Role of 99mTc-sestamibi Scintimammography in Predicting Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer: A Prospective Study.

Background: Neoadjuvant chemotherapy (NACT) is the first line of management for locally advanced breast cancer (LABC). However, chemoresistance is prevalent in 18%-50% of the cases. One of the important and most studied causes of chemoresistance is P-glycoprotein (Pgp) expression. 99mTc-sestamibi scintimammography may serve as a useful imaging tool to predict Pgp expression, thereby response to NACT. Aim: The aim was to study the role of 99mTc-sestamibi scintimammography in predicting response to NACT in treatment-naive, biopsy-proven LABC patients. Materials and Methods: 99mTc-sestamibi scintimammography (early and delayed images) was performed on a total of 34 patients. Eight patients were lost to follow-up, and only 26 (25 females and 1 male) patients were available for final analysis, with a mean age of 49.7 ± 10.7 years. 99mTc-sestamibi washout rate (WOR) (%) and T/B buildup were calculated. Pre-NACT and Post-NACT tumor sizes were measured clinically, and a % decrease in tumor size was calculated. The WOR and T/B buildup values were correlated with the % decrease in tumor size. Results: We found a statistically significant negative correlation between WOR (%) and % decrease in tumor size and a statistically significant positive correlation between T/B buildup and % decrease in tumor size. Furthermore, we found a positive correlation between the early T/B ratio and the Ki-67 index (P = 0.22). Conclusion: Early categorization of responders and nonresponders can help in optimal therapy planning. 99mTc-sestamibi scintimammography can serve as an imaging marker for Pgp expression, thereby predicting clinical response to NACT in LABC patients. Further studies with larger sample sizes are warranted to consolidate the above findings.

Differential expression of CK7, CK20, CDX2 in intestinal and pancreatobiliary types of preriampullary carcinoma.

CONTEXT: Incidence of periampullary carcinoma is low, approximately 0.5-2% of all gastrointestinal malignancies. Histologic subtyping has a prognostic bearing. The purpose of this study is to differentiate periampullary carcinomas based on immunohistochemistry (IHC) by using cytokeratin 7 (CK7), cytokeratin 20 (CK20), caudal type homeobox 2 (CDX2). AIMS: To analyze the usefulness of IHC as single/panel of markers that included CK7, CK20, and CDX2. SETTINGS AND DESIGN: This was a prospective study done from January 2017 to September 2018. SUBJECTS AND METHODS: A total 50 pancreaticoduodenectomy specimens were evaluated and classified as intestinal (INT) and pancreaticobiliary (PB) types based on their morphological and immunohistochemical features, respectively. The morphologic subtypes, expression of IHC markers were correlated with different histologic parameters. STATISTICAL ANALYSIS: Chi-square test was used to study the association between different IHC markers with histologic parameters. Probability (P) values <0.05 were regarded as statistically significant. RESULTS: The expression of CK7, CK20, CDX2 were studied in 50 cases to classify them as INT and pancreatobiliary subtypes. CK7 has high sensitivity (88.2%), CDX2 has high specificity (96.4%), CK20+/CDX2+ has both high sensitivity (94.2 percent) and specificity (89.2 percent) in differentiating INT from pancreatobiliary subtypes. The morphologic subtypes showed correlation with two variables (tumor grade, pathologic T stage). CK20 and CK20/CDX2 expression showed a positive correlation with tumor grade, pathologic T staging, and lymphovascular invasion. CONCLUSIONS: In conclusion, morphological classification can significantly discriminate histologic types, IHC plays a moderate role. However, the combined expression of CK20 and CDX2 is helpful in subtyping.

Comparison of Modified Ultrafast Giemsa Stain with the Standard May Grunwald Giemsa Stain in FNAC of Various Organs.

Background: The May-Grünwald Giemsa Stain is one of the preferred Romanwsky stains in studying cell morphology of air-dried smears with respect to cellular and nuclear size details and metachromatic extracellular ground with an approximate staining time of 20-30 min. A reduction in staining time and possible application of an ultrafast stain for rapid onsite evaluation (ROSE) of cytological material is the need of the hour. With the application of the new modified ultrafast Giemsa (MUFG) technique, rapid staining can be achieved, thereby helping in triaging of samples and, most importantly, providing an early preliminary diagnosis. Aims: The aim is to assess the quality index of the MUFG technique in FNAC of various organs in comparison with the standard MGG stain. Materials and Methods: A total of 61 FNAC cases were studied by random sampling. Two smears were prepared for each case and stained by both. Scores were given based on five parameters, and the quality index was calculated. Statistical Analysis: Results were analyzed using mean, median, standard deviation, "t" paired test, "P" value, and M-diff for statistical significance. Results: The quality index of MUFG smears was comparable to the standard MGG stain in salivary gland, breast, and thyroid aspirates and low in lymph node and soft tissue aspirates. MUFG is a rapid cost-effective stain which can be applied in the setting of ROSE for a preliminary diagnosis. Conclusion: MUFG is a reliable alternative and rapid technique for cytology diagnosis.

