Cytological Diagnosis of Pilomatrixoma and its Diagnostic Pitfalls.

Background: Pilomatrixoma (PMX) is a relatively uncommon benign cutaneous neoplasm arising from skin adnexa. It presents as a subcutaneous asymptomatic nodule mostly in the head and neck region and is frequently misdiagnosed by the clinicians. Although easily diagnosed on histopathology, the cytologic features of PMX are less distinctive, depending on the stage and evolution of disease and may mimic other benign or even malignant lesions. Aim: To study the cyto-morphological features of this uncommon neoplasm and identify its potential diagnostic pitfalls on fine needle aspiration cytology (FNAC). Material and Methods: Archival records of histopathologically diagnosed Pilomatrixoma were analyzed during study period of 2.5 years. Clinical diagnosis, preoperative FNA characteristics, and histopathological details were studied in each case. Cytologic pitfalls resulting in misdiagnosis of PMX cases on FNAC were evaluated in discordant cases. Results: The series showed male preponderance, with head and neck being the commonest site. Out of 21 histopathologically proven cases of PMX, cytological correlation was available in 18 cases. A correct cytologic diagnosis of PMX/adnexal tumor was rendered in 13 cases. Erroneous diagnosis was given in 5 cases mainly because of the predominance of one component over the other or non-representative-aspirated material. Conclusion: The present study highlights the importance of careful screening of FNAC smears keeping in mind the variability in the relevant cytologic features of PMX and creates awareness about the lesions that can mimic Pilomatrixoma resulting in diagnostic dilemma.

Large Solitary Pyogenic Liver Abscesses: A Review of Their Management at a Tertiary Care Hospital.

Background and objective Liver abscesses are one of the common surgical diseases to be treated as an emergency in any tertiary care hospital in India. The formation of abscesses in the liver is still a major problem and associated with significant morbidity in developing countries. We come across all types of liver abscesses, such as amoebic (most common), pyogenic, mixed, and occasionally fungal. There have been several studies on the percutaneous modality of treatment for pyogenic liver abscesses. Most of the studies suggest that percutaneous catheter drainage (PCD) offers a better approach than aspirations for treating pyogenic liver abscesses. However, a few recent studies suggest that percutaneous aspiration leads to equally good results when compared to percutaneous drainage. In this study, we aimed to review the management of solitary large pyogenic liver abscesses and to assess the effectiveness of ultrasonography (USG)-guided aspiration in the procedure.  Methods A retrospective study was carried out at the Department of General Surgery of our institute. In this study, a total of 27 patients treated for solitary pyogenic liver abscess were included. All patients with a large liver abscess greater than 5 cm without the features of frank peritonitis were included. These patients were followed up regularly for six months. Results The single-attempt USG-guided aspiration was successful in 70.3% of patients. Repeat USG-guided aspiration was performed in 18.5% of patients. In 7.4% of patients, a USG-guided percutaneous pigtail catheter was placed. And only 3.7% of cases required exploratory laparotomy.  Conclusion Based on our findings, USG-guided aspiration is a fairly efficient method for treating a large solitary pyogenic abscess with acceptable results, shorter hospital stays, and minimal complications.

Anorectal malignant amelanotic melanoma: Report of a rare aggressive primary tumor.

Malignant melanoma of the anorectal region is a very rare aggressive malignant neoplasm and it constitutes 1% of all malignant lesions of this area. About 70% of these lesions are pigmented, whereas 30% are amelanotic. Demonstration of immune markers of melanoma by immunohistochemistry (IHC) is required for confirming the diagnosis of amelanotic malignant melanoma. Here, we report a case of anorectal malignant amelanotic melanoma in a 65-year-old male with no medical comorbidities, who presented with chief complaints of bleeding per rectum associated with prolapsing mass per rectum of 7 months duration. On external examination and proctoscopy, three prolapsed pedunculated fungating masses were seen externally protruding out of the rectum approximately 4 cm from the anal verge. Contrast-enhanced computed tomography of the whole abdomen and pelvis was suggestive of moderately enhancing lobulated anorectal mass with large polypoidal intraluminal component arising from anorectal walls and extension into mid-lower rectum with liver and locoregional lymph nodes metastasis. The patient was taken up for palliative local excision. Per-operatively, three large irregular highly vascular pedunculated rectal growth was seen. The growth was excised and sent for histopathological examination. Microscopic examination of mass show spindle-to-ovoid tumor cells with hyperchromatic central to eccentric nuclei arranged in intersecting fascicles with a focal alveolar pattern. The large number of atypical mitotic figures (40-50/10 High Power Field (HPF)) was seen along with areas of necrosis and the presence of few bizarre binucleated and multinucleated giant cells. A differential diagnosis of malignant amelanotic melanoma was given along with undifferentiated carcinoma, gastrointestinal stromal tumor , and Non-Hodgkin's lymphoma. On IHC, the tumor cells were reactive for HMB45, S-100, and SOX-10. Thus a diagnosis of malignant amelanotic melanoma was confirmed. The patient had symptomatic improvement.

