Santosh Kumar Mondal

The Bethesda system for reporting thyroid fine needle aspirates: A cytologic study with histologic follow-up

Background: The Bethesda system for reporting thyroid cytopathology represents a major step towards standardization, reproducibility, improved clinical significance, and greater predictive value of thyroid fine needle aspirates (FNAs). Aims: To elucidate the utility of the Bethesda system in reporting thyroid FNAs. Materials and Methods: We retrospectively reviewed thyroid FNAs between April 2009 and March 2012, classified them using the Bethesda system, found out the distribution of cases in each Bethesda category, and calculated the malignancy risk for each category by follow-up histopathology. Results: Of the 1020 FNAs, 1.2% were non-diagnostic, 87.5% were benign, 1% were atypical follicular lesion of undetermined significance (AFLUS), 4.2% were suspicious for follicular neoplasm (SFN), 1.4% were suspicious for malignancy (SM), and 4.7% malignant. Of 69 cases originally interpreted as non-diagnostic, 12 remained non-diagnostic after re-aspiration. In 323 cases, data of follow-up histopathologic examination (HPE) were available. Rates of malignancy reported on follow-up HPE were non-diagnostic 0%, benign 4.5%, AFLUS 20%, SFN 30.6%, SM 75%, and malignant 97.8%. Conclusions: Reviewing the thyroid FNAs with the Bethesda system allowed a more specific cytological diagnosis. In this study, the distribution of cases in the Bethesda categories differed from some studies, with the number of benign cases being higher and the number of non-diagnostic and AFLUS cases being lower. The malignancy risk for each category correlated well with other studies. The Bethesda system thus allows standardization in reporting, improves perceptions of diagnostic terminology between cytopathologists and clinicians, and leads to more consistent management approaches.

Histologic pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms: A 10-year study in a tertiary hospital of eastern India

OBJECTIVE The aim was to study the distribution of morphological pattern of benign and malignant ovarian neoplasms in different age groups in eastern India and to determine the likelihood of bilateral involvement in different morphologic subtypes. MATERIALS AND METHODS 957 cases of ovarian tumors were studied over a period of 10 years (from January 2001 to December 2010). RESULTS Most of the benign tumors occurred between 20 and 40 years of age, while the malignant lesions presented commonly between 41 and 50 years. The most common histological types were serous cystadenoma (29.9%), followed by mature teratoma (15.9%) and mucinous cystadenoma (11.1%). Major proportion of malignant ovarian tumors was contributed by surface epithelial tumors (60.9%). Serous cystadenocarcinoma was the predominant malignant tumor (11.3%). Metastatic tumors were found to involve the bilateral ovaries in 72%, while 49.5% of malignant serous tumors were bilateral. Borderline serous tumors showed bilateral involvement more commonly (27.4%) than borderline mucinous tumors (15.7%). Most of the malignant tumors presented as stage III (60%) or stage II (20%) disease. The overall survival rate was 85% for stage I tumors, 65% for stage II, 30% for stage III and 15.5% for stage IV tumors. CONCLUSION We noted an earlier age at presentation of malignant tumors. Mature teratoma was found to be the second most common benign tumor (after serous cystadenoma). We also noted a lower percentage of endometrioid tumors. Lower number of stage IV tumors was noted, with a significant number of malignant ovarian tumors presenting at an earlier age.

Neonatal sepsis: Role of a battery of immunohematological tests in early diagnosis

Background and Objective: Worldwide, many neonates with sepsis die due to lack of early diagnosis. In this study we attempt to analyze the value of various immunological and hematological parameters, singly and in combination, for the diagnosis of neonatal sepsis, with the aim being to formulate guidelines for the early diagnosis of the condition. Materials and Methods: In this prospective study, 62 patients having clinical suspicion of neonatal sepsis were evaluated with a battery of investigations. Neonates admitted for other causes and without clinical suspicion of sepsis were selected as controls (n=40). The tests included blood culture, hemoglobin level, total and differential blood count, absolute neutrophil count, ratio of immature to total neutrophil count (I/T ratio), micro-erythrocyte sedimentation rate (m-ESR), C-reactive protein (CRP), platelet count, serum IgM level, and plasma fibrinogen level. Patients were divided into proven cases (positive blood culture) and probable cases (negative blood culture). Results: Positive blood culture was seen in 38 cases (61.3%). Raised m-ESR (>8 mm in the first hour) was seen in 63.2% of proven and 66.7% of probable cases. I/T ratio of ≥0.2 was seen in 63.2% and 58.3% of proven and probable cases, respectively. Morphological changes in neutrophils were detected in 68.4% of proven cases and 91.7% of probable cases. Positive CRP test (≥6 mg/l) was found in 84.2% of proven cases and 100% of probable cases. Raised serum IgM, leucopenia, and neutropenia were seen in a small number of patients (11%–37%). Raised fibrinogen level (>400 mg/l) was seen in patients as well as in controls. Conclusions: The four useful tests that we identified were m-ESR, I/T ratio, morphological changes in neutrophils, and CRP; and role of these tests in early diagnosis of neonatal sepis were statistically significant (P<.05). The most sensitive test was CRP (84%) and the most specific test was m-ESR (94%). A combination of three or all of these four tests was highly specific (95%–100%).

