Stromal microenvironment namely angiogenesis, tumor-infiltrating lymphocytes, and matrix metalloproteinase in invasive breast carcinoma: Do they have a prognostic role?

Background: The role of stromal microenvironment in growth, invasiveness, and metastatic potential of breast carcinoma (BC) is being recognized increasingly, both to predict prognosis and as potential therapeutic targets. The present study aimed to evaluate the correlation of angiogenesis, tumor-associated lymphocytes, and stromal CD10 expression with clinicopathologic parameters. Materials and Methods: This study included 100 consecutive cases of invasive BC undergoing modified radical mastectomy. Relevant clinical details, pathological grade, lymph nodal status, and clinical stage were noted. Paraffin-embedded sections were subjected to immunohistochemistry for CD34, CD20, CD45RO, and CD10. Microvessel density (MVD), tumor-associated lymphocytes, and stromal CD10 expression were estimated from these sections. Statistical analysis was done using nonparametric tests to correlate the clinic-pathologic features with each of these parameters. Results: MVD was found to be significantly higher in Grade III, node-positive cases, and higher stage breast cancers (P < 0.05). The number of T-lymphocytes was higher in node-positive cases, while B-lymphocytes were lower in number in higher grade tumors. CD10 expression showed a significant positive association with tumor grade, nodal status, and stage (P < 0.05 for each). Conclusion: This study demonstrates that changes in stromal microenvironment of BC such as MVD, tumor-associated lymphocytes, and stromal CD10 expression correlate with the clinicopathological parameters and hence may be exploited as prognostic markers or therapeutic targets, based on further larger studies.

Primary cutaneous ewing's sarcoma/primitive neuroectodermal tumor: report of the first case diagnosed on aspiration cytology.

BACKGROUND: Extraskeletal Ewing's sarcoma (ES) was first recognized as a soft tissue tumor in 1975. Primacy cutaneous occurrence of Ewing's sarcoma/primitive neuroectodermnal tumor (ES/PNET) has been reported in only 31 cases so far. To the best of our knowledge, there is no report of preoperative cytologic diagnosis of cutaneous ES/PNET in the available literature except for this one. CASE: A young adult presented with a recurrent swelling on the medial aspect of the left leg that had been present for the past 5 years. Fine needle aspiration cytology yielded cellular smears showing a small round cell tumor. Immunostaining on cell block material showed positivity for CD99, S-100 protein and neuron-specific enolase. A cytologic diagnosis of primary cutaneous ES/PNET was made. Local excision was performed, and the patient was well after 2 years of follow-up. CONCLUSION: Primary cutaneous ES/PNET is a rare cutaneous tumor with a favorable clinical outcome. It can be diagnosed on cytology; however, immunocytochemistry is mandatory for differentiation from other small round cell tumors.

Cytodiagnosis of papillary carcinoma of the breast: Report of a case with histological correlation.

Papillary lesions of the breast pose diagnostic challenges on aspiration cytology due to overlapping features of benign and malignant entities. Accurate cytologic diagnosis of papillary breast carcinoma cannot usually be made pre-operatively. We present the case of an adult female who underwent fine-needle aspiration (FNA) of a left breast lump. FNA smears were highly cellular showing cohesive clusters, complex papillary fragments and few singly dispersed intact cells. The tumor cells had hyperchromatic nuclei, prominent nucleoli and mild nuclear pleomorphism. A cytologic impression of papillary lesion, possibly malignant (in view of high cellularity, complex papillae and single intact cells) was rendered. The lesion proved to be a papillary carcinoma with microscopic foci of stromal invasion on histologic examination. Papillary carcinoma, an uncommon subtype of breast carcinoma, should be considered while evaluating a papillary lesion with complex branching papillae containing delicate fibrovascular cores and singly lying intact atypical cells.

Coexisting iron deficiency anemia and Beta thalassemia trait: effect of iron therapy on red cell parameters and hemoglobin subtypes.