Tissue microarray based immunohistochemical study of TLE1 in synovial sarcoma and its histologic mimics.

BACKGROUND AND AIMS: Molecular analysis is gold standard for diagnosis of synovial sarcoma (SS) but use of these ancillary techniques is limited by many practical issues like cost and limited resources. Several studies analyzed TLE1 as a diagnostic immunohistochemical marker for synovial sarcoma and few studies disagreed. The objective of the study was to evaluate immunohistochemical expression of TLE1 in synovial sarcoma and its histological mimics. METHODS: The study included a total of 63 cases; of which 28 were synovial sarcomas (SS) and 35 its histologic mimics. A tissue microarray was constructed from these cases and subjected to TLE immunostaining. Nuclear immunoreactivity of TLE1 was graded as 0, 1+, 2+ and 3+ based on intensity and percentage of cells. RESULTS: All SS except one (27/28; 96.4%) were positive for TLE 1. These included 18 of monophasic spindle cell type (94.7%), 5 biphasic type (100%), followed by two each (100%) of poorly differentiated and calcifying type of SS. Of the other tumours 2 GISTs (50%), 2 haemangiopericytoma (66.7%), 2 schwannomas (50%) and one mesenchymal chondrosarcoma (33.3%) were positive for TLE1. CONCLUSION: TLE 1 is a highly sensitive marker with reasonable specificity for synovial sarcoma. Awareness of TLE1 expression in other tumours, is important to avoid misdiagnosis.

Immunohistochemical Analysis of Anti-phospholipase A2 Receptor Antibody on Renal Biopsies: A Single Tertiary Care Center Study.

Membranous nephropathy (MN) is one of the common cause of nephrotic syndrome. The discrimination between primary MN (iMN) and secondary MN is essential because of treatment implications. Immunohistochemical (IHC) evaluation with the help of anti-phospholipase A2 receptor (PLA2R) antibody helps in tissue evaluation of iMN, which is an easy, cost-effective, and pathologist-friendly technique. The study included 82 cases of MN over a period of 3 years. IHC using PLA2R antibody was performed on iMN and secondary cases with adequate tissue. Cases of minimal change disease (MCD) were included as control. Granular staining along the basement membrane in the absence of staining of podocytes was considered positive. Medical records were verified for clinical information, baseline biochemical parameters, details of viral markers, connective tissue disease profile, and basic imaging workup. Of the 82 cases of MN, 51 were iMN and 31 secondary MN (sMN). Thirteen MCD cases were included as control. IHC with PLA2R antibody showed a sensitivity of 91.8% and specificity of 95.1%, positive predictive value of 95.7%, and negative predictive value of 90.7% in the diagnosis of iMN. The other parameters, either clinical or laboratory, did not show significant differences between iMN and sMN groups. The results of PLA2R staining by IHC were comparable with other studies and showed a higher sensitivity (91.8%) and specificity (95.1%). IHC with anti-PLA2R antibody can be considered as the standard diagnostic approach to identify iMN and offer scope for individualized treatment.

Cytomorphology and Histology Correlation of Rosai-Dorfman Disease: A 15-Year Study from a Tertiary Referral Centre in South India.

