Alok Dixit

Fine-needle aspiration of the thyroid: A cytohistologic correlation with critical evaluation of discordant cases

Background: There is some gray zone of thyroid cytology, where the diagnostic efficacy declines sharply rendering it difficult to exactly categorize the lesion resulting in discrepancy. The aim of the study is to assess the accuracy of fine needle aspiration of the thyroid and critically evaluate the cytohistological discordant cases. Materials and Methods: A total of 447 patients with thyroid swelling were aspirated during a seven-year study period. Cases showing cytohistologic disparity were reevaluated for the detection of possible causes of failure. Results: In our study, cytohistologic concordance was achieved in 80.28% of the cases. Of the discordant cases, false positives accounted for 11.60% and false negatives for 9.8%. Suboptimal material and underdiagnosis of papillary carcinoma due to cystic degeneration were recognized as common pitfalls. Too much emphasis on cellularity and architectural pattern led to the erroneous false positive diagnoses. Conclusion: Strict adherence to adequacy criterion and meticulous examination of all the smears are of paramount importance in reducing discrepant cases.

Current scenario of attitude and knowledge of physicians about rational prescription: A novel cross-sectional study

Background: In the last 30 years concepts in pharmacology have moved from Essential Medicines (EM) to P-drugs via the Rational Use of Medicines (RUM), but no structured study has evaluated the level of understanding among the working clinicians about these concepts. Aim: The present study was designed to assess the attitude and knowledge of clinical practitioners about the concepts of RUM, EM, P-drugs, and sources of drug-information, across North India. Materials and Methods: A cross-sectional study was carried out in and around the teaching hospitals attached to Medical Colleges, enrolling 504 clinicians from six centers across North India to fill-up a questionnaire containing 25 questions. Statistical Analysis: The results were compiled using percentages and averages. Univariate analysis, which explores each variable in a data set separately, was carried out by using the Fishers exact test. Results: Only one-fourth of the participants claimed that they always prescribed Essential Medicine; no one could correctly count the number of drugs / drug combinations in the Indian Essential Drug list; only 15.1% of the clinicians wrote the generic names of drugs on the prescription slip; about one-third of clinicians were not fully aware about the adverse effects, drug interactions, and contraindications of the drugs they prescribed; about 83% of physicians admitted to relying on information from Medical Representatives and an interest in research activities seemed to be lost. Conclusion: Results show a sorry state of affairs among clinicians, as far as the level of understanding about EM, P-drugs, and RUM is concerned, and it points toward arranging more continuing medical education (CME) for clinicians with regard to these concepts.

Cytological features of malignant eccrine acrospiroma presenting as a soft tissue mass axilla: A rare sweat gland tumor with histologic correlation

Malignant eccrine acrospiroma is an infrequent, highly malignant primary skin tumor derived from eccrine sweat glands. Though fine-needle aspiration cytology (FNAC) is a well-established diagnostic tool, but if a skin adnexal tumor or primary skin lesion is suspected clinically, the usual approach is biopsy due to easy accessibility. Being itself rare, cytologic features of this lesion is hardly encountered in case reports. As a result, very little is known about the appearance of adnexal tumors like malignant eccrine acrospiroma on fine-needle aspiration samples. A 50-year-old man presented with swelling in the left axilla, clinically suspected to be a soft tissue sarcoma. Fine-needle aspiration was advised, and a cytological diagnosis of malignant eccrine acrospiroma was rendered which was later confirmed on histological examination. Rapid, accurate diagnosis of these tumors is imperative as they have very poor prognosis and an aggressive course with recurrence and/or metastasis. FNAC plays a decisive and easy diagnostic modality in these unusual, rare cases of highly malignant primary skin tumor, and awareness of the lesions is indispensable in their management.

