Diagnostic Accuracy of Intraoperative Touch Imprint Cytology for the Diagnosis of Axillary Sentinel Lymph Node Metastasis of Breast Cancer: Comparison With Intraoperative Frozen Section Evaluation.

Introduction The intraoperative frozen section is a recommended method to detect breast cancer metastasis to axillary sentinel lymph nodes (SLNs); however, frozen section is not widely available and requires an experienced staff. Alternatively, touch imprint cytology (TIC) is a simple and cost-effective technique to detect metastasis. Therefore, in this study, we assessed the diagnostic accuracy of TIC for detecting SLN metastasis and compared it with intraoperative frozen section evaluation. Methodology A retrospective study was conducted in the Department of Histopathology, Liaquat National Hospital and Medical College, for a duration of two years. A total of 114 patients undergoing surgery for primary breast cancer were included in the study. All patients had clinically and radiologically negative axillary lymph nodes. SLN sampling was done using radioactive dye and sent for intraoperative consultation. The SLNs were sliced at 4-mm intervals and two TIC slides and three step-levels for frozen section were prepared, and the results were compared with final (paraffin) section histology. Results The sensitivity, specificity, and diagnostic accuracy of TIC was 83.7%, 98.5%, and 92.1%, respectively. Alternatively, the sensitivity, specificity, and diagnostic accuracy of frozen section was 93.9%, 100%, and 97.4%, respectively. The sensitivity of TIC and frozen section for detecting micrometastasis was 14.3% and 57.1%, respectively, with a diagnostic accuracy of 90.3% and 95.8%, respectively. Alternatively, with respect to macrometastasis, the sensitivity and specificity of TIC were 95.2% and 98.5%, respectively, while the sensitivity and specificity of frozen section were 100%. Conclusion TIC is a quick and effective technique for detecting breast cancer metastasis in axillary SLNs. Although frozen section had an overall higher sensitivity than TIC, the sensitivity of TIC for detecting macrometastasis was comparable to the frozen section. Therefore, we conclude that TIC is a good alternative to the frozen section in facilities where the frozen section is not available.

p16 Immunohistochemical Expression in Head and Neck Squamous Cell Carcinoma: Association With Prognostic Parameters.

Background p16 is a tumor suppressor gene, over expression of which is considered as a surrogate marker of oncogenic human papillomavirus (HPV) infection. Moreover, p16 over expression correlates with good prognosis in head and neck squamous cell carcinoma (HNSCC). In the present study, we aimed to evaluate the frequency of p16 overexpression in HNSCC in our setup and its association with clinicopathologic parameters. Methods We performed p16 immunohistochemistry (IHC) on 144 cases of HNSCC. Association of p16 overexpression with various clinicopathologic parameters including T-stage, N-stage, grade, recurrence status, and risk factors was evaluated. Results p16 over expression was noted in 22.9% (33 cases), while 21.5% (31 cases) were focal positive and 55.6% (80 cases) were negative for p16 over expression. On the basis of percentage of expression; > 70% p16 expression was noted in 4.9% (7 cases), 9% (13 cases) showed 51% - 70% p16 expression, 9% (13 cases) revealed 11%-50% p16 expression, while 77.1% cases revealed no expression or < 10% p16 expression. Significant association of p16 expression was noted with nodal metastasis and extranodal spread while no significant association of p16 was noted with other prognostic parameters and risk factors. Conclusion Our data revealed that high expression (> 50%) of p16 is low in oropharyngeal squamous cell carcinoma in our setup. These finding suggest a low prevalence of HPV as a cause of HNSCC in our population. Moreover, p16 expression was found to be associated with some good prognostic parameters like lack of nodal metastasis, however, no significant association was noted with overall disease-free survival.

Utility of the GeneXpert Mycobacterium tuberculosis/Rifampin (MTB/RIF) Assay on Paraffin-Embedded Biopsy Tissue Samples for Detecting Tuberculosis: Comparison With Histopathology.

