Application of the Bethesda system for reporting thyroid cytopathology for classification of thyroid nodules: A clinical and cytopathological characteristics in Bhutanese population.

INTRODUCTION: The existence of baseline data on the spectrum of thyroid nodules in Bhutanese patients is unknown. Fine-needle aspiration cytology (FNAC) is regarded as the gold standard diagnostic test for pre-op assessment of thyroid lesions. MATERIALS AND METHODS: We conducted a retrospective study, involving 765 patients who underwent FNAC of the thyroid gland, at Jigme Dorji Wangchuck National Referral Hospital, Thimphu, between January-2018 to December-2020. We aimed to assess the cytomorphological spectrum of thyroid nodules, classify them as per The Bethesda system for reporting thyroid cytopathology (TBSRTC), assess risk of malignancy (ROM), and evaluate the accuracy of FNAC in diagnosing thyroid malignancy. RESULTS: Colloid nodule (37.4%) and papillary thyroid carcinoma (4.2%) constituted the majority of benign and malignant cytological diagnoses, respectively. According to TBSRTC, majority of the cases (82.0%) fell under the Bethesda II category. Bethesda III was the least common (1.4%) category. As compared to histopathological diagnosis; the sensitivity, specificity, positive and the negative predictive values of FNAC in diagnosing thyroid malignancy were 90.0%, 93.3%, 93.10%, and 90.32% respectively. The ROM increased concurrently with the grade of the Bethesda category and was more or less close to the ROM reference range, published in the TBSRTC. CONCLUSION: Benign thyroid nodules (82.0%) constituted a majority of thyroid nodules in Bhutanese patients. FNAC was found to be reliable in detecting thyroid malignancy. From the literature, TBSRTC was found to be a more convenient method for reporting thyroid cytology. Henceforth, as most institutes, we plan to implement TBSRTC for reporting thyroid cytopathology.

An Unusual Presentation of a Huge Nabothian Cyst of Cervix With Manifestation of Uterine Prolapse: A Case Report.

BACKGROUND: Nabothian cysts are common benign cervical lesions in women of reproductive age. They usually occur due to childbirth or minor trauma; mostly are small and asymptomatic. However, huge nabothian cysts may have variable presentation and can even mimic malignancy thus, biopsy is recommended to rule out malignancy. The unusual presentation of nabothian cyst as uterine prolapse makes it a diagnostic challenge for management of the patient similar to the present case. CASE REPORT: We report a case of a huge nabothian cyst in a perimenopausal, multiparous woman who presented with complaints of something coming out of vagina suddenly after mild heavyweight lifting and pain abdomen. Pelvic examination revealed a second degree uterine prolapse with a large lump protruding outside the vagina. Transvaginal ultrasonography demonstrated a multicystic cervical mass of size 9.5 cm × 8.0 cm arising from the posterior lip of cervix that was protruding through the vaginal canal. After excision of mass, prolapse became first degree. Histopathologic diagnosis was a cervical nabothian cyst. Patient had persisting first degree uterine prolapse along with posterior vaginal wall prolapse on subsequent postoperative follow ups. Hence, vaginal hysterectomy with repair to the vaginal wall was performed later. CONCLUSION: The present case of nabothian cyst is reported for its unusual presentation as uterine prolapse. The risk factors for pelvic organ prolapse (POP) in the present case are advancing age, multiparity and perimenopausal status. The connective tissue and levator ani muscle became weak and the nabothian cyst unmasked the POP that was latent and asymptomatic by increasing the prolapse from first degree to second degree.

Mature cystic teratoma of ovary with squamous cell carcinoma arising from it.

Clinicians, pathologists, and radiologists should be aware of rare malignant ovarian tumors arising in mature cystic teratoma (MCT). Suspicion should be raised if the patient is elderly, the tumor is huge, and the tumor has large solid foci. However, malignant transformations in MCTs in younger women have been reported.

Unusual presentation of oral pyogenic granulomas: a review of two cases.

Pyogenic granuloma is a benign vascular neoplasm of the oral cavity that usually presents as a small nodular lesion, the gingiva being the commonest site. Occasionally it occurs at uncommon sites with unusual sizes. Here we describe two cases of oral pyogenic granulomas that had an unusual presentation.

Tubercular Ulcer of Tongue in an Elderly Patient Masquerading as a Traumatic Ulcer.

Tuberculosis is still one of the most prevalent diseases in developing countries like Nepal. However, due to the effectiveness of DOTS therapy, vaccination, and education, the prevalence of tuberculosis has fallen in recent years. Although the pulmonary and extrapulmonary tuberculosis, especially the tubercular lymphadenitis, is still very common in our country, the tuberculosis of oral cavity is an uncommon condition. We present a case of an elderly male who presented with the complaint of nonhealing ulcer of lateral border of tongue for 2-month duration which was masquerading as a traumatic ulcer due to sharp teeth adjacent to the lesion. Deep biopsy was taken under local anesthesia. Histopathological examination revealed that it was tuberculosis. Antitubercular therapy was then started which cured the lesion.