High-grade plasmablastic neoplasm of humerus in an HIV-negative patient, which was indeterminate between plasmablastic lymphoma and plasmablastic myeloma

Plasmablastic lymphoma (PBL) of bone is a rare neoplasm that shares many confusing cytomorphological and immunohistochemical features with plasmablastic plasma cell myeloma (PBPCM). A 47-year-old female patient presented with a bony swelling and bone pain in the left humerus for the last 6 months. On radiological examination (x-ray and computed tomography) it appeared to be a lytic lesion, and a pathological fracture was detected. The patient was HIV-negative. Fine needle aspiration (FNA) was done from the lesion, which was inconclusive. Subsequently, incisional biopsy was taken. Histopathological examination and immunohistochemistry confirmed a high-grade plasmablastic neoplasm, favoring a diagnosis of PBL. Most of the reported cases of PBL have occurred in HIV-positive patients, and the bone is a very rare site. PBL can be confused with PBPCM. A final diagnosis should be rendered only after thorough histopathological and immunohistochemical examination.

Signet ring cell carcinoma of gallbladder with celiac lymph node metastasis in a young man.

Gall bladder cancer is uncommon and histologically most of these are adenocarcinomas. Signet ring cell carcinoma is a rare malignancy of gallbladder. Only few cases of this histologic type have been published and detailed knowledge of this disease is not available. Here, signet ring cell carcinoma of the gallbladder in a 32-year-old man is being reported. The patient had metastasis in the celiac group of lymph nodes at the time of diagnosis. The patient underwent radical surgery, followed by chemotherapy but succumbed to the illness two months post-operatively. Newer treatment modalities and advanced information may improve the prognosis of the disease.

Malignant lymphoma in Eastern India: A retrospective analysis of 455 cases according to World Health Organization classification

Background: Malignant lymphoma (ML) is one of the most common cancers and is most prevalent in developed countries. The distribution of different subtypes of ML varies in the different geographical locations according to World Health Organization (WHO) Classification. Aims and Objectives: The study was aimed to analyze the different patterns of ML in Eastern India and to compare it with other geographical locations. Materials and Methods: Four hundred and fifty five patients of two large hospitals in Eastern India were included over a period of four years and were categorized according to WHO classification, using the morphology and immunohistochemistry. Results: There were 347 (76.3%) non Hodgkin lymphomas (NHL), and 108 (23.7%) Hodgkin lymphomas (HL). Diffuse large B-cell lymphoma was the most common of the NHL type (35.2%) followed by the follicular lymphoma (19.3%). B-cell lymphoblastic lymphoma was the least common type of NHL (1.4%). Mixed cellularity (33.3%) and nodular sclerosis (26.9%) were the two most common type of HL. Childhood lymphoma comprised of 12.5%of all ML. T-cell NHL and HL were the common lymphomas in this age group. Conclusion: Incidence of follicular lymphoma is lower compared to western studies and mixed cellularity is the most common subtype of HL unlike nodular sclerosis subtype in Western world. Burkitts type NHL though is the most common subtype of childhood ML in many studies. However, in our study, T-cell NHL is the most common type of childhood ML.

Follicular dendritic cell sarcoma of the tonsil

Follicular dendritic cells (FDCs) are non-phagocytic, non-lymphoid cells of immune system, which are necessary for antigen presentation and regulation of the reactions in the germinal centers of lymph node. Follicular dendritic cell sarcoma (FDCS) is unusual and those with an extranodal origin in the head and neck region are extremely rare. Here, we report a case of FDCS of the left tonsil in a 27-year-old male patient. The patient presented with swelling of the left tonsil and resultant difficulty in swallowing for last three months. The tumor was excised and was sent for histopathologic examination. Microscopic examination and immunohistochemical analysis proved the case to be FDCS. After the diagnosis, the patient received post-operative radiotherapy. The patient is on six months follow-up which is uneventful.

