Charu Agarwal

Parathyroid lesions: Difficult diagnosis on cytology.

Cytology of parathyroid lesion (PL) is often confused with that of thyroid lesions. Differentiation between thyroid and PL is very difficult on cytomorphology because of their similar features and close anatomical proximity. Three cases of PLs reported on cytology in last one year were retrieved from archives of cytology department. Their cytomorphological details were studied and were correlated with the available biochemical parameters. Histopathology was available in two cases. Radiological assistance and parathyroid hormone (PTH) assessment in our cases formed the basis of diagnosing PLs on cytology. We discuss the differential diagnosis and pitfalls in cytological diagnosis of PLs. However, histopathology remains the gold standard for diagnosis. Interpretation of PLs on cytology remains problematic due to its rarity and limited available literature. The cytomorphology combined with clinical and biochemical data supported by histopathology are necessary to improve the diagnostic sensitivity of PLs. Diagn. Cytopathol. 2016;44:704–709.

A rare tumor of salivary gland: Diagnostic Dilemma on fine needle aspiration cytology

Salivary gland cytopathology is a diagnostically challenging area with overlapping cytomorphological features between benign, malignant, and metastatic tumors. We report the case of 45-year-old male who presented with two swellings in right retroauricular and infraauricular region along with a palpable single right cervical lymph node. On ultrasonography of the neck, a possibility of malignant lesion was given. Contrast enhanced computed tomography of the head showed a large well-defined space occupying lesion in right temporooccipital region eroding the skull bone with both extra and intracranial extension. Fine needle aspiration was performed from both swellings and cervical lymph node. Based on cytological features and clinicoradiological examination, a possibility of metastasis from epithelial malignancy (adenocarcinoma) was suggested. The retroauricular region swelling was excised, and a diagnosis of salivary duct carcinoma was given on histopathology. In this article, we discuss the diverse presentation, cytomorphological features, and differential diagnosis of this rare salivary gland tumor.

Apocrine carcinoma of breast: A rare entity posing cytological challenge

Dear Sir, Fine Needle Aspiration Cytology (FNAC) is an important and primary screening tool for all breast lumps with high level of sensitivity and specificity. Diagnosing Apocrine Carcinoma (AC) on FNAC is very challenging on account of various mimickers like apocrine cyst, apocrine metaplasia, apocrine adenoma, apocrine carcinoma in situ, and oncocytic carcinoma. We report a case of 57 years old female who presented with a hard painful ill-defined lump in left breast in upper inner quadrant of 5 3 4 cm size present since 1 year. Nipple areola complex was normal with no discharge. No axillary lymph nodes were palpable. Other breast was unremarkable. FNAC smears showed high cellularity comprising of tumor cells arranged in sheets, clusters and singly scattered (Figure 1A). Cells showed moderate to marked pleomorphism with high N:C ratio, large nuclei with coarse chromatin, prominent nucleoli, and intranuclear inclusions in some and moderate amount of granular cytoplasm (Figure 1B and inset). Few binucleated, multinucleated, and bizarre cells along with tumor giant cells were also noted. An impression of Duct Carcinoma of breast was given and a possibility of apocrine carcinoma was suggested. Left modified radical mastectomy with axillary dissection was performed. On serial sectioning, a greyish white tumor measuring 5.5 3 3.5 3 3 cm was seen. Hematoxylin and eosin stained sections showed tumor cells predominantly arranged in a tubular pattern with hobnailing and apical snouting at places (Figure 2). These cells had moderate to abundant granular cytoplasm with nuclei showing marked pleomorphism, coarsely granular chromatin, prominent nucleoli, and intranuclear inclusions in some (Figure 3). High mitotic activity of 12– 13/10 HPF was seen. All the margins were free of tumor. There was no lymphovascular invasion. PAS positive diastase resistant mucoid material was seen at luminal surface of tumor. A final diagnosis of Apocrine Carcinoma, Modified Bloom Richardson’s Grade III was given. Immunohistochemistry for ER and PR came out to be negative while Her2neu was positive (31; Figure 3 inset, A). Focal cytoplasmic positivity was noticed for GCDFP-15 (Figure 3 inset, B) and Androgen receptor (AR). Breast apocrine cells have large vesicular nuclei with prominent nucleoli, abundant eosinophilic cytoplasm with apical snouting at places that are shed into the lumen of the ducts. Presently, very little is known about the molecular mechanisms underlying apocrine metaplasia. Malignant transformation of apocrine epithelium was first described by Krompecher in 1916. The major diagnostic pitfall is to differentiate AC from benign apocrine metaplastic lesions. The cell borders in AC tend to be ragged and indistinct in contrast to the well-defined borders of

Are all granulomatous mastitis cases tuberculous?: a study on the role of cytology in evaluation of granulomatous mastitis

