Sternoclavicular Tuberculosis: An Unusual Presentation.

Extra pulmonary tuberculosis is on the rise worldwide, and younger patients, are females. And people from Asia and Africa are at high risk. Sternoclavicular TB is extremely rare, even in countries that have a high prevalence of TB. It can be in the absence of pulmonary TB. It has a varied clinical presentation. Painless chest wall swelling can be the presenting symptom of sternoclavicular diagnosis. Ultrasonography and high-resolution computed tomography can identify the nature of the lesion and the extent of bone involvement. Aspiration from the swelling or histopathology examination is mandatory for diagnosis. Caseous necrosis is diagnostic of TB. Detection of acid-fast bacilli in smears or tissue or molecular methods is required for definitive diagnosis. A high degree of clinical suspicion is required for early diagnosis. The treatment of thoracic TB is the subject of controversy. Anti-tubercular drugs are the mainstay of treatment. Surgical intervention is basically for flattening cold abscesses and removing infected tissue, including affected bones and cartilage.

Image-guided fine-needle aspiration cytology or core biopsy - A key to definitive diagnosis of tuberculous mastitis.

Despite advances in the treatment, tuberculosis (TB) is still a global health problem. The diagnosis of extrapulmonary TB in their primary form is very challenging. Breast TB is very uncommon and accounts for < 0.1% of all breast lesions. Due to rarity of the disease and difficulty in diagnosis, we report a case of a 40-year-old female who had a hard lump in the right breast. Full-field digital mammography suggested the lesion as American College of Radiology Breast Imaging Reporting and Data System-5 (ACR BIRADS-5) (highly suggestive of carcinoma). Histopathological examination of multiple cores of the breast tissue showed lymphocytic inflammatory infiltrates confined to breast lobules. Fungal stains and Ziehl-Neelsen (ZN) stain were negative. A diagnosis of chronic mastitis with the possibility of autoimmune lobular mastitis was suggested. Subsequent image-guided fine needle aspiration smears showed epithelioid granulomas mixed with lymphocytes. Areas of amorphous-to-granular eosinophilic material (caseous necrosis) were seen at places. ZN stain showed acid-fast bacilli. A diagnosis of tuberculous mastitis was given.

Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition).

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Coexistence of Ectopic Tubal Pregnancy with Serous Tubal Intraepithelial Carcinoma: A Rare Case Report with Review of Literature.

Serous tubal intraepithelial carcinoma is a precursor lesion for high-grade pelvic serous carcinoma. The incidence is 0.6%-6% in tubectomy specimens of women who are BRCA-1,2 positive or have a strong family history of breast or ovarian cancer. STIC in women who do not have BRCA-1,2 mutations or concomitant high-grade serous carcinoma is exceedingly rare. Ectopic tubal gestation coexisting with serous tubal intraepithelial carcinoma is very rarely reported. These lesions pose considerable difficulty in the diagnosis. A combination of histology and immunohistochemical expression p53 and ki67 substantially improves the reproducibility of the diagnosis. Diagnosing these lesions will help identify potential at risk patients and their families for carcinoma. Adequate prolonged follow-up for incidental serous tubal intraepithelial carcinoma is the mainstay. We report one such case of a 31-year-old female who was operated for the right tubal gestation and found to have serous tubal intraepithelial carcinoma.

Cytomorphological Spectrum of Granulomatous Mastitis: A Study of 33 Cases.

