Malignant transformation in mature cystic teratoma of the ovary: a retrospective study of eight cases and review of literature.

INTRODUCTION: Mature cystic teratoma (MCT) is the most common type of ovarian germ cell neoplasm, but occasionally it may undergo malignant change in any one of its elements. In this study, these rarely encountered tumors, occurring over a period of 25 years, were studied. MATERIAL AND METHODS: A retrospective, tertiary hospital-based study was carried out in all histopathologically diagnosed cases of MCT (230) of the ovary from January 1990 to December 2014. The clinicopathological features of malignant transformation (MT) in MCT of the ovary were retrieved from the archives of the Department of Pathology and were analyzed. RESULTS: Two hundred thirty (230) mature cystic teratomas of the ovary were found. MT was noted in eight of these cases, i.e. 3.5% of all the MCT. The mean age of the patients with MCT was 32.5 ±13.11 while the mean age of the patients with malignant transformation in MCT was 44.2 ±8.94 years. Grossly the mean size of the malignant teratoma was 11.7 ±2.7 cm, whereas it was 7.6 ±2.1 cm for mature cystic teratoma. Squamous cell carcinoma (SCC) was the most frequent MT seen in four out of eight cases, while one case showed an adenocarcinoma and the other a malignant melanoma, and two cases had transitional cell carcinoma. CONCLUSIONS: The rate of malignant transformation in MCT increases with age and is much higher in the postmenopausal age group. Moreover, although SCC is still the commonest, transitional cell carcinoma (TCC) may also develop not infrequently as malignancy apart from other rare differentiations such as adenocarcinoma or malignant melanoma in an MCT.

Correlation of FOXL2 with Inhibin and Calretinin in the Diagnosis of Ovarian Sex Cord Stromal Tumors.

OBJECTIVE: Alpha-inhibin and calretinin have been traditionally used as immunomarkers for sex cord stromal tumors. However, the variation in their immunoreactivity and their lack of specificity for sex cord stromal tumor makes the search for a more sensitive and specific immunohistochemical marker essential in routine diagnosis of sex cord stromal tumor. This study was conducted to correlate the diagnostic utility of FOXL2 with inhibin and calretinin in the diagnosis of sex cord stromal tumors of ovary. MATERIAL AND METHOD: The study was conducted in the department of pathology. 31 cases of sex cord tumors received in past eight years (2002-2010) were included in this study. Immunostaining for inhibin, calretinin and FOXL2 was performed and compared on the basis of staining intensity and percentage positivity on all the cases. RESULTS: Calretinin was found to be positive in 29/31 sex cord stromal tumors with variable intensities and was negative in two cases of sex cord stromal tumors, inhibin was positive in 28/31 and only three cases had no cytoplasmic staining. All the 31 cases included in this study were positive for FOXL2 with variable staining intensities and percentage positivity. Ten cases of each surface epithelial and germ cell tumors were also negatively stained with FOXL2. CONCLUSION: In contrast to inhibin and calretinin, FOXL2 had a sensitivity and specificity of 100% for all the cases of sex cord stromal tumors included in this study.

Detection of Helicobacter pylori in Nasal Polyps.

To detect the presence of Helicobacter pylori in nasal polyps. A case-control study was conducted enrolling 35 patients with nasal polyps (cases) and patients undergoing septoplasty (controls). Fresh tissue samples were used for urea broth test and imprint cytology, while formalin fixed tissue sections were used for morphology, special stains and immunohistochemistry for H. pylori. Fresh stool samples from both groups were tested to correlate the gastrointestinal status. H. pylori was detected in 40.0 % (14/35) of cases and 8.5 % of controls (3/35) (p = 0.004) by immunohistochemistry. Amongst cases, eight were positive with urea broth test, six with imprint cytology (Giemsa stain), three with H & E, and nine with modified McMullen's stain. Hyperplasia of the lining epithelium and lymphoid aggregates were significantly noticed in nasal polyps positive for H. pylori. Stool antigen test was positive in subjects who were positive for H. pylori in the nasal mucosa. There appears to be an association between H. pylori and nasal polyps. Immunohistochemistry is more sensitive and specific method to detect H. pylori. H. pylori induced inflammatory tissue reaction pattern indicates a possible causal association. Further studies are needed to prove the causal relationship between H. pylori and nasal polyps.

