Role of Magnetic Resonance Mammography in the Evaluation of Indeterminate Breast Lesions.

Background: Malignancy of the breast is one of the most common cancers among females worldwide. Magnetic resonance mammography (MRM) is a valuable complement to conventional methods for the early diagnosis of disease, thereby providing patients with a better prognosis. The number of unnecessary biopsies and repeated excisions in cases of indeterminate breast lesions detected on conventional imaging is high. Aims: The purpose of this study was to evaluate the role of MRM in the evaluation of indeterminate breast lesions [Breast Imaging Reporting and Data System (BIRADS) 3/4] found in conventional mammography and ultrasonography (USG), taking the histopathological examination (HPE) as the gold standard. Materials and methods: A total of 38 patients with conventional radiological imaging diagnosis of indeterminate breast lesions (BIRADS 3/4) were included in this study and evaluated using contrast-enhanced MRM according to the MR-BIRADS lexicon (5th edition). Morphological characteristics of lesions were evaluated to determine the probability of malignancy. Histopathology was kept as the gold standard for comparing all the statistical parameters. Results: There were a total of 40 lesions, 35 masses, and five nonmass enhancement (NME) available for evaluation out of the 38 patients. The sensitivity of margins to detect malignancy approached 100%; however, it had a slightly lower specificity of 66.67%. Magnetic resonance imaging (MRI) showed good diagnostic performance with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 85, 90, 89.47, 85.71, and 87.50%, respectively. Conclusion: The MRI has been shown to be useful as a problem-solving tool in breast cancer screening, clarifying indeterminate findings and avoiding unnecessary short follow-ups and percutaneous biopsies. How to cite this article: Mishra E, Kaur N, Kaur R, et al. Role of Magnetic Resonance Mammography in the Evaluation of Indeterminate Breast Lesions. J Assoc Physicians India 2023;71(11):76-84.

Fine needle aspiration cytology of dermatofibrosarcoma protuberans arising in a burn scar.

Tumours developing after a protracted period of time in burn scars are a notable complication with carcinomas forming a major share. The occurrence of burn scar sarcomas is scarce with dermatofibrosarcoma protuberans (DFSP) being an uncommon entity having only three prior reported cases. The authors report a case of a 32-year-old male patient with a 5 year prior history of thermal burn who presented with an expanding painless swelling for 2 years in the right flank region, diagnosed as DFSP on fine needle aspiration cytology and subsequently confirmed on histopathology.

Changes in ocular surface status after phacoemulsification in patients with senile cataract.

AIM: To evaluate the signs and symptoms of dry eye after phacoemulsification; effects on the status of ocular surface using impression cytology; and associated risk factors. METHODS: Prospective study included 50 eyes (50 patients) with no dry eye signs or symptoms, who underwent clear corneal phacoemulsification for senile cataract. Dry eye indices used included Ocular Surface Disease Index scoring, Schirmer I test, tear break up time, tear meniscus height, corneal fluorescein staining, lissamine green staining and goblet cell density (GCD) with the help of impression cytology. Primary outcome measures included post-operative changes in the dry eye indices. Secondary outcome measures included correlation of the dry eye signs and symptoms with various risk factors. RESULTS: Aggravation of both the signs and symptoms of dry eye were noted in immediate post-operative period. The sharp deterioration was followed by a recovering trend towards the end of sixth week. A decrease in GCD was also noted. Risk factors for deterioration include age, duration of exposure to microscope light and effective phacoemulsification time. Diabetic status, socio-economic status and site of incision did not have any effect on dry eye status. CONCLUSION: There is a transient deterioration of "dry eye" status post-phacoemulsification. The patients should be carefully counselled about the evanescent nature of the disease. Incision can be given at the site of high corneal curvature to neutralize astigmatism without any fear of inducing dry eye. Minimum light exposure and ultrasound energy should be used during the surgery.

Phaeohyphomycosis Caused by Rhytidhysteron rufulum and Review of Literature.

