Saniya Sharma

Effect of steroids on the activation status of platelets in patients with Immune thrombocytopenia (ITP)

Abstract The activation status of platelets in Immune Thrombocytopenia (ITP) patients – which is still somewhat controversial – is of potential interest, because activated platelets tend to aggregate (leading to excessive clotting or thromboembolic events) but cannot do so when platelet numbers are low, as in ITP. Although corticosteroids are the first line of therapy in ITP, the effect of steroids on activation of platelets has not been evaluated so far. We examined the status of platelet activation (with and without stimulation with ADP) in ITP patients, at the start of therapy (pre-steroid treatment, naive) and post-steroid treatment (classified on the basis of steroid responsiveness). We used flow cytometry to evaluate the levels of expression of P-selectin, and PAC-1 binding to platelets of 55 ITP patients and a similar number of healthy controls, treated with and without ADP. We found that platelets in ITP patients exist in an activated state. In patients who are responsive to steroids, the treatment reverses this situation. Also, the fold activation of platelets upon treatment with ADP is more in healthy controls than in ITP patients; treatment with steroids causes platelets in steroid-responsive patients to become more responsive to ADP-activation, similar to healthy controls. Thus steroids may cause changes in the ability of platelets to get activated with an agonist like ADP. Our results provide new insights into how, and why, steroid therapy helps in the treatment of ITP.

Amelioration of collagen antibody induced arthritis in mice by an antibody directed against the fibronectin type III repeats of tenascin-C: Targeting fibronectin type III repeats of tenascin-C in rheumatoid arthritis

&NA; Tenascin‐C (TN‐C) levels are elevated in the synovial tissue and fluid, as well as cartilage of rheumatoid arthritis (RA) patients. In addition, the presence of TN‐C fragments has also been documented in arthritic cartilage. We have previously shown that a single chain variable fragment antibody (TN64), directed against the fibronectin type III repeats 1–5 (TNfnIII 1–5) of TN‐C, effectively inhibits fibrotic pathology. Given that fibrosis results from chronic inflammation, and the fact that increased levels of TN‐C in the synovial fluid of patients with RA contributes to synovial inflammation and joint destruction, we aimed to investigate the role of TNfnIII 1–5 region of TN‐C in RA pathogenesis. Using either the wild type or variants of the two integrin‐binding motifs (RGD and AEIDGIEL) present within the TNfnIII 1–5 polypeptide, we demonstrate that the adhesion and migration of synovial fibroblasts is RGD‐dependent. The antibody TN64 is effective in inhibiting migration of cells in response to TnfnIII 1–5, and prevents fibroblast‐mediated destruction of cartilage. The TN64 antibody was further tested in collagen antibody induced arthritic (CAIA) mice. Our data shows the efficacy of TN64 in preventing induction of arthritis, with significant downregulation of RA‐associated cytokines. This suggests that components of the extracellular matrix such as the TNfnIII 1–5 region of TN‐C could be exploited to develop therapies to suppress inflammation seen in RA. The TN64 antibody is one such promising candidate in the development of novel treatments for RA.

Cytomorphological features as predictors of epidermal growth factor receptor mutation status in lung adenocarcinoma

Background: Epidermal growth factor receptor mutation-positive (EGFR-p) lung adenocarcinomas are sensitive to tyrosine kinase inhibitors. Although histopathological subtype is an independent predictor of mutation status, there is a paucity of data on the cytomorphological features correlating with the EGFR mutation status. Therefore, the aim of this study was to determine whether certain cytomorphological features correlate with EGFR mutation in lung adenocarcinoma. Materials and Methods: A retrospective analysis of 48 lung adenocarcinoma cases diagnosed on fine needle aspiration cytology with known EGFR mutation status was conducted. All cytology smears with cellblock sections were reviewed. The cytomorphological features including tumor pattern, stromal features, nuclear and cytoplasmic features, and tumor grade were evaluated. Clinicoradiological features such as age, sex, smoking, tumor size, clinical stage, metastases, and presence of mass, nodule, lymphadenopathy, pleural effusion, and clinical outcome were also assessed. Results: Of 48 cases, 19 were EGFR-p and 29 were negative. EGFR-p cases showed a positive and significant correlation with flat monolayered sheets and acini, mild nuclear atypia, fine chromatin and smooth nuclear margins and these tumors were well differentiated. EGFR-negative tumors were moderate to poorly differentiated with predominance of solid clusters, moderate to marked nuclear atypia, with irregular nuclear margins and coarse chromatin. Clinically, female sex, nonsmoking status, smaller tumor size, and good clinical outcome correlated with EGFR-p status. Conclusion: Certain cytomorphological features correlate with and may suggest EGFR mutation status in advanced lung adenocarcinoma in an appropriate clinical context.

