DNA ploidy and S-phase fraction analyses of hyperplastic, atypical and cancerous endometrium using flow cytometry from paraffin-embedded tissues

Atypical hyperplasia of the endometrium is an entity that needs to be clearly distinguished from other florid hyperplastic states on the one hand and from well-differentiated adenocarcinomas on the other. This may at times be difficult on pure morphological grounds. In this study, DNA ploidy and S-phase fraction of hyperplastic, atypical and cancerous endometrium were evaluated using flow cytometry from paraffin-embedded tissues. In total, 72 cases (24 hyperplastic, 24 atypical and 24 adenocarcinomas) were selected. All hyperplastic endometria showed a diploid stemline, while 2/24 atypical hyperplasias showed aneuploid (Near-diploid) peaks. Both of these cases were severely atypical and one of these, on hysterectomy, showed early invasive carcinoma. There was no significant difference in mean S-phase fractions of hyperplastic vs. atypical endometria. DNA aneuploidy was significantly more common with much higher S-phase fractions in poorly and moderately differentiated carcinomas than in well-differentiated ones. It was concluded that aneuploid (near-diploid) peaks, if ever present in atypical hyperplasias, may indicate an aggressive disease/neoplastic transformation.

Cancer patterns in Karachi division (1998-1999)

OBJECTIVE

A minimal cancer incidence data for Karachi, the largest city of Pakistan, is being presented here, for the years 1998-1999. The city has a population of 9,802,134; males 5,261,712 (52.6%) and females 4,540,422 (47.4%); census 1998.

METHODOLOGY

A predominantly mixed (passive and active) registration system has evolved in Karachi, the data sources being the hospitals within the Karachi Division. The reported/retrieved cancer data sets at the Karachi Cancer Registry are checked, coded, computerised in an analytical format and analysed.

RESULTS

The incident cancer cases registered in Karachi, during the 2-year period, 1st January 1998 to 31st December 1999 were analysed. The age-standardised incidence rate (ASR) of cancer, all sites was 132.4/100,000 for the males. Cancer of the lung 10.8%; ASR 17.3 was the most frequently recorded malignancy, followed by oral cavity 10.5%; ASR 13.2 and larynx 5.0%; ASR 7.4. The age-standardised incidence rate (ASR) of cancer, all sites was 133.0/100,000 in the females. Cancer of the breast, 32.0%; ASR 40.7 was the most frequently recorded malignancy, followed by oral cavity 8.1%; ASR 11.7 and gall bladder 3.6%; ASR 5.5.

CONCLUSION

The present data has been calculated with an estimated 15-20% probable under ascertainment. Tobacco-associated cancers in Karachi were responsible for 38.3% of the tumours diagnosed amongst the males. Two principal cancers, breast and oral cavity were responsible for 40.1% of the cancers in females. A rare finding was the high incidence of gall bladder cancer in the females. At present it is difficult to determine whether this indicates a genuine high risk or a selection bias. A continuous process of cancer registration to study the trends in the incidence and an adequate cancer control program are possible and essential for Pakistan and can be based on the pattern being practiced in Karachi.

Clinical, pathological and molecular factors predicting axillary node involvement in primary breast cancer in Pakistani women

BACKGROUND

Axillary lymph node involvement in primary breast cancer is one of its most important prognostic features. Thus any factors that may predict axillary lymph node involvement in this setting could be potentially helpful in treatment planning and other interventions.

OBJECTIVE

The objective of this study was to evaluate clinical, pathological and immuno-histochemical markers in univariate and multivariate analysis, which may be helpful predictors of axillary lymph node involvement in breast cancer.

METHOD

A retrospective analysis of 555 cases. Of these 58% had axillary nodal positivity and 42% were negative.

CONCLUSION

Factors of no significance included patient's age, height, weight, age of first pregnancy, parity, marital status, menopausal status, family history of breast cancer, side of tumor. In univariate analysis the age of menarche, duration of symptoms, tumor size, site in outer quadrant, S phase and skin and nipple involvement all predicted axillary nodal involvement. The length of breast-feeding, increased intraductal component and increased PCNA were inversely proportional to nodal involvement. In multiple regression analysis however only size of the tumor, involvement of the skin and nipple and disease in the outer quadrant of breast were the factors, which assumed significance.

Epidermal growth factor receptor (EGFR) as a prognostic marker: an immunohistochemical study on 315 consecutive breast carcinoma patients

OBJECTIVE

To assess the independent and interdependent prognostic value of epidermal growth factor receptor (EGFR) in carcinoma of breast in female population. The Type 1 family of growth factor receptors includes epidermal growth factor receptor (EGFR also known as EGFR1).