Phaeohyphomycosis is caused by a heterogeneous group of mycelial dematiaceous (phaeoid) fungi, which produce melanin pigment. This condition is often confused with chromoblastomycosis. Rhytidhysteron is a dematiaceous fungus, which has been recently found to be causing human infections. Till date only three cases of infection with Rhytidhysteron rufulum have been reported in the literature. All three cases have been from North India. Hereby, we present another two cases where Rhytidhysteron was isolated. Both the patients belonged to Chandigarh (India) and presented with subcutaneous lesions. The isolates were confirmed by ITS sequencing. Both the patients were immunocompetent and gave no history of trauma or any other predisposing factor. Phaeohyphomycosis are often missed due to lack of knowledge regarding the fungi causing the infections and there is need for clinical, pathological and microbiological correlation for effective diagnosis and treatment in these cases.

A prospective study of mucormycosis in north India: experience from a tertiary care hospital.

Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the Order Mucorales and class of Mucormycetes. We conducted a prospective study of 38 patients who were diagnosed as having mucormycosis in a tertiary care hospital during January 2010 to June 2011. The cases were analyzed regarding the site of involvement, underlying disease and species of fungi isolated, antifungal susceptibility pattern of the isolates, and outcome of therapy. The mean age of the patients was 40.43 years, with 72% male. Rhino-orbital mucormycosis (61.5%) was the most common presentation followed by cutaneous manifestations (31%), gastrointestinal symptoms (5%), and pulmonary (2.5%). Diabetes mellitus (56%) was the significant risk factor in rhino-orbito-cerebral presentation (OR = 7.55, P = 0.001). Among 23 culture isolates, Rhizopus arrhizus (37.5%) was the most common, followed by Apophysomyces variabilis (29.2%), Lichtheimia ramosa (16.7%), Rhizopus microsporus (4.2%), Rhizomucor pusillus (4.2%), and Apophysomyces elegans (4.2%). Rhizopus arrhizus was most commonly isolated from rhino-orbito-cerebral mucormycosis and Apophysomyces species were generally obtained from cutaneous mucormycosis. In vitro antifungal susceptibility showed that 16 isolates were sensitive to amphotericin B (MIC less than 1 µg/ml), while in contrast, all isolates were found to be resistant to voriconazole (MIC- 0.25 to >8), fluconazole (MIC > 32), flucytosine (MIC > 32). Treatment regimens included antifungal therapy, reversal of underlying predisposing risk factors, and surgical debridement. Combination of surgery and medical treatment with amphotericin B was significantly better (OR = 0.2, P < 0.04) than amphotericin B alone (61.5% vs. 10.3% patient survival). The awareness of fungal diseases amongst clinicians is required to decrease the fatal outcome of disease.

Sudden cardiac death in 2 young siblings.

Hypertrophic cardiomyopathy is a disease known for exhibiting phenotypic and genetic heterogeneity. At times, sudden cardiac death may be the first and foremost manifestation of the disease. We report 2 cases of hypertrophic cardiomyopathy causing sudden death, which were diagnosed on autopsy with special emphasis on histopathological findings of this entity. The role of a pathologist cannot be undermined as the disease is a diagnostic challenge often overlooked by the neophytes in the field due to unawareness.

Complementary value of DNA flow cytometry and image morphometry in detection of malignant cells in effusion fluids.

BACKGROUND: In cytologic evaluation of body cavity effusions, the morphologic changes exhibited by reactive mesothelial cells often confound the diagnosis. This study investigates the role of DNA flow cytometry (DNA FCM) and image morphometry (IM) in improving diagnostic accuracy. METHODS: 53 pleural and 47 ascitic fluid samples were evaluated cytologically. All were also subjected to flow cytometry to assess DNA ploidy. Image morphometry was used to measure nuclear diameter, nuclear perimeter and nuclear area. RESULTS: On cytomorphology 79% cases were diagnosed as benign, 19% as malignant and 2% as suggestive of malignancy. DNA FCM showed aneuploidy in 13 of 19 malignant cases and diploidy in 6 cases. The mean nuclear area of the benign group was 60.14 ± 39.91 µm² and that of malignant cases was 190.54 ± 56.06 µm². Using DNA FCM and IM, one of the two cases "suggestive of malignancy" was placed in the benign group and the other in the malignant group. Also, these modalities were able to pick up one case of malignancy that was diagnosed as benign on cytology. CONCLUSIONS: Cytomorphology remains the foremost diagnostic modality in detecting malignant cells in effusions. DNA flow cytometry and image morphometry hold a valuable complementary value.