Introduction The Xpert Mycobacterium tuberculosis/Rifampin (MTB/RIF) assay is a qualitative nested real-time polymerase chain reaction (PCR) performed on the GeneXpert instrument system. Although, the utility of this technique for detecting tuberculosis (TB) in sputum and pus samples is well established, however, the usefulness of GeneXpert on biopsy samples is still a matter of debate. Therefore, in this study, we evaluated the utility of GeneXpert for detecting MTB in biopsy specimens diagnosed with TB. Methods A retrospective observational study was conducted at the Department of Pathology, Liaquat National Hospital and Medical College. The data collection period was between January 2016 and December 2018 over a period of three years. Specimens included trucut/incisional biopsies and lymph node excisions. Cases with a favoured histopathological diagnosis of TB were included in the study. The Xpert MTB/RIF assay was performed on the samples obtained from paraffin-embedded biopsy tissue material, and comparison of histological features with Xpert MTB/RIF assay was performed. Results A total of 114 cases were included in the study. The mean age of the patients was 40.53±16.83 years, and 57.9% of patients were male. 68.4% of cases were extra-nodal with the lung being the most common extra-nodal site. On histopathological analysis, caseation necrosis, epithelioid granulomas and Langhan's giant cells were present in 64.9%, 70.2%, and 59.6% cases, respectively. On GeneXpert PCR assay, MTB was detected in 26.3% cases. A significant association of MTB detection on Xpert PCR assay was noted with the presence of necrosis on histopathology. Conclusion In our study, we noted that the MTB detection rate by GeneXpert assay on histopathologically diagnosed cases of TB was only 26.3%, and the detection rate was significantly increased in the presence of caseation necrosis on a biopsy tissue sample. Despite the low detection rate due to rapid turnover time, GeneXpert assay is an excellent adjunctive tool for detecting MTB in paraffin-embedded tissue samples.

Comparison of Liquid-Based Cytology and Conventional Papanicolaou Smear for Cervical Cancer Screening: An Experience From Pakistan.

Introduction After the introduction of cervical cancer screening program with cervical cytology, a marked decline in deaths secondary to cervical cancer was observed in developed countries. Two methods are used for cervical cytology. The first one is the conventional Papanicolaou (PAP) and the second one is liquid-based cytology (LBC). Although various studies in western countries established the role of LBC in cervical cancer screening, no large-scale study was conducted in our population to compare the two techniques for cervical cancer screening. Therefore, in this study, we compared the diagnostic utility of these two techniques for detecting cervical epithelial lesions. Methods A total of 3,929 patients, who presented to the Gynecology Clinic, Liaquat National Hospital, for cervical cancer screening from January 2015 until December 2019, over a period of five years, were included in the study. A total of 1,503 specimens were prepared by LBC, and 2,426 specimens were prepared by a conventional PAP smear method. All smears were interpreted using the Bethesda System of Reporting Cytopathology. Results The mean age of the patients was 39.46±11.14 years. For cytological evaluation, 98.7% of specimens were adequate. The inadequacy rate was 1.3% for conventional PAP smear and 1.2% for LBC. While 97.2% of specimens were reported as negative for intraepithelial lesion or malignancy, 1.1% of specimens showed squamous epithelial lesions. There was a significant difference in the detection rate of squamous epithelial lesions using the two techniques. The detection rate of squamous intraepithelial lesions using LBC was 2.1%, which was higher than that of the conventional PAP smear (0.6%). The detection rates of glandular lesions using LBC and conventional PAP smear were 0.5% and 0.2%, respectively. Conclusion We found a higher disease detection rate of squamous epithelial lesions using LBC compared to conventional PAP smear. Therefore, we recommend a widespread use of LBC for mass cervical cancer screening in our population.

Utility of Fine Needle Aspiration Cytology in the Evaluation of Lymphadenopathy.

