Cystic Neutrophilic Granulomatous Mastitis.

Granulomatous lobular mastitis (GLM) is an infrequent inflammatory breast disease, which can simulate malignancy on the basis of clinical and imaging features. It is typically found in parous or lactating women. The differential diagnosis of granulomatous mastitis includes infections caused by bacterial, fungal or mycobacterial agents, and autoimmune disorders like rheumatoid arthritis, sarcoidosis, giant cell vasculitis, and granulomatosis with polyangiitis. Cystic neutrophilic granulomatous mastitis (CNGM) is a sporadic sub-type of GLM that can be linked with infection with Gram-positive bacilli, specifically, Corynebacterium. It is characterised by lipogranulomas that comprise of "cystic" spaces lined by neutrophils which may contain Gram-positive rod-shaped bacteria. The majority of cases of GLM are still "idiopathic" as this pattern of inflammation still remains a mystery. We herein report three cases of CNGM and review the relevant literature. Key Words: Granulomatous mastitis, Corynebacterium, Gram-positive rods, Inflammatory breast disease, Cystic neutrophilic granulomatous mastitis.

Cytological features of a complete hydatidiform mole in a cervicovaginal smear: A case report.

Exfoliated trophoblastic cells can be seen in a cervicovaginal smear in cases of normal pregnancy or gestational trophoblastic disease (GTD) and can mimic high-grade squamous intraepithelial lesion (HSIL) or malignancy. Although they appear highly anaplastic, cytological features such as high nuclear to cytoplasmic ratio, irregular nuclear contours and scanty basophilic cytoplasm admixed with cytologically benign squamoid and endocervical cells can aid in differentiating them from malignant cells. We present a case of a 37-year-old woman with abnormal uterine bleeding for 3-months. There was no history of recent pregnancy or previous GTD. Her cervicovaginal smear showed a hypercellular smear exhibiting cytologically benign superficial and intermediate squamous cells along with clusters of benign endocervical cells with interspersed mononucleate cells. These mononucleate cells were large, with a hyperchromatic, pleomorphic nuclei, and scant basophilic cytoplasm. Cytological features were suggestive of trophoblastic cells and workup for pregnancy and GTD was advised. Her laboratory investigations showed markedly raised levels of ß human chorionic gonadotropins (ß-HCG) and ultrasound showed a uterine mass with snowstorm appearance. A uterine evacuation was performed after which histopathological examination showed microscopic features consistent with a complete hydatidiform mole. The rare presence of trophoblastic cells in a cervicovaginal smear can easily be confused with malignant cells and can be misleading to the pathologist. Trophoblastic cells should always be kept in mind when evaluating a cytology smear of a young patient irrespective of gestational status.

Pleomorphic Xanthoastrocytoma; Clinicopathological spectrum of An Intriguing neoplasm.

BACKGROUND & OBJECTIVE: Pleomorphic xanthoastrocytoma (PXA) is a rare primary WHO Grade II astrocytic tumor comprising of < 1% of all astrocytomas. It is generally benign and slow growing however disease progression and malignant transformation with anaplastic features have been infrequently reported. Our objective was to assess clinicopathological characteristics of this rare tumor at our center. METHODS: A retrospective study was conducted at Aga Khan University Hospital from January 1992 till January 2016. Data was entered on a proforma including patient demographics, clinical features, tumor location, histological features and follow-up, where available. RESULTS: Forty Seven cases of PXA were retrieved during the study period. The mean age was 23.8 years (SD=15.1) and median age was 19 years. The most frequent symptom was head ache (n=31). Male were more frequently affected (n=26). The commonest location was temporal lobe. On microscopic examination, tumors were pleomorphic without mitoses or necrosis, however two cases showed increased mitotic activity, and one case revealed associated gliosarcoma. Follow-up of only 29 cases was available for a period ranging between 2 and 184 months (85 months +/- 56 months). Outcome was good in 27 patients with the last follow up showing no radiographic or clinical evidence of tumor recurrence. CONCLUSIONS: PXA is an infrequent tumor in our population also, with less than 50 cases identified in two decades study period. Due to its rarity and its bizarre histomorphology, it should be diagnosed correctly, as it has got better prognosis than other astrocytic tumors.

