A histopathological and immunohistochemistry analysis of endometrial lesions among women presenting with abnormal uterine bleeding.

Objectives: We aimed to histopathologically evaluate the morphological spectrum, apoptotic index (AI), and mitotic index (MI) of endometrial lesions in patients presenting with abnormal uterine bleeding (AUB). Methods: A cross-sectional study was done over a period of 18 months where a total of 60 newly diagnosed cases of perimenopausal women presenting with AUB were included. All H and E stained pathology slides from the specimens were reviewed for initial histopathological evaluation and diagnosis. Immunohistochemistry for Bcl-2 and Bax was done. The study subjects were divided into two groups: Group 1 included 30 cases of histologically proven proliferative endometrium (PE) and endometrial polyps and Group 2 included 30 cases of hyperplasia, endometrial epithelial neoplasia (EIN)/or carcinoma. For all cases, AI and MI were calculated and compared among the two groups. Statistical Analysis: Quantitative variables were compared using the Independent t-test/Mann-Whitney test between the two groups and Kruskal-Wallis test for comparison between more than two groups. Qualitative variables were correlated using the Chi-square test. P < 0.05 was considered statistically significant. Results: In our study of 60 patients of AUB, the mean age was 45.87 years with a parity of 2 or more in most of the patients. Most of the patients in our study had heavy menstrual bleeding (66.67%) with associated complaints of weakness, pallor, and low backache. Out of 60 patients of AUB, Endometrial carcinoma was diagnosed in 13 (21.67%) patients, with the most common histopathological type being Endometrioid carcinoma. There was a significant difference in the AI, MI, and the ratio of AI/MI among various histopathological diagnoses. AI was highest for Endometrial carcinoma and lowest for hyperplasia and polyps. MI was also highest for Endometrial carcinoma and lowest for hyperplasia and polyps. However, the ratio was incongruent as it was highest for hyperplasia without atypia and lowest for PE with endometrial carcinoma being midway. The Bcl-2 expression of relatively benign conditions (Group 1) was significantly higher than Group 2 (Endometrial epithelial neoplasia/carcinoma). Bax intensity showed an almost inverse pattern, being highest in endometrial carcinoma and lower in hyperplasia and polyps with the lowest expression in PE. Even the Bcl-2:Bax ratio was also highest for PE and lowest for endometrial carcinoma with others falling in between them. Conclusion: It can be concluded that the combination of the proliferative and apoptotic markers and the ratio will help as a tool in aiding the diagnosis of endometrial lesions for patients presenting with AUB.

Critical Analysis of Laboratory Requisition Forms Received in a Cytopathology Laboratory of a Tertiary Care Centre: An Audit and Review of Literature.

Background: A laboratory requisition form (LRF) is the main communication link between the laboratories and the clinicians. In a cytopathology laboratory, incomplete forms with inadequate information significantly impact the quality of the results and waste precious time of the lab. Aims: The aim of this study was to audit the LRFs for adequacy of demographic and clinical data and to analyze the reasons for the same. Settings and Design: A retrospective study was conducted in the cytopathology laboratory of a tertiary care center. Materials and Methods: All the original LRFs received for Pap smears and FNACs of 1-month duration were retrieved. The forms were scrutinized for the presence of specific parameters which were classified as patient information, clinician information and clinical information. In addition to the completeness of the form, clarity of the data was also noted. Statistical Analysis: The data were entered on excel worksheets and percentage of Pap smear and FNAC forms lacking information of various parameters was calculated. Results: A total of 431 LRFs were received in the month of January 2020. These included 274 Pap smear LRFs and 157 FNAC LRFs. Patient information was mentioned in predominantly all the forms, however, clinician and clinical information, which is indispensible for reporting, was missing in a significant proportion of the Pap smear and fine needle aspiration cytology (FNAC) forms. Conclusions: Receiving inadequately filled LRFs has been an age-old problem in all medical laboratories. Audit of inadequacy of LRFs helped in assessing the prevailing practices in the hospital and gave an insight into the quality of information available to the cytologists for reporting. Many clinicians withhold information out of ignorance about its importance or due to lack of time to fill up the details on the LRF. Also, filling out a LRF is a task usually delegated to the junior doctor in the OPD and the significance of filling the LRF correctly and comprehensively is often not emphasized upon adequately by the senior clinicians. This audit helped us taking preventive action by giving feedback to the clinicians and emphasizing to them the importance of clinical data on the LRF and in improvising the LRF using a more objective and user-friendly format.

Cichorium intybus attenuates streptozotocin induced diabetic cardiomyopathy via inhibition of oxidative stress and inflammatory response in rats.

