Lumps and Bumps on the Abdominal Wall: Role of Fine Needle Aspiration Cytology.

OBJECTIVE: Abdominal wall masses often pose diagnostic challenges for clinicians due to their nonspecific symptoms. They include a wide spectrum of lesions ranging from inflammatory to tumor-like masses and malignancies. The majority of the malignant nodules are metastatic in origin and may be the initial presentation of a primary malignancy; hence, an early diagnosis is important. Fine-needle aspiration cytology (FNAC) is a valuable diagnostic tool in the evaluation of such lesions. This was a retrospective study of the cytomorphological spectrum of abdominal wall masses, conducted at a tertiary health care centre over a three-year period. MATERIAL AND METHODS: The study included patients of all age groups presenting with an abdominal wall mass. These lesions were assessed by FNAC. The diagnosis was made on cytology smears and subsequently correlated with the histopathological diagnosis, wherever possible. RESULTS: Of the 70 cases, 21 were non-neoplastic and 49 neoplastic. A benign neoplasm was the most common lesion (52.9%), followed by non-neoplastic lesions (30%) and malignant neoplasms (17.1%). Lipoma was the most common benign neoplasm and metastasis was the commonest malignant neoplasm. The most common type of tumor metastasising was adenocarcinoma and the primary tumors were predominantly intra-abdominal. No false-negative results were seen. CONCLUSION: Most of the abdominal wall masses display a characteristic cytomorphology, which needs to be identified and recognized by a cytopathologist for an accurate diagnosis. FNAC plays an invaluable role in the detection of metastases, especially at sites such as the umbilicus, which may be the only manifestation of an underlying advanced malignant disease.

Nonmeningothelial Dural-Based Lesions: A Histopathological Analysis.

Introduction We report 30 cases of nonmeningothelial dural-based lesions encountered during a 3-year study period. Materials and Methods We retrospectively reviewed pathology records of patients operated for extra-axial, dural-based lesions during the years 2016 to 2018 and included nonmeningothelial lesions as a part of this study. Results Among the 3,243 neurosurgical specimens for histopathologic examination, only 30 (0.93%) were "nonmeningothelial dural-based lesions." Six (20%) patients were in the pediatric age group. Pathologic assessment identified 13 cases of solitary fibrous tumor/hemangiopericytoma (43.3%) and 7 cases of Ewing's sarcoma/primitive neuroectodermal tumor (23.3%). Two cases (6.7%) were of metastasis. Other lesions included a single case each of non-Hodgkin's lymphoma, undifferentiated sarcoma, solitary plasmacytoma, and granulocytic sarcoma. Nonneoplastic lesions included two cases each of Rosai-Dorfman disease and nonspecific inflammatory lesions. Conclusion Nonmeningothelial dural-based lesions being rare, thorough examination of morphological features is a must by the pathologist, to arrive at the accurate diagnosis. Ancillary tests, if required, should be employed in the context of the morphologic picture.

Lhermitte-Duclos disease: A series of six cases.

The Lhermitte-Duclos disease (LDD), also known as dysplastic cerebellar gangliocytoma, is a rare lesion characterized by variable enlargement of cerebellar folia. The pathological basis of LDD has long been debated, as it has overlapping features of both, a neoplasm and hamartoma. Association between LDD and Cowden syndrome (CS) has been established based on the presence of phosphatase and tensin homologue germline mutation in both. We present a series of six cases of LDD: Four females and two males, aged between 16 and 38 years, presenting with headache and imbalance on walking of 1-7 months duration. Histomorphology showed thickening and vacuolation of the molecular layer, loss of Purkinje cells, and replacement of granular cell layer by large dysplastic ganglion cells. Awareness of histological features of this rare entity and a higher level of suspicion is required for the correct diagnosis, which, in turn, should prompt thorough investigations to exclude features of associated CS. LDD is a rare entity, awareness of its histological features and correlating them with radiology is essential, especially in tiny biopsies; to render the correct diagnosis. Diagnosis of LDD warrants further clinical workup and close follow-up for the associated features of CS.

An Autopsy Study of Cerebrovascular Atherosclerosis in the Elderly.