Morphological markers of chromosomal instability as predictors of malignancy in pleural effusion.

BACKGROUND: Malignancy in pleural effusion is an indication of poor prognosis. The distinction between malignant cells and reactive mesothelial cells in effusion cytology is sometimes difficult and requires ancillary techniques. Evaluation of morphological indicators of chromosomal instability (CI) like micronuclei (MN), chromatin bridging (CB), nuclear budding (NB), and multipolar mitosis (MM) on routine cytology smears is a promising tool to distinguish malignant from benign ascitic fluids. However, it has been scarcely evaluated in pleural effusions. The present study was conducted to evaluate the diagnostic value of these markers in differentiating between malignant and benign pleural fluids. METHODS: It is a cross sectional study in which a total of 72 pleural fluid samples over a period of 2 years received in the cytology department of the hospital were evaluated. The cytological analysis was done by two independent cytopathologists and interpreted as either malignant or benign. Four morphological markers of CI were counted in the May-Grünwald Giemsa (MGG) stained smears of all the cases and the score was compared with the conventional cyto-morphological diagnosis. RESULTS: Out of 72 cases, there were 42 malignant and 30 benign effusions on cytological examination. The mean score of micronuclei count, nuclear budding, chromatin bridging and multipolar mitosis in malignant effusions were 7.26 ± 2.74, 9.55 ± 5.53, 1.83 ± 1.17, and 2.21 ± 1.62 respectively that was significantly higher than the benign effusions (1 ± 0.71, 1.1 ± 0.86, 0.38 ± 0.50, and 0.15 ± 0.37 respectively) (p < .05). On Receiver operating characteristic (ROC) curve analysis, a cut-off of 5 for the MN count had a sensitivity of 88% and specificity of 100% in detecting malignant pleural effusion [Area under curve (AUC) 95.8%, p < .001]. CONCLUSION: Evaluation of morphological indicators of CI on routine MGG stained smears is a simple and cost-effective method to differentiate between benign and malignant pleural fluids.

Iodine-125 brachytherapy for choroidal melanoma by using Ocuprosta seeds with indigenous non-collimated plaques: Our initial experience.

PURPOSE: Brachytherapy is the gold-standard treatment for choroidal melanoma. This study evaluated iodine-125 brachytherapy by using Ocuprosta seeds with indigenous non-collimated plaques in Asian patients. METHODS: Retrospective single-center study in a tertiary care hospital of 12 eyes with choroidal melanoma in 12 Asian patients who underwent brachytherapy with Ocuprosta seeds fixed on non-collimated plaques and had a follow-up of at least 32 months (mean: 42.4 ± 9.5 months; median: 40 months). Radiotherapy was planned after developing the digital 3D model of the tumor within the eye by using radiological images and clinical pictures. Ocuprosta iodine-125 seeds were used on indigenous non-collimated gold plaques to deliver the radiation for precalculated time. "Successful outcome" was taken as a decrease in the volume of the tumor, and "unsuccessful outcome" was defined as no change in the tumor volume or increase in the tumor volume at 24 months after brachytherapy. RESULTS: The mean decrease in tumor volume was 21% (914.5 ± 912.2 mm3 to 495.7 ± 633.6 mm3) after brachytherapy, which correlated with the baseline volume of the tumor. Ten eyes (83.3%) showed a reduction in tumor volume, whereas two eyes showed an increase in the volume of the tumor after brachytherapy. One of the cases with a reduction in tumor size developed neovascular glaucoma. Enucleation was done in three eyes. A globe salvage rate of 75% and tumor regression rate of 83% were seen in the present study using Ocuprosta seeds. CONCLUSIONS: Iodine-125 brachytherapy with uncollimated indigenous gold plaques is an effective treatment modality for choroidal melanomas in Asian patients.

The Fallacies of the Breast MRI: A Case Study.

