Ritika Walia

Intralesional radiofrequency ablation for nodular angiolymphoid hyperplasia on forehead: a minimally invasive approach.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an idiopathic acquired condition characterized by erythematous papulo-nodular lesions with a predilection for the head and neck. The lesions are cosmetically disfiguring, resistant to most medical and surgical therapies and tend to recur. We report the novel use of radiofrequency equipment in the management of nodular ALHE on forehead of a 53-year-old man. Intra-lesional radiofrequency ablation was done using a modified 18 gauge intravenous cannula and three sittings over a period of four years yielded cosmetically acceptable results with no recurrence and minimal side effects.

Evaluation of epidermal growth factor receptor mutations based on mutation specific immunohistochemistry in non-small cell lung cancer: A preliminary study

Background & objectives: Studies have shown that immunohistochemical (IHC) staining using epidermal growth factor receptor (EGFR) mutation specific antibodies, is an easy and cost-effective, screening method compared with molecular techniques. The purpose of present study was to assess the percentage positivity of IHC using EGFR mutation specific antibodies in lung biopsy samples from patients with primary lung adenocarcinoma (ADC). Methods: Two hundred and six biopsies of primary lung ADC were subjected to EGFR mutation specific antibodies against del E746-A750 and L858R. Detection of EGFR mutation done by high resolution melting analysis (HRM) was used as gold standard. A concordance was established between molecular and IHC results. Frequency of IHC positivity was assessed. Results: Of the 206 patients, 129 were male and 77 were female patients, with a mean age of 54.1 yr. Fifty five (26.6%) patients (36 men; 19 women) showed positivity for IHC of del E746-A750 (33) and L858R (22). HRM results were available in 14 patients which showed EGFR mutations in correspondence with del E746-750 or L858R in 64.2 per cent cases. Positive cases on HRM were further confirmed by DNA sequencing and fragment analysis. Three patients showed exon20 variation. Two cases were negative for mutation. The genotype of del E746-750 mutation was more common than L858R. A concordance was established between molecular mutation and IHC in 85.7 per cent cases. Interpretation & conclusions: In this preliminary study from India mutation specific IHC was used for assessment of mutation status of EGFR. Although the number tested was small, a good concordance was observed between molecular EGFR mutation and IHC expression. IHC methodology is a potentially useful tool to guide clinicians for personalized treatment in lung ADC, especially where facilities for molecular analysis are not readily available and for use in small biopsies where material is scant for molecular tests.

Diagnostic utility of conventional transbronchial needle aspiration without rapid on-site evaluation in patients with lung cancer.

Background: Endobronchial involvement is frequently absent in many patients with bronchogenic carcinoma. Malignant involvement may be confined to lymph nodes/peribronchial locations only or may be present along with endobronchial lesions. Transbronchial needle aspiration (TBNA) is a flexible bronchoscopic technique which can be employed to obtain tissue samples from mediastinal lymph nodes or peribronchial locations. Although a safe and cost effective bronchoscopic modality, it is frequently underutilized owing to concerns regarding its diagnostic utility and safety. Herein, we describe our experience over 1 year on the diagnostic utility of TBNA without rapid on-site evaluation (ROSE) in patients with suspected diagnosis of lung cancer. Materials and Methods: We retrospectively reviewed the cases in which conventional TBNA-without ROSE was performed for suspected lung cancer, between January 2012 and December 2012. Each lymph node station from which aspiration was performed was sampled thrice and smears were prepared on slides which were later examined by a cytopathologist. Results: Twenty-six cases were retrieved in which conventional TBNA without ROSE for suspected lung cancer with mediastinal involvement was performed during the study period. Adequate lymph node sampling could be achieved in 57.7% cases. Conventional TBNA was diagnostic in 11 out of the 26 (42.3%) patients. The diagnostic yield improved to 73.3% in patients in whom an adequate lymph nodal sample could be obtained. TBNA was the sole diagnostic sample in six (54.5%) patients. Alternative diagnoses (sarcoidosis and tuberculosis) were obtained in two patients. Conclusion: Conventional TBNA without ROSE is a safe and efficacious flexible bronchoscopic procedure which should be performed routinely from bronchoscopically accessible locations in patients with a suspected diagnosis of lung cancer.

Utility of conventional transbronchial needle aspiration with rapid on-site evaluation (c-TBNA-ROSE) at a tertiary care center with endobronchial ultrasound (EBUS) facility

Background: Conventional transbronchial needle aspiration (c-TBNA) is an underutilized bronchoscopic modality. Endobronchial ultrasound (EBUS) guided-TBNA though efficacious is an expensive modality, facilities of which are available at only limited centers. c-TBNA is cost-effective and has potential for wide utilization especially in resource-limited settings. Rapid on-site evaluation (ROSE) improves the yield of c-TBNA. Materials and Methods: A retrospective review of the bronchoscopy records (May 2012 to July 2014) was performed. The patients who underwent c-TBNA with ROSE were included in the study and their clinical details were extracted. Convex probe EBUS-TBNA was being regularly performed during the study period by the operators performing c-TBNA. Results: c-TBNA with ROSE was performed in 41 patients with mean age of 42.4 (16.2) years. The most frequently sampled node stations (>90% patients) were the subcarinal and lower right paratracheal. Representative samples could be obtained in 33 out of the 41 patients (80.4%). c-TBNA was diagnostic in 32 [tuberculosis (TB)-8, sarcoidosis-9, and malignancy-15] patients out of the 41 patients. The overall diagnostic yield (sensitivity) of c-TBNA with ROSE was 78%. Mean procedure duration was 18.4 (3.1) min and there were no procedural complications. Conclusion: c-TBNA with ROSE is a safe, efficacious, and cost-effective bronchoscopic modality. When it was performed by operators routinely performing EBUS-TBNA, diagnostic yields similar to that of EBUS-TBNA can be obtained. Even at the centers where EBUS facilities are available, c-TBNA should be routinely performed.

