Ujjawal Khurana

Evaluation of aspiration cytology of the liver space occupying lesions by simultaneous examination of smears and cell blocks.

This study was undertaken to compare the efficacy of cytologic smears and histological sections from cell blocks in diagnosis of space occupying lesions (SOLs) of the liver and to classify the lesions on the basis of combined cytohistologic diagnosis. The study was conducted on 50 patients who had radiologically detected SOL/SOLs in the liver and ultrasound‐guided fine needle aspiration of liver was done. In all the cases, both smears and cell blocks were made. Forty‐seven cases were diagnosed as malignant and three as benign on both cytologic smears and cell blocks. Hepatocellular carcinoma was diagnosed in 8 (16%) cases and metastasis in 39 (78%) cases. The subtyping of malignancy could not be done on 11 (22%) cytologic smears and 8 (16%) cell block sections. However, on combined cytohistologic correlation, 17 (34%) out of these 19 (38%) cases could be subtyped. Sensitivity of cytologic smears and cell blocks in subtyping of malignancy was 72.3% and 82.9%, respectively. Combined cytohistologic diagnosis was found to be significantly better than isolated cytologic and cell block diagnosis (P ≤ 0.05). To conclude, FNA of the SOLs of the liver is an effective procedure for diagnosing malignancy. However, cytological examination alone may fail to pinpoint the type of the tumor. Concomitant examination of cell block not only confirms the malignancy but also helps in subtyping it. Diagn. Cytopathol. 2009.

Cytologic diagnosis of intravascular papillary endothelial hyperplasia: a report of two cases and review of cytologic literature.

Background: Intravascular papillary endothelial hyperplasia (IPEH), previously known as ‘Masson’s hemangioma’, is a reactive endothelial proliferation that occurs most commonly in the vessels of the head, neck, and extremities. The cytologic findings of the lesion are varied and depend on the age of the lesion. Cases: Case 1 is a 61-year-old man who presented with a swelling on the medial aspect of the forearm. The clinical diagnosis was lipoma. Cytologic smears showed spindle cells tagging onto a rich capillary network and smaller round cells arranged around hyaline cores. The cytologic diagnosis was benign vascular tumor. On histolopathogic examination a diagnosis of IPEH was given. Case 2 is a 45-year-old man who presented with swelling on the dorsal aspect of the wrist. The cytologic diagnosis of giant cell tumor was made based on the presence of scattered spindled cells and multinucleate giant cells. The giant cells had various shapes like round or crescent and had 10–25 nuclei. The lesion was excised and a diagnosis of IPEH was rendered. Conclusion: These two cases highlight the varied cytomorphology of IPEH making the pinpoint diagnosis of this lesion difficult on cytologic smears.

A Man With Painful Nodules on Both Ears

A man in his 40s presented with a 2-year history of a few small painful nodules on both ears. The nodules were painful on touch, especially while the patient was sleeping in a lateral position. There was no history of trauma. However, he used to wear a cap, which created pressure and friction on the upper part of both ears. On examination, the free border of the helix of both the ears showed a few dull red, dome-shaped, firm nodules 2 to 3 mm in size with central crusting (Figure, A). They were tender on palpation. No cervical lymphadenopathy was observed. One of the nodules on the right ear was excised; histopathologic features of the nodule are shown in the Figure, B. It showed a sharply defined, centrally depressed ulcer covered by a hyperkeratotic parakeratotic scale, occasional bacterial colonies, and plasma. The adjacent epidermis showed hyperplasia. The base of ulcer showed eosinophilic degeneration of collagen and solar elastosis. In addition, there were a few proliferating blood vessels and mild lymphomononuclear infiltrate. Underlying cartilage was not seen in the section. On serial sectioning, cartilage was seen and found to be normal. A B