METHODS

The expression of EGFR protein was analysed immunohistochemically on 315 tumour specimens of infiltrating ductal carcinoma of breast. These patients also had axillary lymph nodes sampling.

RESULTS

Overexpression and/or amplification of EGFR was observed in 70 (22.00%) tumours. Eleven (16%) were grade I, 43 (61%) grade II and 16 (23%) grade III tumours. Axillary lymph node metastasis had significant correlation with intensified positivity of EGFR (p < 0.05). Significant number of EGFR positive patients developed local recurrence and distant metastases to brain, liver and bone (p < 0.05). EGFR positivity showed significant correlation with the disease free and overall survival (p < 0.05). At a median follow-up of 48 (4 years) months in EGFR positive patients, the overall survival was 3.39 years and disease free survival was 2.86 years. EGFR negative tumour patients showed a better survival. In this group the overall survival was 4.62 years and the disease free survival was 4 years.

CONCLUSION

EGFR analysis can be a useful indicator for the selection of patients who are at the high risk, for hormonal therapy decisions and can be useful as a target for new treatment modalities.

Immunohistochemical cathepsin-D expression in breast cancer: correlation with established pathological parameters and survival

Breast cancer is an increasingly important cause of illness and death among women. In recent years, several novel prognostic determinants of breast cancer have been identified, including Cathepsin-D (CD) protein. CD protein expression was analyzed immunohistochemically (IHC) in tumor specimens (315 patients) of infiltrating ductal breast carcinoma. These patients also had axillary lymph node sampling. Overexpression of CD was observed in 39% of the tumors. IHC results were compared with the histological grade. Seventy nine percent (n = 95; 79%) tumor positivity was seen in grade II tumors, followed by grade I (n = 13; 11%) and grade III tumors (n = 12; 10%). Axillary lymph node metastasis had no significant correlation with CD positivity (p > 0.05). Bone metastases were significantly correlated with CD positivity (p < 0.05). CD positivity showed no significant correlation with disease-free and overall survival (p > 0.05). At a median follow-up of 48 (4 years) months in CD-positive patients, overall survival was 3.17 years, and disease-free survival 2.67 years. The overall survival of CD-negative tumor patients was 3.50 years, and disease-free survival was 2.93 years. We conclude that in comparison with cytosol-based quantitative studies, CD expression is not a good prognostic marker when, as in all ICH studies, only the expression in the tumor is considered.

Evaluation and reinforcement of the correlation of S-phase fraction with nodal metastases, tumor grade and tumor size in breast carcinoma patients in Pakistan

The aim of this study was to evaluate the S-phase fraction (SPF) of tumors in breast cancer patients in Pakistan. Its association with the traditional morphological prognostic markers, i.e., axillary lymph node metastasis, tumor size and grade, was also studied. Flow cytometry was used to estimate SPF on breast cancer tissues from 166 patients reported at the Aga Khan University Hospital between the years 1997 and 2000. Univariate analysis was done to find any association between SPF and the aforesaid variables. For the ease of analysis, the cases were subdivided into two categories depending on the SPF value, i.e., <10% (low-risk group) and > or = 10% (high-risk group). The mean and median SPF values were 21.45% and 20.035%, respectively, with a range of 3.26% to 54.30%. Twenty-six (15.66%) of the cases had SPF <10%, 57 (34.34%) had SPF from 10%-20%, and 83 (50%) had SPF >20%. A significant correlation between SPF and nodal metastasis was observed (p = 0.0111), but not between SPF and the number of lymph nodes involved when metastatic cases were subdivided into <4 lymph node-positive cases and > or =4 lymph node-positive cases. Significant correlations were also found between SPF and tumor grade (p = 0.0244), as well as between SPF and tumor size (p = 0.048). In conclusion, DNA flow cytometric analysis of SPF carried out in our laboratory could reasonably predict the chances of lymph node metastasis, tumor grade and size in breast cancer patients, thus proving to be an important prognostic marker in the Pakistani setting. This requires further investigations regarding the survival of patients so as to evaluate its capacity of predicting the outcome of Pakistani patients.