Teratoid Cyst of the Postauricular Region: The First Ever Case Report.

Rudolf Virchow is considered to be the first scientist to have used the word sebaceous cyst. It was thought that these lesions occurred due to retention of sebaceous secretion consequent to obstruction of sebaceous ducts of sebaceous glands, although that was found not to be the case. In all these cysts, the cavity is filled with keratin. There are six types of keratin-filled cysts, namely, epidermoid, dermoid, teratoid, keratinous, trichilemmal, and teratoma cyst, which have one common name "dermoid cyst." Of the six, teratoid cyst is the least common. In contrast to other dermoid cysts, teratoid cysts contain tissue elements derived from all the three germ layers, namely, ectoderm, mesoderm, and endoderm. Teratomas can be differentiated from teratoid cysts by the fact that recognizable organ structures may be found in the former; examples include teeth and skin. Teratoid cysts can develop anywhere in the body but rarely arise in the head and neck region. They have never been reported in the postauricular region. In this case report, we present a case of teratoid cyst in the postauricular region in a 21-year-old female. The significance of this case lies in its rarity.

Intramuscular Hemangioma of Thyrohyoid Muscle.

Intramuscular hemangiomas are rare benign vascular neoplasms. IMH accounts for less than 1% of all hemangiomas. These neoplasms commonly occur in trunk and extremities but are rare in head and neck region. The present case is a 17-year-old female patient, who presented with a painless, slowly enlarging mass in left sided upper neck for 4 years. Investigations were suggestive of vascular neoplasm. She underwent excision of the mass in toto under general anesthesia. Postoperative period was uneventful. Histopathological examination of the mass revealed it as mixed type of intramuscular hemangioma. She did not have any signs of recurrences on her last follow-up at 6 months postoperatively. This case report discusses the rare IMH arising from thyrohyoid strap muscle.

An Uncommon Case of Chronic Tubercular Appendicitis.

Tuberculosis (TB) is a common disease that ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). However, primary TB of the appendix is rare and may or may not be associated with specific clinical features. Thus, diagnosis is made only after histopathological examination. It suggests that all surgically removed appendices should be subjected to histopathological examination. This reported case is an uncommon case of chronic tubercular appendicitis.

An uncommon presentation of Kikuchi Fujimoto disease: a case report with literature review.

BACKGROUND: Kikuchi-Fujimoto disease is so named because Kikuchi and Fujimoto were the first scientists to describe it in Japan in 1972. Although the disease has been reported from all over the world and more so from Asia, it is rare. To date only eight cases have been reported from Nepal. Cervical lymphadenopathy, fever and raised Erythrocyte Sedimentation Rate are usual presenting features of this disease. We describe a case which presented with thrombocytopenia and axillary lymphadenopathy in addition to the usual features. Out of the total eight cases that have been reported from Nepal so far, no patients had thrombocytopenia and only one patient had axillary lymphadenopathy. CASE PRESENTATION: A 24-year-old Nepali female presented with a 3-week history of low-grade fever, headache, and painful, discrete, unilateral left-sided cervical and axillary lymphadenopathy. Among the multitude of tests that were carried out, Erythrocyte Sedimentation Rate was raised and there was thrombocytopenia while other tests were normal. Painful lymphadenopathy pointed to bacterial lymphadenitis while chronic low-grade fever suggested tuberculosis. A cervical lymph node was excised for histopathological examination to reach an accurate diagnosis. On the basis of pathognomonic features viz., paracortical foci composed of various types of histiocytes including crescentic type in the background of abundant apoptotic karyorrhectic debris, a diagnosis of Kikuchi-Fujimoto disease was made. On follow-up evaluation after 6 weeks, the patient had no systemic symptoms, enlarged lymph nodes had regressed in size significantly, and Erythrocyte Sedimentation Rate and platelet count had become normal. CONCLUSION: Kikuchi-Fujimoto disease should be kept in the differential diagnosis of lymphadenopathy in young patients, female or male even in tuberculosis-endemic countries and even in patients who have unusual features; for example thrombocytopenia and involvement of axillary lymph nodes in addition to cervical lymph nodes as in this case.

Mature Nasopharyngeal Teratoma in a Child.

Teratomas are neoplasms derived from the germ cell with components of all the three embryonic layers. These are rare neoplasms in head and neck region which can occur in any age group but are more prevalent in children. The present case is an 11-year-old girl who was brought with history of painless and progressive swelling in the oropharynx for 3 years with the associated left sided nasal blockage and nasal discharge. CT scan was suggestive of benign nasopharyngeal mass highly suspicious for lipoma. Excision of the mass was done under general anaesthesia. Peroperatively, it was a smooth, pedunculated mass arising from the left lateral wall in the nasopharynx. On cut section, it was solid to cystic mass similar to fatty tissue. Her HPE report came out to be mature teratoma of nasopharynx.