Narender Tejwani

Role of Ki-67 as a proliferative marker in lesions of thyroid

BACKGROUNDnSpecific criteria are used to diagnose thyroid neoplasms; however, the distinction between certain neoplasms, such as follicular adenoma and carcinoma, could be difficult. Thus, additional diagnostic features that can assist in this distinction would have great clinical usefulness.nnnAIMSnTo evaluate the role of the proliferative marker Ki-67 in nonneoplastic and neoplastic lesions of the thyroid, with a special emphasis on the distinction between follicular adenoma and follicular carcinoma.nnnSETTINGS AND DESIGNnA retrospective study from a tertiary care center.nnnMATERIALS AND METHODSnOne hundred cases of thyroid lesions, including 50 nonneoplastic and 50 neoplastic lesions, were retrieved from the archives of the Department of Pathology, Pt. BD Sharma PGIMS, Rohtak, Ki-67 immunostaining was performed by peroxidase-antiperoxidase method and compared with mitotic counts.nnnRESULTSnKi-67 labeling index (LI) showed a progressive rise from multinodular goiter to benign to malignant neoplasms. A statistically significant difference was observed in Ki-67 counts between multinodular goiter vs papillary carcinoma (P < 0.05) and follicular adenoma vs follicular carcinoma (P < 0.05). The correlation between mitotic counts and Ki-67 LI was found to be significant.nnnCONCLUSIONSnIn the present study, Ki-67 was found to be useful in differentiating between follicular adenoma and follicular carcinoma, but since the sample size of our study was small, larger studies are needed to confirm this observation as well as to assign a cutoff value for differentiating benign from malignant tumors.

Pilomatricoma coexistent with epidermal cyst.

complicating squamous cell carcinoma. Three cases of opportunistic infestation of an ulcerative, neglected SCC with Diptera larvae, and another case following radiotherapy for SCC of the temple have been reported. The treatment of myiasis consists of mechanical or surgical removal of the larvae with hemostatic or ordinary clinical pincers, or techniques involve blocking the spiracles of the larva and stimulating premature extrusion. Surgical management is most frequently recommended. Preventive measures, including basic health care, hygiene, and access to primary health services, are fundamental to prevent cases such as this one.

Chronic Childhood Idiopathic Myelofibrosis in Down’s Syndrome: A Case Report

Idiopathic myelofibrosis a disease of elderly is rarely seen in children. A case of chronic idiopathic myelofibrosis in an 8xa0year old boy with Down’s syndrome is reported here, who presented with progressive pallor and hepatosplenomegaly. Peripheral blood examination revealed pancytopenia, macrocytic anemia and tear drop cells. No blasts were found. Bone marrow aspirate yielded a dry tap and trephine biopsy showed marrow fibrosis with osteosclerosis. Focally megakaryocytes were increased in number with atypical morphology. No blasts were seen. Review of literature revealed 47 reported cases of childhood idiopathic myelofibrosis. Six cases were associated with Down’s syndrome and only 3 of them had features of chronic idiopathic myelofibrosis without evidence of acute megakaryoblastic leukaemia.

Benefits of Pre-harvest Peripheral Blood CD34 Counts Guided Single Dose Therapy with PLERIXAFOR in Autologous Hematopoietic Stem Cell Transplantation: A Retrospective Study at a Tertiary Care Institute in India

Peripheral blood is a convenient source of stem cells for hematopoietic stem cell transplantation. However, in autologous transplants, the harvest failure rates are high because of inadequate mobilization using G-CSF alone. Plerixafor is a potent mobilizer when used with G-CSF. However, its routine use is limited by high cost. This is a retrospective study done at a tertiary care oncology centre in India. All the harvest records were analyzed between Jan 2015 and Nov 2017. May 2016 onwards pre-harvest peripheral blood CD34 count was done in all cases of autologous transplants on day 4 of G-CSF therapy and they were given a single dose of Plerixafor if counts wereu2009<u200920 cell per cumm. The results were compared amongst various groups. A total of 321 cases were analyzed. 172/321 were allogenic transplant cases of which 5% (nu2009=u20097) failed to achieve a target live stem cell dose ofu2009>u20092 million per kg of the recipient. The overall failure rate in autologous group (nu2009=u2009149) was 27% (nu2009=u200941) (pu2009≤u20090.001 auto vs. allo). The failure rate was higher (36%, nu2009=u200928/77) when no intervention with Plerixafor was done. The overall failure rate in the group treated with pre-harvest 34 count based single dose therapy of Plerixafor was 18% (nu2009=u200913/72, pu2009=u20090.01). However, within this intervention group, the patients who had pre-harvest peripheral blood CD34 above the desired cutoff had a higher failure rate of 21% (pu2009=u20090.13). Pre-harvest CD34 count based intervention with Plerixafor help optimizing the cost.