Relationship of p53 expression with clinicopathological variables and disease outcome: a prospective study on 315 consecutive breast carcinoma patients

Breast cancer is an increasingly important cause of illness and death among women. In recent years several novel prognostic determinants of breast cancer have been identified which includes p53. Alterations of p53 are one of the most common abnormalities detected in primary breast cancer. In this study alteration of p53 in primary carcinoma breast was correlated with other pathological variables and disease outcome. In this prospective study the expression of p53 oncoprotein was analyzed immunohistochemically on 315 patient's tumour specimens of infiltrating ductal carcinoma of breast from 1992 to 1997. These patients also had axillary lymph nodes sampling. Both univariate and multivariate statistical analysis was performed to analyze results including disease outcome. Overexpression of p53 was observed in 55.23% tumours. Axillary lymph node metastasis had significant correlation with positivity of p53 (p<0.05). A significant number of p53 patients developed local recurrence and distant metastases to brain, liver, lung and bone (p< 0.05). At a median follow-up of 48 months (4 years) in p53 positive patients, the median overall survival (OS) was 3.0 years and disease free survival (DFS) was 2.5 years. p53 negative tumour patients showed a better survival. In this group the median OS was 3.8 years and the DFS was 3.3 years. The above findings have reinforced the view that p53 immunohistochemical detection is of help in detecting a subgroup of breast carcinoma patients who are at high risk. This may also be of particular relevance in decisions regarding adjuvant chemotherapy to these patients.

Case control study of prognostic markers and disease outcome in inflammatory carcinoma breast: a unique clinical experience

Inflammatory breast carcinoma (IBC) is a rare but aggressive form of breast cancer. In this first-ever study, we investigated the role of nine prognostic markers' expression (estrogen receptor [ER], progesterone receptor [PR], p53, C-erbB-2, epidermal growth factor receptor [EGFR], cathepsin D [CD], proliferating cell nuclear antigen [PCNA], DNA ploidy, and S-phase fraction [SPF]) and disease outcome in IBC cases compared with the control group. A case control study of IBC was conducted on 40 test cases with two controls per case matching age, grade, and number of axillary lymph nodes sampled. During 7 years of this study, 10% of all patients with breast cancer had IBC. In this study, 84% of IBC cases showed positive axillary lymph nodes compared with 63% in control group. The expression of nine prognostic markers, that is, ER, PR, p53, C-erbB-2, EGFR, CD, PCNA, SPF, and DNA ploidy, was studied by immunohistochemistry and flow cytometry. Hormone receptor status showed an inverse correlation (p < 0.05). Among p53, C-erbB-2, EGFR, and CD in the IBC group, only p53 showed a significant correlation, with 70% positivity in IBC versus 48% positivity in the control group (p < 0.05). Much higher SPF and PCNA positivity was seen in the IBC group compared with the control group (p < 0.05). DNA ploidy also showed a significant correlation compared with the control group (p < 0.05). After a median follow up of 18 months, median overall survival in the IBC group was 1.8 years (range 0.6-5.8 years) compared with 3.0 years (range 2.5-7.0 years), with a p value of 0.0001.

Technetium-99m direct radiolabeling of lanreotide: a somatostatin analog

Lanreotide, a synthetic octapeptide analog of a native hormone somatostatin, was labeled with a commonly available, inexpensive radionuclide 99mTc. Labeling was accomplished by reduction of the cysteine bridge, which provided sulfhydryl groups for chelation with 99mTc. Stannous chloride was used as reducing agent, while tartrate acted as transchelating agent. Lanreotide (100 microg), stannous chloride dihydrate (100 microg) and tartaric acid (64 microg) were dissolved in acetate/acetic acid buffer (pH 2.8). After overnight (approximately 18 h) incubation, approximately 444 MBq (12 mCi) 99mTc was added and kept in boiling water for 30 min. More than 97% labeling efficiency was confirmed by RP-HPLC, ITLC-SG and C18 cartridge analysis. Radiolabeling results in one major peak when analyzed by reverse-phase HPLC. The stability of the 99mTc-peptide bond was evaluated by cysteine challenge studies.

Morphological pattern of salivary gland tumours

OBJECTIVE

To delineate the spectrum of salivary gland tumors in our setup.

SETTING

The Aga Khan University Medical Centre, Karachi.

METHOD

Tumors were analysed considering histological type, age and sex of the patients and anatomic location. The diagnosis of individual tumours was based on the 1991 World Health Organisation Classification.