OBJECTIVES: Rosai-Dorfman disease (RDD) is an uncommon, benign histiocytic disorder of unknown etiology, typically presenting in young adulthood. We highlight the cytomorphology of RDD and correlate it with the histopathology. STUDY DESIGN: All cases diagnosed as RDD on fine-needle aspiration cytology between January 2001 and June 2015 were included. Clinical details were obtained from medical records. The cytology smears were reviewed along with the histopathology and immunohistochemistry, wherever available. RESULTS: The study included 10 cases ranging in age from 11 to 68 years (median 29). There was a male predominance with a male:female ratio of 1.5:1. The patients commonly presented with bilateral cervical lymphadenopathy. Extranodal involvement was seen in 2 cases in the nose and mandible, respectively. Of these 10 cases, 8 were later biopsied. The cytological features included numerous crescentic histiocytes, emperipolesis, reactive lymphocytes and plasma cells. A histological diagnosis of RDD was made in 7 out of 8 cases, and 1 was diagnosed as Hodgkin lymphoma. CONCLUSION: FNA represents an efficient, minimally invasive, cost-effective and reliable technique for the diagnosis of RDD and may obviate the need for further biopsy. However, the disease has close differential diagnoses, including Langerhans cell histiocytosis, granulomatous lesions, and Hodgkin lymphoma. Hence, it must be remembered that there can be pitfalls when the diagnosis is made by cytology alone.

Utility of immunochemistry in cytology.

BACKGROUND: The role played by cytology in primary diagnosis is undeniable. With improved management protocols and targeted therapy, the need for accurate diagnosis has become mandatory. Immunochemistry and molecular techniques are increasingly being used on limited tissue samples. AIMS: This study was conducted to find out the impact of immunocytochemistry (ICC) on cytology material in cytology practice. MATERIALS AND METHODS: Immunochemistry was done on alcohol-fixed smears and cell-block preparations. It was done with i6000 BioGenex autostainer using BioGenex reagents. RESULTS: A total of 148 cases occurring over a period of 3 years (September 2010-June 2013) were analyzed. Staining was done on cytology smears in 77 cases and on cell-block sections in 71 cases. ICC helped in diagnosis in 8 cases, confirmed the diagnosis in 26 cases, helped in subtyping in 60 cases, and helped in prognostication in 6 cases. ICC has altered the diagnosis in two cases. It was noncontributory in 43 cases, and the material was inadequate in three cases. CONCLUSION: In 102 cases (69%), ICC proved to be a useful adjunct in the diagnosis and prognostication; hence, its use is recommended in practice to aid in cytology services.

Spectrum of IgA nephropathy in a single center.

Immunoglobulin A (IgA) nephropathy (IgAN) is the most common biopsy-proven primary glomerular disease in the world and a major contributor to the worldwide burden of endstage renal failure, with a wide geographical variation. To determine the incidence, clinical profile and histological pattern of IgAN in our institute, we reviewed all the patients who had native kidney biopsies with the diagnosis of primary IgAN during the period from 1998 to 2009 in the context of the clinical features. A total of 116 patients with IgAN were finally analyzed; 85 (73%) of the patients were male, the mean age of the patients was 29.2 ± 12.2 (range 10-70) years and the mean duration of disease was 10.4 ± 18.7 months (median: 2 months). Hypertension was present in 74 (63.2%) cases. Gross hematuria was rare. The most common clinical presentation was nephrotic syndrome, followed by chronic renal failure. The mean proteinuria level was 2.5 ± 2.3 g/day (median: 1.7 g/day) and the mean serum creatinine level was 3.04 ± 3.3 mg/dL (median:1.7 mg/dL). The morphological sub-classification (Haas): Class I was the most common (44.4%), followed by class V (23%). IgA co-deposition with C3 and lambda was the most common finding in the immunofluorescence study. The glomerular filtration rate decreased with advanced histological damage. The incidence of IgAN was 7.5%, which is lower as compared with studies from elsewhere. IgAN in our population had a more severe clinical presentation.

Isolated musculoskeletal hydatid disease: diagnosis on fine needle aspiration and cell block.

Hydatidosis is a zoonotic infection caused by Echinococcus granulosus. The most common sites of involvement are liver and lungs. Isolated musculoskeletal hydatidosis in absence of visceral involvement is rare and it mimics bone or soft tissue neoplasm. Fine needle aspiration cytology and cell block aids in diagnosis in such unusual location. Here we present one such rare case of isolated musculoskeletal hydatidosis diagnosed on fine needle aspiration cytology and cell block which was mimicking as fibrous dysplasia on radiology.

Solid-pseudopapillary neoplasm of the pancreas: a clinicopathological and immunohistochemical study of 33 cases from a single institution in Southern India.

