Debarshi Saha

Cutaneous neurocristic hamartoma presenting as cutis verticis gyrata.

Cutaneous neurocristic hamartoma is a rare developmental complex melanocytic lesion of neural crest origin in the dermis and subcutis with diverse histological differentiation including melanocytic, neurosustentacular, and mesenchymal elements. Cutis verticis gyrata is a cerebriform thickening of the scalp manifesting as folds, ridges, or creases. We report a case of cutaneous neurocristic hamartoma of the scalp in a 20-year-old woman presenting as cutis verticis gyrata. Microscopically, the lesion involved the dermis and the subcutis. Dendritic pigmented melanocytes were seen in between the collagen bands. Plexiform islands consisting of cords and palisades of spindled cells were also apparent. Immunohistochemically, HMB-45 positivity was observed in the dendritic melanocytic cells. S-100 protein was positive in dendritic melanocytes and in the Schwannian cells. The stromal cells showed CD34 staining. This lesion is presented because of its rarity, unusual clinical appearance, and resemblance to both a neurocristic hamartoma and large plaque type of blue nevus.

Evaluation of Fluorescent Staining for Diagnosis of Leprosy and its Impact on Grading of the Disease: Comparison with Conventional Staining

INTRODUCTION Leprosy is a chronic infectious disease caused by Mycobacterium leprae (M. leprae). Histopathological examination of skin lesion is the gold standard for diagnosis. We evaluated the possible role of fluorescent microscopy in this direction which is increasingly used for rapid screening. AIM To compare the efficacy of auramine rhodamine stain with Ziehl-Neelsen and modified Fite-faraco staining in diagnosing M. leprae in tissue sections. STUDY DESIGN Experimental, cross-sectional and retrospective study conducted for 4 years. METHODS AND MATERIALS Skin biopsies of sixty clinically diagnosed leprosy patients were stained by Ziehl-Neelsen, Fite-Faraco and fluorescent stain. The presence of the bacilli and the bacillary index was scored for each case. The bacillary index by each staining methods were compared. STATISTICAL ANALYSIS SPSS v 17 (IBM, New York) used for data analysis. Chi-Square test was used to calculate significance between differences. The p-value of <0.05 was considered as statistically significant. Pearson Correlation (r-value determined) was also used for comparison between groups. RESULTS Sensitivity of fluorescent stain for indeterminate and borderline tuberculoid leprosies were 100% each. Positivity rates and mean bacteriological index with fluorescent stain was higher (43.3 and 11.5 respectively) as compared to that of Ziehl- Neelsen and Fite-faraco when the bacillary load was less (bacillary index < 3). There was significant correlation between the three staining types at higher bacillary load. There was a higher mean bacillary index with fluorescent stain as well as detection of an additional multibacillary case. CONCLUSION Fluorescent method is more sensitive than modified fite-faraco method in detecting lepra bacilli in tissue sections especially in cases with bacillary index less than three. With its higher sensitivity, paucibacillary cases could be upgraded to multibacillary thus affecting treatement decisions.

Unusual lesions of the mediastinum

Objectives: To study unusual lesions in the mediastinum, which do not originate from the thymus, lymph nodes, neural tissues or germ cells, and tissues that normally engender pathologic lesions in the mediastinum. Materials and Methods: Of the 65 cases seen, 12 unusual lesion were encountered in a 5½ year period from 2006 to 2011. Results: Two cases of nodular colloid goiter and one each of the mediastinal cyst, undifferentiated carcinoma, and Langerhans cell histiocytosis (LCH) affected the anterosuperior mediastinum. In the middle mediastinum, one case each of the mesothelioma, malignant gastrointestinal stromal tumor (GIST), squamous cell carcinoma (SCC), solitary fibrous tumor (SFT), and pleomorphic sarcoma (PS) was seen. One case of meningeal melanocytoma (Mme) and primary pleural liposarcoma (PL) involved the posterior mediastinum. Persistent disease was seen in LCH after 2 years. Of all the cases with malignant lesions, only the patient with SCC was alive after 1 year. Conclusion: The cases of primary and SCC, LCH, melanocytoma, liposarcoma and PS, and GIST are unexpected and very rarely have paradigms in the mediastinum. Radiologic impression and knowledge of the compartment where these lesions arose from hardly assisted in arriving at a definitive opinion as the lesions were not typical of this location. A high index of suspicion and the immunohistochemical profile facilitated the final diagnosis.