Atypical Teratoid/ Rhabdoid Tumor of Brain: a Clinicopathologic Study of Eleven Patients and Review of Literature

Background: Atypical teratoid/ rhabdoid tumor (AT/RT) is a rare aggressive embryonal central nervous system (CNS) tumor of infancy and early childhood. Majority of the cases arise in the posterior fossa, and remaining in the cerebrum. Aims: To analyze the clinicopathologic features of AT/RT on a cohort of cases. Materials and methods: All reported cases of AT/RT at the Department of Pathology and Laboratory Medicine, Aga Khan University Hospital (AKUH) from 2007 to 2016 were reviewed for clinical and pathological features. Immunohistochemical stain for INI-1 was performed in all 11 cases. Follow up was obtained. Results: A total of 11 cases were identified. Seven patients were males and 4 were females. The ages ranged from 1 month to 48 months (mean 26.6 months). Six tumors were located in the cerebrum and 3 in the posterior fossa. Exact Location was not known in 2 cases. Histologically, rhabdoid cells were present in sheets in variable proportions in five cases, Medulloblastoma and PNET like areas were seen in 2 cases each. Immunohistochemical stains EMA (10/10), vimentin (7/7), CKAE1/AE3 (8/9), and CD99 (3/4), GFAP (6/10), ASMA (3/4) and synaptophysin (3/4) were positive in varying proportions while desmin was negative in all 6 cases in which it was performed. All 11 tumors lacked immunoreactivity for INI-1 protein. Four patients died of disease with a follow up ranging from 5 to 24 months. Conclusions: AT/RT is a rare highly aggressive embryonal tumor of CNS. A male predominance was noted in our series. We report the first and largest series from Pakistan.

Nigella sativa Oil Reduces Extrapyramidal Symptoms (EPS)-Like Behavior in Haloperidol-Treated Rats.

The symptoms of Parkinsonism and oral dyskinesia have been showing to be induced by neuroleptics that significantly affect its clinical use. In this study, we investigate whether Nigella sativa-oil (NS) (black cumin seeds)-a traditional medicine used for the seizure treatment in eastern country-may reduce the haloperidol (HAL)-induced extrapyramidal symptoms (EPS)-like behavior in rats. After combine treatment with HAL (1 mg/kg) on NS (0.2 ml/rat), rats displayed a significant decreased EPS-like behavior including movement disorders and oral dyskinesia as compared to controls. Immunohistochemical analysis indicates that NS reduced astrogliosis in caudate and accumbens nuclei. These results suggest that NS may consider as an adjunct to antipsychotics to reduce the EPS-like side effect.

Olfactory neuroblastoma: A clinicopathological experience of a rare entity from Pakistan.

OBJECTIVES: To present the clinicopathological experience of Olfactory Neuroblastoma (ONB) with emphasis on histopathological and immunohistochemical features. METHODS: A descriptive cross-sectional study was done on 36 cases of ONB, selected by non-probability purposive sampling. Theses cases of ONB were retrieved and reviewed from surgical pathology database of Aga Khan University Hospital reported between January 1993 and March 2015. RESULTS: Tumor size and age of presentation was wide in range without any distinct bimodal distribution. Nasal cavity was most common site along with involvement of paranasal sinuses. More than 50% cases had Kadish stage A. Microscopically, most cases were Grade-1 and majority showed partial or complete lobular architecture. Neurofibrillary matrix was observed in 2/3(rd) of cases. Among immunohistochemical markers, Neuron Specific Enolase was most frequently expressed. Unusual positive expression of Cytokeratin AE1/AE3 and Cytokeratin CAM5.2 was also seen focally in few cases. CONCLUSION: The ONB has great variability of histological and clinical presentation, and immunohistochemical markers are useful to differentiate from more common small round blue cell tumours of nasal cavity.

Commonest Cancers in Pakistan - Findings and Histopathological Perspective from a Premier Surgical Pathology Center in Pakistan.