Background. Coexistence of iron deficiency anemia (IDA) and beta thalassemia trait (BTT) has been the topic of few studies. However, no study from our country was found evaluating the effect of iron therapy in patients with concomitant IDA and BTT. Methods. Over a period of two years, 30 patients with concomitant IDA and BTT were included. All the patients had a complete blood count, serum iron studies, and thalassemia screening using BIORADTM hemoglobin testing system. The patients received oral iron therapy in appropriate dosages for a period of twenty weeks, after which all the investigations were repeated. Appropriate statistical methods were applied for comparison of pre- and posttherapy data. Results. All except two patients were adults with a marked female preponderance. Oral iron therapy led to statistically significant improvement in hemoglobin, red cell indices (P < 0.05), and marked change in serum iron, ferritin, and HbA2 levels (P < 0.001). There was a significant reduction in the total iron binding capacity levels. Conclusion. The present study shows the frequent occurrence of iron deficiency anemia in patients with beta thalassemia trait, which can potentially confound the diagnosis of the latter. Hence, iron deficiency should be identified and rectified in patients with suspicion of beta thalassemia trait.

Detection of Abnormal Hemoglobin Variants by HPLC Method: Common Problems with Suggested Solutions.

Thalassemia and thalassemic hemoglobinopathies pose serious health problem leading to severe morbidity and mortality in Indian population. Plethora of hemoglobin variants is prevalent in multiethnic Indian population. The aim of the present study was to analyze laboratory aspects, namely, hematological profile and HPLC findings of the hemoglobin variants detected, and to discuss problems that we faced in diagnosis in a routine clinical laboratory. We screened a total of 4800 cases in a hospital based population of North India in a 2-years period of by automated HPLC method using the Variant Hemoglobin Testing System (Variant II Beta Thalassemia Short Program, Bio-Rad Laboratories) under the experimental conditions specified by the manufacturer. Whole blood in EDTA was used and red cell indices were determined using automated hematology analyzer. We detected 290 cases with abnormal variants in which beta thalassemia was the most common followed by hemoglobin E. Here, we discuss the laboratory aspects of various hemoglobin disorders and diagnostic difficulties in cases like borderline HbA2 values, presence of silent mutation, alpha thalassemia gene, and few rare variants which at times require correlation with genetic study. Special attention was given to HbA2 level even in presence of a structural variant to rule out coinheritance of beta thalassemia gene.

Fine needle aspiration cytology in diagnosis of salivary gland lesions: A study with histologic comparison.

OBJECTIVES: Fine needle aspiration cytology (FNAC) has been employed in pre-operative diagnosis of salivary gland lesions for many years. Various studies in the existing literature have shown a wide range of sensitivity and diagnostic accuracy of cytologic diagnosis. This study was aimed at evaluating salivary gland FNAC for sensitivity, specificity and diagnostic accuracy at a tertiary care center. MATERIALS AND METHODS: This study included 80 patients who underwent pre-operative FNAC followed by surgical procedure and histologic examination. The histologic diagnosis was considered as the gold standard. FNAC diagnosis was compared with the final histologic impression and concordance assessed. Sensitivity, specificity and diagnostic accuracy of FNAC for malignant lesions were calculated. RESULTS: Of the 80 cases, majority (67.5%) involved the parotid gland. Eight cases (10%) were non-neoplastic lesions, comprised of sialadenitis, retention cyst and sialadenosis. Of a total of 72 neoplasms, 58 were benign and 14 were malignant salivary gland tumors. A cyto-histologic concordance of benign diagnosis was achieved in 85.7% of cases and for malignant lesions in 92.8% of the malignant tumors. FNAC showed a sensitivity of 92.8%, specificity of 93.9%, a positive predictive value of 81.2% and negative predictive value of 98.4% for malignant salivary gland tumors. There was one false-negative diagnosis and four false-positive cases diagnosed on FNAC. CONCLUSION: FNAC continues to be a reliable diagnostic technique in hands of an experienced cytopathologist. The sensitivity of diagnosis of malignant lesions is high, though the rate of tumor type-specific characterization is lower, due to variable cytomorphology. In difficult cases, histologic examination may be employed for accurate diagnosis.

Impact of routine histopathological examination of gall bladder specimens on early detection of malignancy - a study of 4,115 cholecystectomy specimens.

