Flora Dorothy Lobo

Impact of an increase in grading categories and double reporting on the reliability of breast cancer grade.

The present study illustrates the effect of using the consolidated total score (obtained on a 7‐point scale by adding the tubular, nuclear and mitotic scores) as well as double reporting on the interobserver reliability of breast cancer grading by the Nottingham method. 50 consecutive breast cancer slides were graded independently by 5 pathologists. The interobserver reliability between the individual pathologists for final grade, total score and grade components was estimated by quadratic weighted kappa (kw). Similarly, the inter‐observer reliability of double reported scores (obtained by averaging the reported scores of two independent pathologists) for independent observer pairs was estimated. The total scores gave higher reliability figures than the final grade both for individual pathologists and double reported scores. The double reported total scores and grade also gave significantly higher reliability figures than the individual scores and grade (average kw=0.65 and 0.78 for the individual and double reported total scores, respectively; 0.61 and 0.66 for the individual and double reported grades).Therefore, use of total scores in addition to grade as well as double reporting of the same significantly increases the interobserver reliability of breast cancer grading.

A Histomorphological Pattern Analysis of Pulmonary Tuberculosis in Lung Autopsy and Surgically Resected Specimens

Background. Tuberculosis (TB) is a major cause of morbidity and mortality globally. Many cases are diagnosed on autopsy and a subset of patients may require surgical intervention either due to the complication or sequelae of TB. Materials and Methods. 40 cases of resected lung specimens following surgery or autopsy in which a diagnosis of pulmonary tuberculosis was made were included. Histopathological pattern analysis of pulmonary tuberculosis along with associated nonneoplastic changes and identification of Mycobacterium tuberculosis bacilli was done. Results. The mean age of diagnosis was 41 years with male predominance (92.5%). Tuberculosis was suspected in only 12.1% of cases before death. Seven cases were operated upon due to associated complications or suspicion of malignancy. Tubercular consolidation was the most frequent pattern followed by miliary tuberculosis. The presence of necrotizing granulomas was seen in 33 cases (82.5%). Acid fast bacilli were seen in 57.5% cases on Ziehl-Neelsen stain. Conclusion. Histopathology remains one of the most important methods for diagnosing tuberculosis, especially in TB prevalent areas. It should be considered in the differential diagnosis of all respiratory diseases because of its varied clinical presentations and manifestations.

Inflammatory myofibroblastic tumor of the pancreas: A rare entity

Inflammatory myofibroblastic tumor (IMT) is an extremely rare tumor of the pancreas that causes diagnostic dilemma. The biologic behavior of this uncommon lesion is still unknown. In this report, we hereby present the morphological and immunohistochemical analysis of one such case.

Morphological Spectrum of Basal Cell Carcinoma in Southern Karnataka.

INTRODUCTION Basal Cell Carcinoma (BCC) is the most common skin cancer worldwide, which appears over sun-exposed skin as slow-growing, locally invasive lesion that rarely metastasizes. Many phenotypic presentations are possible. BCCs are more common in males and tend to occur in older people. Majority is found on the head and neck. Many histopathological subtypes have been defined including nodular, micronodular, cystic, superficial, pigmented, adenoid, infiltrating, sclerosing, keratotic, infundibulocystic, metatypical, basosquamous and fibroepitheliomatous. Mixed patterns are common. AIM The aim was to study morphological spectrum of BCC in a tertiary care hospital in southern Karnataka. MATERIALS AND METHODS This was a retrospective analysis of 100 cases of BCCs reported in the Department of Pathology over a 9-year period from 2006 to 2014. RESULTS The mean age of presentation was 62 years. There was slight female preponderance (56%). The most common location was face (65%) and the most common presentation was ulceration (45%). Of the 100 BCCs, 50% were nodular, 13% infiltrating, 6% basosquamous, 4% superficial, 3% keratotic, 3% multinodular and 1% mixed. CONCLUSION BCC, besides being the commonest cutaneous cancer, is also known for its numerous histological patterns which are shown to have prognostic implications. This study reveals the frequency of the various histological patterns of BCC in southern Karnataka, where it has been rarely studied before.