Polymorphous low grade adenocarcinoma of lip clinically mimicking squamous cell carcinoma: An unusual presentation.

Polymorphous low grade adenocarcinoma (PLGA) is a malignant neoplasm that frequently occurs in the minor salivary glands in palate and oral cavity. We present a case of upper lip swelling with ulceroproliferative growth, clinically mimicking squamous cell carcinoma (SCC). Fine-needle aspiration cytology smears suggested PLGA, which was later confirmed on histopathology. Clinical presentation of PLGA may simulate SCC.

Evaluation of apoptosis in skin biopsies of patients of borderline leprosy and lepra type 1 reaction.

BACKGROUND: The role of apoptosis is not clear in leprosy and lepra reactions. OBJECTIVES: To evaluate frequency of apoptosis in skin lesions of borderline leprosy and Type 1 lepra reaction. METHODS: Sixty patients with borderline leprosy (30 with clinically diagnosed Type 1 reaction (T1R) (Group I) and 30 without clinical evidence of reaction (Group II)) were analyzed in this prospective study. Apoptosis was detected by two different methods for comparison, that is, histopathologic examination (HPE) and deoxyribonucleic acid (DNA) fragmentation and electrophoresis. Quantification of apoptotic bodies/10 high power fields (HPF) was also done. RESULTS: Out of 30 cases, apoptosis was detected in 29 cases in Group I and 24 cases in Group II by HPE (P = 0.103), whereas, with the use of DNA electrophoresis it was detected in 24 cases in Group I and 18 cases in Group II (P = 0.091). On quantitative estimation it was found that number of apoptotic bodies are higher in Group I in comparison to Group II (2.77 vs 1.99), which is statistically significant. CONCLUSIONS: There was moderate agreement (κ = 0.47) between the two methods of apoptosis detection. Apoptosis was seen more in patients with T1R both qualitatively (statistically nonsignificant) and quantitatively (statistically significant). Clinical significance of this novel finding is that apoptosis can be used as one of the variables for diagnosis of T1R to increase detection rate.

Negative Appendectomy: an Audit of Resident-Performed Surgery. How Can Its Incidence Be Minimized?

Negative appendectomy remains a concern in current surgical practice. Data from the developing world is scarce. Data of appendectomies during the last 5 years were analyzed. Interval and incidental appendectomies were excluded. The demographic details, presenting complaints, clinical signs, and investigations performed were recorded in a predesigned proforma. The data were critically analyzed. Six hundred eighty-five appendectomies were performed during the period. One hundred eighty-five patients with a normal appendix were identified on histopathology. Sixty-seven patients with incidental or interval appendectomies were excluded. Thus, 118 patients had appendectomies performed erroneously. All these patients with presumed diagnosis of acute appendicitis were operated on by resident surgeons. Records of 17 patients could not be retrieved. The most common symptom was abdominal pain (100 %), and the commonest sign was right iliac fossa tenderness (93 %). Most of the patients underwent USG to supplement the diagnosis. CT scan and diagnostic laparoscopy were not performed. The negative appendectomy rate was 17.2 % (12.4 % in males; 33.3 % in females). The highest incidence of negative appendectomy was in females aged 11-20 years (66.7 %). The rate of negative appendectomy at our institute is comparable with the world statistics. More diligence is required in making the clinical diagnosis of acute appendicitis, especially in young females. The use of C-reactive protein and CT scan may decrease the negative appendectomy rate.

Expression of estrogen receptor ß and Ki 67 in benign & malignant human prostate lesions by immunohistochemistry.