Gall bladder carcinoma is the most common cancer of biliary tree, characterized by rapid progression and a very high mortality rate. Detection at an early stage, however, is indicative of a very good prognosis and prolonged survival. The practice of histopathological examination of gall bladder specimens removed for clinically benign conditions and its usefulness has been a subject of controversy. The present prospective study was carried out over a period of four years in order to find out the incidence of unsuspected gallbladder carcinoma in cholecystectomy specimens received in our histopathology laboratory and to analyze their clinico-pathological features. A total of 4,115 cases were examined. Incidentally detected cases comprised 0.44%, which accounted for 72% of all gall bladder carcinomas detected. The majority were in an early, surgically resectable stage. From the results of this study we recommend that in India and other countries with relatively high incidences of gall bladder carcinoma, all cholecystectomy specimens should be submitted to histopathology laboratory, as this is the only means by which malignancies can be detected at an early, potentially curable stage.

Seroprevalence and trend of dengue cases admitted to a government hospital, delhi - 5-year study (2006-2010): a look into the age shift.

BACKGROUND: Diagnosis of dengue infection is easily and best accomplished by demonstration of specific IgM antibodies in blood. We analyzed retrospectively the dengue IgM seropositivity available for samples obtained over a period of 5 years (2006-2010) from patients with suspected dengue fever (DF)-like illness to investigate whether there was an overall increase in the dengue IgM prevalence over this period. METHODS: Blood samples were collected from patients with DF-like febrile illnesses attending the Pediatric, Medicine, and Fever clinics of a Government hospital, Delhi. A total of 8138 individuals (suspected dengue cases) obtained over 5 years were tested for dengue specific IgM antibodies. Year wise, month wise, and age wise data on geographic distribution and clinical manifestations were analyzed. RESULTS: Of the 8138 samples, 1600 (19.66%) were positive for dengue specific IgM. The year 2006 had the highest number of reported cases, 761 (46.23%). In our study, the age group most commonly affected of all 5 years was 11-20 years. Out of the total 1600 cases admitted to the hospital between 2006 and 2010, 279 (58.9%) had DF, 178 (37.6%) had dengue hemorrhagic fever, and 16 (3.38%) had dengue shock syndrome. We found a high burden of dengue in young children and late adolescents in both rural and urban communities at a magnitude greater than previously described. INTERPRETATION AND CONCLUSION: We observed an increase in the dengue positive cases every alternate year, thereby indicating a possible role of herd immunity in northern India. We did not find a steady increase in the number of cases over 5 years. We found an increase in the number of positive cases in children and young adolescents.

Comparison of working formulation and REAL classification of non-Hodgkin's lymphoma: an analysis of 52 cases.

BACKGROUND: Several classification systems have been proposed for non-Hodgkin's lymphoma (NHL), of which Working Formulation (WF) and the recent Revised European American Lymphoma (REAL) classification are the two most widely used. There have been only a few studies comparing the two classification systems. The present study was undertaken in view of the paucity of literature comparing the foresaid classifications. METHODS: This retrospective and prospective study included 52 cases of NHL. These cases were examined thoroughly with the routine stains and immunohistochemistry using a panel comprising CD45, CD20, CD45RO, CD5, and CD30. All the cases were classified using the WF as well as the REAL classification, taking into account the immunohistochemical results. RESULTS: A wide age range and a slight male predominance were noted. The majority of cases were nodal, while 17% were extranodal. Using the WF, intermediate grade was the most common (65·38%), of which malignant lymphoma, diffuse large cell type and diffuse mixed small and large cell type were the two most frequent categories. On immunohistochemistry, 76·9% of the cases were B-cell immunophenotype. Of the various B-cell lymphomas, the most common was follicle center lymphoma and most common T-cell lymphoma was peripheral T-cell lymphoma. A comparison of the two classification systems revealed that T-cell neoplasms were grouped with B-cell lymphomas in the WF. CONCLUSION: Though REAL classification requires a detailed immunohistochemical panel for thorough classification of all cases, the use of a basic panel of B- and T-cell markers allows the distinction between B- and T-cell lymphomas. Hence, REAL classification should be employed for categorization of NHL even in smaller centers with limited immunohistochemical panel.

Cytodiagnosis and pitfalls of genital tuberculosis: A report of two cases.