RESULTS

During the span of eight years (1991-1998), 379 cases of salivary gland tumours were diagnosed. Of these, 205 (65.7%) were male and 174 (34.3%) were female. The median age at the time of diagnosis was 35 years. The median age for patients with malignant lesions (44 years) was 12 years older than those with benign tumours (34 years). Overall, malignant tumours were seen more frequently in males, however benign tumours were distributed equally between the two sexes. The most common site was parotid gland (82.85%). Only five cases of minor salivary gland tumours were seen. The most frequently diagnosed benign salivary gland neoplasm was pleomorphic adenoma (84.5%), followed by Warthin's tumours (6.18%), Mucoepidermoid carcinoma was the most commonly encountered malignant lesion (56.9%), followed by adenoid cystic carcinoma (19.6%).

CONCLUSION

Plemorphic adenoma was the most common benign salivary gland tumour and mucoepidermoid carcinoma was the most frequent malignant neoplasm. Parotid gland was the most common site of origin in both benign and malignant tumours. The overall relative frequency of salivary gland tumours in this series correlates with that reported in the international literature.

Folinic acid protects against suppression of growth by methotrexate in mice

The objective of this study was to investigate whether folinic acid supplementation would protect young mice against suppression of growth by methotrexate (MTX). Four equal groups of Balb/c young male mice (5 animals in each group; mean+/-SD body weight 9.64+/-0.85 g, in their rapid growth phase) were subjected to the following drug treatment: One group was given MTX (3.5 mg/kg body weight) intraperitoneally on every 2nd day, another received folinic acid (7.0 mg/kg body weight) intraperitoneally every 2nd day. The third group was given both of these drugs (MTX on every 2nd day and folinic acid 8 h post-MTX injection). The fourth group was injected with physiological saline every other day to serve as a control group. Total body weight, food and water consumption by animals in each group were monitored every second day for a period of 3 weeks. After this period mice were sacrificed and liver, spleen and kidneys were excised, weighed and analyzed for MTX and dihydrofolate reductase activity. A small segment of the proximal part of small intestine and small pieces of liver and kidney were also removed to study morphological changes. Compared to the groups, which received folinic acid alone, folinic acid plus MTX or physiological saline, mean increase in body weight (6.8+/-0.8 g) of mice over a period of 3 weeks was minimal in the group receiving MTX alone (one-way ANOVA p=0.0001). The mean weights of liver and kidney in this group receiving MTX alone were also found to be significantly less than the mean weights of these organs in the 3 groups (p<0.001). The negative effect on growth of animals appears not only due to malabsorption but inhibition of pathway of de novo DNA synthesis may also be involved. This is supported by loss of villous pattern in small intestine of mice treated with MTX alone and increased accumulation of free MTX and decreased dihydrofolate reductase in the liver of the group receiving MTX alone as compared with the group receiving MTX plus folinic acid. The data indicate that the administration of folinic acid protects mice against suppression of growth by MTX. On the basis of these observations it can be deduced that patients suffering from juvenile rheumatoid arthritis or acute lymphoblastic leukaemia receiving MTX over a long period of time might be at a risk of experiencing short-term suppression of growth, however they could benefit from supplementation with folinic acid.

Histological pattern of central nervous system neoplasms

OBJECTIVE

To see in a large series of patients the histological pattern of CNS neoplasms and to provide a comprehensive data about the frequency of CNS neoplasms in Pakistani patients and to give a clearer idea about their prevalence.

METHOD

Retrospective study of all consecutive cases of CNS neoplasms diagnosed at The Aga Khan University Hospital (AKUH) between 1st January, 1994 and 31st December, 1999.

SETTING

The section of Histopathology, AKUH, Karachi.

OBSERVATION

Our series included a large number of cases i.e., 1110. There are very few local studies on CNS tumours and none so large. Our data was correlated with published Western and Pakistani data. Glial tumours were the commonest primary CNS neoplasms followed by meningiomas. Among glial tumours, astrocytomas comprised the largest group and the majority were high grade (III and IV) astrocytomas. Percentages of anaplastic oligodendrogliomas and ependymomas were also significant. Male to female ratio was 1.6:1. However, meningiomas were more common in females. Almost half of the CNS tumours in patients 15 years or younger were in the posterior cranial fossa. Metastatic tumours were much lower as compared to the West.

CONCLUSION

Except for the high percentages of anaplastic oligodendrogliomas and ependymomas and the low percentage of metastatic tumours, most of our findings roughly correspond with the published data.

Flow cytometric analysis of childhood leukemias

OBJECTIVE

To collect demographic data for childhood (less than 15 years) leukemias in Karachi, describe the accuracy of the cell surface markers routinely used in the flow cytometric analysis of leukemic cells and arrive at an ideal panel of antibodies for analyzing leukemic samples.