“Fruiting Bodies” of Aspergillus flavus A Rare Finding in Histopathology

A 60-year-old male presenting with gradually increasing swelling on the right side of the face, decreased visual acuity, and blackish eschar in nasal cavity underwent biopsy from nasal cavity and palate. After a histopathological diagnosis of mucormycosis with aspergillosis, he was put on liposomal amphotericin B. Thereafter, the patient underwent enucleation of the eyeball and removal of periorbital and paranasal soft and bony tissues. Hematoxylin–eosin-stained tissue sections showed sloughed off respiratory mucosa covered with necrotic slough and inflammatory exudate along with hyphal forms of Aspergillus spp and mucormycosis. Foreign body giant cell reaction, angioinvasion by mucormycosis, and necrotic bone were also seen. In addition, characteristic fruiting bodies or conidial heads of Aspergillus were seen, which were better highlighted on periodic acid Schiff stain (Figures 1 and 2). Both KOH mount and calcofluor white stain documented slender septate hyphae as well as broad aseptate hyphae. However, culture showed only Aspergillus flavus. Thus, the present case showed presence of fruiting bodies of Aspergillus spp in a patient of paranasal aspergillosis and mucormycosis, which is a very rare finding on histopathology. Occasionally, when the fungal ball in the nasal and paranasal region is exposed to air or when there is overwhelming burden of infection, fruiting bodies with conidia can be detected. The structure is composed of a long conidiophore with an expanded vesicle from which radiate numerous phialides ending in short chains of conidia. The presence of a single row of phialides over the upper one third of the vesicle is characteristic of Aspergillus fumigates, whereas A flavus and A niger have a double row of phialides that cover the entire vesicle. Fruiting bodies and hyphae of Aspergillus have also been rarely reported in routine Pap smears and occasionally from the skin of a burn patient. To conclude, the recognition of fruiting bodies of Aspergillus spp helps in differentiating it from other fungi and, in particular, in species identification even on histopathology. Figure 1. The fruiting body of Aspergillus flavus surrounded by dense mixed inflammation (hematoxylin–eosin; 400×)

Pulmonary Alveolar Microlithiasis: A commonly misdiagnosed rare entity

Pulmonary alveolar microlithiasis (PAM) is an uncommon entity which can pose a diagnostic challenge. We report a 45-year-old female who was referred to the All India Institute of Medical Sciences, Bhopal, India, in 2017 with a two-year history of progressively worsening dyspnoea and dry coughing. She had been previously diagnosed with pulmonary tuberculosis elsewhere and prescribed antitubercular therapy; however, there was little improvement in her symptoms. Following referral, the patient was diagnosed with PAM based on high-resolution computed tomography findings and the abundance of lamellar microliths in a bronchoalveolar lavage sample. She was subsequently managed symptomatically and enrolled in a rehabilitation programme.

Fine-needle aspiration cytology of cutaneous granular cell tumor: Report of two cases with special emphasis on cytological differential diagnosis.

Granular cell tumors (GCTs) are uncommon neoplasms with recently postulated origin from Schwann cell or neural crest. It can appear in different parts of the body and is most commonly found in the tongue. The cutaneous presentation is not that uncommon. Fine needle aspiration cytology (FNAC) has been suggested to be the diagnostic modality of choice. It will help to differentiate benign tumors from malignant ones and to differentiate GCT from frequent misdiagnoses such as granular histiocytic reaction, xanthogranuloma, rhabdomyoma, oncocyte rich lesions, alveolar soft part sarcoma (ASPS), epithelioid sarcoma, and carcinoma. We report two cases of GCT who presented with subcutaneous swellings in the right thigh and the left lumbar region for 24 months and 18 months, respectively. In the first case, a cytodiagnosis of chronic inflammation showing histiocytes was suggested while GCT was found in the second case. Subsequent histologic examination of the first case and immunocytochemistry in the second case gave the confirmatory diagnosis of GCT.

Evaluation of diagnostic utility of step sections in dermatopathology: A prospective study of 200 consecutive punch biopsies

Background: Obtaining deeper sections or step sections is a common practice for small skin biopsies. Much of the available literature highlights the importance of step sections in neoplastic diseases of skin. However, the routine dermatopathology practice in developing countries shows a predominant burden of nonneoplastic diseases, and the utility of step sections in this context has not been much reported. Objective: The study was aimed to evaluate the utility of prospective step sections in routine dermatopathology practice. Materials and Methods: The present study comprising 200 consecutive skin biopsies was carried out in a prospective manner. Three slides were prepared in each case: Slide 0 was prepared from the ribbon of tissue obtained from untrimmed block, step sections 1 and 2 were obtained at 50 μm and 100 μm depth, respectively. The diagnosis was rendered on slide 0 and subsequently reviewed after examining step section 1 and 2. Results: Of the 200 cases, additional findings on step sections were found in 18 cases (9%) which led to change in diagnosis in 10 (5%) cases. Step section 1 led to correct diagnosis in 6 cases (3%). Step section 2 led to correct diagnosis in 10 cases (5%); however, this was statistically not significant (P ≥ 0.065) when comparing to step section 1. Additional findings which led to diagnosis was most commonly found in the cases of borderline tuberculoid leprosy (5 out of 10 cases) followed by bullous disorders. Conclusion: We therefore believe that step sections improve the diagnostic accuracy in skin biopsies and they are, especially useful in suspected cases of Hansens disease. There is no statistical advantage of step section 2 versus step section 1; although, step section 2 had shown to include all the additional findings which led to a change in diagnosis.