BACKGROUND: The clinicopathological and immunohistochemical data of solid-pseudopapillary neoplasm (SPN) from India are limited. Our objectives were to evaluate various histopathological parameters and immunomarkers to elucidate the best possible immunomarker combination that can accurately diagnose these tumors. MATERIALS AND METHODS: Clinicopathological features of 33 consecutive cases of SPN were retrospectively analyzed. Immunohistochemistry (IHC) was performed on a tissue microarray of 31 of these cases with antibodies to pan-cytokeratin (CK), vimentin, CD 10, E-cadherin, ß-catenin, estrogen receptor (ER), progesterone receptor (PR), chromogranin. RESULTS: Totally, 32 of 33 patients were females with a mean age of 26 years (range 12-62 years). Majority presented with abdominal pain (93.93%) and/or abdominal mass (48.48%). Location in pancreas included tail (14), head (7), body and tail (6), body (5) and neck (1). The mean diameter of the tumor was 8.6 cm (range 0.5-16 cm). Surgical exploration was done in all cases. On IHC, tumor cells were consistently positive for vimentin and negative for chromogranin (100%). CK was positive in 12 cases (38.7%), CD 10 showed perinuclear dot positivity in 14 (45.16%) cases and cytoplasmic positivity in 05 (16.12%) cases. All cases showed loss of membranous staining for both ß-catenin and E-cadherin with nuclear positivity in 90.32% and 70.16% cases, respectively. PR was positive in 20 (64.51%) cases, while all of them were negative for ER. CONCLUSION: Solid-pseudopapillary neoplasm is a tumor commonly affecting young females. Loss of membrane expression of ß-catenin and E-cadherin with nuclear positivity can be used confirm the diagnosis of SPN.

C4d immunohistochemistry in membranous nephropathy.

BACKGROUND: Membranous nephropathy (MN) is the most common cause of nephropathy in adults. The diagnosis is based on characteristic light microscopic, electron microscope and immunofluorescence (IF) findings. In early MN, the light microscopic findings may be difficult to differentiate from minimal chain disease. In the absence of fresh frozen tissue for IF, immunohistochemistry with C4d aids in the diagnosis. MATERIALS AND METHODS: A total 48 cases of MN diagnosed on renal biopsy were analyzed. The formalin fixed paraffin embedded tissues were stained with routine hematoxylin and eosin stains along with periodic acid-Schiff and silver methenamine stains to highlight the basement membrane. Fresh frozen tissues were available for IF in 40 cases. Immunostaining with C4d was done on paraffin-embedded sections by polymer-Horse Radish Peroxidase (HRP) technique using polyclonal antiserum to C4d (Biogenex, India). RESULTS: There were 25 cases of idiopathic MN, 17 cases of Class V lupus nephritis and 2 cases were secondary to hepatitis C infection with cirrhosis. The glomerular basement membrane (GBM) was diffusely thickened with formation of spikes in 28 cases. In 11 cases the capillary loops were rigid but spikes were not seen and in 9 cases there was no apparent thickening of the basement membrane. All the cases showed diffuse positivity for C4d along the GBM. CONCLUSION: C4d is a reliable method to establish the diagnosis of MN and also a sensitive marker of complement activation reflecting the pathogenesis of MN.

Molecular insights into the association of obesity with breast cancer risk: relevance to xenobiotic metabolism and CpG island methylation of tumor suppressor genes.

Obesity, genetic polymorphisms of xenobiotic metabolic pathway, hypermethylation of tumor suppressor genes, and hypomethylation of proapoptotic genes are known to be independent risk factors for breast cancer. The objective of this study is to evaluate the combined effect of these environmental, genetic, and epigenetic risk factors on the susceptibility to breast cancer. PCR-RFLP and multiplex PCR were used for the genetic analysis of six variants of xenobiotic metabolic pathway. Methylation-specific PCR was used for the epigenetic analysis of four genetic loci. Multifactor dimensionality reduction analysis revealed a significant interaction between the body mass index (BMI) and catechol-O-methyl transferase H108L variant alone or in combination with cytochrome P450 (CYP) 1A1m1 variant. Women with "Luminal A" breast cancer phenotype had higher BMI compared to other phenotypes and healthy controls. There was no association between the BMI and tumor grade. The post-menopausal obese women exhibited lower glutathione levels. BMI showed a positive association with the methylation of extracellular superoxide dismutase (r = 0.21, p < 0.05), Ras-association (RalGDS/AF-6) domain family member 1 (RASSF1A) (r = 0.31, p < 0.001), and breast cancer type 1 susceptibility protein (r = 0.19, p < 0.05); and inverse association with methylation of BNIP3 (r = -0.48, p < 0.0001). To conclude based on these results, obesity increases the breast cancer susceptibility by two possible mechanisms: (i) by interacting with xenobiotic genetic polymorphisms in inducing increased oxidative DNA damage and (ii) by altering the methylome of several tumor suppressor genes.