Theoretical studies on thermal stratification in a side heated cavity

Abstract The Advanced Heavy Water Reactor (AHWR) being designed in India is a vertical pressure tube type boiling water-cooled and heavy water moderated reactor. A key feature of the AHWR is the use of simple passive systems to respond to any postulated accidental condition. Passive Containment Cooling System (PCCS), is one such system, which provides long term cooling for the reactor containment following a Loss Of Coolant Accident (LOCA). The system consists of Immersed Condensers immersed in a gravity driven water pool. One of the important phenomena related to PCCS functioning is the effect of thermal stratification in the water pool. The heat transfer from IC to water pool takes place by natural convection. In this process, the pool water can get stratified. Towards the top of the water pool, the temperature of water may reach almost the boiling point while at the bottom of the pool, the water is likely to remain at the initial temperature. Hence, in order to study the integral system response of PCCS, the phenomenon of stratification requires to be investigated. Towards this objective, the case of a rectangular enclosure heated symmetrically on both the vertical sides was considered and a two-dimensional analysis was done by numerically solving the mass, momentum and energy equations. Theoretical results were generated by the use of a computer code developed for this purpose and the results are then compared with the experimental results available in literature.

The Role of Crush Cytology in the Diagnosis of Large-Intestine Lesions with Correlation on Histopathology

Objective: To study the efficacy of colonoscopic crush cytology as a convenient and near-accurate method to evaluate colonic neoplasms. Study Design: Retrospective and cross-sectional. The original cytologic diagnoses were correlated with a histology report on 100 cases sent to the cytology laboratory over 2 years. Results: Of the 100 cases, 25 were nonmalignant. Of the 75 malignant lesions, 72 could be identified as positive for malignancy on cytology. The false-positives consisted of 6 adenomas and 1 case of ulcerative colitis. Thus, sensitivity and specificity of cytology are 96 and 63.2%, respectively. Of the 6 adenomas diagnosed as malignant, 4 showed high-grade dysplasia, and the other 2 showed superficial ulceration with low-grade dysplasia on histopathology. The ulcerative colitis case showed widespread ulcers and regenerative/reparative features on biopsy. The 3 adenocarcinomas diagnosed s benign on cytology showed an occasional malignant cell with thickened nuclear borders and prominent central nucleoli. Conclusions: With careful attention to the cytomorphology, coupled with good clinical and endoscopic correlation, crush cytology of the large intestine is a reliable diagnostic tool. It categorizes lesions as malignant and benign with a high sensitivity, positive predictive value, and negative predictive value. Adenomas and reparative/regenerative changes seen in inflammatory bowel disease are major pitfalls in the cytology diagnosis of malignancy that may be averted by informing the endoscopic findings and clinical history. Cytology diagnosis saves time and gives proper feedback to the gastroenterologist.

The role of discriminant functions in screening beta thalassemia trait and iron deficiency anemia among laboratory samples

