of a rare entity.

Lipomatous tumors of the uterus are rare neoplasms which can be divided into three broad groups - pure, mixed, and the exceedingly rare malignant liposarcoma. Lipoleiomyoma is a rare benign variant of leiomyoma with an incidence ranging between 0.03% and 0.2%. These tumors are usually seen in obese postmenopausal women and are usually asymptomatic but may also present with typical leiomyoma symptoms. The most common site of occurrence is the uterine corpus. Imaging plays an important role with magnetic resonance imaging being the modality of choice as it delineates the fat component better. The pathogenesis of this lesion is poorly understood. Histology shows a characteristic pattern with an encapsulated lesion with an admixture of smooth muscle cells, lobules of adipocytes and fibrous tissue. Prognosis is excellent. We report a case of lipoleiomyoma in an elderly, obese postmenopausal woman, who presented with abdominal discomfort and discuss the important differential diagnosis.