Background: Stroke is an important cause of mortality with intracranial atherosclerosis as an important risk factor. Geographical variation in the pattern of atherosclerosis is well documented with various studies in stroke patients showing that African Americans and Japanese people tend to have intracranial vascular occlusion, whereas Caucasians more often have extracranial atherosclerotic lesions. Methods: This is a prospective study of 50 cases of Indian elderly patients over 60 years of age where we have studied the CNS vasculature in detail including intracranial atherosclerosis with regards to its incidence, severity, distribution, plaque composition and associated risk factors. We compared the atherosclerotic pathology in the intracranial vessels and the extracranial vessels including the carotids. Results: Out of 50 cases 31 showed intracranial atherosclerosis. Anterior circulation was more commonly affected. A total of 87 of the intracranial arteries showed atherosclerotic plaques, most common nature of the plaques being fibrofatty. Majority of the intracranial vessels showed mild stenosis and multiple vessels were involved in 15 cases while single vessel involvement was seen in 16 cases with the middle cerebral artery being the most common single vessel involvement. Infarcts were seen in 7 cases and all these cases had history of hypertension. Cerebral atrophy was seen in 28 cases. All cases showing frontoparietal and generalized atrophy had carotid artery stenosis. Of the 100 carotid arteries studied (2 per case) 59 showed atherosclerosis. Majority of the carotid arteries showed mild degree of atherosclerosis and the content was predominantly fatty. Conclusion: This study concludes that the pattern of atherosclerosis is different in the Indian population as compared to the western literature. Intracranial atherosclerosis is more common in Indian population with the anterior portion of circle of Willis being more commonly affected.

Eosinophilic meningitis due to A. Cantonensis revealed at autopsy.

Parasitic infection of the central nervous system could be fatal, and its incidence is rising due to increasing worldwide travel. Amongst the various nematodes, Angiostrongylus contonensis is the commonest and causes eosinophilic meningitis. It is a zoonotic disease produced due to the ingestion of raw or undercooked snails or slugs. Most cases of angiostrongyliasis are mild and self-limiting, but death can occur in severe cases lacking timely and proper treatment. Very few autopsy cases of A. cantonensis are reported. We present the case of a 32-year-old mentally challenged orphan male with eosinophilic meningitis at autopsy.

Cavernous Hemangioma of Cavernous Sinus: An Outcome Report of 45 Surgically Treated Patients.

OBJECTIVE: To report an outcome analysis following surgical treatment of 45 patients with cavernous hemangiomas involving cavernous sinus. METHODS: From 1992 to 2020, 45 cases of cavernous hemangiomas involving the cavernous sinus were surgically treated. These patients were retrospectively analyzed. RESULTS: Patients included 12 males and 33 females; the average age was 34 years (age range, 15-61 years). Two patients had only headache as presenting symptom, and 43 patients had headache and diplopia as presenting symptoms. Investigations showed characteristic radiological imaging and encasement of internal carotid artery (35 cases), extension toward the sella, and displacement of cranial nerves III-V. An entirely extradural surgical approach was adopted in 39 cases. Cranial nerves III-V had a discrete dural covering and were always displaced over the dome of the tumor. The sixth cranial nerve was displaced on the dome of the tumor adjacent to the floor of the cavernous sinus. Three patients died in the early postoperative period, all related to excessive bleeding. In 36 patients, ocular movement dysfunction did not recover or worsened. During an average follow-up period of 110 months (range, 6 months to 27 years), 3 patients had tumor recurrence after postoperative imaging had shown complete tumor resection. CONCLUSIONS: Surgery on cavernous hemangiomas of cavernous sinus can be a challenge owing to the vascular profile and complex anatomical location. An extradural approach provides satisfactory exposure for radical tumor resection.

Intravascular papillary endothelial hyperplasia of the cavernous sinus-A rare occurrence.

