Sarla Agarwal

Solid tumors of childhood.

Objective : Cancer is one of the leading causes of death in children. There is the need to have the histologic review of malignancies in children from the Indian sub–continent.Methods : In the present study, malignant tumors received over 12 years were reviewed and re–classified according to classifications based on prognosis.Results : A total of 472 tumors were received over 12 years. Of these 318 were benign and 154 malignant. The commonest malignant solid tumor was lymphoma followed by pediatric renal tumors. The sarcomas included bone tumors, Rhabdomyosarcoma and synovial sarcoma. There were 13 germ cell tumors, 10 retinoblastomas and six neuroblastomas.Conclusion: The review revealed that a definite diagnosis or classification was not assigned in 21 cases in the original reporting. Of these 14 could be assigned a definite category on review and immuno-staining. These included five non-Wilms sarcomas, four Rhabdomyosarcomas, three Ewing’s sarcoma/ PNETs and two Synovial sarcomas. The study also revealed an unexpected high percentage (11%) of epithelial malignancies in children

Malignant chondroid syringoma.

Malignant chondroid syringoma (MCS) is a rare tumor, of the sweat gland; only a few hundred such cases are reported in literature. A female presented with a subcutaneous swelling on the scalp with repeated recurrence and positive regional lymph nodes. Adequate planning for the treatment of this case was possible as preoperative diagnosis of MCS was documented by fine needle aspiration cytology (FNAC). The case was successfully managed with a multimodal approach, which included radical surgery and subsequent radiotherapy. The patient is symptom free after 25 months. The possibility of this type tumor should be entertained when multiple recurrences occur following adequate excision. FNAC has a definitive role in planning rational therapy.

Fine Needle Aspiration Cytology of Malignant Chondroid Syringoma

BACKGROUND: Chondroid syringoma, a tumor of the eccrine glands, was previously called mixed tumor of skin as it has both mesenchymal and epithelial elements. Malignancy in this tumor is extremely rare. Although there are a few reports describing the cytomorphologic features of chondroid syringoma, the cytologic findings of its malignant counterpart have not been described. CASE: A 40-year-old female presented with a recurrent swelling on the scalp of one years duration. Fine needle aspiration yielded blood-mixed gelatinous material. May-Grunwald-Giemsa-stained smears showed epithelial cells arranged in cordlike structures and ill-formed glands against a myxomatous background. The epithelial cells had scanty cytoplasm and markedly pleomorphic nuclei with prominent nucleoli. Afew cells in the stroma had a halo around them and a resemblance to cartilage cells. A preoperative diagnosis of malignant chondroid syringoma was made. The tumor was excised, and the cytologic diagnosis was confirmed on histopathology. CONCLUSION: Cytomorphologic features of a rare case of malignant chondroid syringoma are reported for the first time. The presence of malignant epithelial cells against a myxoid background with a few chondroid foci helped in making a correct preoperative diagnosis.

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).

Extra-nodal Small Cell Lymphocytic Lymphoma of Prostate: An Unusual Cause of Lower Urinary Tract Symptoms

Malignant lymphoma of the prostate is a rare occurrence. We describe a case of 60-year-old man presenting with acute urinary retention due to small cell lymphocytic secondary lymphoma of the prostate. We present the clinical manifestation of the disease emphasizing that all lower urinary tract symptom (LUTS) cases should be evaluated for the potential that metastatic cancers or lymphomas may present with such a diagnosis. We also present and tabulate a detailed review of at least 5 such similar reports (in which LUTS was the presenting symptom) published in the English literature to date.

‘Quick Course’ Neoadjuvant Chemotherapy with Cisplatin, Bleomycin and Vincristine in Advanced Cervical Cancer

To evaluate the response and safety of ‘quick course’ neoadjuvant chemotherapy, 30 patients with advanced squamous cell carcinoma of cervix were given cisplatin, bleomycin, and vincristine weekly for 3 courses. The response was evaluated by subjective parameters and by standard response criteria. In addition to the marked improvement in symptoms, the overall objective response was 60% with a complete pathological response of 6.6%. Tumor volume decreased significantly (p = 0.002) after chemotherapy. Patients with stage IB and 27% (3 of 11) of patients with stage II disease who became technically stage IB (stage reduction) after chemotherapy underwent surgery. Radiotherapy was given to the remaining patients. All patients tolerated the chemotherapy.

Profile of gynecologic malignancies reported at a tertiary care center in India over the past decade: Comparative evaluation with international data

OBJECTIVE Comprehensive statistics on gynecologic malignancies reported from India are deficient. This study was performed to ascertain the profile of gynecologic cancers reported at our center regarding incidence, histologic subtypes, frequency of involvement at various sites and stage at presentation. We endeavored to compare our data with gynecologic cancers reported at other national and international centers. MATERIALS AND METHODS Retrospective review of records of gynecologic cancers obtained from Departments of Pathology and Gynecology, at a tertiary care center, Delhi from January 2000 to December 2009 was performed. Comparison with international data was performed using Fishchers exact test and chi square tests. RESULTS A total of 1315 gynecologic cancers were reported. Cervical malignancies were the commonest at our center as compared to uterine malignancies in data from Surveillance, Epidemiology, and End Results (SEER) Program of United States and European Union. All malignancies except cervical cancers affected a younger age group at our center than in the US population. Cervical cancer presented at a relatively more advanced stage, ovarian cancers at more localized stages, whereas uterine cancers presented at similar stages as compared to Western data. CONCLUSIONS Our registry presents composite data from North India. Higher age and advanced stage at presentation of cervical cancers suggests lacunae in screening programs available. Ovarian malignancies were more localized at presentation than in the Western population for which environmental or genetic factors may be causative.

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.

Role of newer methods of diagnosing genital tuberculosis in infertile women.

Genital tuberculosis is an important under-diagnosed factor of infertility. A vast majority of cases are asymptomatic and diagnosing them will help in treating such patients. We conducted a retrospective study in a tertiary care hospital of Delhi with an aim to compare different methods i.e., histopathological examination (HPE), acid-fast bacilli (AFB) smears, Lowenstein-Jensen (LJ) culture, BACTEC culture and polymerase chain reaction deoxyribonucleic acid (PCR-DNA) for diagnosing endometrial tuberculosis in infertile women. The data from 546 samples of endometrial biopsy histopathology, AFB smears and LJ culture was collected and then analyzed. Of these, HPE for tuberculosis was positive in 13, LJ culture in 10, AFB smear was positive in one case. BACTEC and PCR-DNA were feasible for 90 patients and PCR-DNA was positive in 20 and BACTEC in eight patients. Out of 20 patients with PCR positive results, 15 were only PCR positive and were subjected to hyster-laparoscopy and five had evidence of tuberculosis. Thus, none of the available tests can pick up all cases of genital tuberculosis, but conventional methods i.e., histopathology and LJ culture still has an important role in the diagnosis of endometrial tuberculosis in government setups where BACTEC and PCR are not performed routinely due to lack of resources.