MATERIALS AND METHODS

Data from 62 consecutive cases of childhood leukemias referred to the Department of Pathology, Aga Khan University Hospital, (AKUH) between January 1995 and December 1998 was analyzed using Epi Info Version 6. Flow cytometry on all samples was performed using standard protocols.

RESULTS

The mean age of patients was 8.2 years and 49 (79%) were males. Fifty (81%) had acute lymphoblastic leukemias of which 50% were CD10 positive and 24% CD10 negative Pre-B cell leukemias. Among all Pre B cell All 98% were positive for CD19, 96% for CD22, 89% for HLA-DR and 67% for CD10. Of the 10 AML cases, 100% were positive for CD33, 90% for CD13, 80% for CD19 and 70% for HLA-DR.

CONCLUSION

The mean age in this study population was significantly higher and percentage of CD10 positive Pre-B All is lower than that in the West. Both these factors might be responsible for the poorer prognosis of these patients. It is not possible to specify a minimum or maximum panel of antibodies that should be used for phenotyping all cases of childhood leukemias. A certain degree or redundancy is essential in any panel of antibodies used for flow cytometry of leukemias.

Mantle cell lymphoma presenting as solitary polypoid colonic lesions

Mantle cell lymphoma of the intestine is rare, usually presenting as multiple small polyps. We report three men with colonic mantle cell lymphoma in the form of single large polypoid mass. The clinical picture suggested adenocarcinoma; the diagnosis was made at histology and immunohistochemistry of the colectomy specimens.

DNA ploidy analyses in 218 consecutive Pakistani breast cancer patients: does it add anything?

An analysis was made to evaluate the significance of DNA ploidy in the biology and prognosis of breast carcinoma. This was done by estimating the correlation of DNA ploidy with other established prognostic markers of breast cancer, namely tumor size, tumor grade, lymph node metastasis and S-phase fraction. From 1995 up to year 2000 ploidy analysis was performed on 218 consecutive cases of infiltrating breast carcinoma by flow cytometry using formalin fixed paraffin embedded material. From the laboratory record, data regarding other pathological variables was retrieved. No correlation could be found between DNA ploidy and tumor grade, nor could there be found a correlation with tumor size. For lymph node metastasis there was a significant difference between the proportion of aneuploids and diploids having metastasis in more than 4 lymph nodes. However, no significant difference was found in axillary lymph node positive and negative groups when number of positive lymph nodes was not taken into account. The mean value of S-phase fraction for the aneuploids and the diploids was also insignificantly different. In conclusion DNA ploidy alone did not add much to predict tumor behaviour in terms of known pathologic variables.

Significance of immunohistochemical c-ErbB-2 product localisation pattern for prognosis in human breast cancer

Breast cancer is an increasingly important cause of illness and death among women. In recent years several novel prognostic determinants of breast cancer have been identified, including c-ErbB-2. In this study, expression of c-ErbB-2 in breast carcinoma was correlated with axillary lymph node metastases and disease outcome. The expression of c-ErbB-2 oncoprotein was analysed in 315 tumor specimens of infiltrating ductal carcinoma of breast. They were categorized according to the modified Bloom and Richardson criteria into three histological grades. These patients also had axillary lymph nodes sampling. The expression of c-ErbB-2 oncoprotein was analysed immunohistochemically. Over expression of c-ErbB-2 were observed in 39.36% tumors. Axillary lymph node metastasis had significant correlation with intensified positivity of c-ErbB-2. C-ErbB-2 positive patients did show resistance to chemotherapy when compared for recurrence and distant metastases following surgery (p< 0.05). At a median follow-up of 48 months in c-ErbB-2 positive patients, the overall survival was 3.0 years and disease free survival was 2.5 years. c-ErbB-2 negative tumor patients showed a far better survival. In this group the overall survival was 4.44 years and the disease free survival was 3.78 years. These findings reinforce the view that c-ErbB-2 immunohistochemical detection is of help in detecting a subgroup of breast carcinoma patients who are at high risk. This may also be of particular relevance in decisions regarding adjuvant chemotherapy to these patients.

Retinoblastoma tells the story of our health care system

OBJECTIVE

To review cases of retinoblastoma.

SETTING

Department of Pathology Aga Khan University Hospital Karachi.

METHOD

Twenty-three specimens from cases of retinoblastoma received over a period of eight years were routinely processes and stained with haematoxylin and Eosin stain. Other stains were used for tuberculoses and melanin. Immunochemistry was resorted to in undifferentiated tumors.