Spindle Cell Melanoma: A Comparison of the Cytomorphological Features with the Epithelioid Variant

Objectives: Fine-needle aspiration cytology serves as a rapid and cost-effective tool for the diagnosis of melanoma, especially in the recurrent and metastatic cases. The diagnosis poses a challenge due to the varied morphological patterns. Spindle cell melanoma mimics other sarcomas and carcinomas on morphology. This study highlights the cytomorphological features of spindle cell melanoma and compares them with the conventional epithelioid type. Study Design: Cytology smears of 55 aspirates from 45 diagnosed cases of melanoma from various sites were reviewed. Histopathology correlation was done in spindle and mixed cell tumors. Results: Melanomas with a pure or mixed spindle cell component occurred in 31% of the cases and in a slightly higher age group. These demonstrated prominent cellular cohesion (p < 0.0001), mild to moderate nuclear atypia and inconspicuous to small nucleoli as compared to the epithelioid variant. The presence of melanin pigment was a useful clue to the diagnosis. Most of the cases correlated well with the histomorphology. Conclusion: Spindle cell melanoma is a morphological variant which can be readily misinterpreted due to a lack of classical cytological features of melanoma. Hence, these are vulnerable to be misinterpreted as other neoplasms. An awareness of clinical and cytological features is important to reach the correct diagnosis.

Occult breast primary malignancy presenting as isolated axillary lymph node metastasis - early detection of primary site by 18F-FDG PET/CT.

Breast cancer patients rarely present with isolated axillary lymph node metastasis without any clinical or radiological evidence of primary tumor. Identification of the primary site of tumor helps in planning appropriate patient management which has definite impact on patients survival. We present here a case of 30-year-old female who presented with isolated right axillary lymph node metastasis with no evidence of primary tumor clinically. Conventional imaging modalities were negative for primary site. She underwent whole body 18F-Flurodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) and it contributed significantly in early detection of occult primary tumor in right breast.

Diesel siphoner's lung: Exogenous lipoid pneumonia following hydrocarbon aspiration

Lipoid pneumonia is an unusual and uncommon form of pneumonia caused by aspiration of fatty substances. Hydrocarbon pneumonitis following aspiration of diesel is a form of exogenous lipoid pneumonia wherein, aspirated diesel reaches the alveoli rapidly without evoking any significant cough, but initiates an intense inflammatory reaction in the pulmonary parenchyma. This is a rarely described clinical scenario, although the practice of diesel siphonage from automobiles is a common practice in developing countries. We herein describe a 40-year-old male patient, in whom the diagnosis of lipoid pneumonia was delayed for a long duration and highlight the importance of taking a detailed occupational exposure history in patients with non-resolving pneumonia to rule out the underlying possibility of this rare clinical entity.

Metastatic retinoblastoma of mandible diagnosed on fine needle aspiration cytology.

activity. Because the majority of these flagellate protozoa are un-cultivable and molecular studies are costly, with the need for specialized personnel that are within reach of all laboratories, the observation under light microscope based on morphological features continues to be a simple, practical and inexpensive procedure in order to identify these eukaryotic microorganisms in respiratory secretions.

p40 & thyroid transcription factor-1 immunohistochemistry: A useful panel to characterize non-small cell lung carcinoma-not otherwise specified (NSCLC-NOS) category

Background & objectives: Accurate histopathological subtyping of non-small cell lung carcinoma (NSCLC) is essential for targeted therapeutic agents. Immunohistochemistry (IHC) is helpful in identification of different tumour subtypes. In this study two marker approaches, one each for glandular and squamous cell differentiation was applied to maximize the proportion of accurately subtyped NSCLC not otherwise specified (NOS) tumours on small biopsy samples. Methods: Two hundred and sixty three consecutive lung biopsies of primary lung carcinoma were prospectively studied. These were subtyped first morphologically and then by IHC for p40 and thyroid transcription factor-1 (TTF-1). The diagnosis of NSCLC-NOS before and after addition of IHC was evaluated. Results were correlated and validated with morphologically proven cases and matched surgical specimens. Results: Based on morphology, only 140 of the 263 (53.2%) cases of NSCLC were characterized, whereas 123 (46.7%) were classified as NSCLC-NOS type. With addition of IHC (p40 and TTF-1), the latter category reduced to 14.4 per cent and a sum of 225 (85.5%) cases were accurately subtyped into squamous cell carcinoma, adenocarcinoma and adenosquamous carcinoma. p40 showed 100 per cent sensitivity and specificity for squamous differentiation whereas TTF-1 showed sensitivity of 85.3 per cent and specificity of 98.1 per cent. Ninety per cent correlation of morphologic subtypes was achieved with matched resected specimens. Interpretation & conclusions: Our results showed that an approach of using only a two-antibody panel (p40 and TTF-1) might help in reduction of diagnostic category of NSCLC-NOS significantly and contribute in saving tissue for future molecular testing.

Xanthoma disseminatum associated with inflammatory arthritis and synovitis--a rare association.

Xanthoma disseminatum (XD) is a rare, benign, non‐Langerhans cell histiocytosis characterized by disseminated xanthomatous lesions with a predilection for the face, flexures, and mucosae. Approximately 100 cases have been reported in the literature. We report XD in an 8‐year‐old boy with symmetric synovitis and arthritis involving the wrists and knees. This case is interesting in view of the association between arthritis and synovitis and XD, which to our knowledge has not been reported in the literature. This case has to be differentiated from multicentric histiocytosis, another non‐Langerhans cell histiocytosis, in which joint involvement is common.