Neelam Wadhwa

Syringomatous adenoma of the nipple: a case report

Sir, Nipple tumours are uncommon lesions of the breast. Adenoma of the nipple, syringomatous adenoma and papilloma are the limited tumours involving the nipple and areolar region. Syringomatous adenoma of the nipple is a rare neoplasm, first described by Rosen in 1983. To date, less than 25 cases have been reported in the English literature. It differs from other tumours of the nipple and areolar region in being of skin appendageal origin and differentiation. Incomplete excision of this locally infiltrative tumour is associated with a high rate of recurrence. Nipple sacrifice may be necessary for achieving complete excision and histologically negative margins. To the best of our knowledge, this is the first case to be reported from India. A 20-year-old female presented with a 2-month history of an itchy nipple lump in her right breast. She also complained of one episode of serous nipple discharge. There was no history of bleeding from the nipple, anorexia or weight loss. On examination, the lump was causing nipple enlargement. The overlying skin was ulcerated. The ipsilateral axilla, contralateral breast and axilla were unremarkable. The mass was excised completely with wide margins, including the overlying skin. The surgical specimen was fixed in 10% neutral buffered formalin and paraffin embedded. Four-mm thick sections were cut and stained with H&E. Immunohistochemical staining for epithelial membrane antigen (M 0613, dilution 1:100; Dako, Sweden) and S100 (N 1573, Dako) was performed using the streptavidin–biotin–peroxidase technique. Appropriate positive and negative controls were prepared simultaneously. The gross specimen consisted of a skin-covered nodular soft tissue piece measuring 1 cm in maximum dimension. The surface showed foci of ulceration. Microscopically, a connection between the tumour and overlying skin was present. The epidermis was slightly hyperplastic. An area of ulceration was also seen. Keratotic cysts containing amorphous pink material were present in the superficial portion of the tumour (Fig. 1). The tumour was composed of ducts and tubules scattered in a fibrous stroma. Characteristic commaor tadpole-shaped ducts were seen. The majority of the ducts were lined with doublelayered epithelial cells. A few areas showed epithelial hyperplasia in the form of multilayering and micropapillae. Some ducts were slightly dilated and contained eosinophilic secretions and foamy cells. Lining cells were small, cuboidal, and contained a moderate amount of eosinophilic cytoplasm and central nuclei. Mitotic figures (five to six per 10 high power fields) were seen. Myoepithelial cells were inconspicuous. The stroma was fibrous and unremarkable. Lymphocytes and plasma cells were present in the stroma. There were no areas of haemorrhage or necrosis. At the periphery, the tumour infiltrated into the surrounding smooth muscle of the nipple and underlying breast parenchyma. In the deeper portion, tumour ducts surrounded lactiferous ducts (Fig. 2). The deep resected margin was free of tumour. Staining for epithelial membrane antigen showed positivity limited to the luminal border of epithelial cells. S100 stained tumour-infiltrating Langerhans cells, leaving epithelial cells unstained (Fig. 3). Myoepithelial cells were conspicuously absent. Syringomatous adenoma of the nipple is a rare neoplasm. Its morphological features, namely tadpoleshaped ducts embedded in a fibrous stroma and keratotic cysts, are strikingly similar to syringoma of the skin. However, syringomatous adenoma of the nipple is a locally infiltrating neoplasm, often involving the smooth muscle of the nipple, underlying breast parenchyma and even nerves. Our case showed all the typical morphological features of syringomatous adenoma of the nipple, including origin from overlying epidermis, keratotic cysts and local infiltration. In addition, our case showed uncommon features like epithelial hyperplasia and Fig. 1 Scanner view of tumour showing connection between the tumour and overlying skin. Keratotic cysts are seen in the upper left quadrant (H&E, original magnification, 640).

Fine Needle Aspiration Cytology of Primary Extraskeletal Myxoid Chondrosarcoma

BACKGROUND Extraskeletal myxoid chondrosarcoma is a rare soft tissue tumor of the extremities. Since it usually lacks obvious chondroid differentiation on light microscopy, it needs to be distinguished from other myxoid soft tissue sarcomas. CASE REPORT The diagnosis of extraskeletal myxoid chondrosarcoma was made on fine needle aspiration in a patient with a swelling in the right calf. Cellular myxoid fragments having round to oval cells with grooved nuclei arranged in a cordlike pattern suggested chondroid differentiation. The diagnosis was confirmed by histopathology. CONCLUSION Fine needle aspiration cytology can be diagnostic of extraskeletal myxoid chondrosarcoma even in the absence of obvious chondroid differentiation.