The aim of the present study was to investigate the effects of Cichorium intybus on lipid peroxidation activities of both enzymatic and non-enzymatic antioxidants, inflammatory mediators, myocardial enzymes and histopathology of cardiac tissues in experimental diabetic cardiomyopathy (DCM). DCM was induced by single intraperitoneal injection of streptozotocin (STZ) (40 mg/kg) combined with high energy intake in rats. Seed extract of Cichorium intybus (CIE) (250 mg/kg & 500 mg/kg) was administered orally once a day for 3 weeks. Phytochemical investigations of seed extract revealed presence of some active ingredients such as alkaloids, tannins, saponin, phenols, glycosides, steroids, terpenoids and flavonoids. Seed extract of Cichorium intybus confirmed a significant potency towards restoring the blood glucose, an elevation of the levels of aspartate aminotransferase (AST), lactate dehydrogenase (LDH), superoxide dismutase (SOD), thiobarbituric acid reactive substances (TBARS), blood glutathione (GSH), TNF-α and IL-6 and a reduction in the levels of catalase (CAT) was observed following the STZ treatment. Oxidative stress was accompanied by myocardial degeneration as evidenced by histopathological examination of cardiac tissues. Administration of CIE reduced the lipid peroxides level in heart. Serum levels of AST, GSH, LDH and SOD were brought down to physiological levels by CIE in STZ induced DCM rats. CIE also markedly down-regulated serum TNF-α and IL-6 levels. Catalase that was reduced in serum was brought back to near normal level. The extensive necrotic changes of cardiac tissue by STZ was minimized to normal morphology upon CIE administration. The study demonstrates the cardioprotective effect of CIE via inhibition of oxidative stress and pro-inflammatory cytokines.

Coexistence of tuberculosis and malignancy: a mere coincidence or a causal association.

Tuberculosis (TB) and malignancy are among the most important current global health problems. Many authors suggest that their coexistence is a chance association owing to their high prevalence. There is, however, enough evidence that one condition may predispose the other. In our retrospective report of two cases, TB in draining lymph nodes was discovered incidentally on histopathology, following surgical resection for malignancy. The possibility of coexistent lesions, especially in regions endemic for TB, mandate a detailed histopathological examination to prevent the chances of diagnostic failure and thus therapeutic error.

Tuberculosis 'The Great Imitator': A usual disease with unusual presentations.

BACKGROUND: A number of infectious diseases have been referred to by the phrase 'The Great Imitator', of which the oldest is syphilis; others include Lyme disease, nocardiosis, etc. Tuberculosis has been described as the second great imitator as it can imitate various other disease processes. An awareness of the atypical clinical manifestations of tuberculosis is important, especially in regions where tuberculosis continues to be a major public health problem, such as India. Extrapulmonary tuberculosis (EPTB) constitutes about 15-20% of all cases of tuberculosis in immunocompetent patients and accounts for more than 50% of the cases in human immunodeficiency virus (HIV)-positive individuals. METHODS: We hereby report 4 cases of tuberculosis at unusual sites, which were not suspected clinically and were subsequently diagnosed by pathological examination and by ancillary techniques. OBSERVATIONS AND RESULTS: In all the four cases, the involvement was extrapulmonary in nature and at unusual sites. Three cases were diagnosed by a positive Ziehl Neelsen stain while culture for Mycobacterium tuberculosis was positive in three cases. All the four patients tested negative for HIV status on serology. CONCLUSIONS AND IMPLICATIONS: Unusual presentations, which mimic many diverse conditions, as seen in this series, highlight the importance of a high index of suspicion in the timely diagnosis of tuberculosis. Evidence of systemic or lung involvement may not always be present and laboratory and radiological findings play an important role.

Expression of Apoptosis Related and Proliferative Proteins in Malignant Lympho-Proliferative Disorders.