Bisalbuminemia: A Rare Finding on Serum Electrophoresis

Bisalbuminemia is an uncommon finding that is seen as bifid albumin peak on serum protein electrophoresis. We report here this unusual finding in an adult male diagnosed with multiple myeloma on routine workup.

Budding Yeast Forms on Peripheral Blood Smear: An Intriguing Finding

54 year old female, case of metastatic carcinoma breast presented to the emergency in semi-comatose state. Investigations revealed normal renal and mildly deranged liver functions. Hemogram done from central line sample showed Hb 9.7 of g%, neutrophilic leukocytosis and adequate platelets. Peripheral blood smear (PBS) showed numerous intracellular (within neutrophils and monocytes) yeast forms (Fig. 1) which were morphologically difficult to differentiate from histoplasma species. The organisms were positive for PAS and Gomori methenamine silver (GMS) stain and negative for mucicarmine & India ink preparation. Fresh blood and tracheal secretion culture revealed yeast within 24 h of incubation. Subculture streaking revealed dry, dull creamy white heaped up colonies of Candida. Identification was done on Vitec-2 which revealed Candida tropicalis. The patient succumbed to her metastatic disease and bacterial sepsis developing during ICU stay 7 days later. Candida is commonest cause of blood stream fungal infection but still it is rarely reported in PBS [1]. This is because 1–5 9 10 CFU/mL organisms are required to detect them on PBS [2]. An awareness of morphology of these organisms is essential for identification and differentiation from other causes of blood stream fungal infections like Histoplasma and Cryptococcus.

Multiple Auer Rod Like Inclusions in Multiple Myeloma

Multiple myeloma is characterized by clonal plasma cell proliferation associated with end organ damage. In addition to classical morphological variants, several different types of nuclear and cytoplasmic inclusions have been described. We have come across a case of multiple myeloma with numerous Auer rod like cytoplasmic inclusions, with morphology like faggot bodies. A 54 year old male presented with back pain since last 6 months with progressive weakness. There was no history of organomegaly, sternal tenderness, lymphadenopathy, gum hypertrophy or bleeding manifestations. The clinical examination revealed only anemia. No other finding was seen on physical examination. Lab investigations showed hemoglobin of 7.1 g/dL with adequate total leucocyte counts, differential counts and platelet counts. The peripheral smear showed presence of rouleax formation. A bone marrow aspirate smear revealed 72% atypical plasma cells with immature nuclear chromatin, poorly defined cytoplasmic borders, many binucleate and syncytial forms. In addition, almost all the cells showed numerous intracytoplasmic thin slender Auer rods like structures (Fig. 1). Many cells had bundles of these structures resembling faggot cells (Fig. 2). Cytochemistry for myeloperoxidase, Sudan black, periodic acid Schiff and nonspecific esterase stain was negative using adequate positive controls. Serum imunofixation electrophoresis showed presence of a monoclonal band along with IgG kappa clonality. Skeletal survey showed multiple lytic lesions in left humerous and left iliac bone. A final diagnosis of multiple myeloma was made. Auer rod like inclusions have been described previously in multiple myeloma, prolymphocytic leukemia, aplastic anemia, B cell acute lymphoblastic leukemia, chronic lymphocytic leukemia and hypogammaglobulinemia [1]. All cases published till date revealed that this phenomenon is primarily restricted to IgA or IgG and kappa secreting myelomas [2–5]. Our case also showed IgG-j-type light chain restriction. Auer rod-like inclusions in myeloma are composed of crystallized lysosomal enzyme depositions. However, the exact nature of these inclusions is not known. Morphologically it is difficult to differentiate these structures from Auer rods seen in immature myeloid cells. One of the methods is to perform myeloperoxidase staining which is classically negative in these crystalline structures since true Auer rods shows bright staining [1]. However, positive myeloperoxidase and nonspecific esterase (NSE) have been reported in these Auer rods like structure [2, 5]. Many ultrastructural differences have also been described in literature [5]. In view of these conflicting results it is advised to carefully analyze these inclusions to differentiate it from true Auer rods seen in myeloid progenitors. To conclude Auer rod like inclusions in a case of multiple myeloma is a rare finding and should never be analyzed in isolation. A panel of cytochemical tests, detailed history, examination, laboratory investigations and other biochemical tests are required to avoid misinterpretation and misdiagnosis. Disclaimers The identity of the patient is not disclosed here in this case.

