Debasis Gochhait

Takayasu arteritis (TA) first presenting with intestinal ischemia: a case report and review of gastrointestinal tract involvement (ischemic and non-ischemic) associated with TA

Takayasu arteritis (TA) is a large vessel vasculitis involving the aorta and its major branches. Insidious inflammation usually results in gradual arterial narrowing; however, critical organ ischemia is rare. We describe a young male with TA who presented with acute mesenteric ischemia requiring intestinal resection, followed by critical limb ischemia. In our literature review, we identified intestinal gangrene as a rare manifestation of TA. However, intestinal ischemia as the first manifestation of TA has been scarcely reported in the literature. Also, ischemia of the intestine occurring together with critical limb ischemia is extremely unusual. Rheumatologists should be aware of TA as a rare cause of gastrointestinal vasculitis in young adults, which can be easily suspected by routinely examining all the peripheral pulses.

Lipoblastoma presenting as a rapidly growing paravertebral mass and masquerading as myxoid liposarcoma on fine needle aspiration cytology.

Lipoblastoma is a peculiar variant of lipoma occurring almost exclusively during infancy and early childhood. It is found most commonly in the upper and lower extremities; less common sites are head and neck, trunk, mediastinum, and retroperitoneum. It has a greater predilection for boys and commonly presents as a slowly growing soft‐tissue mass. We present here the case of a five‐ year old female child with a lipoblastoma presenting as a paravertebral mass in the right lower back which progressed rapidly in the previous six months causing diagnostic difficulty on fine needle aspiration cytology. Diagn. Cytopathol. 2016;44:426–429.

Granular cell tumor of cecum: a common tumor in a rare site with diagnostic challenge

Granular cell tumor (GCT) also known as Abrikossoff’s tumor is a benign neoplasm that is usually seen in the fourth to sixth decades of life with slight female preponderance. It is most frequently seen in the oral cavity, skin, and subcutaneous tissue. Gastrointestinal tract involvement is uncommon, in which esophagus is the most commonly affected site. There are case reports of GCT in stomach, appendix, colon and rectum. In this article, we report a case of GCT involving cecum. The cell of origin in GCT is controversial. There are various pools of thoughts regarding its histogenesis, the details of which are reviewed in this article with emphasis on the diagnostic difficulties encountered in this tumor.

Generalized lichen planus developing at the healed sites of erythema multiforme in a human immunodeficiency virus-seropositive patient

Dermatol 1998;31:675. 6. Zaias N, Rebell G. A simple and accurate diagnostic method in chromoblastomycosis. Arch Dermatol 1973;108:545‐6. 7. Goette DK, Robertson D. Transepithelial elimination in chromomycosis. Arch Dermatol 1984;120:400‐1. 8. Uribe F, Zuluaga AI, Leon W, Restrepo A. Histopathology of chromoblastomycosis. Mycopathologia 1989;105:1‐6. 9. Queiroz‐Telles F, Santos DW. Challenges in the therapy of chromoblastomycosis. Mycopathologia 2013;175:477‐88. 10. Badgwell Doherty C, Doherty SD, Rosen T. Thermotherapy in dermatologic infections. J Am Acad Dermatol 2010;62:909‐27.

Solitary fibrous tumor of the liver: a rare tumor in a rarer location

Solitary fibrous tumor is an uncommon mesenchymal neoplasm. Liver is a rare location of this tumor. We report a case of hepatic solitary fibrous tumor in a 56-year-old female, who presented with right upper abdominal pain. An extended right hepatectomy was performed. Histopathological and immunohistochemical examination revealed solitary fibrous tumor of the liver.

Lichen planus pigmentosus: A short review

Lichen planus pigmentosus (LPP) is a condition characterized by persistent and asymptomatic slaty-gray pigmentation, predominantly in the face. Classically, the pattern is “actinic” with symmetric and diffuse pigmentation in sun-exposed areas, commonly in dark-skinned individuals. It can also rarely present as macular pigmentation of the flexures in the lighter-skinned. LPP is a disease of the middle-aged, with onset in the third to fourth decades of life and few studies show as slightly greater incidence in females. The photo-distributed or actinic pattern, which is more common, is a disease of tropics and Type IV–Type V skin types. Reports are mainly from India, the Middle East, and South America. The inversus type is relatively rare, predominantly occurring in Caucasians. LPP is thought to be a type hypersensitivity IV reaction to unknown antigen with lichenoid inflammation, leading to melanin incontinence and superficial dermal pigmentation. The natural course of the disease is not clear with some cases showing spontaneous resolution, and some cases with persistence of pigmentation for years. In addition, LPP may have marked overlap clinically and histologically with conditions such as pigmented contact dermatitis, differentiation of which may not be possible in routine practice. Because of these issues, as well as the relative rarity of the condition, there is not much evidence on the efficacy of the various treatment options. Currently, none of the available treatment options show consistent responses or a clear superiority to other modalities, the evidence on efficacy being restricted to a few case series.