Magnetic resonance imaging (MRI) of breasts using diffusion-weighted imaging and dynamic contrast enhancement is now well-established imaging for the evaluation and characterization of suspicious breast lesions, where it has become a problem-solving tool. Breast lesions are characterized according to their morphological features and enhancement characteristics. Breast MRI is helpful in the evaluation of breast lesions in patients with dense breasts and women with breast implants and to differentiate scars and recurrence. However, this technique has its own limitations, a few of which are elucidated in the present case report.

Comparative Analysis of Conventional Cytology and Liquid-Based Cytology in the Detection of Carcinoma Cervix and its Precursor Lesions.

Context: The conventional smears (CS) and Liquid based cytology (LBC) are important tools to detect carcinoma cervix and its precursor lesions. Aims: The present study was done to compare the cytomorphological features of cervical lesions using both techniques and compare with the histopathological diagnosis. Settings and Design: This was a prospective observational study over a period of 1.5 years at a tertiary care hospital. Methods and Material: A total of 969 women in the age group of 21-65 years presenting with either routine screening or complaints of vaginal bleeding, discharge, or pelvic pain were enrolled for the study. Both the CS and LBC smears were analyzed and compared with the corresponding histopathology diagnosis. The data was analyzed using Statistical Package for the Social Sciences (SPSS) software and P values <0.05 were considered significant. Results: There were 8.57% unsatisfactory smears in CS as compared to 0.5% in LBC smears. Liquid-based cytology was superior to conventional preparations in terms of smear adequacy, lesser hemorrhagic and inflammatory background, and presence of more endocervical cells. Liquid-based cytology showed a better yield in detecting all the types of epithelial cell lesions with a concordance rate of 73.9% between the two techniques. On histopathology correlation of these lesions, LBC had a higher sensitivity (96.67%) and diagnostic accuracy (99.08%) as compared to CS (73.33% and 92.66%, respectively). Conclusions: Liquid-based cytology is superior to conventional cytology for the detection of epithelial cell lesions. Reduction in the unsatisfactory smears, a cleaner background, and better representation of the sample are more significantly appreciated on LBC in contrast to CS.

Vocal Cord Nodule with Stromal Atypia: Case Report and Review of Literature.

Vocal cord nodule is a common reactive transformation of the laryngeal mucosa encountered routinely. Although benign, rare instances of stromal atypia have been demonstrated, which can often be confused with other spindle cell lesions. There is a dearth of literature explaining this peculiar transformation. Hence, the diagnosis of these lesions can be put-forth only after histopathological evaluation and appropriate immunohistochemical analysis. Herein, we report a case of a 55-year-old male who presented with vocal cord nodule with stromal atypia.

Clinico-pathological Spectrum of Primary Skin Malignancies in an Indian Tertiary Care Hospital.

Background: Skin malignancies are the most common form of malignant disease in the western world, predominantly affecting older age groups. The majority of skin cancers are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma, which account for more than 95% of total skin malignancies. However, in India, these constitute only 1-2% of all cancers. There is an increase in incidence in India over 10 years of period. There is scarcity of data on the clinico-pathological profile of these tumours from this geographical region. Materials and Methods: This was a retrospective study conducted in a tertiary care teaching hospital in which archival records and histopathology sections of all patients of skin carcinomas diagnosed over a period of 5 years (January 2016 to December 2020) were analysed. The clinical parameters and histopathological features of the cases were analysed and correlated for any possible association. Results: Out of the 230 skin malignancies studied, SCC constituted the most common type (n = 148), followed by BCC (n = 70) and malignant melanoma (n = 12). The tumour commonly presented in the 6th decade of life with slightly higher male preponderance (M: F =1.6:1). Sun-exposed areas were the most common sites, and the common presentations included non-healing ulcer, fungating/cauliflower/polypoidal growth, and hyperpigmented or nodular plaque. In SCC, previous history of diabetes and burns was noted in 10% and 3.4% of the patients, respectively. Conclusion: SCC is likely the most common histological type of skin malignancies in India. The clinico-pathological profile of skin malignancies of patients depends on multiple factors, notably the skin colour and the geographical location.