Introduction Fine needle aspiration cytology (FNAC) is a quick, effective and relatively inexpensive technique to evaluate the visibly accessible superficial masses. As cervical, axillary and inguinal lymphadenopathies are commonly encountered clinical problems, in this study, we evaluated the utility of FNAC for assessment of lymphadenopathy. Methods A retrospective observational study was conducted in the Department of Cytopathology, Liaquat National Hospital and Medical College, over the duration of three years. A total of 559 cases were included in the study that underwent FNAC. After palpation, two to three passes were performed with a 22-23 gauge needle along with a plunger for FNAC. The obtained material was spread on three slides that were then stained with hematoxylin and eosin (H & E), Papanicolaou (PAP), and Diff-Quik methods. The remaining material was used for cell block preparation. Results The mean age of the patients was 37.05±18.03 years. In 98.7% of cases, the material was adequate for a satisfactory cytological examination. The most common site of FNAC was the cervical lymph node and tuberculous lymphadenitis (37%) was the most common diagnosis on FNAC, followed by reactive lymphadenitis (27.2%). Reactive lymphadenitis was seen more frequently in the younger age group (<15 years), whereas metastatic carcinoma was more commonly seen in the older age group (>50 years). Tuberculous lymphadenitis was noted more frequently in the middle age group (16-35 years). Moreover, tuberculous lymphadenitis was noted more commonly in cervical lymph nodes, while metastatic carcinoma was more frequently observed in axillary and inguinal lymph node FNACs. Conclusion FNAC is a quick and reliable method to categorize the cause of lymphadenopathy into reactive, inflammatory/infectious, metastatic, and lymphoproliferative, avoiding the necessity of an incisional/trucut biopsy. Moreover, age, gender, and site of involvement are useful predictors of the cause of lymphadenopathy. We noted that in the younger age group, reactive lymphadenitis was more common, whereas tuberculous lymphadenitis and metastatic carcinoma were more frequent in middle and older age groups, respectively. On a similar note, tuberculous lymphadenitis was more frequent in cervical lymph nodes than axillary and inguinal lymph nodes, while metastatic carcinoma was more common in these latter two sites.

Prognostic significance of p16 & p53 immunohistochemical expression in triple negative breast cancer.

Background: p16 and p53 genes are frequently mutated in triple negative breast cancer & prognostic value of these mutations have been shown; however, their role as immunohistochemical overexpression has not been fully validated. Therefore we aimed to evaluate the association of p16 and p53 overexpression in triple negative breast cancer with various prognostic parameters. Methods: Total 150 cases of triple negative breast cancers were selected from records of pathology department archives that underwent surgeries at Liaquat National hospital, Karachi from January 2008 till December 2013. ER, PR and Her2neu immunohistochemistry were re-performed to confirm triple negative status. p16 & p53 immunohistochemistry was performed on all cases and association with various clinicopathologic parameters was determined. Results: Mean age of the patients involved in the study was 48.9 years. Most of the patients presented at stage T2 with a high mean ki67 index i.e. 46.9%. 42.7% of cases had nodal metastasis. Although 84% cases were of invasive ductal carcinoma; however a significant proportion of cases were of metaplastic histology (9.3%). Fifty-one percent (76 cases) of cases showed positive p53 expression while 49% (74 cases) were negative. Higher percentage of p53 expression was found to correlate with higher T stage, high ki67 index and higher nodal stage. On the other hand, strong intensity of p53 expression was positively correlated with higher tumor grade and ki67 index. Seventy-one percent (98 cases) of cases showed positive p16 expression, whereas 24.8% (34 cases) were negative and 3.6% (5 cases) showed focal positive p16 expression. However, no significant association was found between p16 expression and various clinical and pathologic parameters. Similarly, no significant association of either p16 or p53 over-expression was noted with recurrence status of patients. Conclusion: On the basis of significant association of p53 over-expression with worse prognostic factors in triple negative breast cancer, therefore we suggest that more large scale studies are needed to validate this finding in loco-regional population. Moreover, high expression of p16 in triple negative breast cancer suggests a potential role of this biomarker in triple negative breast cancer pathogenesis which should be investigated with molecular based research in our population.

Immunohistochemical expression of epidermal growth factor receptor (EGFR) in South Asian head and neck squamous cell carcinoma: association with various risk factors and clinico-pathologic and prognostic parameters.

