Anila Sharma

Primary Hodgkin lymphoma of the ileum

Primary classical Hodgkin lymphomas of the gastrointestinal tract are rare lymphoproliferative neoplasms as against other well established mucosa-associated lymphoid tissue (MALT) lymphomas. The primary nature of these cases is established based on chest radiograph, computed axial tomography, positron emission tomography, peripheral blood and bone marrow biopsy examination. Here, we report a 79-year-old male patient, who presented to the emergency department with complaints of abdominal discomfort on right side and low grade fever. An ultrasonogram was performed which suggested of an intestinal perforation. An emergency laporotomy was done with resection of the ileal segment. The histomorphology of the resected ileal segment revealed features of classical Hodgkin lymphoma which were confirmed by immunohistochemistry. Epstein Barr virus encoded RNA (EBER) via in-situ hybridization was positive and provided substantial evidence of EBV etiology.

Immunohistochemical Profile of Breast Cancer Patients at a Tertiary Care Hospital in New Delhi, India

BACKGROUND To assess the immunohistochemical expression of estrogen receptor (ER), progesterone receptor (PgR) and human epidermal growth factor receptor-2 (HER2) neu receptor in breast cancer and their associations with various clinicopathological characteristics. MATERIALS AND METHODS This is a retrospective analysis of women who presented with primary, unilateral breast cancer in the Department of Medical Oncology at Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India during the period from January 2008 to December 2011. Data were retrieved from the medical records of the hospital including both early and locally advanced cancer cases. ER, PgR and HER2neu expression in these patients was assessed and triple negative patients were identified. Associations of triple negative and non-triple negative groups with clinicopathological characteristics were also evaluated. RESULTS A total of 1,284 women (mean age 52.1 years, 41.9% premenopausal) were included in the analysis. Hormone receptor positivity (ER and/or PgR) was seen in 63.4% patients, while 23.8% of tumors were triple negative. Only 23.0% were HER2 positive. Around 10.0% of tumors were both ER and HER2 positive. ER and PgR positivity was significantly associated with negative HER2 status (p-value<0.0001). Younger age, premenopausal status, higher tumor grade, lymph node negativity, advanced cancer stage, and type of tumor were strongly associated with triple negativity. Significantly, a smaller proportion of women had ductal carcinoma in situ in the triple negative group compared with the non-triple negative group (35.6% versus 60.8%, p-value<0.01). CONCLUSIONS The present analysis is one of the largest studies from India. The majority of the Indian breast cancer patients seen in our hospital present with ER and PgR positive tumors. The triple negative patients tended to be younger, premenopausal, and were associated with higher tumor grades, negative lymph nodes status and lower frequency of ductal carcinoma in situ.

Effect of Complexation of NaCl Salt with Polymer Blend (PEO/PVP) Electrolytes on Ionic Conductivity and Optical Energy Band Gaps

Sodium ion conducting polymer blend electrolyte films, based on polyethylene oxide (PEO) and poly vinyl pyrrolidone (PVP) complexed with NaCl salt, were prepared using solution casting technique. The complexation of the salt with the polymer blend was confirmed by X‐ray diffraction (XRD), Fourier transform infrared spectroscopy (FT‐IR) and UV‐vis spectroscopy. Frequency and temperature dependence of electrical conductivity of the films was studied with impedance analyzer in the frequency range of 1 Hz to 1 MHz and in the temperature range of 303–348 K. UV‐vis absorption spectra in wavelength region 200–800 nm, were used to evaluate the optical properties like direct and indirect optical energy band gaps, optical absorption edge. The optical band gaps decreased with the increase of Na+ ion concentration. This suggests that NaCl, as dopant, is a good choice to improve the electrical and optical properties of PEO/PVP polymer blend electrolytes.

Peri-ampullary collision tumor - high grade neuroendocrine carcinoma and signet ring cell carcinoma: A case report and review of literature

We report a case of 50-year-old male with obstructive jaundice diagnosed as peri-ampullary collision tumor comprising of large cell neuroendocrine carcinoma and signet ring cell carcinoma. The association of neuroendocrine (usually carcinoids) and adenocarcinoma is extremely uncommon with only few case reports available in the reported literature.

Unusual metastasis of medullary thyroid carcinoma to the breast: A cytological and histopathological correlation

Breast metastases are a relatively rare condition and account for approximately 0.5–2% of all breast tumors. Recognition of metastatic tumors in the breast is important because it would prevent unnecessary mutilating surgery and would lead to appropriate treatment of the primary tumor. Breast metastases from medullary thyroid cancer (MTC) are very rare with only 21 reported cases in the literature. Some MTCs mimic primary invasive lobular carcinoma of the breast histopathologically and radiologically, making the distinction between the two diagnostically challenging. We present the case of a 45-year-old female presenting with a lump breast, which was later found out to be metastasis from medullary carcinoma thyroid.