Primary giant cell tumor of the female breast: a diagnostic red herring with therapeutic implications

Primary giant cell tumor of the female breast is extremely rare. Major diagnostic difficulty is encountered not only by the surgeon but also by the radiologist and pathologist. Pathologically, it is similar to the bone and soft tissue counterparts. However, this is not always true. We describe a patient presenting clinically as cystosarcoma phyllodes and histopathological examination revealed a primary giant cell tumor which was confirmed by immunohistochemistry and electron microscopy. Interestingly, an intimate relationship between the mononuclear component of the tumor cells with eosinophils and mast cells was observed electron microscopically.

Gangliocytic Paraganglioma With Atypical Immunohistochemical Features Presenting as Extrahepatic Biliary Obstruction

Gangliocytic paraganglioma is a rare benign tumor of upper gastrointestinal tract that most commonly involves the second part of duodenum. The tumor is detected incidentally on imaging in most of the cases. However, presentation with extrahepatic biliary obstruction is extremely rare. We recently encountered a 50-year-old male patient who was evaluated for extrahepatic biliary obstruction and was found to have a periampullary mass on imaging. The patient underwent pylorus-preserving pancreaticoduodenectomy along with liver biopsy and hepatoduodenal lymph node dissection. On histopathological examination, a tumor was detected in the periampullary region of duodenum, which was confirmed to be gangliocytic paraganglioma on immunohistochemistry along with atypical histological and immunohistochemical features.

Acute leukemia / myelodysplastic syndrome as a sequelae of carcinoma breast: A report of five cases from north India

A second malignant neoplasm has been found to be more frequent than might be expected from the general population rates. Therapy-related myelodysplastic syndrome and acute leukemia are dreaded long-term complications of five cases of hematological malignancies following treatment for successful breast cancer therapy (therapeutic drugs or radiotherapy). We encountered carcinoma from north India over a 7-year period from 1999 to 2005. The patients presented 2-5 years after treatment of breast carcinoma. Three patients underwent surgery and received chemoradiotherapy. One patient received chemotherapy after surgery. One patient underwent only surgery and after 3 years presented with acute myeloid leukemia and bone marrow metastasis of carcinoma of the breast. At the time of presentation, all the patients had either bicytopenia or pancytopenia. A close follow-up with complete blood cell counts of the patients who previously had carcinoma of the breast is suggested for early detection of hematological abnormalities. However, the poor prognosis, limited financial resources and poor health insurance coverage results in few patients and their family members opting for treatment.

Blocking osteopontin-fibronectin interactions reduce extracellular fibronectin deployment and arthritic immunopathology