Intravascular papillary endothelial hyperplasia (IPEH) is a benign, reactive proliferation of endothelial cells within areas of thrombus. It most commonly occurs in the skin and subcutaneous tissue, with less than 40 cases reported in intracranial location. Ours is the first case report from India of IPEH in the cavernous sinus. A 45-year-old male presented with headache and decreased visual acuity. Magnetic resonance imaging (MRI) revealed a well-defined, homogeneously contrast-enhancing mass in the cavernous sinus. Postoperatively, examination of tissue showed organizing thrombus within the vessel wall along with delicate, acellular, pseudopapillary cores. The fibrin-rich connective tissue of these showed blue staining with Masson's trichrome stain. These were lined by a single layer of endothelial cells without evidence of atypia; no nuclear pleomorphism, hyperchromasia, atypical mitosis, or areas of necrosis were seen. Hence, it was diagnosed to be IPEH. Follow-up MRI revealed no residual disease and the patient is disease-free at 8 months. Recognition of this entity by pathologic examination is important to rule out angiosarcoma. Gross total resection is curative. Residual lesions have the potential for recurrence, requiring adjuvant therapy.

Melanoma of the central nervous system: A report of three cases.

Melanomas within the Central Nervous System (CNS) are most commonly metastatic lesions, with primary melanomas comprising only 0.05-0.07% of all brain tumors. We report three cases of primary CNS melanoma. The patients were young adults. There were two females and one male. On preoperative investigations, two cases were misdiagnosed to be angiomas on Magnetic Resonance Imaging (MRI). The melanotic nature of the lesion was an intraoperative observation. Pathologic examination showed features of malignancy with invasion of tumor cells into the brain parenchyma. In two patients, presence of systemic lesions were ruled out after surgery by whole-body Positron Emission Tomography (PET) scan. These patients were subject to adjuvant radiotherapy, while one patient succumbed immediately post-surgery. Primary CNS melanomas are rare with no defined treatment protocols. Histopathology diagnosis is crucial to rule out pigmented mimics.

Glioblastoma Occurring as Second Primary in a Treated Case of Diffuse Large B-Cell Lymphoma.

Glioblastoma as second primary malignancy (SPM) has been reported after prostate cancer, meningiomas, Hodgkin's lymphoma. We report an extremely rare case of glioblastoma as SPM, occurring after remission of diffuse large B-cell lymphoma (DLBCL). Fifty-year-old male presented with loss of consciousness followed by right-sided weakness. He was treated with chemotherapy for DLBCL of the cervical lymph nodes, 5 years back. Present scans revealed well-defined intra-axial lesion in the left parietal lobe, suggestive of central nervous system (CNS) involvement by lymphoma. Left parieto-occipital craniotomy was performed and microscopic examination revealed the tumor to be Glioblastoma, WHO Grade IV. The tumor cells were positive for glial fibrillary acid protein and negative for leucocyte common antigen. He was treated by radiotherapy and temozolomide. Pathologic examination is a must for CNS lesions. Had it not been for the biopsy, the patient would have been treated as a recurrence of CNS lymphoma by chemotherapy and would have probably succumbed.

Large lateral intraventricular tumors - Outcome of radical surgery.

This is a retrospective analysis of 145 cases of lateral intraventricular tumors that were larger than 4 cm in their maximum dimension. The aim of surgery was radical tumor resection. During the period January 2000 to December 2019, 145 cases of lateral intraventricular tumors were treated by surgery by an interhemispheric approach. There were 101 males and 44 females. The ages of the patients ranged from 2 months to 77 years (average 29 years). Histological examination of tumors identified 73 central neurocytomas, 20 choroid plexus papillomas, 23 subependymal giant cell astrocytomas (SEGA), 5 ependymomas, 21 gliomas, 2 primitive neuroectodermal tumors (PNET/embryonal tumors) and 1 atypical teratoid rhabdoid tumor (ATRT). Nineteen patients had mild to severe hemiparesis in the immediate post-operative period. Eight patients died in the postoperative period. At a follow up of 1 year 137 patients were leading active and symptom free lives. Twenty seven patients received adjuvant radiation treatment. At a follow-up of more than 3 years, 8 additional patients died of their disease. Tumor recurrence or re-growth was observed in 13 patients and 2 patients needed reoperation. Surgery on large lateral intraventricular tumors can be associated with significant postoperative morbidity and mortality. Majority of tumors in this location are relatively 'low-grade' malignant tumors and when successfully treated, the long term outcome can be gratifying.

Endodermal cyst: rare intraaxial brainstem location. Illustrative cases.