CONTEXT: There are no recent authoritative data about incidence and prevalence of various types of cancers in Pakistan. AIM: To determine the frequency of malignant tumors seen in our practice and provide a foundation for building a comprehensive cancer care strategy. MATERIALS AND METHODS: 10,000 successive cases of solid malignant tumors reported in 2014 were included. All cases had formalin fixed, paraffin embedded specimens available and diagnosis was based on histological examination of H and E stained slides plus ancillary studies at the Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi. The latest WHO classifications were used along with the latest CAP protocols for reporting and the most updated TNM staging. RESULTS: There were 9,492 (94.9%) primary tumors while 508 (5.1%) were metastatic. Some 5,153 (51.5%) were diagnosed in females and 4,847 (48.5%) in males. The commonest malignant tumors in females were breast (32%), esophagus (7%), lymphomas (6.8%), oral cavity (6.7%) and ovary (4.8%), while in males they were oral cavity (13.9%), lymphomas (12.8%), colorectum (7.9%), stomach (6.9%) and esophagus (6.6%). Malignant tumors were most common in the 5th, 6th and 7th decades. About 8% were seen under 20 years of age. CONCLUSIONS: Oral cavity and gastrointestinal cancers continue to be extremely common in both genders. Breast and esophageal cancers are prevalent in females. Lung and prostate cancer are less common than in the west. Ovarian cancer was very common but cervix cancer was less so.

Central, Extraventricular and Atypical Neurocytomas: a Clinicopathologic Study of 35 Cases from Pakistan Plus a Detailed Review of the Published Literature.

BACKGROUND: Central neurocytomas are rare neuronal neoplasms with a favorable prognosis. They are typically located in the lateral ventricles of the brain and mostly histologically correspond to WHO grade II with a Mib 1 labelling index of <2%. Similar tumors located in the cerebral hemispheres and spinal cord, for example, are called "extraventricular neurocytomas". A few tumors histologically show atypia, mitoses, vascular proliferation and/or necrosis and a Mib 1 index >2 % and are designated as "atypical neurocytomas. AIM: The aim of our study was to describe the common as well as unusual morphologic features and the role of various immunohistochemical stains in the diagnosis of these rare tumors. MATERIALS AND METHODS: We retrieved and reviewed 35 cases diagnosed between 2001 and 2015. RESULTS: Sixty percent of patients were males, and the mean age was 26 years. 31 cases (88.6%) were intraventricular and 4(11.4%) were extraventricular. Histologically, 6 cases (17.1%) were compatible with "atypical neurocytomas". All cases showed the classic morphology comprising nests and sheets of uniform, round cells with uniform round to oval nuclei with finely speckled chromatin and perinuclear cytoplasmic clearing (halos). All cases also showed delicate, fibrillary, neuropil-like matrices. Other common histologic features included capillary-sized blood vessels in a branching pattern in 57.1%, foci of calcification in 34.3% and perivascular pseudorosettes in 20%. Rare findings included Homer- Wright or true rosettes in 8.6% and ganglioid cells in 2.9%. Synaptophysin was the most consistent and valuable marker, being positive in almost all cases. GFAP positivity in tumor cells was seen in 25.7% of cases. Follow up was available in 13 patients. Of these 9 had histologically typical and 4 had atypical tumors. Only 1 (with an atypical neurocytoma) died, probably due to complications of surgery within one month, while 12 (including 3 with atypical neurocytomas) remained alive. Recurrence developed in 1 of these 12 patients (histologically consistent with typical morphology) almost 9 years after surgery. Only 4 patients, including 2 with atypical tumors, received postoperative radiotherapy, all with surgery in 2010 or later. Overall, prognosis was excellent with prolonged, recurrence free survival and most patients, even without receiving radiation therapy, were alive and well for many years, even a decade or more after surgery, without developing any recurrence, indicating the benign nature of these neoplasms.

Symptomatic Surgically Treated Non-neoplastic Cysts of the Central Nervous System: A Clinicopathological Study From Pakistan.

OBJECTIVE: To report clinicopathologic features of symptomatic surgically removed non-neoplastic cysts of the central nervous system (CNS). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from 2003 to 2012. METHODOLOGY: All non-neoplastic CNS cysts reported during the study period were retrieved and reviewed. Age, gender, location, histologic type and clinical features were noted. RESULTS: A total of 124 cysts were diagnosed in the study period. These included 44 epidermoid cysts (mean age 30.5 ± 13.8 years), 35 colloid cysts (mean age 31 ±13.2 years), 32 arachnoid cysts (mean age 24.8 ±20.2 years), 6 dermoid cysts, 3 enterogenous cysts and Rathke's cleft cysts each and 1 ependymal cyst. All cyst types mainly presented in young adults in both genders with signs and symptoms of a mass lesion. CONCLUSION: Non-neoplastic cyst mainly presented like a CNS mass lesion in young adults. Epidermoids were the most common type of these cysts in the present series followed by the colloid and the arachnoid cysts.