BACKGROUND: In this study, we intend to determine the immunohistochemical expression of EGFR in cases of head and neck squamous cell carcinoma and its association with prognostic clinico-pathologic features. METHODS: A total of 115 cases of head and neck squamous cell carcinoma treated at Liaquat National Hospital, Karachi, Pakistan, were included in the study. Clinico-pathologic features, risk factors, and recurrence status of cases were evaluated, and EGFR immunohistochemistry was performed. RESULTS: In our study, 52 cases (45.2%) of head and neck SCC were positive and 10 cases (8.7%) were focal positive for EGFR expression, while 53 cases (46.1%) were negative for EGFR expression. High EGFR expression (> 70%) was noted in 6.1% (7 cases), while 12.2% (14 cases) and 26.1% (30 cases) revealed 51-70% and 11-50% EGFR expression respectively. On the basis of intensity, strong EGFR expression was noted in 13.9% (16 cases) while 16.5% (19 cases) and 23.5% (27 cases) revealed intermediate and weak EGFR expression respectively. Significant association of EGFR expression was noted with tumor stage and disease-free survival. CONCLUSION: We found a significant association of EGFR expression with tumor stage and disease-free survivals, which are the most important prognostic factors in head and neck squamous cell carcinoma; therefore, EGFR expression can help as a prognostic biomarker in head and neck squamous cell carcinoma. On the other hand, we suggest that molecular studies should be performed in squamous cell carcinoma of head and neck in our setup to identify patients that can avail response from anti-EGFR therapy.

Cytokeratin 5/6 and cytokeratin 8/18 expression in triple negative breast cancers: clinicopathologic significance in South-Asian population.

OBJECTIVE: Cytokeratin 5/6 and Cytokeratin 8/18 are basal and luminal markers of breast cancer and they have pathological and prognostic significance in breast cancer. We performed Cytokeratin 5/6 and CK8/18 immunohistochemistry on 150 cases of triple negative breast cancers and association with various clinicopathological features was evaluated. RESULTS: Positive CK5/6 expression was noted in 8% (12 cases) of TNBC while 2.4% (4 cases) showed focal positive (< 10%) and 89.3% (134) were negative with CK5/6. Complete loss of CK8/18 expression was seen in 4.7% (7 cases) while 32.7% (49 cases) revealed focal loss of CK8/18 and 62.7% (94 cases) showed intact normal expression of CK8/18. No significant association of CK5/6 and CK8/18 with various clinicopathological parameters was observed. We found a low expression of basal cytokeratin (CK5/6) in TNBC our studied population, while loss/altered expression of CK8/18 in approximately 38% of TNBC. Although no prognostic relevance of these finding was noted in our study, however these findings are different from those reported in literature in other parts of the world. Therefore we suggest a more through immunohistochemical and genomic profiling of TNBC in our population for better understanding of this disease in this part of the world.

Accuracy of intraoperative frozen section for the evaluation of ovarian neoplasms: an institutional experience.

BACKGROUND: Ovarian neoplasms are a heterogeneous group of tumors including surface epithelial, germ cell and sex cord stromal tumors with a subset having low malignant potential (borderline tumors). While the surgical management plan differs in different categories of tumors, preoperative diagnosis is seldom available. In these circumstances, the role of frozen section becomes invaluable. In the current study, we aimed to evaluate the accuracy of the frozen section of ovarian tumors in our setup. METHODS: It was a retrospective study involving 141 cases of ovarian tumors undergoing surgical resection with frozen section evaluation from January 2009 to December 2014. After gross examination, one to five blocks were prepared on the frozen section depending upon the size of the specimen. After frozen section reporting, specimens were processed routinely for final paraffin section evaluation. Results of frozen and paraffin sections were categorized in benign, borderline, and malignant, and accuracy of frozen section was determined. RESULTS: Out of 141 cases, 107 were diagnosed as benign on final (paraffin) examination, while 6 were borderline and 28 were malignant. Out of 107 benign cases, 45 were non-neoplastic cystic lesions of the ovary including endometriotic, follicular, and corpus luteal cysts. The most common benign neoplastic tumor was mature cystic teratoma (20 cases) followed by mucinous cystadenoma (19 cases), serous cystadenoma (14 cases), sex cord stromal tumors (8 cases), and Brenner tumor (1 case). Among borderline cases, four cases were serous and two of mucinous neoplasms. The most common malignant neoplasm was serous carcinoma (11 cases) followed by mucinous carcinoma (6 cases). The overall accuracy of frozen section diagnosis is above 99 %. The sensitivity and specificity for benign tumors were found to be 100 and 97 %, respectively. The sensitivity and specificity for borderline tumors was 83 and 99 %, respectively, while for malignant tumors, it was 96 and 100 %, respectively. CONCLUSIONS: We found a high sensitivity and specificity of frozen section for the diagnosis of ovarian tumors and to determine its malignant potential. Therefore, it should always be used when the preoperative diagnosis is not definite to govern extent of surgical resection. However, under-diagnosis can occur in tumors of borderline category which can be minimized by increased sampling on the frozen section.

