Mrinalini Kotru

Role of fine-needle aspiration cytology in evaluation of cutaneous metastases

Skin is an uncommon site for metastasis. This study was done to evaluate the role of FNAC as an important tool for investigating cutaneous and subcutaneous nodules in patients with known malignancy or as a primary manifestation of an unknown malignancy.

Cytologic and histologic features of primary mucinous adenocarcinoma of skin in the axilla: a case report.

BACKGROUND Primary mucinous adenocarcinoma of the skin is a rare tumor; its location in the axilla is rarer still. It closely mimics metastatic adenocarcinoma histologically. Owing to the good prognosis of the tumor, it is imperative that it is diagnosed or at least suspected to save the patient from unnecessary investigation and a radical treatment. Fine needle aspiration cytology (FNAC) is a very useful preoperative investigation for its diagnosis; however, cytologic description is not available in the literature so far. CASE A 50-year-old man presented to the outpatient surgery department with a lump in the left axilla for 6 months. FNAC of the lump was done. The cytologic smears were hypercellular, with loosely dispersed cells in a background of pale pink material. On high-power examination, cells were monomorphic with plasmacytoid appearance and no atypia. Occasional mitotic activity was seen. A possibility of appendageal tumor was suggested and excision biopsy advised. On subsequent biopsy a diagnosis of primary mucinous adenocarcinoma of the skin was made. CONCLUSION Because of the better prognosis of primary mucinous adenocarcinoma of the skin vis-a-vis metastatic adenocarcinoma; preoperative diagnosis is necessary. FNAC can serve as a rapid and accurate first-line investigation.

Usefulness of histopathological examination in uterine prolapse specimens.

Background:  Uterovaginal prolapse frequently occurs in postmenopausal women. Hysterectomy with pelvic floor repair is one of the frequently performed surgeries in treating women who have completed their family and are not particular about preserving menstrual function. These hysterectomy specimens are submitted for histopathological examination to confirm the diagnosis.

Limitations in the role of ulcer edge biopsy in establishing the aetiology of nontraumatic small bowel perforation.

Spontaneous small intestinal perforations are common in India. Surgeons operating on patients with an obscure peritonitis should be aware of the diverse aetiologies of small intestinal perforations in order to be able to provide the appropriate management. We reviewed the pathology records of 165 patients operated on for nontraumatic perforations of the small intestines in our hospital between 2005 and 2007. Perforation edge biopsy was diagnostic in 53 cases, with typhoid being the most common aetiology, followed by TB. The majority of cases, however, revealed only a non-specific inflammatory granulation tissue. However, the sensitivity of biopsy diagnosis could be increased by taking additional biopsy material from the mesenteric lymph nodes, tubercles or omental nodules. We conclude that perforation edge biopsy is useful in a third of cases, but the diagnostic rate could be improved by taking additional biopsy material.

PEComata: highly melanotic multiple perivascular epithelioid cell tumors (PEComa) of the uterus

Perivascular epithelioid cell tumors (PEComas) are mesenchymal neoplasms with a distinct perivascular epithelioid cell differentiation. Primary PEComas comprise a rare and unusual group of neoplasms with unpredictable malignant potential. The term ‘‘PEComa’’ was originally coined by Zamboni et al. in 1992 (1), and is the current nomenclature for tumors composed of PECs, other than angiomyolipoma (AML), clear cell sugar tumor of the lung (CCST) and lymphangioleiomyomatosis (LAM), which are related lesions with distinct clinical features. PEComas, occasionally associated with the tuberous sclerosis complex, are defined by the presence of perivascular epithelioid cells that coexpress muscle and melanocytic markers. Consequent to the World Health Organization’s endorsement of PEComa as a bona fide entity (2), an increasing number of reports have documented PEComas arising in various anatomic locations, including the bladder, kidney and prostate. Characteristic features of perivascular epithelioid cells are positive staining for HMB-45, abundant clear to eosinophilic granular cytoplasm, and often a relationship with abnormal vessels (in LAM or AML). Other features include expression of another melanoma-associated antigen MART-1 (Melan-A), coexpression of muscle markers without cytokeratin or S-100 expression, and promelanosomes. There have been few reported cases of PEComa arising in the uterus (3–9). We report a unique case of PEComa––multiple fibroid-like and deeply pigmented. A 38-year-old woman presented with menorrhagia and lower abdominal discomfort. There was no evidence of any other lesion or disease. On ultrasonography, the uterus showed multiple hypoechoic lesions consistent with fibroids. The