Diagnostic utility of p53 and CK20 immunohistochemical expression grading urothelial malignancies.

INTRODUCTION: Current grading system in application by WHO/ISUP divides urothelial malignancies in low and high grade by morphologic criteria while strict segregation may become cumbersome in limited tissue specimens. As grading these carcinomas are of utmost prognostic significance after depth of invasion, therefore we evaluated the role of immunohistochemical expression of p53 and cytokeratin 20 as an adjuctive tool in grading urothelial carcinoma. METHODS: The study was conducted in Aga khan university hospital, Histopathology section from December 2010 till June 2011 for duration of six months. It involved 95 cases of urothelial carcinomas diagnosed on trans-uretheral resection specimens of bladder growth. Immunohistochemical expression of p53 and cytokeratin 20 was performed according to standard protocols and correlated with grade and depth of invasion. RESULTS: There were 48 cases (50.5%) of low grade and 47 cases (49.5%) of high grade urothelial carcinoma included in the study. Male to female ratio was 4.3:1. Majority of patients (80%) were seen in 45 to 90 years age group. Diffuse positive expression of cytokerain 20 was noted in 33 cases (68.8%) of high grade and 19 (40.4%) low grade tumors. Strong positive expression of p53 was seen in 35 cases (72.9%) of high grade while only 17 cases (36.2%) of low grade tumors showed strong p53 expression. CONCLUSION: Significant difference in expression of Cytokeratin 20 and p53 was found between low and high grade urothelial carcinoma. Therefore we suggest combined use of these markers may be helpful in assigning grade to urothelial carcinoma especially when histologic features are borderline.

Gastrointestinal, liver and biliary tract pathology: a histopathological and epidemiological perspective from Pakistan with a review of the literature.

AIM: To present an epidemiological and histological perspective of diseases of the gastrointestinal tract (including liver and biliary tract) at the Section of Histopathology, Department of Pathology, AKUH, Karachi, Pakistan. MATERIALS AND METHODS: All consecutive endoscopic biopsies and resections between October 1 and December 31, 2012 were included. RESULTS: A total of 2,323 cases were included. Carcinoma was overwhelmingly the commonest diagnosis on esophageal biopsies (69.1%); chronic helicobacter gastritis (45.6%) followed by adenocarcinoma (23.5%) were the commonest diagnoses on gastric biopsies; adenocarcinoma (27.3%) followed by ulcerative colitis (13.1%) were the commonest diagnoses on colonic biopsies; acute appendicitis (59.1%) was the commonest diagnosis on appendicectomy specimens; chronic viral hepatitis (44.8%) followed by hepatocellular carcinoma (23.4%) were the commonest diagnoses on liver biopsies; chronic cholecystitis was the commonest diagnosis (over 89%) on cholecystectomy specimens. CONCLUSIONS: Squamous cell carcinoma comprised 88.8% of esophageal cancers. About 67% were in the lower third and 56.5% were moderately differentiated; mean ages 49.8 years for females and 55.8 years for males; 66% cases were from South West Pakistan. Over 67% patients with gastric adenocarcinoma were males; mean ages 59 and 44 years in males and females respectively, about 74% gastric carcinomas were poorly differentiated; and 62.2% were located in the antropyloric region. About 63% patients with colorectal adenocarcinoma were males; mean ages 46.1 and 50.5 years for males and females respectively; tumor grade was moderately differentiated in 54%; over 80% were located in the left colon. In 21.2% appendicectomies, no acute inflammation was found. Acute appendicitis was most common in young people. Hepatitis C (66.3%) was more common than hepatitis B (33.7%); about 78% cases of hepatocellular carcinoma occurred in males; females comprised 76.7% patients with chronic cholecystitis; and 77.8% patients with gall bladder carcinoma. All resection specimens showed advanced cancers. Most cancers occurred after the age of 50 years.