BACKGROUND: This report detailed an extremely rare location of an endodermal cyst. Such location of the tumor can pose radiological confusion and a therapeutic dilemma. However, when identified, it can be a pleasant surprise for the surgeon and provide the possibility of a symptom-free long life for the patient. OBSERVATIONS: This report discussed two young patients who presented with relatively short-duration reports of ataxia and diplopia. Investigations revealed intraaxial brainstem lesion. During surgery, thick, pus-like fluid was evacuated and part of a wall was resected. Histology revealed that the lesion was an endodermal cyst. Both patients are well and are lesion- and symptom-free for 24 and 72 months. LESSONS: Endodermal cysts are some of the few long-standing and benign intraaxial brainstem lesions.

Bony lesions of cranium and spine: A study of 123 cases.

CONTEXT: Bony lesions involving the cranium and spine have a wide range of etiologies, ranging from congenital, traumatic, inflammatory, to neoplastic. AIM: The aim was to analyze the histological spectrum of various bony lesions of cranium and spine received as biopsies from the neurosurgery department in our hospital. MATERIALS AND METHODS: There were 123 cases of bony lesions of cranium and spine diagnosed over a period of 5 years during 2015-2019 in the neuropathology laboratory. These cases were studied retrospectively. RESULTS: Out of the total 123 cases of bony lesions analyzed, 75 affected the cranium and 48 affected the spine. Overall, neoplastic lesions (83) were more frequent than the nonneoplastic lesions (40). In the cranium, neoplastic lesions (66/75) outnumbered the nonneoplastic ones (9/75), whereas in the spine, nonneoplastic lesions (31/48) were more common. Chordoma (40/83) was the most common neoplasm, whereas tuberculous osteomyelitis (30/40) was the most common nonneoplastic lesion encountered. Majority of the patients were adult males aged between 21 and 50 years. Rare lesions such as spinal osteochondroma, poorly differentiated neoplasm metastatic to the cervical spine from a primary salivary gland neoplasm, spinal metastasis of a glioblastoma, and intraosseous meningioma of cranium were recorded. CONCLUSIONS: The study provides epidemiological information regarding the incidence and nature of bone lesions of the spine and cranium.

Solitary Plasmacytoma with Amyloid - An Unusual Dural-Based Lesion.

Solitary plasmacytoma of the dura without systemic involvement are extremely rare lesions, with <15 cases reported in the literature. Among these, ours is the second case to show the presence of amyloid. Fifty-year-old male had presented with headache, sudden onset right-sided weakness, and vomiting. Magnetic resonance imaging revealed an extra-axial mass in the left fronto-parietal region measuring 10 cm × 8.7 cm × 3.9 cm, suggestive of meningioma. The left fronto-parietal craniotomy was performed and multiple tissue bits aggregating to 10 cm × 8.5 cm × 2 cm along with thinned out membrane-like bit of calvarium was sent for pathologic examination. H and E stained sections showed sheets of plasmacytoid cells along with amyloid, which showed apple-green birefringence on Congo red staining. On immunohistochemistry, tumor cells were positive for CD38, CD138, showed kappa light chain restriction and were negative for CD45, CD34. Hence, it was diagnosed as a plasma cell neoplasm. Further work-up with whole-body positron-emission tomography scan revealed no systemic involvement. Dural-based lesions can mimic meningioma radiographically as well as intraoperatively. Histopathological examination unveils the diagnosis, to guide appropriate therapeutic regimens.

Meningiomas with Collagenous Rosettes: A Report of Three Cases.

Formation of rosettes is very rarely encountered in meningiomas. The 2016 WHO classification of central nervous system tumors mentions it as a rare pattern secondarily encountered in different variants. We report three cases of meningiomas forming collagenous rosettes. Case 1 was a 60-year-old male with a right frontoparietal mass lesion. Excisional biopsy showed features of atypical meningioma (WHO Grade II) with diffusely scattered collagenous rosettes. Case 2 was a 48-year-old male with right frontoparietal space-occupying lesion. Microscopy revealed a papillary variant of meningioma (WHO Grade III) with prominent diffusely scattered collagenous rosettes. Case 3 was a 75-year-old female with left parietal convexity tumor. Microscopy revealed a clear-cell meningioma (WHO Grade II) with cerebral invasion. Focal collagenous rosettes and fibrosclerotic whorls were noted. In all three cases, Masson's trichrome was used to confirm collagenous nature of the rosettes. All three tumors were positive for epithelial membrane antigen and vimentin.

