Ashish K. Mandal

Absence of human papillomavirus DNA in breast cancer as revealed by polymerase chain reaction

SummaryOncogenic human papillomavirus (HPV) types 16 and 18 commonly associated with cervical cancer are found in many epithelial malignancies at extra-genital sites including breast. The transforming gene products of HPV have also been shown to immortalize breast epithelial cellsin vitro. But the findings of HPV DNA in breast carcinoma are found to be contradictory. In the present study fine needle aspirate cell (FNAC) samples from 26 breast cancer patients and four breast tumour biopsies were analysed for the presence of HPV 16 and 18 DNA sequences by both polymerase chain reaction (PCR) and Southern blot hybridization. Of 26 fine needle aspi rate cell samples and four breast cancer biopsies, not a single sample was found to be positive by either PCR or Southern blot hybridization. The observation of complete absence of HPV DNA sequences in breast cancer refute the possibility of any role for oncogenic genital HPV types 16 and 18 in the pathogenesis of breast cancer.

Novel germline mutations in breast cancer susceptibility genes BRCA1, BRCA2 and p53 gene in breast cancer patients from India

Mutations in breast cancer susceptibility genes, BRCA1 and BRCA2 account for more than 80% of hereditary breast and ovarian cancers. p53 tumor suppressor gene that controls cellular growth and differentiation is also known to be mutated in more than 50% of human cancers including breast cancer. We have carried out a study on BRCA1 and BRCA2 along with p53 gene mutations in both sporadic as well as familial breast cancer patients from India where breast cancer is fast emerging as a major cancer among premenopausal urban women. We examined 124 untreated primary breast cancer patients comprising 100 sporadic and 24 familial cases including 56 age-matched healthy controls for the presence of BRCA1, BRCA2 and the p53 gene mutations using PCR-SSCP and direct nucleotide sequencing. Certain frequently mutated exons such as 2, 5, 11, 13 and 20 of BRCA1, exons 2, 9, 11 (for 6174delT), 18 and 20 of BRCA2 and 4–9 exons of p53 gene were analyzed in sporadic breast cancer while all 22 coding exons of BRCA1 including its flanking intronic regions along with above mentioned exons of BRCA2 and p53 gene were analyzed in familial breast cancer patients. We identified six patients (25%) with BRCA1 mutation of which three were found to be of novel type one in exon 16 (4956insG) and two in exon 7 (Lys110Thr) (Ser114Pro) out of 24 familial breast cancer patients studied from two different geographic regions/populations of India. Two sisters from a single family (12.5%) out of eight families from Goa with Portuguese colonial origin showed presence of founder Ashkenazi Jewish BRCA1 mutation (185delAG) along with (IVS7 561−34T>C; IVS18 527166G>A). While from New Delhi, four (25%) of 16 breast cancer families showed BRCA1 mutations; a frame shift protein truncating (4956insG), a transition nonsense (Gln1395Stop) and two amino acid substitutions (Lys110Thr) and (Ser114Pro). Only one (4%) p53 mutation (Val97Ile) in its exon 4 along with BRCA1 mutation (4956insG) could be detected. No major sequence variation in BRCA2 gene was observed except for G203A at 5′ UTR of exon 2, a common population polymorphism in two Goan patients who also showed silent nucleotide change for amino acid serine at codon 1436 of BRCA1 gene. None of the 100 sporadic breast cancer patients revealed any protein truncating or deleterious BRCA1 or BRCA2 gene mutation. Interestingly, three (3%) p53 mutations in its exon 5 were detected in sporadic breast cancer patients. Although three novel BRCA1 mutations including a founder Ashkenazi Jewish BRCA1 mutation were recorded in Indian women with familial breast cancer, the overall prevalence of BRCA gene mutations in Indian women with a family history of breast cancer appears to be low.