Lymphangioma circumscriptum in the scrotum: a case report.

INTRODUCTION: Lymphangioma circumscriptum is a rare benign skin disorder involving hamartomatous lymphatic malformation of deep dermal and subcutaneous lymphatic channels. It is a therapeutic challenge for the dermatologist when it occurs at common sites such as axilla, shoulder, groin and buttocks and a diagnostic challenge for the surgeon when it occurs at rare sites such as the scrotum. Surgical treatment is the most commonly used method to treat scrotal lymphangioma circumscriptum but there are high rates of recurrence. CASE PRESENTATION: We report the case of a 30-year-old Pakistani man who presented with scrotal swelling which was clinically misinterpreted as an infectious disorder. Later on re-resection of deeper tissue was performed to prevent recurrence. He is still being followed-up on a regular basis. CONCLUSION: Awareness of the occurrence of lymphangioma circumscriptum in the scrotum in adult men without prior disease is mandatory to avoid missing the diagnosis and to ensure proper treatment.

Central nervous system lesions: correlation of intraoperative and final diagnoses, six year experience at a referral centre in a developing country, Pakistan.

BACKGROUND AND AIMS: Intraoperative consultation of CNS lesions provides accurate diagnosis to neurosurgeons. Some lesions, however, may cause diagnostic difficulty. In this study accuracy of intraoperative consultations of CNS lesions and discrepancies in diagnosis and deferrals were analysed. METHODS: All CNS cases from May 1, 2004 to September 20, 2010 in which intraoperative frozen section had been performed, and which were reported in the Section of Histopathology, Aga Khan University Hospital, Karachi Pakistan were retrieved. The diagnoses given on FS were compared with the final diagnosis given on permanent sections (and additional material if received), as indicated in the frozen section and final pathology report. RESULTS: During the study period, 171 CNS cases were received for intraoperative consultation. In all cases, cryostat sections (FS) plus cytology smears were prepared. The ages of the patients ranged from 03 to 77 years. 106 were males and 65 were females. Out of these 171 cases, 160 cases (94.1 %) were concordant, 10 cases (5.8 %) were discrepant, and one case was deferred until permanent sections. The diagnostic accuracy of frozen section was 88.9%. The sensitivity and specificity were 94.8% and 87.5% respectively. The positive predictive value was 98.6% and negative predictive value was 63.6%. All our cases in which intraoperative consultation was requested were sent for primary diagnosis. Adequacy per se was not a criterion for sending cases for intraoperative consultation. CONCLUSIONS: Our results show a reasonably high percentage of accuracy in the intraoperative diagnosis of CNS lesions. However, there are limitations and some lesions pose a diagnostic challenge. There is a need to improve our own diagnostic skills and establish better communication with neurosurgeons.

Incidence, trends and morphology of ovarian cancer in Karachi (1995-2002).

INTRODUCTION: Cancer ovary is the third most common malignancy diagnosed in women in Karachi, a moderate to high risk region for the disease. MATERIALS AND METHODS: Three hundred and thirty seven cases of ovarian cancer registered at the Karachi Cancer Registry for the years 1995-2002 were reviewed. RESULTS: The age- standardized incidence rate (ASR) world per 100,000, crude incidence rate per 100,000 (CIR) and frequency of ovarian malignancies in 1995-1997 were 10.9, 5.9 and 6.2% respectively. Corresponding figures for 1998-2002 were 8.1, 5.1 and 4.8%. The mean age at presentation in 1995-1997 was 45.7 years (95%CI 42.9, 48.4; SD∓15.9), range 95 (3 to 98) years and in 1998-2002 it was 45.0 years (95%CI 42.8, 47.3; SD±16.1), range 79 (3 to 82) years. Eleven (3.3%) cases of childhood cancers, 13 (3.9%) adolescent cases, 126 (37.4%) reproductive age (20-44 years) and 187 (55.5%) cases in the 45+ age group were registered. Epithelial malignancies were the most common cancers above the age of 20 years (78.4%), the commonest amongst these was serous adenocarcinoma (33.3%). Germ cell tumors were more common (5.6%) in children and adolescents. Microscopic confirmation was 99.0%. Presentation was of a moderately differentiated (grade 2) malignancy with a regional or distant spread of disease in three fourths of the cases. CONCLUSIONS: The incidence of cancer ovary, though stable in Karachi, involves a relatively younger age group with a strong family history in a fourth of the cases. The disease presents at an advanced stage. An ageing population over time may translate into a higher incidence of ovarian cancer. The current incidence of cancer ovary in Karachi is an enigma and belies reproductive protective factors. Studies focused on the genetic risk factors in this population are recommended.