OBJECTIVE: Granulomatous mastitis is an uncommon benign breast disease. Varied aetiologies such as tuberculosis, foreign body reactions, sarcoidosis, fungal and parasitic infections and autoimmunity have been suggested. Pre-operative definitive diagnosis is essential for proper treatment. In developing countries like India, fine needle aspiration is still widely used as a reliable technique for preoperative evaluation of palpable breast lumps. The objective of this study is to study the cytomorphological features of different forms of granulomatous mastitis and correlate with other clinical findings including histological features. MATERIALS AND METHODS: A total of 33 cases of granulomatous mastitis were reviewed. The patients underwent fine needle aspiration. Cytomorphological features were studied in detail and correlated with histopathological features and other clinical findings. RESULTS: All the 33 patients showed varied cytomorphological features which included epithelioid cells/granuloma with lymphocytes/plasma cells/polymorphs with or without necrosis/caseous necrosis and with or without giant cells. Ziehl Nelson stain showed acid fast bacilli in 13 smears. Out of 17 cases, the eight cases showed positive acid fast bacilli culture. Fungal stain such as Grocott-Gommeri Methane amine did not show fungi. Based on cytomorphological features in aspiration smears, they were grouped into 4 Groups. A total of 27 breast lesions were diagnosed as tuberculous mastitis, the four lesions were diagnosed as idiopathic granulomatous lobular mastitis and two lesions were diagnosed as foreign body granulomatous mastitis. Grocott-Gommeri Methane amine did not showed fungi. Based on cytomorphological features in aspiration smears, they were grouped into 4 Groups. A total of 27 breast lesions were diagnosed as tuberculous mastitis, the four lesions were diagnosed as idiopathic granulomatous lobular mastitis and two lesions were diagnosed as foreign body granulomatous mastitis. CONCLUSION: Epithelioid granulomas with caseous necrosis with or without acid fast bacilli in cytology smears are diagnostic of tuberculosis. Cytology smears showing epithelioid granulomas with predominant polymorphs without necrosis and acid fast bacilli, a diagnosis of idiopathic granulomatous lobular mastitis must be considered. Histopathological examination is essential for definitive diagnosis in these cases.

Cytomorphological Spectrum of Thyroiditis: A Review of 110 Cases.

INTRODUCTION: Different types of thyroiditis may share some parallel clinical and biochemical features. Timely intervention can significantly reduce morbidity and mortality. AIM: Aim of this study is to find the frequency of various thyroiditis, study the cytomorphological features and correlate with clinical findings including radiological findings, thyroid function test, and anti-thyroid peroxidase antibodies (Anti-TPO antibodies). MATERIALS AND METHODS: The study included consecutive 110 cases of thyroiditis. Detailed cytomorphological features were studied and correlated with ultrasonography findings, thyroid function test, anti-thyroid peroxidase antibodies (anti-TPO) and histopathological features where thyroidectomy specimens were received for histopathological examination. RESULTS: The majority were Hashimoto's thyroiditis (n = 100) and females (n = 103). Other forms of thyroiditis were Hashimoto's thyroiditis with colloid goiter (n = 5), De Quervain's thyroiditis (n = 3), and one case each of postpartum thyroiditis and Hashimoto's thyroiditis with associated malignancy. The majority of patients were in the age group of 21-40 (n = 70) and the majority (n = 73) had diffuse enlargement of thyroid. The majority of patients were hypothyroid (n = 52). The serum anti-TPO antibodies were elevated in 47 patients out of 71 patients. In the 48 patients who underwent ultrasonography, 38 were diagnosed as having thyroiditis. The most consistent cytomorphological features seen in fine-needle aspiration smears of Hashimoto's thyroiditis were increased background lymphocytes, lymphocytic infiltration of thyroid follicular cell clusters, and Hurthle cells. CONCLUSION: The diagnostic cytological features in Hashimoto's thyroiditis are increased background lymphocytes, lymphocytic infiltration of thyroid follicular cell clusters, and Hurthle cells. FNAC remains the "Gold Standard" for diagnosing Hashimoto's thyroiditis. Clinical history, thyroid function, and biochemical parameters are the key for diagnosis of other forms of thyroiditis.

Multiple lumps in the breast due to Mycobacterium fortuitum.

Although breast tissue is the most resistant to tuberculosis, its incidence is increasing worldwide. High incidence of breast tuberculosis is presumed in India. The rapidly growing nontubercular mycobacteria, such as Mycobacterium fortuitum and Mycobacterium chelonae, are of increasing clinical importance because infections due to these organisms are often hospital acquired. The true incidence of M. fortuitum is unknown but it has been estimated to be between 4 and 6 cases per one million people. It causes skin or soft tissue infections following trauma or surgery. Breast infection with M. fortuitum is very uncommon. The most common clinical presentation of breast tuberculosis is a painless lump. Multiple lumps are rarely reported. The culture and molecular studies are the keystone for differentiation of various mycobacterium species. We report one such case of a 25-year-old female presenting with multiple painless lumps due to M. fortuitum infection in the left breast.

A pure primary transitional cell carcinoma of the ovary: A rare case report with literature review.