BACKGROUND & OBJECTIVE: The current study aimed to perform an immunohistochemical analysis of patterns of apoptotic and cell proliferative related protein expression in different histological grades and immune phenotypes of malignant lymphomas and other lymphoproliferative disorders. METHODS: This observational study was carried on 60lymph node biopsies of lymphoproliferative disorders. The biopsies were analyzed histologically and immunohistochemically. RESULTS: A total of 60 lymph node biopsies were included in the study, of which 81.6% were of malignant lympho-proliferative lesions. The majority of the biopsies were B-cell (66%) and were grouped in the intermediate grade. Bax and BCL-2 protein expression was presented by percentage of immune positive neoplastic cells per 10fields and graded on a scale of 1 to4. A Bcl-2, Bax Protein Ratio (BBPR) was determined for each case by dividing the estimated Bcl-2 protein (percentage of Bcl-2 positive cells x Bcl-2 staining intensity) by the estimated Bax protein (percentage of Bax positive cells x Bax immunostaining intensity). The mean BBPR was found to be significantly higher in indolent lymphomas (2.64 ± 1.3) as compared to aggressive lymphomas (0.47 ± 0.9) (P<0.01). The expression of P53 and PCNA in 35 biopsies of Non Hodgkin Lymphomas (NHL) was found to increase from low to high grade tumors. CONCLUSIONS: A significant correlation was found between BBPR and predicted biological behavior of indolent and aggressive lymphomas. This indicates the important role of Bcl-2 and Bax in biological behavior of lymphomas. Furthermore, P53 and PCNA expression were found to increase from low to high-grade tumors suggesting their prognostic value in NHL.

A Critical Appraisal of the Spectrum of Image Guided Fine Needle Aspiration Cytology: A Three Year Experience from a Tertiary Care Centre in Delhi.

OBJECTIVE: Image guided fine needle aspiration cytology (FNAC) is a safe, simple, rapid, cost effective and accurate modality in evaluation of deep seated lumps (abdominal, pelvic and intrathoracic masses) which are unapproachable by blind FNAC. In this study, a critical analysis of the utility of image guided FNAC in deep seated and otherwise inacessible mass lesions was carried out. MATERIAL AND METHOD: Fifty-four ultrasound (USG) or computed tomography (CT) guided FNACs from lumps at any location in the body, that is, thoracic, abdominal, pelvic etc over a period of 3 years (January 2012- December 2014) were included in the study. The most common site aspirated, the indications for a guided aspiration and the accuracy of aspiration cytology in comparison to the histological diagnosis were evaluated, wherever possible. RESULTS: Fifty-four image guided FNACs were performed (46 USG guided and 8 CT guided). Inconclusive, inflammatory, benign tumors, suspicious and malignant lesion rates were 5.6%, 29.6%, 11.1%, 5.6%, and 48.1%, respectively. The most common site was the liver (25.5%), followed by the thyroid (18.5%), lung (14.8%), gallbladder (11.1%), and lymph nodes (7.4%). Cytohistological correlation could be performed in 32 cases with a diagnostic accuracy of 100%. CONCLUSION: FNAC coupled with a diagnostic imaging technique such as USG or CT can improve the diagnostic yield and a definite diagnosis can be reached in most of the cases.

Delayed Uterine Necrosis: Rare Cause of Nonhealing Wound.

Uterine necrosis is a very rare condition and most of the reported cases occurred after pelvic arterial embolization for post-partum haemorrhage, embolization of fibroid uterus or application of B-Lynch sutures. A case of delayed myometrial necrosis is reported in post-cesarean patient where no embolization or uterine compression sutures have been applied. Patient presented with foul smelling discharge from the gaped abdominal wound following caesarean section. Abdomen was closed after exploration and lavage. Patient did not have complete healing and area of unhealed wound remained through which subinvoluted uterus was peeping out. Patient was taken for resuturing again but the uterus was found to be completely necrotic and hysterectomy was performed. Patient responded to treatment.

Primary Endometrial Squamous Cell Carcinoma In Situ: Report of a rare disease.

Squamous cell carcinoma (SCC) of the endometrium, whether primary or secondary to cervical cancer, is a rare entity. Primary endometrial squamous cell carcinoma in situ is even more uncommon; it usually occurs in postmenopausal women and has a strong association with pyometra. We report a 60-year-old multiparous postmenopausal woman who presented to the Hakeem Abdul Hameed Centenary Hospital, New Delhi, India, in May 2014 with a lower abdominal swelling corresponding in size to a pregnancy of 26 gestational weeks and vaginal discharge of one year's duration. A total abdominal hysterectomy with a bilateral salpingooophorectomy was performed, which revealed an enlarged uterus with pyometra. Histopathology showed that the entire endometrial lining had been replaced with malignant squamous cells without invasion of the myometrium. Immunohistochemistry revealed that the tumour cells were positive for p63 with a high Ki-67 labelling index. No adjuvant therapy was required and the patient was disease-free at a seven-month follow-up.

Postoperative thrombocytosis: An unusual case report.