ABSTRACT Elevated levels of a thrombin‐cleaved fragment of osteopontin (OPNT) are seen in synovial fluid (SF) and tissues of rheumatoid arthritis (RA) patients. OPNT binds to integrins on cell surfaces, inducing adhesion, migration and survival of inflammatory cells in the synovial joints, where OPNT binds to fibronectin to link fibroblast‐like synoviocytes (FLS) with B cells, stimulating the latter to produce inflammatory cytokines. Our aim was to block OPNT‐fibronectin interactions and examine whether this reduces inflammation. A human antibody (phage displayed) library was used to select scFv antibodies cognate to OPNT, and a particular scFv antibody (scFv 31) was evaluated. Adhesion, migration and fibronectin polymerization of FLS cells derived from RA patients were monitored, in cultures incorporating scFv 31. Also, scFv 31 was used in mice with CAIA (collagen antibody‐induced arthritis), subjected to clinical and histological assessment, analysis of fibronectin and cartilage damage and induction of pro‐inflammatory cytokines. The scFv antibody, scFv 31, appeared to cause significantly reduced migration of synovial fibroblasts, altered cell morphology, changes in actin stress fiber arrangement, and marked reduction in fibronectin. In CAIA mice, scFv 31 appeared to prevent arthritic changes through inhibition of synovial hypertrophy and loss of articular cartilage, decrease in fibronectin polymerization and expression of pro‐inflammatory cytokines implicated in arthritis. Osteopontin‐fibronectin interaction(s) appear to play a role in the expression of key inflammatory molecules by B cells infiltrating the synovial joint. The scFv antibody, scFv 31, provides a potential therapeutic lead for inhibition of some processes implicated in rheumatoid arthritis. HighlightsA polypeptide corresponding to thrombin‐cleaved osteopontin (OPNT) was expressed.Phage display technology was used to make an scFv antibody (scFv 31) against OPNT.Antibody scFv 31 blocks osteopontin‐fibronectin interactions.Antibody scFv 31 alters B cell adhesion to fibroblasts and fibronectin deployment.Antibody scFv 31 reduces arthritic immunopathology.

Testicular Metastasis in Prostate Adenocarcinoma: a Rare and Incidental Diagnosis on Histopathology

Sir, Testicular metastasis is a rare phenomenon and occurs at a relatively older age compared to primary testicular tumors. Tumors showing testicular metastases include renal cell carcinoma, colonic carcinoma, transitional cell carcinoma, bronchogenic carcinoma and esophageal carcinoma [1]. Prostatic adenocarcinoma, though the most common malignancy in the males, rarely metastasises to the testes [1]. The morphology of the metastatic disease can be atypical, thus posing a diagnostic difficulty. Immunohistochemistry (IHC) plays an important role in confirming the diagnosis. We report a 62-year-old male who presented with bilateral lower limb deep venous thrombosis (DVT). On digital rectal examination, he was found to have a hard nodular prostate. On evaluation, serum PSAwas markedly elevated, i.e. 243 ng/ml (normal <4.5 ng/ml). Trans-rectal ultrasound (TRUS) guided prostatic biopsy revealed adenocarcinoma with a Gleason score of 9 (4 + 5). Contrast-enhanced computed tomography (CECT) of the pelvis revealed enlarged pelvic lymph nodes. He was put on warfarin (3 mg/day) for DVT. As a part of hormonal ablation, bilateral orchiectomy was planned. Clinically, both the testes were of normal size. Grossly, both the testes were of normal size and cut surface did not reveal any tumor deposits. However, microscopically, the right testis showed tumor cells arranged in the cribriform pattern, small glands, single cell infiltration and lymphovascular emboli (Fig. 1a). On IHC, the tumor cells were positive for PSA (Fig. 1b). Hence, a diagnosis of metastatic adenocarcinoma from prostate was confirmed. Testicular metastasis is an uncommon phenomenon with the lungs and kidneys being the most common primary sites. Rare primaries are the stomach, pancreas, urinary bladder and rectum. One of the factors hypothesised for this low incidence is the relatively low temperature of the scrotum [2]. Lioe and Biggard evaluated 85 testicular tumors and found that secondaries comprise 10 % of testicular tumors [3]. Garcia-Gonzalea R et al. found a 0.68 % incidence of metastases to the testes with solid malignant extragonadal neoplasms in their autopsy series of 738 males [4]. Prostatic adenocarcinoma though has a high frequency of dissemination, metastasis to the testes is extremely rare. Patel SR et al. in their study of 20 cases of testicular metastases, however, found prostate as the most common primary site [5]. This may be explained by a high percentage of therapeutic orchiectomy in their series as in our patient. Most cases are unilateral testicular metastasis occurring in the fifth to sixth decades of life and diagnosed incidentally at histopathology or autopsy with rare symptomatic presentation. Inaba Yet al. reported a case of testicular metastasis from prostatic adenocarcinoma presenting with scrotal swelling [6]. Persistent or recurrent urinary symptoms have also been reported. The testes are usually normal in bulk and shape, rendering difficult detection of tumor. The PSA levels are elevated in most cases though low levels do not exclude this diagnosis [7]. The most common mechanism postulated is invasion into lymphovascular spaces which also explains a high frequency of metastasis to the regional pelvic lymph nodes as in our case. * Uma Nahar Saikia umasaikia@gmail.com