Primary transitional cell carcinoma (TCC) of the ovary is a rare and recently recognized subtype of ovarian surface epithelial-stromal cancer. Pure forms of the TCC ovary account for only 1% of surface epithelial carcinomas. The clinical presentation is indistinguishable from other types of ovarian cancers. They have a favorable response to chemotherapy than other surface epithelial cancers. We report a case of 55-year-old woman who presented with a hard mass in the abdomen. Computed tomography-diagnosed it as a carcinoma of the ovary. Tumor was immunoreactive with Wilms' tumor protein-1 and nonreactive with cytokeratin 7 (CK7) and CK20. Histopathology diagnosis of primary TCC of the ovary was made. These tumors are needed to be differentiated from metastatic TCC from other sites and undifferentiated carcinomas of ovaries. Clinical features and immunohistochemistry are helpful. Surgical resection is the primary therapeutic approach followed by standardized chemotherapy.

Pattern of palpable breast lesions on fine needle aspiration: A retrospective analysis of 902 cases.

BACKGROUND: Breast lumps constitute a significant proportion of surgical cases in women of both developed and developing countries. The aim of this study is to look the frequency distribution of various breast lesions on fine needle aspiration (FNA). MATERIALS AND METHODS: The 902 patients who presented with palpable breast lump, irrespective of age and sex were included in the study. Frequency distribution of various breast lesions with respect to age and sex was studied. Cytology grading in breast carcinoma was correlated in 69 cases with histology grading. RESULTS: The majority (N = 871) of patients were females with maximum (N = 566) patients between second and third decade. The 773 patients had benign breast lesions and maximum (N = 341) patients were in the second decade. Fibroadenoma was the commonest benign lesion followed by fibrocystic change and mastitis. Out of 119 malignant breast lesions, 31.93% [N = 38] were between 41-50 years of age, 28.57% [N = 34] in 51-60 years and 22.68% [N = 27] in between 31-40 years of age. Out of 119 malignant breast lumps and majority were infiltrating ductal carcinoma (N = 108). Cytology grading correlated maximum with histology grade in Grade I followed by Grade II and Grade III. CONCLUSION: With experienced hands, FNA is safe, cost effective and a reliable technique for preoperative evaluation of palpable breast lumps. FNA features are more informative when combined with physical and radiology findings (Triple test). Fibroadenoma, fibrocystic change and mastitis form the major bulk of benign breast lesions. Epithelioid cells when seen in inflammatory breast FNA smears, tuberculosis must be ruled out. In India, breast carcinoma arises in younger patients as compared to western countries. Grading of breast carcinomas must be done on FNA smears for selecting neoadjuvent therapy. Clinical breast examination and mammography screening in females should be encouraged in developing countries from the third decade onwards for early detection of breast carcinoma.

Recurrent solitary fibrous tumor in distal lower extremity: An extremely rare entity.

Solitary fibrous tumor (SFT) represents a spectrum of mesenchymal tumors, encompassing tumors previously termed hemangiopericytoma, as having intermediate biological potential. Though they can occur at any site, lower distal extremity is a rare site and recurrence in it is extremely rare. Behavior of SFT is unpredictable. Histomorphology and clinical follow-up have poor correlation. The most important single indicator of clinical outcome is complete excision of the tumor at the time of primary presentation. Tumors with positive margins require close follow-up for several years owing to the potential for late local recurrence.

Cytomorphologic spectrum of Hashimoto's thyroiditis and its clinical correlation: A retrospective study of 52 patients.

BACKGROUND: Hashimoto's thyroiditis (HT) is an autoimmune disease and it is more prevalent in Asians. The incidence of HT seems to be increasing in the recent times. It is one of the most common cause of hypothyroidism. The purpose of this study is to review the cytomorphologic spectrum of HT and correlate it with clinical findings including thyroid function and antibody profile. MATERIALS AND METHODS: We retrospectively analyzed the fine-needle aspiration (FNA) features of 52 HT patients. Based on cytomorphologic features patients were categorized into three groups. Clinical findings including thyroid function and thyroid peroxidase (TPO) antibody profile were correlated with cytomorphologic features in all three groups. RESULTS: Majority of the patients were females and in 2(nd), 3(rd) and 4(th) decades. Diffuse goiter and thyroid hypofunction were the common findings. Significant number of patients had thyroid hyperfunction. Increased lymphocytes on the background and lymphocytic infiltration of thyroid follicular cell clusters in cytology smears were diagnostic of HT. The 32 patients showed elevated titers of TPO antibodies. In the early stages and mild form of the disease, results of thyroid function and anti TPO antibodies are quite variable. CONCLUSIONS: HT is a disease of young and middle age and mostly occur in females. Clinical findings alone may not be adequate for definitive diagnosis. FNA is the gold standard for diagnosis. In the presence of abundant colloid, follicular hyperplasia or co-existing neoplasm, careful interpretation of cytology smears should be done. Aspiration from more than one site minimizes the diagnostic pitfalls.