Estrogen regulates the growth of prostate through two receptors Estrogen receptor α & ß of which ERß is proposed to be antiproliferative. There is a wide variation in the results of various studies regarding the localisation, level of expression of ERß in benign & malignant lesions of prostate and its relation to the grade of tumor emphasizing the need for additional studies to standardize the distribution of this receptor in prostate. This was a prospective study conducted in Department of Pathology, UCMS, Delhi, evaluating ERß & Ki 67 immunoexpression in 60 cases of benign and malignant lesions of prostate (30 each). Tissue for study included prostatic core biopsy and TURP chips. After histomorphological diagnosis, immunohistochemical staining was performed using a monoclonal antibody. Nuclear expression of ERß & Ki67 was evaluated and compared between the two study groups (benign & malignant lesions) using Pearson chi square test. ERß was predominantly localized to nuclei of secretory epithelium of prostatic glands. Expression of ERß was higher in benign glands compared to carcinoma. However, majority of carcinomas retained ERß expression though at much lower levels. Expression of Ki 67 was higher in carcinoma than benign hyperplasia. There was no correlation between the ERß status, Ki 67 expression & grade of tumor. Expression of ERß is downregulated in carcinoma compared to benign hyperplasia and is consistent with its chemopreventive role in prostate. It might have a therapeutic implication as agonists' targeting this receptor could be a part of treatment protocol for those patients of carcinoma who retain this receptor at significant levels.

Role of hospital-based cancer registries: a decade of experience of cancer cervix from a tertiary care centre, India.

BACKGROUND: Hospital-based registries are important tools for policy formulations and region-specific data creation, particularly in case of cervical cancer, which is preventable by an effective screening program. OBJECTIVE: To study the epidemiological characteristics and trends in cervical neoplasia in an urban population over a decade. MATERIALS AND METHODS: Data were collected from the histopathological records of patients from January 2000 to December 2009. RESULTS: A total of 1315 gynecological malignancies were reported with cancer cervix being the most common (70.4%) with a progressive increase in the number from 56 in 2000 to 157 in 2009. Squamous cell cancer was the predominant variant with majority in advanced stage. The mean age was 50.1 years with doubling of cases in the ≤35-year category. Of 742 colposcopic biopsies performed, cervical intraepithelial neoplasia (CIN) 1 was diagnosed in 34.9%, CIN 2 in 11.8%, CIN 3 in 7.8%, and microinvasive cancer in 0.8% cases. CONCLUSION: Though screening programs are in place, their effectiveness can be judged only by such reporting systems that aid in modifying the current cancer control strategies.

Evaluation of key histologic variables in skin biopsies of patients of borderline leprosy with type 1 lepra reaction.

BACKGROUND: Leprosy remains an important health problem mainly in the African and South-East Asia regions. Type 1 reaction is an immune-mediated phenomenon known to complicate at least 30% of patients of leprosy. Diagnosing type 1 reaction correctly is important for timely institution of therapy to prevent and treat neuropathy-associated disability and morbidity. There is paucity of literature on definitive criteria for histologic diagnosis of type 1 reaction. This study was conducted to determine the key histologic variables for diagnosing type 1 reaction. METHODS: This was a prospective study recruiting 104 patients with borderline leprosy. Three pathologists blinded to the clinical diagnosis independently assessed the cases. The agreement between each histological variable and clinical diagnosis was then calculated by using Cohen's kappa (Κ) coefficient. RESULTS: Histological diagnosis of type 1 reaction was given to 27 (67.5%) of 40 clinically diagnosed cases of type 1 reaction cases. Histological variables chosen as key variables for histological diagnosis of type 1 reaction were presence of giant cells, dermal edema, intragranuloma edema, granuloma fraction 31-50%, and presence of medium to large giant cells. CONCLUSION: This study has shown that T1R are still underdiagnosed histologically in comparison with clinical assessments. The key variables for diagnosing type 1 reaction were proposed.