Introduction: Most important differential diagnosis for microcytosis and hypochromia is beta thalassemia trait (BTT) and iron deficiency anemia. Aim: To study the utility of discriminant functions (DFs) and red cell indices in distinguishing BTT and iron deficiency anemia. Methods: The study is observational (cross sectional). A total of 350 patients, 43 BTT, and 307 iron-deficiency anemia reflecting actual disease prevalence were included. Their complete red blood cell parameters, hemoglobin A2, and serum ferritin level wherever required were obtained. Receiver operator characteristic curve was drawn for each DF and results compared with other studies. Results: Among the six DFs, the highest sensitivity (97.7%) and specificity (98.6%) was shown, respectively, by Shine and Lal (S and L) and England and Fraser index (E and F) in identifying cases of BTT. Youden index of the Mentzer index (MI) was the highest (69.0) and S and L, the lowest (13.2) indicating MI to be the most efficient and the S and L, the least in differentiating the two entities. Red cell distribution width index (RDWI) showed the highest accuracy (91.6%), whereas S and L showed the least accuracy (29.6%). Conclusion: MI was the most efficient in discriminating BTT from iron deficiency anemia (IDA). RDWI stands to be the most accurate. S and L could at best be used as screening tool rather than DF. No study except one agreed with us because convenient sampling used in other studies generated bias in their results. Statistically, this study bears far more relevance than other studies because the sample distribution reflects the prevalence of IDA and BTT in the community.

HER2 and Helicobacter pylori Status in Resected Gastric Cancers: A Pathological Study of a Gastroenterological Issue

Introduction: Human epidermal growth factor receptor 2 (HER2)/neu is a critical target for gastric carcinoma treatment utilizing trastuzumab. Helicobacter pylori is a well known causative agent of gastric carcinoma. Aim: To study association of HER2/neu expression with the presence of H. pylori infection in resected carcinoma stomach patients. Materials and Methods: A cross-sectional study of 85 gastrectomies received in the department from January 2010 to September 2014 was done. HER2/neu was studied using Immunohistochemistry (IHC) and Giemsa stain was used to detect presence of H. pylori. Chi-square test and Fisher’s exact test were used, to test the correlation between the various parameters. A p-value <0.05 was considered significant. Results: Our study population included 67 (78.8%) males, and 18 (21.2%) females, ranging from 22 to 84 years, mean 57.68±12.12 years. HER-2 expression, graded from 0 to 3± was correlated with location, histologic type, grade, local invasion, metastasis to lymph nodes, TNM tumour staging and H. pylori infection, graded from 0 to 3+ using Giemsa stain. HER2/neu 3+ was observed in intestinal type of gastric cancer (5/55, 9%) only. Scores 2+ and 3+ were more common in H. pylori-negative patients (5/26, 19.2%) than H. pylori-positive patients (4/59, 6.8%) (p=0.02). TNM stage, extent of local invasion and lymph node metastasis in intestinal gastric carcinomas correlated significantly with HER2/neu expression. H. pylori was present in 59 (69.4%) and absent in 26 (30.6%). Conclusion: H. pylori-negative gastric cancer showed significant immunophenotypic HER2/neu overexpression i.e., H. pylori might protect against HER2 overexpression that correlated significantly with higher TNM stages of intestinal-type gastric cancer. In contrast, H. pylori infection correlated significantly with Lymph-Vascular Invasion (LVI) but was pN1/2+, thereby diminishing prognostic importance. H. pylori induced intestinal metaplasia was not significantly associated with intestinal-type gastric cancer.

Significance of Serum Lactate Dehydrogenase in Childhood Acute Lymphoblastic Leukaemia

Introduction: Acute Lymphoblastic Leukaemia (ALL) is the most common childhood malignancy accounting for approximately 30% of childhood malignancies. The incidence rate of leukaemia in various parts of India varies from 0.3-1.2%. Lactate Dehydrogenase (LDH) is a pyridine-linked enzyme which is involved in metabolism of glucose in normal tissue. In leukaemic cells, there is loss of coordination of glycolytic sequence and tricarboxylic acid cycle, which leads to increased utilization of glucose. As there is high cell turnover, this leads to increased cell burden and high levels of serum LDH in ALL and the increase is much more than other haematological malignancies barring Burkitts lymphoma. Aim: To study the level of LDH in ALL cases at the time of diagnosis in comparison with Non ALL cases. Materials and Methods: Fifty five cases of ALL and 23 cases of Non ALL haematological malignancies as control were evaluated based on clinical manifestations, haematological parameters, peripheral blood picture and bone marrow findings. Serum LDH was estimated at the time of presentation by Cobas 6000, a photometrically automated system. Statistical analysis was done using SPSS version 20. Results: In our study, high serum LDH levels were seen in 89.1% (49) cases and normal levels in 10.9% (6) cases. High blast percentage i.e., >20% on peripheral smear (65.5%) was associated with high serum LDH level. On correlation of serum LDH with peripheral smear blast percentage, a p-value of <0.05 was obtained which shows a significant correlation Conclusion: Serum LDH level can be considered as a simple cost-effective tool in the presumptive evaluation of childhood Acute Lymphoblastic Leukaemia. LDH in combination with Uric acid helps in detecting tumourlysis syndrome at an early stage thereby aiding in early management.