Spectrum of cytological findings in patients with neck lymphadenopathy--experience in a tertiary care hospital in Pakistan.

INTRODUCTION: Lymph adenopathy is of great clinical significance as underlying diseases may range from a treatable infectious etiology to malignant neoplasms. In fact it is also essential to establish that the swelling in question is a lymph node. Fine needle aspiration cytology (FNAC) plays a vital role in solving these issues, nowadays being recognized as a rapid diagnostic technique because of its simplicity, cost effectiveness, early availability of results, accuracy and minimal invasion. FNAC is particularly helpful in the work-up of cervical masses and nodules because biopsy of cervical adenopathy should be avoided unless all other diagnostic modalities have failed to establish a diagnosis. OBJECTIVE: To determine the epidemiological and cytomorphological patterns of enlarged neck nodes. STUDY DESIGN: This retrospective observational study was performed at the Section of Histopathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan. MATERIALS AND METHODS: Three Hundred and seventy seven (377) neck swelling specimens obtained over a period of two and a half years registered from different regions of Pakistan were selected. Data were analyzed using SPSS 17. RESULTS: Of a total of 377 cases of FNAC performed on neck nodes, the most frequent cause of lymphadenopathy was found to be tuberculosis with 199 cases (52.7%), followed by reactive lymphoid hyperplasia with 61 cases (16.1%). Metastatic carcinoma was found to be the third most common cause with 33 cases (8.7%). A diagnosis of lymphoproliferative disorder was rendered in 21 cases (5.5%). Acute and chronic non-specific inflammation was seen in 16 cases (4.2%). In 47 cases (12%) FNAC was inconclusive. CONCLUSION: In our study, the predominant cause of enlarged neck nodes was tuberculous lymphadenitis, followed by reactive lymphadenitis and malignant neoplasm, especially metastatic carcinoma and lymphoma. FNAC was helpful in establishing the diagnosis in approximately 98% of the cases.

Primary renal leiomyosarcoma.

Primary renal sarcomas are very rare. We report a case of renal leiomyosarcoma with 36 months follow-up. Neither ultrasonography, computed tomography nor magnetic resonance imaging are able to differentiate between leiomyosarcoma and renal cell carcinoma. Radical nephrectomy and adrenalectomy was curative. Diagnosis was established on histology and immunohistochemistry. There were no metastases. Histology and later on immunohistochemistry is the only mean by which these tumours can be diagnosed. After a period of 36 months, patient is alive and well.

Incidence and current trends of colorectal malignancies in an unscreened, low risk Pakistan population.

INTRODUCTION: Karachi falls into a low risk region for colorectal cancer (CRC). The incidence rate is known but detailed epidemiology and pathology data regarding the disease are not available. The aim of this study was to describe CRC with reference to incidence, gender, topographic sub-site, tumor morphology, grade and stage at diagnosis and to determine the trends of incidence. MATERIALS AND METHODS: Four hundred and seventy three cases of colorectal cancer submitted to the Karachi Cancer Registry for Karachi South, years 1995-2002 were reviewed. Cases were analyzed in two time periods (1995-7 and 1998-2002) to facilitate the study of time trends. RESULTS: A total of 151 CRC cases were registered during period one [86 (57%) males; 65 (43%) females] and 322 cases [210 (65%) males; 112 (35%) females] in period two. Age standardized rate (ASR) world per 100,000, crude incidence rate (CIR) and relative frequency in period one were 5.3, 3.2 and 4.1% in males and 5.5, 3.2 and 3.2% in females respectively. Corresponding figures for period two were 7.1, 4.5 and 4.7% for males and 5.2, 2.8 and 2.7% in females. The male, female ratio was equal for colon (1:1). Men had more rectal cancers (2:1) and overall CRC (1.7:1). The mean age of the patients varied with sub-site and gender from 43.7 years to 51.2 years. Cancers of the rectum presented at a relatively earlier age. Less then 5% of the cases were diagnosed in adolescents, 50% above 50 years of age and only 30% above 60 years. The ratio under-40 to above-40 for CRC patients was 0.3, which is much higher than the international average, indicating a younger age group at risk. The first cases were observed in adolescents (15-19 years) and a peak was observed in the seventh decade. Colon to rectum ratio was 1:1 in males and 2:1 in females. Most cases presented with advanced disease, though some down staging was observed in period 2 (1998-2002). CONCLUSION: The current low but increasing incidence (especially in men), the younger age and advanced stage of CRC at diagnosis reflects a low risk, unscreened population. With existing prevalence of high risk factors in Pakistan, the low CRC incidence may be an artifact. There are concerns that an aging population over the next decade and changing lifestyle patterns may translate into a higher CRC incidence. Screening must be considered as part of the health sector planning for the future and include the high risk younger age groups.