OBJECTIVE Granulomatous mastitis is a rare inflammatory condition of the breast clinically mimicking breast carcinoma and pyogenic abscess, thereby creating a diagnostic dilemma. Tuberculous mastitis is a rare clinical entity accounting for approximately 3% of all mammary lesions. All cases of granulomatous mastitis diagnosed cytologically over a period of 3 years were evaluated to ascertain the cases with tuberculous etiology. MATERIAL AND METHOD Fine needle aspiration cytology of the breast lump was performed and all the cytological parameters were evaluated. Wherever histopathology was available, the diagnosis was confirmed on Hematoxylin & Eosin stained sections and the Ziehl Neelsen (ZN) stain was applied. RESULTS A total of 10 cases of granulomatous mastitis were diagnosed on cytology during the 3-year period. On cytological smears, four cases showed presence of ill-formed granulomas and one case had scattered epithelioid histiocytes; however, the rest of the cases had well-formed granulomas. Finally, four out of ten cases were labeled as tuberculous mastitis based on the ZN stain/Tuberculosis-Polymerase chain reaction (TB-PCR) and the other six cases were granulomatous mastitis. CONCLUSION Cytology plays a significant role in the diagnosis of granulomatous mastitis. This study re-emphasizes the role of the cytopathologist in the accurate and early diagnosis of these lesions so that unnecessary surgery can be avoided, and also highlights the fact that all granulomatous mastitis cases are not tuberculous.

Platelet parameters: Can they serve as biomarkers of glycemic control or development of complications in evaluation of type 2 diabetes mellitus?

Background: Platelet function plays a crucial pathophysiological role in the development of atherothrombosis in patients with type 2 diabetes mellitus (DM). Platelet count (PC) and mean platelet volume (MPV) are simple, effective, and cheap tests that may be used to predict angiopathy in type 2 DM. Objectives: The aims of this study were to analyze various platelet parameters including PC, plateletcrit (total mass of platelets) (PCT), and mean platelet indices that are MPV, platelet distribution width (PDW), and platelet-large cell ratio (PLCR) in the type 2 DM patients, to compare various platelet indices between DM patients (with and without complications) and controls. Materials and Methods: This was a cross-sectional study conducted over a period of 3 months. Complete blood count along with blood glucose and HbA1c was estimated. The study population was divided into three groups: Group 1: Normal controls (n = 30); Group 2: DM patients without complications (n = 30); and Group 3: DM patients with complications (n = 30). Based on HbA1c levels among the diabetic patients, the diabetic groups were also classified as DM with HbA1c <7% and DM with HbA1c >7%. Results: All the platelet parameters were found to be higher among DM with complication as compared to DM without complication, and this was found to be statistically significant. Among the platelet parameters, MPV, PCT, and PDW were found to be higher among DM with HbA1c >7% as compared to DM with HbA1c <7%, and this was found to be statistically significant while there was no significant differences in PC and PLCR between the two groups. Conclusion: Monitoring of DM to prevent the occurrence of vascular complications is the need of the hour. The results of the study suggest a role of various platelet indices as a simple and cost-effective tool to monitor the progression and control of DM.

Basaloid Squamous Cell Carcinoma of Tonsil: an Unusual and Aggressive Variant

BSCC is an unusual and aggressive variant of squamous cell carcinoma (SCC) [1, 2]. It was first described byWain et al. in 1986 [3]. The upper aerodigestive tract is the most common site with incidence in decreasing order being tongue followed by hypopharynx and supraglottic larynx. However, tonsil is an uncommon and a rare site of BSCC [4]., About 170 cases of BSCC have been found to be reported in the head and neck region, while only 14 have been reported in the tonsil worldwide till date [5]. Males in the age group of 60 to 80 years are more commonly affected [6]. The close association between basaloid and squamous component is the histopathological characteristics of tumour.

Association of coagulation profile with microvascular complications and glycemic control in type 2 diabetes mellitus – a study at a tertiary care center in Delhi

Introduction Type 2 diabetes mellitus, characterized by insulin resistance, corresponds to approximately 90% of cases of diabetes worldwide. Hyperglycemia in diabetes contributes to hyperfibrinogenemia and activates the coagulation cascade thereby producing atherothrombotic events. Objectives This study was designed to evaluate the coagulation profile (activated partial thromboplastin time, prothrombin time and fibrinogen) in Type 2 diabetes and to analyze correlations between body mass index, fasting blood glucose, glycated hemoglobin and duration of diabetes with coagulation parameters. Methods This study included 60 type 2 diabetics and 30 controls. Diabetic patients were grouped in two sets based on the presence or absence of microvascular complications. The demographic profile and clinical details were recorded. Fasting blood glucose, glycated hemoglobin, coagulation parameters such as prothrombin time, activated partial thromboplastin time and fibrinogen along with other biochemical parameters were investigated. Results There were statistically significant differences in the coagulation parameters between the two groups of diabetics (with and without complications). The present study also found significant correlations between age and the duration of diabetes with and without complications and coagulation parameters such as the activated partial thromboplastin time, which was found to be significantly lower, and fibrinogen, which was found to be significantly higher in subjects with complications compared to subjects without complications. Conclusion Clinical tests for prothrombin time, activated partial thromboplastin time and fibrinogen are relatively inexpensive and readily available. The present study shows that shortened prothrombin time, activated partial thromboplastin time and increased fibrinogen levels might be useful hemostatic markers in diabetic patients, especially in those at high-risk for thrombotic complications.