Florid Plasmacytosis in Angioimmunoblastic T Cell Lymphoma: A Diagnostic Conundrum

Angio-immunoblastic T-cell lymphoma (AITL) is a rare subtype of non-Hodgkins lymphoma (NHL), accounting for about 1–2% of all NHLs and 15–27% of peripheral T-cell lymphomas [1]. Most patients present with systemic lymphadenopathy, constitutional symptoms or abnormal immunological features. Abnormal laboratory test findings include cytopenias, positive Coomb’s test, polyclonal hypergammaglobulinemia, elevated LDH or presence of autoimmune antibodies. Circulating plasma cells and plasmacytoid lymphocytes have been occasionally detected in AITL patients. However, plasma cells[2 9 10 cells/ll mimicking plasma cell leukemia or exuberant reactive plasmacytosis in bone marrow in the order of [50% plasma cells including atypical forms is infrequently reported in AITL [2, 3]. We reviewed twelve cases of AITL reported in last 5 years at our institution. Bone marrow involvement by AITL was seen in one case (1/ 12 = 8.1%) while two cases (2/12 = 16.6%) revealed extensive bone marrow involvement by plasmacytes along with peripheral blood spillage, that led us to investigate for a coexisting myeloma or plasma cell leukemia. Case 1

Impact of 2013 ASCO/CAP HER2 reporting guidelines in breast cancer: An assessment study from Indian oncology centre that primarily performs HER2 IHC testing with special emphasis on IHC equivocal category

The ASCO/CAP guidelines for HER2 reporting in breast cancer published in 2007 and were updated in 2013 to assure that the right patient receives the targeted therapy. The updated guidelines have lowered the threshold for HER2 positivity criteria and altered the equivocal category for both IHC and FISH. This first study from India addresses the impact of these updated guidelines in the various reporting categories at a tertiary care centre. We compared the trend of HER2 IHC reporting 1 year before (Period A) and 1 year after (Period B) the implementation of updated 2013 ASCO/CAP guidelines. All HER2 equivocal IHC cases of post 2013 guidelines were reclassified as per 2007 guidelines to detect additional number of cases that have been put into equivocal category. Reflex FISH correlation was also assessed to detect any additional cases eligible for anti HER2 therapy with implementation of these updated guidelines. With implementation of updated 2013 guidelines, there was significant decrease in the number of cases scored as 1+ (from 30.7% to 20.6%; P value: .0001) while significant increase in number of 2+ cases (from 20.2% to 27.3%; P value: .004). Post 2013 guidelines, 39% (64 cases) of tumors were additionally put into the equivocal category which would have been considered as negative (score 1+) as per 2007 guidelines. The reflex FISH testing in these equivocal cases resulted in detection of only 1.5% of additional cases eligible for anti HER2 therapy. With implementation of updated 2013 guidelines, there is no significant increase in HER2 positivity trend. However, there is appreciable increase in IHC equivocal cases which subsequently led to increased reflex FISH testing without significantly contributing to the detection of additional eligible cases for anti HER2 therapy, but resulted in delaying of definite HER2 status along with financial implications.

Clinical Impact of Mismatch Repair Protein Testing on Outcome of Early Staged Colorectal Carcinomas