Epithelioid gastrointestinal stromal tumour of the ileum; a diagnosis using fine needle aspiration cytology

Dear Editor, A gastrointestinal stromal tumour (GIST) is a primary mesenchymal neoplasm of the gastrointestinal tract. The most common sites are the stomach (60%), jejunum and ileum (30%), duodenum (5%), rectum (4%), colon and appendix (1–2%), and oesophagus (< 1%). It occurs predominantly in adults over 50 years, with a median age of 58 years. There is no sex predilection. The overall incidence has been estimated as 10–20 per million and they constitute 0.1–3.0% of gastrointestinal malignant tumours. GIST was recently defined by it’s ultrastructural and immunohistochemical similarity to the interstitial cells of Cajal. This relation is reflected by immunopositivity for C-KIT (CD117). Demonstration of C-KIT positivity is important in the diagnosis of GIST because of the heterogeneity of the GIST morphology. However, nearly 5% of GISTs are negative for c-kit by immunohistochemistry and tend to be either KIT wild type or to harbour platelet derived growth factor receptor alpha mutations. Microscopically, most GISTs are of three main histological subtypes: spindle cell type (approximately 70%), epithelioid type (20%), and mixed spindle and epithelioid type (10%). Authors have established FNAC as a reliable method for diagnosing GIST pre-operatively; however, the cytomorphology of epithelioid GIST is not widely described. A 58-year-old male presented with rapidly onset abdominal swelling over a duration of 1 month. The patient also had a history of abdominal pain and difficulty in passing stools for 1 week. There was no history of weight loss or loss of appetite. On examination, the abdomen was soft. There was a large irregular mass over the hypogastric, umbilical and left lumbar region which was approximately 20 9 15 cm. On computerised tomography, there was a 21 9 19 9 14 cm sized multilobulated soft tissue density mass lesion noted in the abdominopelvic region, with heterogeneous enhancement, with multiple non-enhancing areas and vascular channels within the lesion, probably originating from the superior and inferior mesenteric arteries. The lesion was displacing the bladder anteriorly and reaching up to the anterior parietal wall. Posteriorly the lesion is closely abutting/compressing the wall of the rectum and sigmoid colon. The colonic bowel wall is not discernible at the rectosigmoid junction and the sigmoid colon level with a superior displacement of the rest of the left-sided large bowel loops. Radiological possibilities of retroperitoneal sarcoma and lymphoma were suggested. Fine needle aspiration cytology was performed as the mass was palpable and smears were stained for May-Gr€ unwald Giemsa (MGG) and Papanicolaou (Pap) stain and material was collected for cell block preparation. Cytology smears were richly cellular and showed loosely cohesive clusters of cells with epithelioid differentiation with abundant vascularity. Individual cells showed mild nuclear pleomorphism with a round to oval nuclei, finely granular chromatin, conspicuous nucleoli and abundant pale cytoplasm. Many of the cells showed the presence of cytoplasmic processes. At places, there was a presence of extracellular collagen-like material in between cell clusters representing skeinoid fibres. Based on these cytological features, a provisional diagnosis of an epithelioid gastrointestinal stroma tumour was offered. The cell block was examined which showed nests of tumour cells with a similar morphology with surrounding vascular channels. CD117 was strongly positive in the cytoplasm further confirming the diagnosis (Figures 1 and 2). On the basis of the cytological diagnosis, the patient underwent a laparotomy and on intraoperative finding, the mass was attached to the ileum and Correspondence: Dr Adarsh Barwad, Assistant Professor, Department of Pathology, JIPMER, Puducherry 605006, India Tel.: +919626573095; Fax: +911126588663; Email: adawad@gmail.com

Metastatic hepatocellular carcinoma masquerading as soft tissue sarcoma: A diagnostic challenge

Metastasis of visceral malignancies to soft tissue is not very common, the bulk of such malignancies being adenocarcinomas. The commonest primary tumors are lung and breast carcinoma followed by the gastrointestinal tract and female genital tract malignancies. The most common metastatic soft tissue sites are abdominal wall and scapular region followed by thigh and chest wall. In a study by Plaza et al. in 27% of metastatic deposit cases (out of a total of 118 cases), the initial manifestation of internal malignancy was soft tissue deposit which were misinterpreted clinically as soft tissue tumor/sarcoma. We encountered exceedingly rare instances of hepatocellular carcinoma (HCC) with initial presentation as soft tissue mass. The large size of the soft tissue tumor and cytomorphology favored a sarcoma with epithelioid morphology. However, a rare possibility of metastatic carcinoma was considered which was confirmed after Cytokeratin (pan CK) immunohistochemistry (IHC).

Diagnosis of pseudo-gout (calcium pyrophosphate deposition disease) clinched on cytology

Calcium pyrophosphate dihydrate (CPPD) deposition disease is a metabolic arthropathy which results from deposition of calcium pyrophosphate crystals in and around joints especially the hyaline cartilage and disc material. This metabolic disease in uncommon in the smaller joints and multiple diagnostic modalities along with biochemical investigations would be necessary for definite diagnosis. We highlight the case of a 48 year old male who presented with a painful mass at the base of left thumb and was clinic‐radiologically suspected as malignancy. Cytological examination (fine needle aspiration cytology [FNAC]) showed numerous extracellular rods shaped and rhomboid blunt‐ended crystals along with foreign body type of giant cells. The main emphasis here is on the pivotal role played by FNAC in accurately diagnosing the disease where other modalities like radiology and histopathology failed to do so. The exact categorization of crystals is important from treatment point of view to avoid any major deformities in the joints/systemic manifestation.

Neoplasms with cytoplasmic vacuoles - Many differential diagnoses on cytology

cellular with relatively monotonous cells arranged in a dyscohesive pattern. The dominant morphology was centrally located nuclei and abundant cytoplasm having tiny punched out well-defined cytoplasmic vacuoles. Scattered cells with plasmacytoid morphology and absence of cytoplasmic vacuoles were also noted along with some multinucleated tumour giant cells (Figure 2). Most tumour cells had nucleoli, but they were not prominent. Occasional cells showed intranuclear inclusions, and mitotic figures were infrequent. No pigmented cells were noted in the smear. Considering the solitary superficial swelling, recurrence history and the described cytomorphology, possibilities considered were malignant adnexal tumour or a superficial epithelioid sarcoma. Initial immunohistochemical stains included pancytokeratin, vimentin and S100 (Figure 3). The tumour cells were positive for vimentin and S100 and negative for pancytokeratin.