A Long-Standing Primary Vaginal Paraganglioma—Coexisting with Esophageal Carcinoma

Sir, Paraganglioma is a rare neoplasm derived from the neural crest cells residing in the paraganglia of the autonomic nervous system. Primary vaginal paraganglioma is extremely rare. [1]. Herein, we present a unique case of a vaginal paraganglioma which was radiologically interpreted as a metastatic nodule in a young female, which is a known case of esophageal carcinoma. A 28-year-old married female presented with dysphagia to solid foods was diagnosed as having keratinizing squamous cell carcinoma of the lower esophagus on biopsy 5 years back. She received neoadjuvant chemoradiotherapy (NACRT). Post-NACRT PET-CT revealed moderate to intense FDG (flurodeoxyglucose) uptake with decline in SUV max to 6.7 indicating a favorable response to chemotherapy. However, PET-CT revealed an intense FDG-avid (SUV max = 20.9) homogeneous soft tissue lesion measuring 2.1 × 2.1 cm in the left lateral vaginal wall with well-maintained fat planes with the adjacent urinary bladder wall (Fig. 1a). On pervaginum examination, a firm, well-defined mass measuring 2 × 3 cm was noted along the middle one-third of the left lateral vaginal wall, though she did not have any gynecological complaints. Fine-needle aspiration cytology (FNAC) from the vaginal mass did not reveal any malignant cells, and the cells were interpreted as histiocytes. Following this, she underwent trans-hiatal esophagectomy which confirmed the diagnosis of keratinizing squamous cell carcinoma. Her follow-up PET-CT scan post-surgery showed similar FDG uptake in the vaginal mass, without any increase in its size. However, the most recent PET-CT scan showed increase in the FDG uptake. Contrast-enhanced computed tomography (CECT) showed the vaginal lesion to be heterogeneously enhancing soft tissue mass measuring 3.6 × 2 cm with increased vascularity and a clinical possibility of metastatic tumor deposit was favored. USGguided FNAC from the mass revealed predominantly blood along with few histiocytic collections (Fig. 1b). Finally, the mass was surgically excised and the vaginal wall was reconstructed. Grossly, it measured 3 × 3 cm and had a firm and brown-colored cut-surface. On microscopic examination, the tumor exhibited a classical Zellballen pattern comprising of nests and islands of tumor cells with a prominent intervening fibrovascular stroma (Fig. 1c). The tumor cells were large and polygonal shaped with fine-stippled chromatin, inconspicuous nucleoli, and abundant granular eosinophilic to clear cytoplasm with well-defined cell membranes. Tumor cell nests were bordered by few spindle-shaped sustentacular cells (Fig. 1a). At the periphery, the blood vessels were evenmore prominent and hyalinized. No mitosis or necrosis was noted. On IHC, the tumor cells were strongly positive for chromogranin (Fig. 1d), synaptophysin (Fig. 1e), neuron-specific enolase (NSE), and CD 56. S-100 protein highlighted the sustentacular cells (Fig. 1f), and pan-cytokeratin was negative. Based on these morphological features, a diagnosis of primary vaginal paraganglioma was made. Retrospective review of FNAC smears revealed few singly scattered tumor cells with round nuclei and abundant granular cytoplasm consistent with * Rashi Garg rashiigarg@gmail.com

Myeloperoxidase Deficient Acute Promyelocytic Leukemia: Report of Two Cases

Acute promyelocytic leukemia (APL) is characterized by the presence of ‘abnormal promyelocytes’ which show variable morphology but a characteristic strong myeloperoxidase (MPO) positivity on cytochemistry and immunohistochemistry (IHC). The characteristic morphology and cytochemistry is often considered as a strong evidence to make a morphological diagnosis of APL and often enough to prompt a haematologist to start all-trans-retinoic acid (ATRA), before a confirmatory molecular diagnosis arrives. We herein describe two cases of classical APL having an absent/reduced MPO activity.