Thrombocytosis is often an incidental finding seen in 35-50% of cases and the cause determination creates a diagnostic challenge. Extreme thrombocytosis is rare and seen in 2-5.8% patients only. Among the various causes of increased platelet count, surgical procedures have attracted much attention in both experimental and clinical domain. The appearance of thrombocytosis after surgery needs to be diagnosed to establish the type of thrombocytosis (clonal or reactive), as treatment and prognosis are quite different between them. This case report is vital because of two reasons: First, the increase in platelet count is difficult to rationalize than many of the other thrombocytoses, such as those related to primary augmentation of the function of the bone marrow; second, the association of platelets with the clotting process has led to the belief that their increase after a surgical procedure is connected with the occurrence of postoperative thrombosis. This case presents an interesting finding from a patient who has undergone major abdominal surgery and has shown an unexpected perpetual increase in platelet count.

Plasmacytoid variant of urothelial carcinoma: Diagnostic challenges and role of immunohistochemistry.

Plasmacytoid carcinoma of the urinary bladder or plasmacytoid urothelial carcinoma (PUC) is rare and only recently described a histological variant of transitional cell carcinoma. The morphological resemblance of PUC to other malignancies is a source of diagnostic dilemmas and often misdiagnosis. Immunohistochemistry plays a pivotal role in narrowing the differential diagnosis and reaching to a conclusive diagnosis. A diagnosis of PUC usually carries a dismal prognosis. Hence, correct diagnosis is important. We report here a 52-year-old male with a plasmacytoid variant of urothelial carcinoma.

The role of laboratory investigations in evaluating abdominal tuberculosis.

BACKGROUND AND OBJECTIVES: Tuberculosis (TB) continues to be a major health problem in developing countries like India. Abdominal TB is defined as an infection of the peritoneum, or hollow or solid abdominal organs with Mycobacterium tuberculosis (Mtb). The gastrointestinal tract is one of the most frequent sites of extrapulmonary involvement in TB. The present study was undertaken to evaluate the role of laboratory investigations in the diagnosis of abdominal TB. MATERIALS AND METHODS: The study was conducted on 300 patients admitted to various departments of our hospital from November 2005 to October 2007. Detailed histories and thorough clinical examinations together with relevant hematological, biochemical, cytological, radiological, and histopathological investigations were carried out in suspected cases of Koch's abdomen. RESULTS: Erythrocyte sedimentation rates with positive results were seen in 79.3% patients. Serological test enzyme-linked immunosorbent assay was performed on only 30 patients and was found to be positive for IgG, and IgM in 25 cases with a sensitivity of 83%. Thirteen out of 15 cases were positive for adenosine deaminase done on ascitic fluid. The results of the two patients who underwent Mtb polymerase chain reaction (PCR) were consistent with TB. Out of 21 image-guided fine-needle aspiration cytology (FNAC) cases, 10 (48%) of the positive cases showed caseating necrosis while 7 (33%) had noncaseous necrosis. Stain for acid-fast bacilli (AFB) was performed on all cases and was positive in 42 cases (38.8%). Lymph node biopsy was done in 95% of the cases. CONCLUSIONS: Serological investigations have a limited value, while PCR is a highly specific test. Since cost restricts its use, only two patients in our study could afford it. BACTEC is more sensitive and faster than culture techniques for the diagnosis of mycobacterial infections. FNAC is a reliable, cost effective alternative, and 81% diagnostic yield in the present study suggests that ultrasound guidance is a useful tool. Histopathological evaluation with positive AFB staining remains the gold standard for diagnosing abdominal TB. However, although the demonstration of AFB in aspirates and tissue sections is a definitive diagnostic method for TB, the positivity for AFB is variable.

Cellular leiomyoma versus endometrial stromal tumor: A pathologists' dilemma.

Uterine smooth muscle tumors and endometrial stromal tumors (ESTs) are the two major types of mesenchymal tumors of the uterus, the latter being fairly uncommon. Among these, endometrial stromal sarcoma (ESS) accounts for 0.2-1.5% of all uterine malignancies. Although routine histopathological examination is sufficient to distinguish between ESS and smooth muscle tumors in most of the cases, the distinction between ESTs and highly cellular leiomyomas (CMs), on several occasions becomes a great diagnostic challenge for the pathologist. The differentiation between EST and CM is necessary on account of the variable clinical course and slight variation in the therapy. However, this is difficult due to the tendency of endometrial stromal cells to differentiate into well-developed smooth muscle cells as well as overlapping immunohistochemical profile in some cases. We hereby report a series of cases which posed a diagnostic challenge to us as to whether they are CMs or ESTs. We therefore discuss the histological features which helped us resolve this dilemma as well as the utility of immunohistochemistry (IHC) as a diagnostic aid in arriving at a final diagnosis in such problematic cases.

Giant Cell Tumor Bone in an Elderly Male- an Unusual Case Misdiagnosed on MRI as a Malignant Sarcoma.