Xanthogranulomatous cholecystitis mimicking advanced gallbladder carcinoma - Analysis of 8 cases.

BACKGROUND/AIM: Xanthogranulomatous cholecystitis (XGC) is a rare destructive inflammatory disease of the gallbladder. It is frequently misdiagnosed as gallbladder carcinoma (GBC) as it mimics latter with regard to clinical manifestations, imaging and intraoperative findings, often leading to extended surgical resection in these patients. The aim of this study was to evaluate the diagnostic dilemma of XGC cases clinico-radiologically diagnosed with GBC. MATERIALS AND METHODS: From January 2017 to June 2019, a total of eight cases histopathologically diagnosed as XGC, were misdiagnosed with GBC based on preoperative and intra-operative findings. The clinical characteristics, imaging, intra-operative findings, and surgical data of these patients were collected and analyzed. RESULTS: A total of 2154 cholecystectomy specimens were received in the histopathology section during the study period. Sixty-nine cases (3.2%) were histologically diagnosed as XGC, of which 8 cases (11.6%) were preoperatively diagnosed with GBC. These cases were predominantly seen in males in the age range of 24-62 years. The most common clinical presentation was chronic cholecystitis. Gallstones were present in all the 8 cases. Six cases presented with heterogeneous enhancement within thickened gallbladder walls on imaging. Intraoperatively, adhesions to adjacent organs were observed in seven cases. All these eight cases misdiagnosed with GBC underwent aggressive surgical treatment following which histopathology ultimately revealed XGC. CONCLUSION: Neither clinical manifestations nor laboratory tests/radiological methods can provide an effective means of differentiating between XGC and GBC. Preoperative diagnosis is difficult, and histopathology remains the gold standard to differentiate the two entities.

Recently Described Entity of Intracholecystic Papillary Neoplasm of Gallbladder with Coexisting Xanthogranulomatous Cholecystitis: an Unusual Association.

Intracholecystic papillary neoplasm (ICPN) of the gallbladder is a relatively new concept and is suspected to share clinicopathologic features with intraductal papillary mucinous neoplasm (IPMN) of the pancreas and intraductal papillary neoplasm of the bile duct (IPNB). The literature on the clinicopathologic characteristics of preinvasive intraepithelial neoplasms of the gall bladder is fairly limited, partly owing to variability in its definition and terminology. We report an extremely rare case of coexistent xanthogranulomatous inflammation and intracholecystic tubulo-papillary neoplasm with low-grade dysplasia in a 48-year-old male patient. Although there are many case reports of simultaneous carcinoma gallbladder with xanthogranulomatous cholecystitis (XGC), however, the association of ICPN with XGC has not been previously described. To the best of our knowledge, this is the first case report of ICPN of gallbladder coexisting with xanthogranulomatous cholecystitis.

Integration in Medical Education.

The term integration has gained importance in Medical education over the last two decade, and is believed to facilitate knowledge, that is more meaningful to clinical practice. A move towards integration in medical education is likely to reduce fragmentation of the medical course and motivate students towards better learning, It aims to improve medical education by bridging the traditional barrier between basic and clinician sciences. Integration is one of the major changes incorporated in the new competency based curriculum for undergraduate medical program in India. There are associated changes in the assessment system too in relation to integration. However, the concept of integration/integrated curriculum lacks significant clarity as how to implement it in medical institutions with added paucity of literature on this important topic. Integrated teaching is the integration of the concepts wherein various subject-based knowledge or aspects of one theme or topic are assimilated to provide the holistic approach. Our review focusses on the need for integration with comparative analysis of the two most important models of integration (Fogarty and Harden) which are being followed, delving on their common features for simplifying this complex topic as well as for better understanding of the concept. We have also proposed six steps for implementation of integration. We conclude that the proposed change from conventional to new integrated curriculum requires robust planning and coordination amongst the various stakeholders in medical institutions.