Adult Wilms’ Tumor: Management Considerations

Adult Wilms’ tumor are rare tumors. Recommended treatment guidelines are similar to those followed for Wilms’ tumor of childhood. Presented herein is a case of an Adult Wlims’ tumor stage II favorable histology which failed to respond to the first line combination chemotherapy schedule of Cyclophosphomide, vincristine, and Actinomycin D. In view of similar such reports in the literature a more aggressive chemotherapy schedule of Cisplatin and Etoposide based combination may be recommended as the first line of treatment for Early stage Adult Wilms’ tumor.

ER, PR and Ki-67 expression status in granulomatous and chronic non-specific endometritis

Aim:  To study the changes in the histological pattern, distribution and intensity of sex steroid receptors (estrogen and progesterone) and cell proliferation by Ki‐67 expression by semi‐quantitative scores in granulomatous and chronic non‐specific endometritis in the premenstrual phase.

Eosinophils as a marker for invasion in cervical squamous neoplastic lesions.

To the Editor: We read with interest the article “Eosinophils as a marker for invasion in cervical squamous neoplastic lesions” by Spiegel et al. (1). Their study on stromal eosinophils associated with invasion in cervical squamous neoplasms suggesting that eosinophils may be used as surrogate marker for invasion prompted us to study 58 cervical lesions similarly. Thirty-two cases of squamous-cell carcinoma (30 of large cell nonkeratinizing type and 2 of keratinizing type) (Group I), 11 cases of cervical intraepithelial neoplasia (CIN) II and III (three with foci of microinvasion) (Group II), and 15 cases of chronic cervicitis with squamous metaplasia including two cases of CIN I (Group III) were analyzed for the presence and number of eosinophils as proposed by Speigel et al. (1). Leucocytes with brightly eosinophilic granules and bilobed nuclei were counted as eosinophils. Intravascular eosinophils were excluded from the counts. Scoring was performed at high dry magnification (×400) on Nikon Labophot 2 microscope (field area, 0.152 mm). Stromal eosinophils were present in 23 of 32 (71.8%), 3 of 11 (27.3%), and 4 of 15 (36.6%) cases in Groups I, II, and III, respectively; the 3 cases with eosinophils in Group II all had microinvasion. The differences between Groups I and II (p < 0.05) and between Groups I and III were statistically significant (p < 0.005). Stromal eosinophil scores were high in Group I, with up to 20 eosinophils/HPF. The scores for Group II and III were five eosinophils/HPF and two eosinophils/HPF respectively. Eosinophils 10 per 10 HPFs were seen in 19 of 23 (82.6%) cases of invasive carcinoma, 1 of 3 (33.3%) cases in Group II, and in none of the cases in Group III. The difference in stromal eosinophil density per 10 HPFs between Groups I and III was statistically significant (p < 0.005). The distribution of stromal eosinophils was focal and random. In cases of microinvasion, eosinophils were seen near the foci of invasion and occasional eosinophils infiltrated between tumor cells. Variable number of lymphocytes and plasma cells were present in all cases. Tumor-associated eosinophilia has been reported in a wide variety of malignancies (2), including carcinoma of cervix (2,3). Spiegel et al. have, however, highlighted the significance of eosinophils in high-grade squamous intraepithelial lesions (HSILs). Their proposal that stromal eosinophil counts 5 per HPF and 10 per 10 HPFs in cervical biopsy specimens should alert pathologists to exclude invasive carcinoma is appropriate. In our study, we also found that 5 eosinophils per HPF and 10 eosinophils per 10 HPFs correlated well with invasion. All the cases of chronic cervicitis/CIN I had a stromal eosinophil density significantly lower than in the other groups. More importantly, within Group II (CIN II and III), only the 3 cases with microinvasion had 5 eosinophils per HPF. These observations are similar to those reported by Speigel et al. We also agree that the presence of stromal eosinophils in cases of CIN II and III should initiate a diligent search for invasion with deeper sections and/or additional biopsies. The presence of eosinophils near areas of ulceration should be differentiated from stromal eosinophils. Increased number of stromal eosinophils have also been described in a variety of nonmalignant conditions such as parasitic infestations, topical applications, and prior surgical procedures (4). These associations should be excluded when evaluating the significance of stromal eosinophils in squamous neoplastic lesions of the cervix.