CD138 Negative Plasma Cells in Relapsed CNS Multiple Myeloma

CD138 (Syndecan-1) is a heparin sulphate proteoglycan responsible for growth factor binding, cell adhesion, apoptosis and control of myeloma growth [1]. CD138 negative plasma cells are a sub-population of malignant plasma cells (PCs) which may be more primitive and have a higher proliferative potential than CD138 positive plasma cells [1]. Certain studies have also suggested that CD138 negative cells play a key role in myeloma cells-mediated biomechanical changes of bone marrow stem cells in multiple myeloma (MM) patients [2]. We present a case of relapsed myeloma with CD138 negative plasma cells and CNS dissemination. A 46 year old male presented with a swelling in the skull since three months without any constitutional symptoms. Physical examination was unremarkable except for a mass in the skull in the right parietal region. Complete hemogram showed Hb = 11.6 g/dl, TLC = 10,300/cmm, Plt = 306,000/cmm and a DLC of N62/L28/M6/E4. LFT and RFT were within normal limits. Viral serology was negative. Skeletal survey revealed lytic lesions in right parietal bone. Serum protein electrophoresis showed ‘‘M’’ spike of 3.33 g/dl in the gamma region. b2-microglobulin was markedly raised (2500 ng/ml). Patient underwent craniotomy, following which the biopsy of the extradural tumor mass showed features suggestive of plasmacytoma. Bone marrow evaluation revealed infiltration with 50% plasma cells including a few atypical forms. A final diagnosis of multiple myeloma was made on the basis of clinicoradiological, biochemical, tissue biopsy and bone marrow aspirate findings. Patient was started on Lenalidomide/ Dexamethasone based regimen for 3 cycles followed by 2 cycles of VTDbased regimen Vincristine/Thalidomide/ Dexamethasone) and underwent autologous stem cell transplantation (ASCT) with Melphalan conditioning in first complete remission (CR). He was thereafter kept on close follow-up on Thalidomide maintenance. However, his M band continued to rise while on therapy and he had to be shifted to CTD regimen followed by DT-PACE regimen but still showed poor response. 3 years post-ASCT, he was admitted with altered sensorium, visual hallucinations and right-sided hemiplegia. Positron Emission Tomography (PET-CT) showed metabolically active bony, hepatic, stomach, kidney and adrenal lesions with bilateral lung nodules, soft tissue, mesenteric and muscle deposits. However, no mass lesions were noted in the brain parenchyma (confirmed by MRI). Bone marrow was uninvolved at relapse. Serum Protein Electrophoresis showed a small monoclonal spike in gamma globulin region (0.42 g/ dl). SFLC (kappa/lambda) ratio was 0.03. CSF cytology, with cell count of 10 WBCs/cumm showed numerous cells with plasmablastic morphology having moderate N/C ratio, round nucleus, prominent nucleoli and moderate amount of cytoplasm (Fig. 1a). Flowcytometry of CSF fluid was done which showed CD45?(dim)/CD38?(bright)/CD56?/ CD138-/CD19-/CD20-/CD3immunophenotype, with no clonal restriction for kappa or lambda light chains (Fig. 1b–i). Patient was started on Bortezomib based regimen, with Wide-Base Radiotherapy. However, his condition failed to improve and he left against medical advice. Disclaimers: The identity of the patient is not disclosed here in this case. The authors state that there is no conflict of interest present.

Diagnostic Dilemma in the Morphological Detection of Flower Cells in Lymphomas

Abstract“Flower cells” are described typically in HTLV-1 induced adult T cell leukemia. Very few case reports have been published documenting flower cells in B cell lymphomas. We herein present a case of Burkitt lymphoma proven on the basis of immunophenotyping and FISH studies, with “flower cells” morphology.