An unusual case of reversible acute kidney injury due to chlorine dioxide poisoning.

Chlorine dioxide is a commonly used water disinfectant. Toxicity of chlorine dioxide and its metabolites is rare. In experimental studies, it was shown that acute and chronic toxicity were associated with insignificant hematological changes. Acute kidney injury due to chlorine dioxide was not reported. Two cases of renal toxicity due to its metabolites, chlorate and chlorite were reported. Herein, we report a case of chlorine dioxide poisoning presenting with acute kidney injury.

Role of cytology in fibroadenoma with clinging carcinoma.

Fibroadenoma is the most common benign breast tumor in adolescent girls and young women with a peak incidence in the second and third decades of life. Carcinoma arising within a fibroadenoma is rare and is usually discovered incidentally. We describe a case of clinging type of ductal carcinoma in situ (DCIS) arising within a fibroadenoma. Clinging carcinoma, a variant of DCIS is an under recognized entity. Diagnosis of DCIS is made based on architecture and cytology. This case report highlights the role of fine needle aspiration cytology in the diagnosis of this entity coexisting in a fibroadenoma.

Primary extra nodal non Hodgkin lymphoma: a 5 year retrospective analysis.

BACKGROUND AND AIM: The incidence of extra nodal non Hodgkin lymphoma (ENL) is rising throughout the world. However, data regarding ENL as a group is limited. The aim was to study the epidemiological and histomorphological trends of primary ENL (pENL) in India. MATERIAL AND METHODS: The biopsy materials from sixty eight patients with pENL (45 male, 23 female, M:F= 1.9:1), diagnosed over a five year period (2005-2009), were analysed and pathologically reclassified according to the World Health Organization (WHO) classification, 2008 criteria. RESULTS: Primary extra nodal non Hodgkin lymphomas constituted 22.0% (68/308) of all non Hodgkin lymphomas (NHL). The mean age at presentation for pENL and primary nodal NHL was 43 years and 58 years, respectively with a male predilection (M: F=2:1). Central nervous system (CNS) constituted the most common extranodal site (20/68, 29.5%) followed by gastrointestinal tract (17/68, 25%), and nose/nasopharynx (8/68, 11.8%). Diffuse large B-cell lymphoma (DLBCL, not otherwise specified), extranodal marginal lymphoma of mucosa associated lymphoid tissue (MALT) type, and B cell NHL unclassified (U) were the three most common histological types observed. T-cell phenotype was rarely noted (4%). Follicular lymphomas and anaplastic large cell lymphoma, seen among nodal NHL, were absent at extra nodal sites. Majority (41/68, 60%) of the patients with pENL were immunocompetent and 55% were in stage I-II with favorable prognosis. CONCLUSION: Central nervous system was the most common site of ENL, followed by gastrointestinal tract. Majority of pENL occurred in immunocompetent hosts with a favorable prognosis.

Utility of concentration method by modified bleach technique for the demonstration of acid-fast bacilli in the diagnosis of tuberculous lymphadenopathy.

BACKGROUND: Microscopy detection of acid fast bacilli (AFB) by Ziehl-Neelsen (ZN) method has many advantages when it comes to speed and feasibility though it has a low sensitivity. If the sensitivity could be improved, it has the potential to become an even more valuable tool for detection of AFB. OBJECTIVES: To evaluate the efficacy of bleach concentration method in the cytodiagnosis of tuberculous lymphadenitis in comparison with routine Ziehl-Neelsen method and to compare the positivity in various cytomorphological categories. MATERIALS AND METHODS: A total of 112 cases of tuberculous lymphadenitis diagnosed by fine needle aspiration cytology (FNAC) were categorized into six cytomorphological patterns. The acid-fast bacilli positivity by routine staining was correlated with modified bleach methods of ZN staining. Sensitivity of routine ZN and modified bleach concentration was compared. RESULTS: The classic cytomorphological pattern of tuberculosis of epithelioid granulomas, langhans giant cells and caseous necrosis was seen in 37.5% of cases. Routine ZN staining detected AFB in 12.5% of cases and the modified bleach method in 60.7%. Modified bleach method showed AFB positivity in additional 54 cases where routine AFB staining was negative. The modified bleach method showed AFB positivity in all cases where routine ZN staining was positive. CONCLUSION: The modified bleach method was more sensitive and safer than routine ZN staining. As the background was clear, the bacilli were easily visible and the screening time was shorter.