CNS neoplasms in Pakistan, a pathological perspective.

The Section of Histopathology, Aga Khan University is the largest center for histopathology in Pakistan and is the major reporting and referral center for CNS neoplasms in the country. Over the years, a significant increase has been noted in the number of CNS neoplasms reported annually. This increase most likely represents increased number of neurosurgical procedures being performed. A major problem that we face as histopathologists is absence of clinical history or radiological films in a large number of cases.

BK Virus Associated Late Onset Haemorrhagic Cystitis After Allogeneic Peripheral Blood Stem Cell Transplant.

Haemorrhagic cystitis (HC) after allogeneic stem cell transplant is a clinical disorder with multiple etiologies. There is an inflammation of the bladder mucosa leading to painful haematuria. Early onset HC is mainly attributed to conditioning chemotherapy consisting of cyclophosphamide. Late onset HC is now being related to reactivation of latent polyoma BK virus (BKV). We describe the case of a 37 year old male with acute myeloid leukemia presenting with haematuria after allogeneic stem cell transplant.

Trends and morphology of central nervous system malignancies in Karachi.

INTRODUCTION: This study was conducted to assess the patterns of primary central nervous system (CNS) malignancies in Karachi South (KS), a moderate risk population in Asia. MATERIALS AND METHODS: Data for 321 registered cases were reviewed and analyzed in two periods 1995-1997 (111 cases, 75 (67.6%) male (M); 36 (32.4%) female (F)) and 1998-2002 (210 cases, 124 (59.1%) M; 86 (40.9%) F). RESULTS: Age standardized incidence rate per 100,000, crude incidence rate and relative frequency in 1995-1997 were 3.5, 2.8 and 3.5% (M) and 1.8, 1.6 and 1.7% (F). Corresponding figures for 1998-2002 were 3.3, 2.7 and 2.7% (M) and 3.3, 2.7 and 2.1% (F). Mean age of male and female patients during 1995-1997 was 33.3 years (SD± 20.4) and 30.7 years (SD±19.6). Mean ages for 1998-2002 were 33.2 years (SD±19.5) and 28.7 years (SD±18.5) for males and females respectively. In males, 199 malignancies were reported, 106 (86.9%) cases in the brain, 10 (5.5%) in meninges and 12 (6.0%) in the spinal cord; 122 cases were observed in females, 177 (89%) cases in the brain, 8 (6.6%) each in the meninges and spinal cord. The most common morphology was astrocytoma (72 (36.2%) (M); 40 (32.7%) (F)). Mean age of low grade astrocytoma was 27.8 years (M) and 27.0 years (F); anaplastic astrocytomas, 40.5 years (M), 34.1 years (F) and glioblastoma, 45.7 years (M) and 38.3 years (F). Youngest cases were registered for cerebellum and brain stem. CONCLUSION: The incidence of CNS malignancies is stable in males and gradually increasing in females. Astrocytoma is the commonest morphology; they affect a younger age group and show an age gradient in proportion to tumor grade. The mean age varied by sub-site and histology. Focus should be directed towards the understanding the biological nature and risk factors prevalent in this population.