A Comparative and Evaluative Study of Two Cytological Grading Systems in Breast Carcinoma with Histological Grading: An Important Prognostic Factor

Objective. Cytonuclear gradings in the breast carcinoma raise the level of FNA reportage and improves patient management. Our aim was to evaluate and compare two cytological grading methods (Robinsons and Mouriquands) in breast carcinoma and correlate it with Nottingham modification of Scarff-Bloom-Richardson (SBR) histological grading. Materials and Methods. 30 cytologically proven cases of infiltrating ductal carcinoma were graded cytologically and histologically. Cytograding was done by Robinsons and Mouriquands methods (grades I to III) followed by comparison of the two methods. Cytogradings were correlated with SBR grading method. Sensitivity, specificity, diagnostic accuracy, and concordance and discordance rates were evaluated. Results. An overall concordance of 76.66% between cytogradings, of 83.33% between Robinsons method and SBR, and of 66.66% between Mouriquands method and SBR was seen. Robinsons method correlated best with SBR in all the three nuclear grades. Robinsons method showed a diagnostic accuracy of 90% with 91.30% sensitivity while Mouriquands method had an accuracy of 76.66% with 95.65% sensitivity. The specificity by Mouriquands method was quite low (14.28%) as compared to Robinsons method (85.71%). Conclusion. Comprehensive cytological grading of breast cancer by Robinsons method seems better because of more objective set of criteria, easy reproducibility, and specificity.

Oral Brush Liquid-Based Cytology: A Study of Concordance between a Cytotechnologist and a Cytopathologist

Objective: Oral cancer accounts for almost 40% of all cancers in the Indian subcontinent. Techniques like oral scrape cytology are helpful in early diagnosis of premalignant lesion and thus prevention of malignant transformation. The purpose of this study is to evaluate the performance of cytotechnologists in assessing the adequacy and preliminary diagnostic accuracy of oral brush liquid-based cytology. Study Design: 110 oral brush liquid-based cytology smears were prospectively screened by a cytotechnologist for adequacy assessment, and a preliminary diagnosis was recorded. Smears were subsequently studied by the reporting cytopathologist for the final diagnosis. The performance of the cytotechnologist in the assessment of adequacy and the preliminary diagnosis were compared with the final interpretation rendered by the cytopathologist. Results: There was no significant difference in adequacy assessment between both observers, and good concordance was observed in the identification of frankly malignant lesions; however, in premalignant cases, complete agreement in all the cases was not observed. Maximum numbers of discrepant cases were seen in high-grade squamous intraepithelial lesions, 4/17 were downgraded to low-grade squamous intraepithelial lesions and 2/17 to negative for intraepithelial lesion or malignancy, respectively. Conclusion: Trained cytotechnologists are capable of assessing the adequacy and identifying the malignancy in oral brush liquid-based cytology smears, and hence there is potential for them to perform initial screening of such cases.

Assessment of Awareness among Clinicians about Concepts in Undergraduate Pharmacology Curriculum: A Novel Crosssectional Study

Objective: In the last 30 years, concepts in pharmacology have moved from Essential Medicines (EM) to P-drugs via the Rational Use of Medicines (RUM), but no structured study has evaluated the level of understanding among working clinicians about these concepts. The present study is designed to fulfill that lacuna. Materials and Methods: A cross-sectional study was carried out in and around the teaching hospitals attached to Medical Colleges, enrolling 504 clinicians from six centers across North India to fill-up a questionnaire containing 25 questions. The results were compiled using percentages and averages. Results: Only one-fourth of the participants claimed that they always prescribed Essential Medicines; no one could accurately count the number of drugs / drug combinations in the Indian Essential Drug list; only 15.1% of the clinicians used to write the generic names of drugs on a prescription slip; about one-third of the clinicians were not fully aware about the adverse effects, drug interactions, and contraindications of the drugs they prescribed; about 83% of the physicians admitted to rely on information from Medical Representatives (MRs) and the interest in research activities seemed to be lost. Conclusion: Results show a sorry state of affairs among clinicians, as far as the level of understanding about EM, P-drugs, and RUM is concerned, and points toward arranging more continuing medical education (CME) for clinicians regarding these concepts.

Cytological diagnosis of bancroftian filariasis presented as a subcutaneous swelling in the cubital fossa: an unusual presentation

Filariasis is a disabling parasitic disease and the prevalence of lymphatic filariasis caused by Wuchereria bancrofti is quite high in India. However, W. bancrofti presenting as a subcutaneous swelling and a demonstration of microfilariae in cytological smears from upper extremity lesions is extremely rare. We report a case of 20-year-old male who presented with a small subcutaneous swelling near medial aspect of the left cubital fossa. The wet mount preparation showed many motile microfilariae. Cytology smears revealed a large number of sheathed microfilariae with the tail tip free of nucleus, identified as W. bancrofti without significant inflammatory cell infiltrate. Indirect ELISA was highly positive for specific recombinant W. bancrofti filarial antigen (WL-L2). The role of cytology cannot be underestimated in clinically unanticipated cases of bancroftian filariasis, especially with the amicrofilaremic state. Filariasis should always be considered in the differential diagnosis during cytological evaluation of any swelling, especially in endemic areas.