Role of peritoneal washing cytology in ovarian malignancies: correlation with histopathological parameters.

BACKGROUND: Peritoneal dissemination of ovarian tumors is a major prognostic parameter in ovarian malignancies. Analysis of peritoneal washing cytology serves as a useful predictor of ovarian surface involvement and peritoneal metastasis even in the absence of clinical omental spread. The aim of the current study is to correlate peritoneal cytology with various histologic features of ovarian cancers in our setup. METHODS: A total of 60 cases of ovarian tumors were included in the study that underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and omental and lymph node sampling during 2009 till 2014 at the Liaquat National Hospital, Karachi. Any free abdominal fluid was aspirated at the time of surgery. In the absence of free fluid, peritoneal washing was done with 50-100 ml of normal saline. Four cytospin preparations were done along with a cell block preparation. Correlation of peritoneal cytology with various histologic parameters was performed. RESULTS: Out of the 60 cases of ovarian tumors involved in the study, 56 were surface epithelial tumors, 2 germ cell tumors, and 2 metastatic carcinomas. The mean tumor size was 9.6 cm. Capsular invasion was seen in 61 % of the cases, and omental metastasis in 51 % of the cases. Serous carcinoma was found to have a significantly higher frequency of positive peritoneal cytology (76.9 %) compared to endometrioid and mucinous carcinomas (44 and 25 %, respectively). A significant positive correlation was seen between positive peritoneal cytology and capsular invasion and omental metastasis with a p value of <0.001. CONCLUSIONS: Positive peritoneal washing cytology has been implemented in ovarian cancer guidelines because of its prognostic significance in ovarian tumors. In addition to being an indicator of peritoneal metastasis, positive cytology also correlates with capsular invasion and histologic type in ovarian tumors. Therefore, it should always be used as an adjunctive tool in the surgical management of ovarian tumors.

Head and neck squamous cell carcinoma - comparative evaluation of pathological parameters in young and old patients.

BACKGROUND: To evaluate pathological features of head and neck squamous cell carcinoma (HNSCC) and to compare these pathological features in patients younger and older than 40 years. MATERIALS AND METHODS: All resection specimens of HNSCC between 2010 and 2013 evaluated. Tumor characteristics - grade, location (site) cervical node status, alongwith presence or absence of extranodal extension, lymphovascular invasion, gender and age - were extracted from surgical pathology reports. RESULTS: Among these n=19 patients (21.8%) were 40 years or younger and n=68 patients (78.2%) were above 40 years of age. The mean age was 34 (20-40 years) in the younger group and 56 (42-86) in the older group. The most common location of HNSCC in both groups was the oral cavity. The analysis of histopathological features including grade of tumor, tumor size, extranodal extension and comparison between two groups do not show any significant difference. CONCLUSIONS: There are no specific pathological characteristics of HNSCC in young patients. An interesting observation is that exposure to expected risk factors is similar in both groups, in younger patients they have less time to act and yet tumors are the same in terms of tumor size, lymph node status and lymphovascular invasion. Therefore further research is recommended to look for potentiating factors.

Diagnostic role of fine needle aspiration cytology (FNAC) in the evaluation of salivary gland swelling: an institutional experience.