IntroductionColorectal cancer is the third most common cancer in men and second most common in women globally. In the present study, we aimed to analyse the proportion of patients with loss of immunostaining for mismatch repair (MMR) proteins in all newly diagnosed stage II cases of colorectal cancer for the purpose of prognostication, for determination of further chemotherapeutic strategy and for familial screening.MethodFrom January 2014 to December 2015, 62 consecutive newly diagnosed cases of stage II colorectal cancer were included in the study. Details of each patient related to their demographic profile and tumour profile were recorded. All the cases were grossed and staged according to College of American Pathologist (CAP) guidelines. The expression of MMR proteins (which was earlier validated on normal as well as tumour tissue) in FFPE tumour tissue using IHC for mut L homologue 1 (MLH1), mut S homologue 2 (MSH2), mut S homologue 6 (MSH6) and post-meiotic segregation increased 2 (PMS2) was studied. Information regarding stage, treatment, clinical outcome and overall survival was retrieved when available.ResultsOut of a total of 371 cases, 62 (16.7%) cases were of stage II CRC, out of which 43 (12%) were treatment naive. Among the selected 62 cases, 26 (41.9%) demonstrated loss of MMR proteins and 36 (58.0%) cases had intact nuclear expression. Out of the cases with MMR loss, 38.4% showed loss of MLH1 and PMS2, 30.7% showed loss of MSH2 and MSH6, 26.9% showed isolated loss of PMS2 and 3.8% showed isolated loss of MSH6. Right-sided location (57.6%) was more common than left-sided (19.2%) and transverse colon (23.0%). Majority of the cases were moderately differentiated (65.3%) in morphology. There was no intratumoural infiltrate in most of the cases (53.8%), and only 3.8% cases showed marked intratumoural infiltrate. Also, peritumoural lymphocytic infiltrate was mild to moderate in most of the cases (26.9%) and marked Crohn’s-like infiltrate was seen in only 7.6% cases.ConclusionOur study shows that the routine evaluation of MMR proteins is achievable and essential for the purpose of prognostication, planning of treatment strategies and ascertaining a hereditary basis of CRC. The incidence of MMR protein loss was quite high in our study compared to other studies probably due to a difference in ethnicity. Though a right-sided predominance was supported, none of the typical morphological features of microsatellite instability (MSI) tumours were substantiated by our study, highlighting the lack of importance of histology for predicting MSI, and emphasising the point that MSI testing should be done as a routine procedure in all stage II CRC. A short follow-up was done for all our cases and comparison between the survival of the chemotherapy treated MSI cases versus those which were treatment naïve was performed and revealed that chemotherapy (CT) did not provide additional benefit to survival; MSI tumours in general are a better prognostic category and do not require additional chemotherapy.

A study of the pathological outcome of positron emission tomography-computed tomography 2-(18F)-fluro-2-deoxy-D-glucose avid lesion: A 5 years retrospective study

INTRODUCTION Positron emission tomography-computed tomography (PET-CT) has been commonly used for staging and follow-up in cancer patients. The present study compares radiological and pathological outcomes at all the sites. The benign nonphysiological uptake reduces the specificity of the modality due to high false positive (FP) rate although sensitivity for malignant lesions may be high. AIMS AND OBJECTIVES To study the sensitivity, specificity, positive and negative predictive value (PPV and NPV) of PET-CT in the detection of malignant lesions for all sites using pathological and final clinical outcome. MATERIALS AND METHODS A retrospective study of 195 cases of PET-CT detected lesions subjected to pathological diagnosis in the form of fine-needle aspiration cytology (FNAC) and/or Tru-cut biopsies were performed on patients with proven or suspected malignancy over a period of 1-year (2009) with a 5 years follow-up. During the same period, 2900 PET-CT imaging studies were performed, of which 195 were suspected to be malignant or benign. Of these, 193 patients were subjected for tissue diagnosis for confirmation. FNAC smears and Tru-cut biopsy were prepared and examined as per standard protocols. RESULTS Of 195 aspirates in 183 aspirates, a conclusive tissue diagnosis was rendered. The follow-up was available in 79 cases of suspicious PET avid lesions for a period of 1-5 years. The PET-CT correlation with the tissue diagnosis and clinical outcome showed the sensitivity of 97.7% and an overall accuracy of 83% for malignant lesions. However, due to a large number of FP (n = 28) the specificity was only 43% and FP rates were 57%. PPV and NPV for malignant lesions was 82.4% and 87.5%, respectively. CONCLUSION PET-CT is a sensitive investigation for detection of malignant lesions in treated and newly diagnosed cases of malignancy.

Study of association of Epstein-Barr virus in lymphomas by Epstein-Barr virus-encoded RNA in situ hybridization: An Indian perspective from a tertiary care cancer institute

Background: The Epstein-Barr virus (EBV), also called human herpesvirus 4, is a virus of the herpes family. The EBV-associated lymphomas include Burkitt lymphoma, classic Hodgkin lymphoma (HL), lymphomas arising in immunocompromised individuals, peripheral T-cell lymphomas, angioimmunoblastic T-cell lymphoma, extranodal nasal-type natural killer/T-cell lymphoma, and other rare histotypes. Objective: The present study evaluated the role of EBV as an etiologic agent in various lymphomas and determined an Indian perspective in a tertiary care cancer center compared to that of Western literature. Materials and Methods: Clinicopathological spectrum was studied in 184 cases of lymphomas using a standard immunohistochemistry panel and in situ hybridization for Epstein-Barr virus-encoded RNA (EBER) expression. Results and Conclusions: The prevalence of EBV was described in various HL and non-HLs and was found similar to that of Western literature. EBER expression was also observed in the nonneoplastic bystander cells in the studied cases which need further evaluation on larger scale studies.