Infiltrating ductal carcinoma breast, metastatic to ipsilateral axillary lymph nodes harbouring primary tuberculous lymphadenitis: a case report

The coexistence of breast cancer and tuberculosis has been described in over 100 cases; however its coexistence in the axillary lymph node is rare with only a handful cases have been reported in the literature. We report a case of infiltrating ductal carcinoma of the left breast, metastatic to ipsilateral axillary lymph nodes harbouring tuberculous lymphadenitis without primary mammary or pulmonary tuberculosis. The case is presented for its rarity and illustrates that the simultaneous occurrence of tuberculosis and carcinoma can create a dilemma in the diagnosis and treatment, so surgeons and pathologists should keep such a combination on the back of their mind, especially in endemic areas.

A comparative study to evaluate liquid dish washing soap as an alternative to xylene and alcohol in deparaffinization and hematoxylin and eosin staining.

Introduction: Our study presents a new deparaffinizing and hematoxylin and eosin (H and E) staining method that involves the use of easily available, nontoxic and eco-friendly liquid diluted dish washing soap (DWS) by completely eliminating expensive and hazardous xylene and alcohol from deparaffinizing and rehydration prior to staining, staining and from dehydration prior to mounting. The aim was to evaluate and compare the quality of liquid DWS treated xylene and alcohol free (XAF) sections with that of the conventional H and E sections. Materials and Methods: A total of 100 paraffin embedded tissue blocks from different tissues were included. From each tissue block, one section was stained with conventional H and E (normal sections) and the other with XAF H and E (soapy sections) staining method. Slides were scored using five parameters: Nuclear, cytoplasmic, clarity, uniformity, and crispness of staining. Z-test was used for statistical analysis. Results: Soapy sections scored better for cytoplasmic (90%) and crisp staining (95%) with a statistically significant difference. Whereas for uniformity of staining, normal sections (88%) scored over soapy sections (72%) (Z = 2.82, P < 0.05). For nuclear (90%) and clarity of staining (90%) total scored favored soapy sections, but the difference was not statistically significant. About 84% normal sections stained adequately for diagnosis when compared with 86% in soapy sections (Z = 0.396, P > 0.05). Conclusion: Liquid DWS is a safe and efficient alternative to xylene and alcohol in deparaffinization and routine H and E staining procedure. We are documenting this project that can be used as a model for other histology laboratories.

Xanthogranulomatous Cholecystitis: A Clinical and Histopathologic Study of 33 Cases from a Tertiary Care Center

Objective: Xanthogranulomatous cholecystitis (XGC) is a rare but recognized variant of chronic cholecystitis, characterized by severe proliferation of fibrous tissue and accumulation of lipid-laden macrophages in areas of destructive inflammation. It is significant as clinico-radiologically it can be confused with the prognostically far more serious condition of carcinoma of the gallbladder. The aim was to evaluate the clinicopathological, pre- and intraoperative findings of XGC and also correlate the mucosal response of XGC with various gallstone parameters. Materials and Methods: In this retrospective 6-year study, 33 XGC (24 women and 9 men; mean age, 48.2 years) cases from 630 cholecystectomies were studied. Results: Cholelithiasis and a thickened gallbladder wall were the most frequent findings both radiologically and intraoperatively. Grossly the gallbladders were normal sized, fibrosed, or enlarged. Xanthogranulomatous nodules were yellowish, single, or multiple, raised above the surface, irregular, and frequently involved the fundus and body (24 cases). A combined stone was a common association (26 cases), mostly solitary and large (≥1 cm). Microscopically, in 24 cases, xanthogranulomatous foci were centered around Rokitansky– Aschoff sinuses and confined to the gallbladder wall, whereas larger diffuse destructive tumor-like masses occupied the full thickness of the gallbladder wall (9 cases) with variable extension into the adjacent fat, connective tissue, and surrounding structures, mainly liver. In four patients, carcinoma of the gallbladder could not be excluded either radiologically or intraoperatively, and were definitively diagnosed histologically as XGC. Conclusions: The correct diagnosis of XGC remains a challenge in medical practice and definitive diagnosis depends exclusively on histopathologic examination. Our study was an effort to contribute toward better understanding of this histopathologic entity.