PREDICTIVE FACTORS FOR SUCCESSFUL EARLY LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS: A PROSPECTIVE STUDY

BACKGROUND Early laparoscopic cholecystectomy has become the treatment of choice for acute cholecystitis. However, the rate of intraoperative conversion to open surgery remains high and has provoked an interest in studying the predictive factors for better patient selection to minimize the conversion rates. MATERIALS AND METHODS 50 patients of acute cholecystitis were operated within 5 days of onset of symptoms. Comparative evaluation of the patient groups undergoing successful versus failed early laparoscopic cholecystectomy was done to identify preoperative factors predicting conversion/failure of the laparoscopic procedure. Predictive factors for intraoperative and histopathological severity of acute cholecystitis were also identified. RESULTS 40 patients underwent successful completion of early laparoscopic cholecystectomy, 8 required conversions to open, while in 2 patients the procedure had to be abandoned due to phlegmon formation. Male sex, preoperative duration of symptoms WBC counts, serum alkaline phosphatase, serum amylase, and serum C-reactive protein were significant predictors of histopathological severity of acute cholecystitis. Intraoperative and histopathological severity of acute cholecystitis had good association with conversion rate of early laparoscopic cholecystectomy. Male sex and serum C-reactive protein levels >3.6 mg/dl at admission were very strong predictors of conversion/failure of early laparoscopic cholecystectomy in acute cholecystitis. CONCLUSION Male patients of acute cholecystitis or patient with serum C-reactive protein levels of >3.6 mg/dl at admission have high risk of conversion in early laparoscopic cholecystectomy and warrant a conservative early management followed by delayed laparoscopic cholecystectomy.

Spindle cell carcinoma of head and neck: an immunohistochemical and molecular approach to its pathogenesis

Background: Spindle cell carcinoma (SpCC) is a rare microscopic type of cancer of the mouth and oropharynx. Although SpCC is thought to arise from squamous cell carcinoma (SCC), it carries a worse prognosis. Aim: To find out the difference in immunohistochemical expression of cytokeratin, vimentin and smooth-muscle actin, and mutational alterations in the K-ras oncogene between the two tumours, in an attempt to characterise SpCC. Methods: Immunohistochemical analysis was performed by standard avidin–biotin complex method in 35 cases each of SpCCs and SCCs. DNA extracted from paraffin wax-embedded tumours was used for PCR followed by single-strand conformation polymorphism for mutational analysis of K-ras exon 1 and exon 2. Results: In the SpCC group, cytokeratin positivity was significantly higher in epithelial areas (52.2%) than in spindle cell areas (16.1%), whereas vimentin was more positive in spindle cell areas (18.7%) than epithelial areas (2.7%). Cells intermediate between epithelial and spindle cell areas were consistently positive for both cytokeratin and vimentin. Cytokeratin was found to be significantly more positive in SCC (72.6%) than the squamous component and spindle cell component of SpCC. In this study, no mutation was detected in the K-ras gene of either the SpCC or SCC group. Conclusions: The spindle cell component of SpCC is intermixed with cells that are morphologically mesenchymal but express dual antigen-positivity characteristic of epithelial (cytokeratin) and mesenchymal (vimentin) cells. These, possibly, are cells in transition suggesting that SpCC may be a sarcomatous metaplasia of SCC.

Solitary Nodular Goiter

OBJECTIVE To study the cytomorphologic features of solitary nodular goiters (SNG). STUDY DESIGN May-Grunwald-Giemsa-stained smears in 441 SNG diagnosed by ultrasonography and fine needle aspiration (FNA) and found to have optimum cellular material at review were subjected to detailed cytologic assessment. The age of the patients ranged from 11 to 75 years, with a median of 35. Male: female ratio was 69:372. The parameters for cytologic assessment included cellularity, colloid content, acinar formation, papillary formation, intranuclear cytoplasmic inclusions, nuclear grooves, marginal vacuoles, Hurthle cells and various inflammatory cells. Histopathology reports on thyroidectomy specimens were available in 27 cases from two Delhi hospitals. RESULTS Hyperplastic nodules (68 cases) differed significantly from colloid goiters (269 cases) by having more cases with excessive cellularity, acinar formation and marginal vacuoles (P < .001). There was also a significant difference with respect to papillary formation and moderate-to-excessive colloid content (P < .001). As compared to hyperplastic nodules, neoplasms (60 cases) had a significantly higher number of cases with papillary formation, intranuclear inclusions and nuclear grooves but lower number of cases with marginal vacuoles (P < .01-.001). Among neoplasms, usual papillary carcinoma (19 cases) differed from follicular neoplasms (20 cases) with respect to acinar formation, papillary formation and nuclear grooves (P < .001). A significant difference was also observed with respect to colloid content and nuclear inclusions. Follicular variant of papillary carcinomas (FVPC) (10 cases) emerged as a distinct cytologic entity following review and differed from usual papillary carcinomas in having a higher number of cases with acinar formation, tubular formation and marginal vacuoles (P < .01-.001) and lower number of cases with nuclear grooves (P = .05). FVPC also differed from follicular neoplasms with respect to papillary formation, tubular formation, intranuclear inclusions and nuclear grooves (P < .01-.001). Overall cytohistologic agreement was achieved in 24 of 27 (88.9%) cases. CONCLUSION Detailed cytologic assessment of FNA smears-in SNG was helpful in highlighting parameters that differentiate between various types of goiters.