Online Medical Teaching in COVID-19 Era: Experience and Perception of Undergraduate Students.

Introduction: Rapid emergence of COVID-19 as pandemic has affected the life of almost every human being and has changed the way people used to interact. It has also affected medical education and clinical training, and forced medical schools to switch over to online mode of teaching. The aim of this study was to learn about the experience and perception of undergraduate students regarding online teaching. Methods: This is a cross sectional observational study conducted among the undergraduate students of Hamdard Institute of Medical Sciences and Research, New Delhi, India. A validated electronic questionnaire with nine questions was sent to 177 students as Google FormsTM. Responses from 161 students were received and analyzed using SPSS software. Results:The majority of students were satisfied with the frequency, organization, content and preparedness of classes. Half of students were neither satisfied with the amount of syllabus covered nor online teaching method. Among various teaching methods, live online lectures were most common and they were also preferred by the majority of students. Most students want hybrid or blended teaching in the post COVID-19 era. Conclusion: Online or e-teaching alone is not preferred by the majority of students. Lack of interpersonal interaction is the most likely reason for this. Hybrid or blended teaching holds the future of medical education as it is more student friendly and efficient.

Video projected practical examination as an introduction to formative assessment tool for undergraduate examination in pathology.

BACKGROUND: Assessment of the medical students includes theory as well as practical assessment. Traditional practical examination in pathology which includes viva and spots is now increasingly being questioned because of their inherent lack of validity and reliability, time consumption, and human resource requirement. Therefore, a need was felt for another form of practical examination which can be used as formative assessment, and if found feasible, can be employed in summative assessment too. AIM: The aim of the study was to develop and implement a new method of video projected practical examination (VPPE) as a formative assessment tool for MBBS second professional students so as to improve their learning and academic performance in practical pathology and also to obtain students' perception regarding the effectiveness of VPPE. METHODOLOGY: The study was carried out with the MBBS second professional students before their end-of-semester examination in the Department of Pathology. In this new method, slide video projection was used as a formative assessment tool during practical examination. Students were randomly divided into two groups. Group I was subjected to VPPE, while simultaneously conventional practical examination was held for Group II. Assessment results of VPPE were compared with conventional practical examination. Faculty and students feedback was also taken at the end of the examination. RESULTS: Mean marks of the students who undertook VPPE was higher than those who gave conventional practical examination. Majority (95.3%) of the students agreed that VPPE is better than conventional practical examination. Most of the faculty members also felt that it is a more valid and reliable assessment tool. CONCLUSIONS: Introducing VPPE as a formative assessment tool in practical pathology enhanced their learning and academic performance. Opinion of examiners and students also showed that VPPE has several advantages over conventional practical examination.

Clinicopathological Study of Eosinophilic Cholecystitis: Five Year Single Institution Experience.

INTRODUCTION: Gallbladder diseases are very common in Northern India, most common of which is Chronic Cholecystitis. Rarely, histopathological diagnosis of Eosinophilic Cholecystitis (EC) is given when transmural cellular infiltrate consists of more than 90% eosinophils. AIM: To determine the prevalence and clinicopathological profile of eosinophilic cholecystitis at a tertiary care hospital of New Delhi. MATERIALS AND METHODS: This was a retrospective clinicopathological study done on twenty two cases of eosinophilic cholecystitis over a period of five years from January 2011- December 2015. In cases diagnosed histopathologically as eosinophilic cholecystitis, clinical details were obtained from hospital records and slides were retrieved. Various histologic features, pattern of the inflammatory infiltrate and association of EC with other medical diseases, drugs and allergic states were evaluated. RESULTS: Out of a total of 1370 cholecystectomy specimens received during five year period, Eosinophilic cholecystitis was diagnosed in 22 (1.6%) of the specimens. Clinically, seven of these patients had a clinical diagnosis of acute cholecystitis. Patient's age ranged from 25-64 years and male to female ratio was 1:2.7. Most common symptom reported was abdominal pain. Most of the cases showed gallstones radiologically (90%) while only two cases showed peripheral eosinophilia (9%). Histologically, mucosal and muscular eosinophilic infiltrate was seen in 72.6% of the cases. No association with drug therapy, allergies or other pre-existing medical conditions was noted. CONCLUSION: EC is a relatively uncommon entity in which histopathology remains the main stay of diagnosis. Although the presentation may be similar to general cholecystitis, if a postoperative histopathological diagnosis of EC is made, then the patient must be investigated thoroughly to rule out other associated disease conditions, which may have a worse prognosis than cholecystitis itself.