BACKGROUND: Fine needle aspiration cytology (FNAC) is a cytodiagnostic method based on morphologic findings of individual and small group of cells aspirated using a fine needle. The aim of the present study is to evaluate the spectrum of salivary gland lesions in our setting and to assess the diagnostic accuracy of FNAC for salivary gland lesions. METHODS: The study involved 187 cases of parotid and submandibular swellings of patients who underwent FNAC at our institution. Thirty one (31) patients with a FNAC diagnosis of neoplastic lesion subsequently underwent excision biopsies. The results of FNAC and final histology were compared and accuracy of FNAC was determined. RESULTS: Mean age of patients was 42 (± 21) years and male to female ratio was 1:1. Chronic sialadenitis was the most common non-neoplastic lesion (33.8%) followed by acute and chronic sialadenitis (29.7%) and chronic granulomatous inflammation (27.0%). Pleomorphic adenoma was the most common benign neoplasm and non-Hodgkin's lymphoma was the most common malignant lesion (38.9%) followed by acinic cell (27.8%) and adenoid cystic carcinoma (16.7%). Total 31 patients subsequently underwent surgical excision, out of which 21 were benign and 9 were malignant, 20 cases (64.5%) were of pleomorphic adenoma, 3 cases (9.6%) of acinic cell carcinoma, 2 cases (6.4%) each of warthin tumor, adenoid cystic carcinoma and non-hodgkin lymphoma and 1 case (3.2%) each of mucoepidermoid carcinoma and mucinous adenocarcinoma. The overall accuracy of FNAC in our study was found to be 83.8% with 77.7% sensitivity and 86.3%, specificity. The revised sensitivity and specificity after adjusting verification bias were 68.5% and 91% respectively. False negative diagnosis was rendered in mucoepidermoid carcinoma and acinic cell carcinoma whereas false positive diagnosis was given in cases of pleomorphic adenoma. CONCLUSION: We found a good concordance between FNAC and histology, however pleomorphic adenoma may impart a diagnostic challenge when inadequately aspirated and therefore we advice either immunohistochemical studies (if cell block material is available) or repeat aspiration in difficult cases.

Diagnostic accuracy of Bethesda system for reporting thyroid cytopathology: an institutional perspective.

INTRODUCTION: Thyroid swelling is common problem among South Asian women. Although benign nodules far outnumber cancerous lesions, the risk of malignancy needs to be evaluated preoperatively for which fine needle aspiration cytology (FNAC) is widely used. Bethesda system for reporting thyroid cytopathology (BSRTC) was introduced to streamline the reporting of thyroid aspirates. We aimed to evaluate the disease spectrum of thyroid cytopathology and correlation of BSRTC with final histopathology in our setup. METHODS: The study was conducted at Histopathology department of Liaquat National Hospital, Karachi, involving 528 patients with thyroid swelling who underwent FNAC. Out of these 528 cases, 61 patients subsequently underwent surgical excision. Results of final histopathology were correlated with cytologic diagnosis. RESULTS: Mean age of the patients included in the study was 39.7 ± 13(14-84) and male to female ratio was 1:3.6. Out of total 528 cases, 403 cases were diagnosed as benign (Bethesda 2) and 67 were Bethesda 3 (follicular lesion of undetermined significance, FLUS) while 22 cases were categorized as either malignant or suspicious for malignancy (Bethesda 6 and 5). Histopathologic correlation was done in 61 cases. For Bethesda 5 and 6 categories, 100% concordance was found, however for Bethesda 2 category, 5 out of 45 cases were found to have malignant diagnosis on final histopathology. The incidence of malignancy in Bethesda categories 2 through 4 were 11.1%, 33.4%, 25%, 100% and 100% respectively. Overall accuracy of FNA cytology was 80.3% with 64.3% sensitivity and 85.1% specificity. CONCLUSION: Our study validated the accuracy of BSRTC in our setup. Therefore we recommend routine use of BSRTC for reporting thyroid cytopathology for initial workup of patients with thyroid nodule. However, risk of malignancy was found to be significantly high in Bethesda 3 category to warrant further workup including ultrasound/thyroid scan in addition to repeat FNAC.