Multiple subcutaneous cysts due to Exophiala spinifera in an immunocompetent patient.

Here we report a case of a 55-year-old Indian male presenting with multiple subcutaneous cysts, which developed from painful nodules at the dorsal right wrist joint. Subsequently a painful nodule appeared on the left knee joint. Cytological examination of the knee swelling revealed a suppurative inflammatory lesion consisting of neutrophils, lymphocytes, multinucleated giant cells and few fungal elements, without involvement of the overlying skin. Exophiala spinifera was cultured (CBS 125607) and its identity was confirmed by sequencing of the internal transcribed spacer (ITS rDNA). The cysts were excised surgically, without need of additional antifungal therapy. There was no relapse during one-year follow-up and the patient was cured successfully. In vitro antifungal susceptibility testing showed that posaconazole (0.063 µg/ml) and itraconazole (0.125 µg/ml) had the highest and caspofungin (4 µg/ml) and anidulafungin (2 µg/ml) the lowest activity against this isolate. However, their clinical effectiveness in the treatment of E. spinifera infections remains to be evaluated. In this case report, we have also compiled cases of human E. spinifera mycoses which have been reported so far.

Cytologic diagnosis of intravascular papillary endothelial hyperplasia: a report of two cases and review of cytologic literature.

BACKGROUND: Intravascular papillary endothelial hyperplasia (IPEH), previously known as 'Masson's hemangioma', is a reactive endothelial proliferation that occurs most commonly in the vessels of the head, neck, and extremities. The cytologic findings of the lesion are varied and depend on the age of the lesion. CASES: Case 1 is a 61-year-old man who presented with a swelling on the medial aspect of the forearm. The clinical diagnosis was lipoma. Cytologic smears showed spindle cells tagging onto a rich capillary network and smaller round cells arranged around hyaline cores. The cytologic diagnosis was benign vascular tumor. On histolopathogic examination a diagnosis of IPEH was given. Case 2 is a 45-year-old man who presented with swelling on the dorsal aspect of the wrist. The cytologic diagnosis of giant cell tumor was made based on the presence of scattered spindled cells and multinucleate giant cells. The giant cells had various shapes like round or crescent and had 10-25 nuclei. The lesion was excised and a diagnosis of IPEH was rendered. CONCLUSION: These two cases highlight the varied cytomorphology of IPEH making the pinpoint diagnosis of this lesion difficult on cytologic smears.

Correlation of Morphological Features of Chromosomal Instability and Flow Cytometric DNA Ploidy Analysis in Aspirates of Breast Carcinoma.

OBJECTIVE: Morphological indicators of chromosomal instability (CI), including multipolar mitoses, chromatin bridges (CB), strings, nuclear buds (NB), micronuclei (MN), and deoxyribonucleic acid (DNA) ploidy analysis help in prognostication of breast carcinoma. The present study was done to evaluate CI in breast carcinoma and correlate with DNA ploidy and tumor grade. STUDY DESIGN: Fifty cases of carcinoma breast diagnosed by fine-needle aspiration cytology were included. Robinson's grading method was used on smears to grade breast carcinoma. To assess the morphological features of CI, the best May-Grünwald Giemsa stained smear was chosen. At least 1,000 epithelial cells on oil immersion magnification (×100 objective) were counted. DNA ploidy on the aspirates was done by flow cytometry. RESULTS: All the patients were female, diagnosed as infiltrating ductal carcinoma on cytology. Eight tumors were grade I, 32 were grade II, and 10 were grade III. MN was seen in 48 cases, NB in 45, and CB in 12 cases. Mean MN, NB, and CB scores in aneuploid (24) cases were 9.96 ± 8.42, 5.29 ± 4.71, and 1.08 ± 1.84 while 6.19 ± 6.67, 1.92 ± 1.79, and 0.11 ± 0.33 were seen in diploid (26) cases. Statistically significant positive correlation was observed between CI and DNA ploidy. CONCLUSIONS: Morphological evaluation of CI by light microscopy on routinely stained breast aspirates is feasible, although a meticulous search is required. Cytomorphological features of CI and ploidy have a positive correlation with increasing tumor grade.