Students' feedback: An effective tool in teachers' evaluation system.

BACKGROUND: Evaluation is an integral part of medical education. Although there are various methods of teachers' evaluation, student's feedback is considered as the most effective and reliable method albeit a controversial one. In this study, we have tried to evaluate the effectiveness of the students' feedback in teachers' evaluation in an upcoming medical college. AIM: The aim of this study was to improve the quality of teaching by introducing students' feedback as a teachers' evaluation system in a new medical college. MATERIALS AND METHODS: A feedback of second professional teachers was obtained from the fourth-semester students. This feedback was obtained through a proforma which was validated through peer review. Based on the feedback, teachers were informed about their strengths and weaknesses in a confidential manner. A uniform opportunity was then provided to these teachers for 3 months to improve their teaching skills. At the end of the period, again a questionnaire was administered to both the students and the teachers to assess the effectiveness of the feedback system. RESULTS: More than two-third of the students and teachers alike agreed that the student's feedback is an effective tool for the faculty development. Majority of the teachers were satisfied with the present format of the feedback system and agreed that it sensitized them toward the students need. CONCLUSIONS: Student's feedback is an effective tool for teachers' evaluation resulting in faculty development. However, other sources of feedback may also be utilized for the overall assessment of a teacher.

Hepatic tuberculosis mimicking metastasis in a case of carcinoma sigmoid colon.

Tuberculosis (TB) presenting as isolated liver mass without clinical evidence of TB is difficult to diagnose preoperatively and is usually mimicked by primary or metastatic carcinoma of the liver. Hepatic TB associated with carcinoma colon is a rare association which has very rarely been reported in the literature. This case illustrates the diagnostic difficulties of hepatic TB and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients. Here, we report a case of 48-year-old female who presented in the casualty with features of acute intestinal obstruction. Preoperatively a mass was seen at the hepatic flexure along with three lesions in the liver presumed to be metastatic in origin. However, histopathology of the mass revealed adenocarcinoma colon and the liver lesion proved to be hepatic TB. We wish to highlight that on encountering a hepatic lesion in a carcinoma colon patient the possibility of hepatic TB should also be kept in mind apart from the obvious possibility of metastasis especially in an endemic country like India.

Coexistent axillary hydatid disease and tuberculosis: Case report of an extremely rare occurrence.

Tuberculous infection is highly prevalent in India, however, hydatid disease is relatively uncommon. Frequent sites of predilection of hydatid disease are the liver and lungs. Other unusual sites of infliction are the peritoneum, thyroid, breast, pancreas, and mediastinum. Hydatid disease in the axilla is quite uncommon. We hereby report a case of coexistent axillary hydatid disease with tuberculous lymphadenitis. To the best of our knowledge, even after extensive search of the literature we did not come across any such case. Fine needle aspiration cytology (FNAC) is a cost-effective procedure performed on an outpatient basis and helped clinch a prompt diagnosis, with minimum discomfort or complications. The role of FNAC in early diagnosis cannot be overemphasized.

Accessory breast tissue mimicking pedunculated lipoma.

Accessory breast tissue is an uncommon condition which occurs in 0.4-6% of women. It is mostly located in the axilla where it can cause diagnostic difficulty, especially if it is unilateral and large. Usually it is bilateral and presents as an asymptomatic mass during pregnancy or lactation. The diagnosis of ectopic breast tissue is important as it can undergo the same pathological changes that occur in a normal breast, such as mastitis, fibrocystic disease and carcinoma. We present a case of a large right-sided accessory breast in a 32-year-old woman that was clinically diagnosed as pedunculated lipoma. However, subsequent histopathological examination proved it to be an accessory breast tissue with lactational changes.