Prevalence of thalassemia and hemoglobinopathy in eastern India: A 10-year high-performance liquid chromatography study of 119,336 cases

Background: Hereditary hemoglobin (Hb) disorders are the most commonly encountered single gene disorders in India. Proper timely identification of these disorders is of paramount importance to prevent thalassemia major and clinically severe hemoglobinopathy as well as for epidemiologic purposes. Aims: Our aim was to determine the prevalence of thalassemia and hemoglobinopathy in patients of a tertiary care hospital of West Bengal, India. Materials and Methods: This prospective study was conducted on 119,336 cases over a period of 10 years. After taking clinical history and familial history, complete hemogram report was obtained by an automated cell counter. High-performance liquid chromatography (HPLC) was performed on the samples with Bio-Rad Variant using beta thalassemia short program. Confirmatory tests were performed whenever required. Results: A normal Hb pattern was observed in 104,804 (87.83%) cases and abnormalities were detected in 14,532 (12.17%) patients. β (beta) thalassemia trait was the commonest abnormality found in 5,488 (4.60%) patients. HbE trait was found in 3,604 (3.02%) patients, β thalassemia major/intermedia in 1,981 (1.66%) cases, and Eβ thalassemia in 1,384 (1.16 %) cases. Other variants detected included HbE disease, sickle-cell disease, sickle β thalassemia, HbD-Punjab trait, HbQ-India trait, α-thal trait, double heterozygous state of HbS and HbE, double heterozygous state of HbS and HbD, HbJ-Meerut, hereditary persistence of fetal hemoglobin (HPFH), HbH, delta β-thal trait, and Hb Lepore. Conclusion: In view of the high prevalence of hemoglobinopathy in this region, a routine premarital screening program is needed for the identification and prevention of high-risk marriages and thus, prevention of the psychosocial trauma of bearing a transfusion-dependent child for life.

Histopathological study of adrenocortical carcinoma with special reference to the Weiss system and TNM staging and the role of immunohistochemistry to differentiate it from renal cell carcinoma.

BACKGROUND Adrenocortical carcinomas (ACC) are rare tumors with an incidence of 1-2/million/year. They account for 0.05-0.2% of all malignancies. AIMS AND OBJECTIVES This study was aimed to evaluate the Weiss system to diagnose ACCs and to compare it with TNM staging. The role of immunohistochemistry (IHC) was also evaluated to differentiate ACC from other differential diagnoses especially, renal cell carcinoma (RCC). MATERIALS AND METHODS A total of 10 ACCs were included from April, 2000 to March, 2012. All the relevant information like weight, tumor size, gross features was recorded. Multiple sections were taken for histologic examination. Immunomarkers like vimentin, synaptophysin, Melan-A, calretinin, inhibin, EMA, cytokeratin, and Ki-67 were used. RESULTS Out of 10 cases of ACCs (diagnosed by the Weiss system), the tumors were in TNM stage I (1 case), stage II (2 cases), stage III (5 cases), and stage IV (2 cases). The Weiss score in stages I-IV was 4; 5-7; 6-8; and 5-9 respectively. ACCs were positive for vimentin, inhibin, Melan-A, calretinin and negative for EMA and cytokeratin. Proliferative index (Ki-67/MIB-1) was ≥ 20 % (20-65%). CONCLUSION Both the Weiss system and TNM staging are useful in predicting the malignant behavior and prognosis of ACC. Weight and tumor size, though originally not included in the Weiss system, are also important parameters. In lower stages (stages I and II), the Weiss score is low (4-7) while the score is high (6-9) when the tumor is in higher stages (stages III and IV). IHC plays a vital role to confirm the diagnosis and to exclude the possibility of RCC.

Chondrosarcoma of the distal phalanx of the right great toe: Report of a rare malignancy and review of literature

Foot is an uncommon site for chondrosarcoma and involvement of phalanges is extremely rare. Here, a case of low-grade chondrosarcoma of the distal phalanx of the right great toe in a 37-year-old male patient is being reported. The patient complained of gradual swelling of the right great toe and pain for last 2 years. X-ray showed a lytic lesion destroying the distal phalanx with soft tissue extension. Amputation of the great toe was done and specimen was sent for histopathological examination. Microscopical examination revealed grade 1 chodrosarcoma infiltrating the surrounding soft tissue and muscle. The patient is on 1-year follow-up which is uneventful.