Clinico-pathological profile of 12 cases of chorangiosis

Chorangiosis is one of the vascular lesions that involvs terminal chorionic villi. It is commonly associated with various feto-maternal conditions like pre-eclampsia, diabetes etc. However, the clinical significance of this pathological finding has not been studied extensively. The aim of this study was to identify the various conditions associated with chorangiosis and to determine its clinical significance. A retrospective study to identify the cases of placentas diagnosed with chorangiosis was carried out and the clinical and morphological details of these cases were reviewed. Immunostaining for CD34 and muscle-specific actin was also performed to confirm chorangiosis and to exclude chorangiomatosis.A total of 12 cases of chorangiosis were retrieved, most of them were of term gestation. Five of these 12 cases were associated with various maternal conditions including syphilis (2 cases) and single cases of pre-eclampsia, diabetes and jaundice. One case in each had abruptio placenta and non-immune hydrops. Of these 12 cases, seven were stillborn. Microscopically, all 12 cases showed extensive chorangiosis involving terminal villi. In addition, two cases showed focal infarction and one had extensive calcification. Immunostaining for CD34 confirmed increased number of capillaries while muscle-specific actin was negative, excluding chorangiomatosis.The clinico-pathological profile presented in this study suggests that chorangiosis has characteristic pathological features for its recognition and needs to be differentiated from similar conditions like chorangioma and chorangiomatosis. Also, chorangiosis has potential clinical significance and should be mentioned in the pathology report and the patient should be investigated for associated conditions like syphilis, pre-eclampsia, diabetes etc.

Oral Leiomyosarcoma in Childhood

BACKGROUND: Leiomyosarcomas are rare tumors in the pediatric age group, and occurrence of this neoplasm in the oral cavity is exceedingly rare. This article highlights the fine needle aspiration (FNA) cytology diagnosis of a case of recurrent oral leiomyosarcoma in childhood. CASE: An 11-year-old male noticed a swelling in the oral cavity near the left lower jaw. It was excised and diagnosed as leiomyosarcoma on histopathology. Four months later the patient presented with a progressive swelling in the oral cavity that extended to the lower jaw. The recurrent swelling was subjected to FNA, and its cytologic features were consistent with leiomyosarcoma. There was a very good initial response to chemotherapy and radiation therapy. However, because of noncompliance with advice for further therapy, the patient had a second local recurrence and dissemination of the disease to the skeletal system, abdomen and thorax. FNA cytology diagnosis of the second locally recurrent lesion and abdominal mass were consistent with leiomyosarcoma. Immunocytochemical staining revealed a positive reaction in the cytoplasm of tumor cells for vimentin and desmin in the FNA smear and paraffin section, respectively. CONCLUSION: Fine needle aspiration cytology is a useful technique for detection of recurrence and metastasis during follow-up of childhood oral leiomyosarcoma.

Malignant fibrous histiocytoma following radiation therapy and chemotherapy for Hodgkin's lymphoma.

Malignant fibrous histiocytoma (MFH) originates from primitive mesenchymal cells and has the capacity for dual differentiation into histiocytes and fibroblasts. MFH occurring as a secondary malignancy following radio-chemotherapy is rare and its exact incidence is not yet known. Here we report a case of a 42-year-old man who developed MFH in his right knee over a period of more than 10 years after radio (44 Gy)-chemotherapy to treat Hodgkins lymphoma. After the diagnosis the patient did not return and was lost to follow-up. This is a rare case with unusual presentation, and it highlights the importance of the awareness and prevention of such secondary tumors.

S-100 as a useful auxiliary diagnostic aid in tuberculoid leprosy

Background:  The diagnosis of tuberculoid leprosy is often difficult on hematoxylin and eosin (H&E) due to the absence of demonstrable nerve destruction. This study evaluates the utility of S‐100 staining in identifying nerve fragmentation and differentiation of tuberculoid leprosy from other cutaneous granulomatous diseases.

Pilomatrixoma: a potential diagnostic pitfall in aspiration cytology

Dear Editor, In 1880, Malherbe & Chenantais described a benign skin tumour, Calcifying epithelioma of sebaceous gland . It is now clear that it shows differentiation towards hair matrix cells and hence is known as pilomatrixoma . Although the usual cytological features of pilomatrixoma are known, situations leading to mistaken diagnosis on aspiration cytology arise very often and these have therapeutic implications for the patient. We present the case of a 1-year-old child with a swelling in the neck, diagnosed as non-lymphomatous small round cell tumour, possibly rhabdomyosarcoma on cytology, which turned out to be a pilomatrixoma on excision biopsy. The cytological features along with recommendations for cytological diagnosis of pilomatrixoma are discussed.