A unique case of diffuse histiocytic proliferations mimicking metastatic clear cell carcinoma in the hydrocele sac.

Reactive histiocytic proliferations are extremely rare in paratesticular structures. Nodular histiocytic proliferations have been described in mesothelial-lined locations and only at few nonmesothelial sites. Diffuse histiocytic proliferations are described only in the pelvic peritoneum. We report the first case of diffuse histiocytic proliferation in the hydrocele sac of a 45-year-old man. Predominant histiocytes showed clear cytoplasm and signet ring-like change. Mucicarmin stain did not demonstrate mucin in the cytoplasm. Immunohistochemistry (IHC) staining showed nonspecific staining of these cells with carcinoembryonic antigen and negative staining with epithelial membrane antigen, pan-Cytokeratin, calretinin, cytokeratin 7, 20 and prostate-specific antigen. Strong diffuse cytoplasmic positivity for CD68 defined the mononuclear phagocyte nature of these cells. Diffuse histiocytic proliferations can occur in the hydrocele sac. Histochemical and IHC stainings are critical for accurate diagnosis and to avoid unnecessary surgery.

Diaphyseal osteosarcoma with varying histomorphologic patterns.

Osteosarcoma is the most common primary malignant tumor of the skeleton involving predominantly metaphysis of the long bones. Diaphyseal osteosarcoma is a rare form, which accounts for approximately 10% of all cases of osteosarcomas. Osteosarcoma contains a family of lesions with considerable diversity in histologic features and grade. We present a case of a 29-year-old male with diaphyseal osteosarcoma of the left tibia, who presented with pain and swelling over middle one-third of the left leg. The biopsy of the lesion revealed varied histomorphologic features in a small tissue studied. This prompted us to report the various histologic patterns of osteosarcoma.

Thyroid tuberculosis: presenting symptom of mediastinal tuberculous lymphadenitis--an unusual case.

Tuberculosis of thyroid gland is extremely rare. It spreads to thyroid by lymphogenous or heamatogenous route or from adjacent focus, either from larynx or cervical and mediastinal adenitis. We report an unusual case of a 33-year-old male with thyroid swelling. Fine needle aspiration (FNA) smears showed epithelioid cells without necrosis and acid fast bacilli (AFB). Subsequent investigation revealed mediastinal tuberculous lymphadenitis on Computerized Tomography (CT) scan. FNA confirmed the diagnosis of mediastinal tuberculous lymphadenitis. We conclude, when epithelioid cells are seen on FNA thyroid, tuberculosis must be ruled out especially in regions where there is high prevalence of tuberculosis.

A focal nodular Hürthle cell hyperplasia in Hashimoto's thyroiditis: A diagnostic dilemma on fine needle aspiration.

Hürthle cells are seen in a variety of nonneoplastic and neoplastic thyroid gland lesions. Number and morphology of Hürthle cell vary in thyroid aspirate. Occasionally, thyroid aspirate in focal nodular Hürthle cell hyperplasia in Hashimoto's thyroiditis exclusively comprise of Hürthle cells and mimics Hürthle cell neoplasm. Fine needle aspiration (FNA) diagnosis in such cases is challenging. A 60-year-old female presented with goiter and clinical features of hyperthyroidism. FNA smears showed Hürthle cells arranged in flat sheets and lying singly with occasional lymphocytes in Hürthle cell sheets. Repeat aspiration from other site showed lymphocytes, infiltrating the thyroid follicular cells. We conclude that a careful search of lymphocytes in Hürthle cell sheets in cytology smears, multiple aspirates, associated clinical findings and ancillary techniques reduce the diagnostic pitfall and avoid unnecessary surgery.