Fibromatosis colli - a rare cytological diagnosis in infantile neck swellings.

Fibromatosis colli or sternocleidomastoid tumour is a rare cause of benign neck mass in infants. It is a self limiting fibroblastic lesion usually presenting with torticollis and a history of birth trauma.It is one of the few causes in which Fine Needle Aspiration Cytology (FNAC) is indicated in a neonate to confirm the diagnosis and to differentiate it from other congenital, inflammatory and neoplastic causes. FNAC provides a rapid, cost-effective, reliable, non invasive method of diagnosis resulting in conservative management of these lesions. We present two interesting cases of neck swelling in infants where FNAC performed as the first diagnostic procedure was instrumental in establishing the diagnosis of fibromatosis colli thus avoiding unnecessary surgical intervention.

Laparoscopic repair of adult Bochdalek's hernia.

Bochdalek's hernia is a type of congenital diaphragmatic hernia occurring in approximately 1 in 2200-12 500 live births. It is considered to be extremely rare in adults and poses a diagnostic challenge. We present a case of a young man who was diagnosed as a case of congenital Bochdalek's hernia and underwent laparoscopic mesh repair.

Role of diagnostic laparoscopy in chronic and recurrent abdominal pain.

BACKGROUND: Chronic abdominal pain is a very common condition presenting to a general surgeon. It is defined as pain lasting for more than 3 months. Sometimes, the diagnosis cannot be established even with the help of advanced radiological investigations. This study aims to define the role of laparoscopy in diagnosing the cause of chronic abdominal pain and thus enabling a definitive management. METHODS: The study included 52 patients admitted to the Department of Surgery, Himalayan Institute of Medical Sciences, Dehradun, India for chronic abdominal pain of unknown origin. All patients underwent diagnostic laparoscopy with methodical inspection of the whole abdomen. RESULTS: Diagnosis was established in 86.5% of cases either by direct visualization or histopathological examination. The most common pathology was chronic appendicitis (19%) followed by adhesions (17.3%) and peritoneal tuberculosis (15.3%). A therapeutic procedure was done in 46% of cases during laparoscopy. No major complication was reported during the study. CONCLUSIONS: Laparoscopy is a safe and effective method to diagnose the cause of chronic abdominal pain in cases where other non-invasive methods prove unreliable.

Omental patch technique for the ileal perforation secondary to typhoid fever.

BACKGROUND/AIM: Enteric perforation is a grave complication of typhoid fever. Laparotomy with primary closure is the treatment of choice depending upon the bowel condition. Fecal fistula formation is the main concern in primary closure and the incidence of this complication dramatically decreases when omentum is used as a patch over primary closure. MATERIALS AND METHODS: A total of 176 patients underwent laparotomy for enteric perforation and they were divided into two groups randomly; Group I--Primary closure with omental patch and Group II--Only primary closure. The outcomes were measured in relation to hospital stay, wound infection, septicemia, fecal fistula, and mortality. RESULTS: The incidence of complications including fecal fistula and mortality is significantly lower in the group I patients. Fecal fistula occurs in 7.7% in group II, while in only 1.1% in group I. The mortality is also lower 3.3% in group II, while 1.1% in group I. CONCLUSION: Primary closure with omental patch is a better option as compared with only primary closure in enteric perforation patients. It can be recommended as an alternative method to primary closure only in enteric perforation patients.

Significance of apoptosis in prostatic intraepithelial neoplasia and carcinoma.

This study was carried out to assess the significance of apoptosis in prostatic intraepithelial neoplasia (PIN) and prostate cancer. A total of 120 prostatic specimens were studied in the department of Pathology [corrected] JNMC, Aligarh. The rate of apoptosis in PIN and prostate cancer was examined by quantifying the number of apoptotic bodies per hundred cells (apoptotic index) on haematoxylin and eosin stained histological sections [corrected] A significant correlation was noted between increasing apoptotic indices and increasing Gleason grades within a cancer.