Histomorphologic spectrum in hyaline vascular variant of castleman disease

INTRODUCTION Castleman Disease (CD) is a rare lymphopro-liferative disorder with heterogenous clinical and pathological features. It is a rare disease with mention in the rare disease data of the orphanet. It can present as unicentric or multicentric disease. Hyaline vascular variant and plasma cell variant are the two pathological subtypes. Hyaline vascular variant accounts for nearly 80% to 90% of unicentric cases. Hyaline vascular subtype variant has follicular and stroma rich subtype. AIM To study the histomorphologic spectrum of hyaline vascular variant of CD. MATERIALS AND METHODS Retrospective cross-sectional, observational study was undertaken from the archival data between January 2009 and April 2015. Only ten cases of hyaline vascular CD were identified after studying the histomorphological characteristics. Both follicular and interfollicular changes were studied in detail. RESULTS The age of presentation ranged from 17 years to 59 years. Seven out of 10 cases were female. Site of presentation included cervical, inguinal, retroperitoneal, intra-abdominal and axillary. Six cases showed predominant follicular change. Two cases were sclerotic subtype. Two cases showed both follicular and interfollicular changes in equal proportion. Distribution of follicles throughout the lymphnode was seen in eight cases. Uniform sized follicles seen in seven out of ten cases. Small germinal centre with lymphocyte depletion was one of the uniform features seen in all 10 cases. Numerous high endothelial vessels were seen in nine cases. Twinning of germinal centre was seen in two cases. All ten cases showed concentric rings of small lymphocytes. Lollipop pattern was relatively rare feature seen in only two cases. CONCLUSION Hyaline vascular variant of CD has considerable morphologic variation with few consistent features seen in most of the cases.

The pitfalls in cytology diagnosis of poorly differentiated neuroendocrine carcinoma of lung and their treatment response

Context: Lung is the most common site of small cell carcinoma (SCLC) – a poorly differentiated neuroendocrine carcinoma (PDNEC). SCLC comprises 15–20% of the invasive cancers of the lung. Aim: This study was conducted to appraise the accuracy and pitfalls of the diagnosis of PDNEC on cytology along with treatment responses if available. Settings and Design: Retrospective study for 2 years yielded 21 cases on cytology. Subjects and Methods: Slides of fine-needle aspiration of lymph nodes, the tumor, bronchial brush, and bronchoalveolar lavage specimens were used. The histological correlation was obtained as were treatment responses. Results: Eighteen SCLCs were confirmed on review. Of these, 13 initial reports were concordant and five, discordant. The rest three cases which initially reported as SCLC were found to be negative (2) and combined SCLC (1). One SCLC with concordant initial and reviewed diagnoses failed to confirm on histopathology. The patients, all heavy smokers, were predominantly males in the seventh to eighth decade age group. The sensitivity and specificity of reviewed diagnoses were better than that of the original. The difference between histopathology and cytology diagnoses (reviewed and original) was statistically insignificant. All patients were categorized as “extensive stage” by positron emission tomography-computerized tomography, and five were treated with etoposide and cisplatin with/without radiotherapy. Conclusion: Age group (61–70) and gender (males) distribution were statistically significant. Intermediate variants of SCLC may be misdiagnosed as adenocarcinoma. Similarly, combined SCLC may be missed on cytology if the observer does not sustain a high index of suspicion. Unequivocal cytology diagnosis opposed to negative histopathology report demands repeat biopsy.