Genital tuberculosis is fairly common in Indian women due to high prevalence of pulmonary tuberculosis in the general population. Histopathological diagnosis is invaluable but often, diagnosis can be made with reasonable accuracy by Papanicolaou (Pap) smear test if the index of suspicion is kept high. Also, genital tuberculosis is considered to be more common in patients less than 40 years of age and rare after menopause. We describe two cases of cervical tuberculosis in patients over 40 years of age, including a postmenopausal case, diagnosed by smear tests and later confirmed by histopathology and bacteriology. The differential diagnoses as well as problems encountered in the diagnosis of a tuberculous lesion in Pap smears are also discussed.

Significance of incidental detection of filariasis on aspiration smears: a case series.

Filariasis is a major public health problem in tropical and subtropical countries including India. Although there are reports of incidentally diagnosed cases of lymphatic filariasis in the existing literature, the significance of this finding needs to be summarised in one place. The association of filariasis with neoplasms is still debatable. For this series, cases diagnosed as filariasis on aspiration cytology (with or without coexistent pathology) over a period of 1 year were retrieved. The cases with a clinical suspicion of filariasis were excluded. Hence, five cases with incidental diagnosis of filariasis on aspiration cytology were included. The site of aspiration included one case each of thyroid, breast, bone marrow, cervical lymph node, and subcutaneous nodule. Of these, three cases showed microfilariae, one showed only adult female worm while one showed both microfilariae and adult worm. Two cases did not show any inflammatory response while three cases showed a variable inflammatory reaction. Only one case (thyroid aspirate) had a coexistent pathology (colloid goitre). Filariasis may be detected in a clinically unsuspected case, especially in an endemic zone. The spectrum of host response may vary from no reaction to a marked inflammatory response. The entire spectrum of changes should be kept in mind while practicing cytopathology in an endemic area. In such situations, a high index of suspicion and careful screening of cytology smears are keys to a correct diagnosis. At the same time, keen search for a coexisting pathology, benign or malignant, is also mandatory.

Nuclear morphometry and texture analysis of B-cell non-Hodgkin lymphoma: utility in subclassification on cytosmears.

Non-Hodgkin lymphoma (NHL) is a heterogeneous group of lymphoid neoplasms and accurate subclassification is an essential prerequisite for proper management of patients. This study was aimed at evaluating the utility of nuclear morphometry and textural features on cytology smears to classify the cases of NHL on aspiration cytology. Fine needle aspiration smears of 50 cases of B-cell NHL were included. Various morphometric and texture parameters were obtained by manually tracing the nuclei on digitized images in each case and discriminant analysis performed using various features taken individually as well as all together. The percentage of cells correctly classified to a particular NHL subtype using the discriminant functions so obtained was noted.Our results show that discriminant analysis done on size parameters could correctly classify a greater number of cells than on shape parameters (36.4% vs. 21.2%, respectively). Texture parameters based on single pixel values (first order texture) were inferior (42.8%) to those based on pair of pixels (58.7%) in subtyping of cells. Discriminant analysis based on color parameters was more effective (61.9%) as compared to rest of the morphometric and textural parameters. Using all the morphometric and textural parameters together, 83.3% of cells could be correctly classified to a particular NHL subtype.The present study, perhaps the first study of detailed morphometric analysis on cytosmears, shows that satisfactory classification of NHL on aspiration cytology is possible using nuclear morphometry and textural parameters considered together. These results are promising for further studies on this subject and development of automated cytodiagnosis.

Clear-cell hidradenoma in a child: a diagnostic dilemma for the cytopathologist.

Primary cutaneous tumors are infrequently subjected to fine needle aspiration cytology. As a result, the cytological reports of skin adnexal tumors like hidradenoma are scarce in the available literature. A young boy with a painless nodule on forehead underwent fine needle aspiration. The smears showed clusters of epithelial cells containing blue cytoplasm, some of which had vacuolated cytoplasm with mild nuclear pleomorphism and occasional larger hyperchromatic nucleus. The cytological features, in conjunction with the clinical examination, suggested a skin appendageal tumor. Though nuclear pleomorphism and occasional larger nucleus posed a cytological diagnostic challenge, a diagnosis of benign appendageal tumor was suggested, considering the young age of the patient. This was later confirmed as a clear-cell hidradenoma on excision biopsy. The cytopathologist should consider skin appendageal tumors during evaluation of cutaneous nodules. An accurate diagnosis requires a close clinico-pathologic correlation.