Significance of acellular smears in conjunctival impression cytology.

OBJECTIVES: Conjunctival xerosis is a marker for vitamin A deficiency. Conjunctival impression cytology (CIC) is a widely used technique to detect xerosis in field studies. Inadequate and acellular samples are generally considered technical failures and are treated as uninterpretable. The purpose of this study is to determine the significance of acellular smears in the detection of vitamin A deficiency. STUDY DESIGN: CIC with transfer (CICT) and blood samples were collected from freshly diagnosed cancer patients and healthy controls. CICT smears were classified as cellular or acellular. Serum vitamin A levels were tested by high-performance liquid chromatography. CICT results were compared with vitamin A levels. RESULTS: CICT was collected from 1,694 subjects. There were 118 (7%) acellular smears, i.e. 99 in patients and 19 in controls. Serum vitamin A levels were available in 112 of these subjects. Levels <20 µg/dl were seen in 82.1% of the subjects with acellular smears and in 18.9% of the subjects with cellular smears (p < 0.001). Of the gastrointestinal and hepatobiliary and hematologic cancers, 15.6% and 10.5% showed acellular smears, respectively. CONCLUSIONS: Acellular smears in conjunctival imprint cytology may indicate hypovitaminosis A, provided technical failure to obtain cellularity is ruled out.

"True" mycotic aneurysm of the anastomotic site of the renal allograft artery.

The incidence of vascular complications after renal transplant as reported varies from 3.5% to 14%. Pseudoaneurysm formation at the site of the anastomosis is a rare complication, and only a few cases have been reported. There also were only a few reports of "true" mycotic aneurysms of the renal allograft artery. We present 2 patients with true mycotic aneurysmal formation of the renal allograft artery after a renal transplant. Both patients presented with fever and increasing serum creatinine levels. Cultures from aneurysm tissue samples have grown Aspergillus flavus. Both patients were subjected to an allograft nephrectomy, and amphotericin was given.

Bcl-2/adenovirus E1B 19 kDa-interacting protein 3 (BNIP3) expression is epigenetically regulated by one-carbon metabolism in invasive duct cell carcinoma of breast.

In view of recent studies highlighting the prognostic relevance of expression and CpG island methylator phenotype (CIMP) of Bcl-2/adenovirus E1B 19 kDa-interacting protein 3 (BNIP3) in invasive duct cell carcinoma (IDC), we hypothesized in this article that impaired one-carbon metabolism might influence CIMP phenotype of BNIP3. In order to substantiate the prognostic relevance of BNIP3, we explored its association with 8-oxo-2'deoxyguanosine (8-oxodG), a marker of oxidative stress with prognostic relevance. BNIP3 expression and CIMP phenotype were studied using semi-quantitative RT-PCR and combined bisulfite restriction analysis (COBRA), respectively, in 56 IDC tumors. Eight polymorphisms in one-carbon metabolism were studied using PCR-RFLP and PCR-AFLP approaches. 8-oxodG was measured using competitive ELISA kit. BNIP3 was found to be upregulated in IDC (cases vs. controls: 0.94 ± 0.05 vs. 0.18 ± 0.08, P < 0.0001). COBRA analysis confirmed hypomethylation of BNIP3 promoter CpG island in these cases. CIMP phenotype of BNIP3 showed positive association with tubule formation (P = 0.034) and methionine synthase reductase (MTRR) A66G (P = 0.002); inverse association with cytosolic serine hydroxyl methyltransferase (cSHMT) C1420T (P < 0.005) and 8-oxodG (<10% vs. >10% methylation: 7.24 ± 2.77 ng/ml vs. 4.42 ± 2.93 ng/ml, P < 0.0005); and no association with nuclear pleomorphism or mitotic index or ER, PR, and HER statuses. Synergistic effect of MTR A2756G and MTRR A66G variants on BNIP3 hypermethylator phenotype was clearly evident (P < 0.0007). MTRR A66G and cSHMT C1420T polymorphisms influence CIMP phenotype of BNIP3, thus epigenetically regulating BNIP3 in breast cancer. The linear association between BNIP3 and 8-oxodG substantiates the role of BNIP3 as redox sensor as well as prognostic marker in breast cancer.