Role of BRCA1 and BRCA2 gene mutations in epithelial ovarian cancer in Indian population: a pilot study.

Ovarian cancer is a silent killer as most patients have non-specific symptoms and usually present in advanced stage of the disease. It occurs due to certain genetic alterations and mutations namely founder mutations, 187delAG and 5385insC in BRCA1 and 6174delT in BRCA2 which are associated with specific family histories. These highly penetrant susceptibility genes responsible for approximately half of families containing 2 or more ovarian cancer cases account for less than 40% of the familial excess malignancy risk. The remaining risk may be due to single nucleotide polymorphisms (SNPs) which are single base change in a DNA sequence with usual alternatives of two possible nucleotides at a given position. Preliminary study involving 30 women with histologically proven epithelial ovarian cancer was conducted and their detailed genetic analysis was carried out. Regions of founder mutations on BRCA1 and BRCA2 were amplified and sequenced using primers designed based on 200 bp upstream and downstream regions of the mutation sites. Five sequence variants in BRCA1 were identified of which three novel sequence variants were found in 23 patients while in BRCA2, one novel sequence variant was found. The three founder mutations 187delAG, 5385insC in BRCA1 and 6174delT in BRCA2 were not seen in any of the subjects.

Role of newer methods of diagnosing genital tuberculosis in infertile women.

Genital tuberculosis is an important under-diagnosed factor of infertility. A vast majority of cases are asymptomatic and diagnosing them will help in treating such patients. We conducted a retrospective study in a tertiary care hospital of Delhi with an aim to compare different methods i.e., histopathological examination (HPE), acid-fast bacilli (AFB) smears, Lowenstein-Jensen (LJ) culture, BACTEC culture and polymerase chain reaction deoxyribonucleic acid (PCR-DNA) for diagnosing endometrial tuberculosis in infertile women. The data from 546 samples of endometrial biopsy histopathology, AFB smears and LJ culture was collected and then analyzed. Of these, HPE for tuberculosis was positive in 13, LJ culture in 10, AFB smear was positive in one case. BACTEC and PCR-DNA were feasible for 90 patients and PCR-DNA was positive in 20 and BACTEC in eight patients. Out of 20 patients with PCR positive results, 15 were only PCR positive and were subjected to hyster-laparoscopy and five had evidence of tuberculosis. Thus, none of the available tests can pick up all cases of genital tuberculosis, but conventional methods i.e., histopathology and LJ culture still has an important role in the diagnosis of endometrial tuberculosis in government setups where BACTEC and PCR are not performed routinely due to lack of resources.

Perineurioma of the pancreas: a rare case.

CONTEXT: Mesenchymal tumors of pancreas are rare. CASE REPORT: We describe a case of perineurioma involving the body and tail of pancreas presenting as a slow growing abdominal lump. CONCLUSION: Though perineurioma may arise from variety of anatomical sites including gastrointestinal tract, there is no previous report of perineurioma arising from the pancreas. 

Role of histopathological examination in nontraumatic perforation of colon.

AIM: Nontraumatic perforation of colon is an uncommon cause of peritonitis requiring early surgical intervention. This study was carried out to determine the prevalence patterns of the different etiologies of nontraumatic perforation of colon. METHODS AND RESULTS: A total of 35 patients with segments of colon or perforation margins removed for perforation were included. Most of the perforations occurred in the caecum, of which two were seen at the ileocaecal junction. The commonest cause was infection (amoebiasis: 13 cases and tuberculosis: 5 cases) followed by ulcers of non specific ulcers (12 cases). There were three cases of adenocarcinoma causing secondary perforation and one case of idiopathic intestinal gangrene and volvulus each. CONCLUSION: In tropics, non traumatic perforations of colon most often involves caecal and ileocaecal segment and the most common etiology is amoebiasis.

Revisiting old slides--how worthwhile is it?