Osteosarcoma: Diagnostic dilemmas in histopathology and prognostic factors

Osteosarcoma (OS), the commonest malignancy of osteoarticular origin, is a very aggressive neoplasm. Divergent histologic differentiation is common in OS; hence triple diagnostic approach is essential in all cases. 20% cases are atypical owing to lack of concurrence among clinicoradiologic and pathologic features necessitating resampling. Recognition of specific anatomic and histologic variants is essential in view of better outcome. Traditional prognostic factors of OS do stratify patients for short term outcome, but often fail to predict their long term outcome. Considering the negligible improvement in the patient outcome during the last 20 years, search for novel prognostic factors is in progress like ezrin vascular endothelial growth factor, chemokine receptors, dysregulation of various micro ribonucleic acid are potentially promising. Their utility needs to be validated by long term followup studies before they are incorporated in routine clinical practice.

Cytologic Diagnosis in Benign Odontogenic Tumor with Abundant Calcification

BACKGROUND Calcifying cystic odontogenic tumor (CCOT) accounts for a mere 2-6.8% of odontogenic tumors. The cytologic features of this uncommon entity are not well characterized and may prove challenging in atypical smears, as in our case. CASE Fine needle aspiration biopsy (FNAB) was performed on a right cheek swelling in a 15-year-old girl. Smears showed numerous polyhedral epithelial cells and occasional columnar cells with calcification and Congo red-negative extracellular homogenous material in the background. The initial diagnosis of CCOT on cytology was confirmed subsequently by histopathologic examination of the excision specimen. CONCLUSION Absence of the characteristic ghost cells or basaloid cells as in our case presents an atypical microscopic picture that may be misdiagnosed as other epithelialodontogenic tumors with calcification. Correlation with clinicaland radiologic information is important in interpretation of FNAB of odontogenic tumors.

Spectrum of cytomorphology of tuberculous lymphadenitis and changes during anti-tubercular treatment

Objective:  To analyse the morphological changes in tuberculous lymph nodes and the clinical response during short course anti tubercular chemotherapy.

Case report: Malignant phyllodes tumor of prostate.

Malignant phyllodes tumor of prostate is described in a 78 year old man. He had symptoms of prostatism since six months before developing acute urinary retention, which was relieved by suprapubic cystostomy. Transabdominal ultrasonography showed a few hypoechoic areas in a 120 gm prostate. Serum prostate specific antigen was 2.7 ng/ml. Transrectal trucut biopsy was inconclusive. With a diagnosis of benign hyperplasia of prostate. Transvesical prostatectomy was performed. Postoperative biopsy showed phyllodes tumor of the prostate with metastastic deposits in the anterior abdominal wall. He received chemotherapy with Vincristine, Mitomycin C, Adriamycin and Cisplatin every 21st day for six cycles in addition to orchiectomy. Routine follow up by transabdominal ultrasound at ten months showed space occupying lesions in the liver. Patient succumbed to his disease a few days later.

Expression of estrogen receptor β and Ki 67 in benign & malignant human prostate lesions by immunohistochemistry.

Estrogen regulates the growth of prostate through two receptors Estrogen receptor α & β of which ERβ is proposed to be antiproliferative. There is a wide variation in the results of various studies regarding the localisation, level of expression of ERβ in benign & malignant lesions of prostate and its relation to the grade of tumor emphasizing the need for additional studies to standardize the distribution of this receptor in prostate. This was a prospective study conducted in Department of Pathology, UCMS, Delhi, evaluating ERβ & Ki 67 immunoexpression in 60 cases of benign and malignant lesions of prostate (30 each). Tissue for study included prostatic core biopsy and TURP chips. After histomorphological diagnosis, immunohistochemical staining was performed using a monoclonal antibody. Nuclear expression of ERβ & Ki67 was evaluated and compared between the two study groups (benign & malignant lesions) using Pearson chi square test. ERβ was predominantly localized to nuclei of secretory epithelium of prostatic glands. Expression of ERβ was higher in benign glands compared to carcinoma. However, majority of carcinomas retained ERβ expression though at much lower levels. Expression of Ki 67 was higher in carcinoma than benign hyperplasia. There was no correlation between the ERβ status, Ki 67 expression & grade of tumor. Expression of ERβ is downregulated in carcinoma compared to benign hyperplasia and is consistent with its chemopreventive role in prostate. It might have a therapeutic implication as agonists’ targeting this receptor could be a part of treatment protocol for those patients of carcinoma who retain this receptor at significant levels.