Giant cell tumor (GCT) of the bone is a benign locally aggressive neoplasm which accounts for 3-8 % of all primary bone tumors. 60-70 % of the patients with giant cell tumor of the bone occur in the age group of 20-40 years. Patients older than 55 years of age very rarely develop GCT. Although many case series have been published on giant cell tumor of the bone, even on extensive search of literature, we found only a single series of 10 cases focusing exclusively on giant cell tumors in elderly. They observed that there was no difference in behavior of GCT in elderly and younger patients in terms of location of tumor, radiographic features and clinical course. We present a case of GCT of tibia in an elderly male without any evidence of malignant transformation or dedifferentiation, despite magnetic resonance imaging revealing features of a malignant lesion.

Extranodal anaplastic large cell lymphoma mimicking sarcoma: A report of an interesting case.

Lymphomas are malignancies of the lymphoid tissues involving cells of the immune system. Primary systemic anaplastic large cell lymphoma (ALCL) represents an aggressive lymphoma characterized by neoplastic proliferation of lymphoid cells with an anaplastic appearance. Large pleomorphic cells are "hallmark" cells with horseshoe-shaped or kidney-shaped nuclei and a constant expression of the CD30 molecule on all neoplastic cells. There is a vast morphological spectrum posing a challenge to pathologists in the diagnosis of ALCL.

Gall bladder lymphoid hyperplasia: masquerading as lymphoma.

Lymphoid hyperplasia of the gall bladder is an extremely rare condition that may be missed on associated radiological or clinical evaluation but is diagnosed on biopsy. We are reporting hereby, a case of reactive lymphoid hyperplasia masquerading as a lymphoma on histopathology. A 58-year-old male was referred to our hospital with complaints of pain abdomen infrequently since last one year. Ultrasonography revealed the presence of single calculus along with features of chronic cholecystitis. Laparoscopic cholecystectomy was performed and the gall bladder was sent for routine histopathological evaluation. On microscopic examination, there were sheets of cells, lymphoid in origin and numerous lymphoid follicles spread throughout the wall of the gall bladder. It was diagnosed as a case of reactive lymphoid hyperplasia with chronic cholecystitis on histopathology.

Microfilariae of wuchereria bancrofti in a patient of chylous haematuria: report of an unusual finding in urine cytology.

Filariasis is a disabling parasitic disease and it constitutes as a major health problem in most of the tropical and sub-tropical countries. One hundred and twenty million people in at least 80 tropical and sub-tropical countries are infected with lymphatic filarial parasite, with one billion people being at risk of the disease. The laboratory diagnosis of filariasis is conventionally made by demonstrating microfilaria in peripheral blood smear. However, microfilaria have been incidentally detected by doing fine needle aspiration of various lesions in clinically unsuspected cases of filariasis. In 1982, detected microfilariae in the sediment smears of cystoscopically catheterized urine samples, but reports on detection of microfilaria in normally voided urine samples are extremely rare. Here, we are reporting, such a case of microfilariae of Wuchereria bancrofti in an 18-year-old boy who presented with chylous haematuria.

Low grade endometrial stromal sarcoma in a premenopausal woman.

Endometrial stromal sarcoma are rare malignant tumors of the uterus and has been described as the second most common malignant uterine mesenchymal tumor. The diagnosis is confirmed on hysterectomy for a presumed benign disease. In the latest World Health Organization (WHO) classification (2003), the term endometrial stromal tumor is applied to neoplasms typically composed of cells that morphologically resemble endometrial stromal cells of the nonneoplastic proliferative phase endometrium. The WHO recognizes three categories of endometrial stromal tumors: Endometrial stromal nodule, low-grade endometrial stromal sarcomas (LGESS), and undifferentiated endometrial sarcoma. We report here an interesting case of a 39-year-old female who presented with irregular bleeding per vaginum and urinary retention with a clinical impression of a leiomyomatous polyp, which on histological examination showed a LGESS.

Adenoid basal cell carcinoma and its mimics.

Basal cell carcinoma (BCC) is the most common malignant tumor of skin. The most common site (80%) is head and neck. BCC exhibits a varied morphology such as adenoid, keratotic, sebaceous, basosquamous, apocrine, eccrine or fibroepithelial. Tumors with a similar histopathological picture are cutaneous adenoid cystic carcinoma and primary cutaneous cribriform apocrine carcinoma. Immunohistochemistry, along with clinical findings, acts as an adjunct in reaching an accurate diagnosis. Here, we present an interesting case of adenoid BCC in a 55-year-old man.