Lichen planus of uterine cervix - the first report of a novel site of occurrence: a case report.

INTRODUCTION: Lichen planus is an immune mediated inflammatory lesion involving skin and mucosal sites including oral mucosa, vulva and rarely vagina. Lichen planus occurring at mucosal sites has been shown to be associated with squamous cell carcinoma in a proportion of cases. To the best of our knowledge, no case of lichen planus of uterine cervix has been reported in the available literature. CASE PRESENTATION: A 45-year-old female underwent vaginal hysterectomy for uterine prolapse. The resected specimen showed a bluish-colored area in the non-dependent part of the ectocervix. Microscopic sections from this area showed dense lymphocytic infiltrate at the junction of mucosa and submucosa causing disruption of the basal cell layer. On immunohistochemical examination there was predominance of CD8+ T lymphocytes at the junction with scattered CD4+ T lymphocytes, characteristic of lichen planus. Based on the history and negative serum antibody titers, other differential diagnoses including lupus erythematosus and drug reaction were excluded. The patient did not have any cutaneous or oral lesions of lichen planus. CONCLUSION: Lichen planus of uterine cervix is a hitherto unreported entity, and is worth studying considering the premalignant potential of lichen planus at other mucosal sites.

Role of platelet volume indices in the differential diagnosis of thrombocytopenia: a simple and inexpensive method.

Thrombocytopenia may result from hypoproliferation in marrow, or peripheral destruction of platelets. Distinction between these two categories is usually made by bone marrow examination. Some studies in literature hint that platelet volume indices are differentially altered in various causes of thrombocytopenia. The present study was aimed at investigating the role of platelet volume indices in the differential diagnosis of thrombocytopenia. Sixty healthy controls and 60 patients (study group) with thrombocytopenia (platelet count < 150 x 10(9)/l) were included in the study. The study group was divided into two categories: hypoproliferative (megaloblastic and non-megaloblastic) and destructive thrombocytopenia. Clinical features, platelet counts and platelet indices were studied in both these categories, and statistical analysis was performed. Platelet counts in the three categories of thrombocytopenia were statistically not different. All the three platelet volume indices were significantly higher in megaloblastic group as compared to the non-megaloblastic hypoproliferative category. Platelet distribution width (PDW) was significantly different between destructive thrombocytopenia and non-megaloblastic hypoproliferative groups. In conclusion, we recommend the division of hypoproliferative category of thrombocytopenia into megaloblastic and non-megaloblastic types. Alterations in platelet indices, especially PDW can differentiate non-megaloblastic hypoproliferative category from both the destructive and megaloblastic thrombocytopenia category. These simple indices can be routinely used in the initial evaluation of a patient with thrombocytopenia.

Avascular necrosis of humeral head in an elderly patient with tuberculosis: a case report.

INTRODUCTION: Osteonecrosis (avascular necrosis) is known to be caused by high-dose corticosteroid therapy, alcoholism and rarely by infections. However, a tubercular etiology of this condition is very rare. A review of the literature yielded only a few cases of polyarticular tuberculosis with osteonecrosis in immunosuppressed individuals. No case of monoarticular tubercular osteonecrosis diagnosed by aspiration cytology was found. Since tuberculosis is a curable disease, an early and accurate diagnosis is essential. CASE PRESENTATION: A 60-year-old Indian man presented with diffuse swelling and pain in the left shoulder for the previous 6 months. A computed tomography scan of the left shoulder revealed crescentic lucency in the humeral head, suggestive of osteonecrosis. Fine needle aspiration cytology smears from the swelling showed features of an acute suppurative lesion. Stain for acid-fast bacillus was positive and thus, a final clinico-pathological diagnosis of osteonecrosis of humeral head with tubercular etiology was rendered. The patient was initiated on anti-tuberculous therapy with symptomatic improvement in his condition. CONCLUSION: Osteonecrosis, a debilitating disease, may rarely occur due to tuberculosis, especially in endemic areas. Fine needle aspiration cytology is an effective and inexpensive modality for an early diagnosis of the tubercular etiology of osteonecrosis.