Usefulness of Histopathological Examination in Nontraumatic Perforation of Small Intestine

IntroductionNontraumatic perforation of small intestine (NTPSI) is a fairly common cause of peritonitis in developing world requiring early surgical intervention. Various etiological factors have been proposed for the cause of small bowel perforation. This retrospective study was conceded with an aim to determine the prevalence patterns of the different etiologies of NTPSI.Materials and MethodsA total of 164 patients were included in the study who had segments of small intestine removed for perforation during emergency procedures. Preoperative definitive diagnoses were not known in these cases. On gross examination, most of the small intestine perforations, n = 110 (67%), were found in the terminal ileum. On microscopy, the most frequent category was that of ulcers of nonspecific etiology, n = 61 (37.2%), which showed general features like inflammatory granulation tissue, serositis, and foreign body giant cell reaction.ResultsIn cases where a definite opinion could be established, infection was the commonest cause, n = 71 (43.3%), wherein tuberculosis (49, 29.9%) and typhoid (22, 13.4%) constituted the greatest number of cases. There were two cases of lymphoma and one case of metastatic adenocarcinoma involving the small intestine. Thus, histopathological examination of operated specimen is a useful guide for the surgeon to decide further management of the patient especially in the case of infections.

Adrenal insufficiency in primary adrenal lymphoma: Innocuous presentation of a rare sinister illness

Adrenal insufficiency can often manifest with nonspecific complaints. Primary adrenal lymphoma is a rare cause of adrenal insufficiency. We present the case of a 55-year-old female who presented with nonspecific complaints of abdominal pain, pallor and weight loss and was found to have primary adrenal lymphoma. The case highlights the need to expeditiously initiate steroid replacement in patients with adrenal insufficiency, while efforts are made to establish the etiology of adrenal insufficiency.

Cartilaginous metaplasia in uterine leiomyoma

IntroductionLeiomyoma is the most common tumor in the uterus. A spectrum of histologic variants have been noted, however, metaplasia in the leiomyoma is a rare phenomenon. Adipose metaplasia being most commonly reported. Cartilaginous metaplasia in leiomyoma is very rare.Materials and methodsWe report first case of pure cartilaginous metaplasia in a uterine leiomyoma.ConclusionCartilaginous areas although rare, may appear in uterine leiomyoma.

Role of FNAC in the diagnosis of intraosseous jaw lesions.

Background FNAC of intraosseous jaw lesions has not been widely utilized for diagnosis due to rarity and diversity of these lesions, limited experience and lack of well established cytological features. Aim of the study was to determine the role of FNAC in the diagnosis of intraosseous jaw swellings. Material and Methods 42 patients underwent FNAC over a period of 7 years (2007-2013), of which 37 (88.1%) aspirates were diagnostic. Histopathology correlation was available in 33 cases and diagnostic accuracy of FNAC was calculated. Results Lesions were categorized into inflammatory 3, cysts/hamartomas 15 and neoplasms 19. Mandibular and maxillary involvement was seen in 21 and 16 patients respectively. Of these, benign cysts and malignant lesions were commonest, accounting for 27% lesions (10 cases) each. One case of cystic ameloblastoma was misdiagnosed as odontogenic cyst on cytology. Overall, sensitivity and specificity of FNAC were 94.7% and 100% respectively with a diagnostic accuracy of 97.3%. Definitive categorization of giant cell lesions, fibro-osseous lesions, odontogenic tumors and cystic lesions was not feasible on FNAC. Conclusions FNAC is a simple, safe and minimally invasive first line investigation which can render an accurate preoperative diagnosis of intraosseous jaw lesions, especially the malignant ones in the light of clinic-radiological correlation. Key words: Jaw swellings, intraosseous, FNAC.

Mucin-secreting gastric adenocarcinoma with Rhabdoid areas

Rhabdoid tumor, first described in kidneys of infants and children, is an aggressive tumor that has been reported in several extrarenal locations. In this report, we describe the case of a 40-year-old patient with gastric adenocarcinoma composed of histologically well-differentiated glandular areas and focal rhabdoid zones. The rhabdoid component showed typical features such as abundant eosinophilic cytoplasm, eccentric nuclei, prominent nucleoli and intense focal positive immunohistochemical cytoplasmic reaction for vimentin. Recognition of the rhabdoid phenotype in gastrointestinal tract neoplasms is important because this feature is associated with poor prognosis and unresponsiveness to conventional therapy.