Primary clear cell carcinoma of the nasopharynx

A 22-year-old female with epistaxis and nose block had a pink, smooth, mucosa covered lesion occupying the nasopharynx. The histopathology and immunohistochemistry of the lesion confirmed the diagnosis of clear cell carcinoma (CCC). Detailed evaluation ruled out a primary tumor elsewhere in the body. After complete excision of the tumor patient received radiotherapy (60 Gray in 30 fractions over 6 weeks). Patient is recurrence free on her 3-year follow-up. Primary CCC of the head and neck is rare. In the past 30 years, less than 100 cases have been reported in English literature. Out of these, only nine cases had nasopharyngeal origin. The literature review of those cases along with our case report suggest that complete excision of nasopharyngeal CCC along with radiotherapy leads to prolonged recurrence free interval. However, extensive tumors of nasopharynx exhibit poor prognosis with repeated local recurrences.

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.

A fortuitous turn of evidence in an elderly female - A case of pulmonary fusariosis

Pulmonary mycosis is seen infrequently in our country. It is more common in the immunocompromised. The infections caused by less known species like Fusarium have been found to be increasing in incidence in other parts of the world. We hereby report its occurrence in a 79-year-old, non-immunocompromised female who presented with pyrexia of unknown origin. Her Alanine Phosphatase (ALP) and Lactate Dehydrogenase (LHD) levels were raised. CT scan showed interstitial thickening in subpleural aspect of lungs and multiple enlarged lymph nodes in mediastinum. Liver showed multiple hypodense lesions. Metastasis was suspected for which Fine Needle Aspiration Cytology (FNAC) of liver was done which showed foci of regenerative hepatocytes with desmoplastic stromal tissue fragments and negative for tumour. Her Alpha Fetoprotein (AFP) was normal. The bronchial tree cytology showed endobronchial cells, dust-laden macrophages and chronic inflammatory cells along with fungi on Pap smear studies. This was confirmed by culture that grew Fusarium species. after one week of incubation. The acutely branching septate hyphae of Fusarium species are identical to those of Aspergillus species. In a patient who has a disseminated infection with a septate fungus, growth in culture is important to identify the specific organism and subsequently treatment with appropriate antifungals. In cases like ours, where the infection simulates malignancy, it is even more important to make the correct diagnosis to give the appropriate treatment.

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.

Fine needle aspiration cytology of sacrococcygeal chordoma- utility in a case of clinical dilemma

Chordoma was originally described by Virchow in 1857 and further characterized by Ribbert in 1894. It is a rare low to intermediate grade malignant notochordal tumor that recapitulates the notochord and has a tendency for recurrences and metastasis.1,2 They represent 1–4% of all malignant bone tumors. Most prevailing theory regarding the development of chordoma is that the notochord fails to degenerate and undergoes malignant transformation. Approximately 50% of chordomas are sacrococcygeal in origin and usually present as destructive bone lesions with a large soft tissue mass.3–5

Lymphoepithelial Sialadenitis Involving HIV-Infected and Sjogren Syndrome Patients: A Cytologic Study

Lymphoepithelial salivary gland cysts are rarely seen in autoimmune diseases particularly Sjogren syndrome as well as in HIV for which medical management is advocated. To study the morphology of these cysts, correlate with the disease process and assess the final outcome. Case series. Fine needle aspiration clinic. HIV-infected and autoimmune disease patients with lymphoepithelial cysts. Antiretroviral therapy for HIV-patients and anti-inflammatory drugs for Sjogren syndrome. Three HIV-infected patients (two children and one adult) and three middle aged female patients presented with parotid and submandibular cysts, two of which were bilateral along with submandibular (one each in the HIV and the autoimmune group). In the adult HIV-patient, the cyst was found at the inception of the disease while the other pediatric HIV-patients just crossed a decade. Of the other three cases of Sjogren syndrome, two were primary and one, secondary to rheumatoid arthritis. All the cysts regressed completely with treatment of the respective diseases which was confirmed by ultrasonograms. Lymphoepithelial cysts are produced by release of serous secretion by the acinar and ductal cells within the epithelial islands in the process of their destruction. Possibly, antibody mediated increased secretion in the initial stages also plays a role. Lymphoepithelial cysts of HIV patients may occur in the course of treatment, not necessarily in the beginning, though it resolves spontaneously. Lymphoepithelial cysts of primary or secondary Sjogren syndrome may be repressed sufficiently by anti-inflammatory/immunosuppressant treatment.