Primary Pineal Rhabdomyosarcoma: A Rare Case.

Primary pineal rhabdomyosarcoma (RMS) is extremely rare, and only three cases have been reported so far. Here, we report a case of 12-year-old male who presented with complaints of diplopia and diminution of vision since 15 days. He also had left-sided facial paresis. Magnetic resonance imaging brain revealed a space-occupying lesion in the region of pineal gland. The patient underwent midline suboccipital craniectomy with excision of tumor. Microscopic examination revealed a highly cellular tumor with areas showing small round cells admixed with cells having abundant eosinophilic cytoplasm resembling rhabdomyoblasts and multinucleated giant cells. Differential diagnoses of pineal anlage tumor and primary RMS were considered. The tumor cells were positive for desmin while being negative for synaptophysin and glial fibrillary acidic protein. Myogenin was used to confirm the diagnosis of RMS, which showed focal nuclear positivity. INI1 was retained. All the markers for germ cell tumors were negative.

Chondrosarcoma of the dorsal spine - A rare case.

Chondrosarcomas of the spine are rare tumors and represent <10% of all chondrosarcomas. In the spine, they may arise from vertebral bodies or posterior elements. They may occur in patients ranging from 13 to 78 years of age. Here, we present a case of a 25-year-old female who presented with complaints of lower backache, stiffness in both lower limbs, and tingling sensation in the right lower limb. On examination, both power and sensations were decreased below waist. Magnetic resonance imaging spine revealed an extradural lesion at D5 vertebral body level with severe cord compression. We received the mass in multiple fragments which were grayish-white and firm to hard in consistency. Microscopically, a chondroid tumor was seen with cells arranged in lobules in abundant myxoid matrix. The neoplastic chondrocytes were large in size and had bizarre hyperchromatic nuclei. Few binucleate and multinucleate forms were also seen along with occasional atypical mitoses. There was permeation and destruction of the host bone, and the tumor was seen invading the marrow spaces. Few foci showed high cellularity. No osteoid formation was seen by the tumor. The tumor was diagnosed as Chondrosarcoma - Grade II.

Solitary Intraspinal Juvenile Xanthogranuloma in an Infant.

Juvenile xanthogranuloma (JXG) is a benign, non-Langerhans cell histiocytic proliferative disorder. We report a case of solitary JXG in an infant presenting as an intraspinal mass. Awareness of this mode of presentation is very important as subsequent prognosis differs from other tumors at the same location. JXG is a self-limiting dermatologic disorder usually occurring in first two decades of life. On rare occasion, it has been reported at extra-cutaneous sites such as central nervous system (CNS), eyes, liver, spleen, lungs and kidneys, and in other age groups. Isolated CNS involvement is extremely rare, especially in the spinal cord.

Ectopic Choroid Plexus Papilloma.

Choroid plexus papilloma is a rare intracranial neoplasm. These lesions most commonly present in the fourth ventricle in adults and lateral ventricle in children. Herein, we report a case of a 57-year-old male with complaint of backache of few weeks duration. Magnetic resonance imaging revealed an intradural and extramedullary space occupying lesion at D8 level. Histology showed multiple free-floating papillae with a central fibrovascular core. The cells showed immunoreactivity for vimentin, glial fibrillary acidic protein, synaptophysin, S-100 protein, and cytokeratins (CK, CK7).

Hydatid disease of the spine: A rare case.

Hydatid disease or hydatidosis is the most widespread zoonosis caused by Echinococcus granulosus. Liver and lungs are the most common sites. Bone involvement is rare and reported in 0.5%-4% with spinal involvement reported in 50% of these cases. We present a case of spinal hydatidosis in a 35-year-old male presenting with lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the spine showed multiple cystic lesions at the T9-T11 level with involvement of the paraspinal muscles. The lesion was seen intraspinal, intradural, intramedullary, and epidural. Radiological impression was aneurysmal bone cyst. The patient underwent laminectomy, and the excised cysts showed characteristic features of hydatid cyst (HC) on histopathology. The patient was started on antihelminthic therapy postoperatively. MRI is a diagnostic modality for HC, but the unusual location and absence of characteristic features can cause diagnostic difficulty. A high index of suspicion should be kept in patients residing in endemic areas and presenting with unusual cystic lesion of spine.