Retrospective review of surgical pathology cases is a sensitive and effective method for identifying diagnostic discrepancies. As such studies from developing countries are limited, we undertook a retrospective review of 2408 surgical pathology cases (excluding skin, liver, and kidney biopsies) by two review pathologists to evaluate the quality of histopathology reporting, to identify the variations therein, and to classify them as major and minor according to the impact these would have on patient diagnosis, prognosis, or management. Diagnostic concordance was achieved in 93.1% of cases. The frequencies of overall and major differences in opinion were 6.9% and 3.4%, respectively. Major discrepancies were more common in non-neoplastic lesions than tumors. Endometrial pathologies were misdiagnosed maximally. The overall diagnostic agreement rate in the present study is in tune with those reported earlier although the frequency of major differences is higher. This is definitely a cause for concern and calls for remedial action.

Hirschsprung's disease: is there a relationship between mast cells and nerve fibers?

AIM: To define the topography of mast cells and their numbers in cases of Hirschsprung's disease (HD) and non-HD, assess neural hypertrophy using imaging software and to study the relationship between mast cells and nerve fibers. METHODS: HE stained sections of 32 cases of chronic constipation in the age group of 0-14 years were reviewed for ganglion cells. AChE staining was performed on frozen sections of colonic and rectal biopsies. Based on their findings cases were divided into HD and non-HD and mast cells stained by toluidine blue were evaluated. Image analysis by computerized software was applied to S-100 stained sections for assessment of neural hypertrophy. RESULTS: Difference between number of mast cells in HD group (mean = 36.44) and in non-HD group (mean = 14.79) was statistically significant. Image analysis morphometry on S-100 stained sections served as a useful adjunct. The difference between number, size, and perimeter of the nerve fibers between HD and non-HD group was statistically significant. CONCLUSION: Mast cells are significantly increased in HD and their base line values are much higher in Indian children than that reported in Western literature. Their role in HD needs further research. Morphometry of S-100 stained nerve fibers is a useful adjunct to conventional methods for diagnosis of HD.

ER, PR and Ki-67 expression status in granulomatous and chronic non-specific endometritis.

AIM: To study the changes in the histological pattern, distribution and intensity of sex steroid receptors (estrogen and progesterone) and cell proliferation by Ki-67 expression by semi-quantitative scores in granulomatous and chronic non-specific endometritis in the premenstrual phase. METHODS: A retrospective study was conducted on 20 cases of granulomatous endometritis, 10 of chronic non-specific endometritis and 30 age matched (2 years) controls with no endometrial lesions. Morphological changes were noted on histological examination and semi-quantitative scoring of Estrogen Receptor (ER), Progesterone Receptor (PR) and Ki-67 expression was done by immunohistochemistry. RESULTS: There was significantly higher ER, PR and Ki-67 expression in endometrial glandular and stromal cells in inflamed endometria as compared with the controls (all P-values < 0.02) regardless of the character of the inflammation. The cases with morphology not conforming to the secretory phase at which biopsy was taken had significantly higher ER, PR and Ki-67 expression in both endometrial and stromal cells indicating a lag in the endometrial maturation (all P-values < 0.02). Interestingly, all parameters except PR expression in glandular cells had a significantly higher expression even in cases with secretory morphology indicating disturbances in local milieu. CONCLUSION: Endometrial inflammation interferes with local expression of ER, PR and Ki-67. This may contribute to infertility regardless of other factors and other endometrial dysfunctional states.

Extra-nodal small cell lymphocytic lymphoma of prostate: an unusual cause of lower urinary tract symptoms.

Malignant lymphoma of the prostate is a rare occurrence. We describe a case of 60-year-old man presenting with acute urinary retention due to small cell lymphocytic secondary lymphoma of the prostate. We present the clinical manifestation of the disease emphasizing that all lower urinary tract symptom (LUTS) cases should be evaluated for the potential that metastatic cancers or lymphomas may present with such a diagnosis. We also present and tabulate a detailed review of at least 5 such similar reports (in which LUTS was the presenting symptom) published in the English literature to date.