RESULTS

Over 60% cases of retinoblastoma were diagnosed after 5 years and nine cases showed involvement of optinerve.

CONCLUSION

Late diagnosis of retinoblastoma effects the stage of the tumors and the prognosis.

DNA ploidy analysis of borderline epithelial ovarian tumours

OBJECTIVE

Borderline epithelial ovarian tumours not uncommonly pose a great difficulty to surgical pathologists as morphologically they may show very similar features as those of malignant epithelial tumours except invasion. However it is important to separate these from their invasive counterparts because of their superior prognosis. Recently, attention has been focussed on the prognostic value of flow cytometric analysis of DNA ploidy in borderline epithelial ovarian tumours. The purpose of this study is to investigate whether flow cytometric analysis of cellular DNA content acts as a useful adjunct to the histopathological diagnosis of borderline malignancy.

MATERIALS AND METHODS

Fifteen histologically confirmed borderline serous epithelial tumours of the ovary were selected. Samples were analyzed on a FACScan flow cytometer using the software MODFIT. A total of 10,000 nuclei were counted each time.

RESULTS

The mean CV for the 15 cases was 3.67 (Range 2.4-5.0). In the DNA histograms a diploid sample was defined as one that had a single Go/Gl peak. An aneuploid tumour was defined as one that displayed an additional distinct peak. All 15 cases of borderline serous epithelial tumours showed a diploid stemline with DNA index between 0.9-1.10.

CONCLUSION

This study suggests that aneuploidy if ever demonstrated in histologically confirmed borderline tumours should prompt extensive sampling of the tumour and a close follow up.

Incidental prostate cancer: the importance of complete prostatic removal at cystoprostatectomy for bladder cancer

Patients with invasive bladder cancer could be at a higher risk for a second malignancy such as an unsuspec- ted prostate cancer. We report a case of muscle-invasive transitional cell carcinoma of the urinary bladder with incidental adenocarcinoma of prostate, and review the literature to highlight the importance of complete prostatic removal to prevent residual disease.

Audit of lymph node biopsies in suspected cases of lymphoproliferative malignancies: implications on tissue diagnosis and patient management

AIMS

To carry out an audit ascertaining the importance of condition of lymph node specimen, submission of clinical history including site of biopsy and immunohistochemical studies on conclusiveness of diagnosis made.

METHODOLOGY

Computer records of the Aga Khan University Hospital, Histopathology Laboratory were used to analyze all cases of lymphoproliferative malignancies presented at the hospital from 1992 to 1998.

RESULTS

Out of a total of 466 cases studied, in 283 (61%) the lymph nodes were fragmented. The site of biopsy was mentioned in 361 (77.5%) cases with the cervical region forming the most common site (56.5%). A clinical history was submitted in 395 (85%) and a conclusive diagnosis was reached in 378 (81%) cases.

CONCLUSION

This audit indicates a strong co-relation between the condition of lymph node biopsies received, clinical history of the patient submitted including site of biopsy, ancillary studies like IHC performed on the eventual outcome in the form of precise diagnosis and categorization of lymphoproliferative malignancies.

Central nervous system lymphomas: a histologic and immunophenotypic analysis

OBJECTIVE

To observe the spectrum of non-Hodgkin's lymphomas involving the central nervous system including morphological subtypes and immunophenotypic status.

SETTING

Retrospective analysis of eleven years (1986 to 1996) data from surgical pathology files of Department of Pathology.

RESULTS

Forty-three cases of non-Hodgkin's lymphomas were diagnosed during the period of eleven years (from 1986 to 1996), all of which were diffuse types. A total of 1177 Central Nervous CNS biopsies were examined, out of which 937 cases were diagnosed as CNS neoplasms, the remaining were non-neoplastic in nature. Among 937 CNS neoplasms, 43 cases (4.6%) were reported as non-Hodgkin's lymphomas. As most of the cases were outside referrals, the primary or secondary nature of the lymphomatous process could not be assessed. Seventeen cases were intracranial, while 26 cases were spinal in location. Majority of the intracranial lymphomas were biopsied from the cerebrum (12 cases). Male to female ratio was 1:2. The median age for intracranial lymphomas was 50 years and for spinal lymphomas 29 years. There were 16 cases (37%) of diffuse large cell lymphomas; 7 cases (16%) of diffuse mixed small and large cell lymphomas; 3 cases (7%) of diffuse large cell immunoblastic lymphomas; 2 cases (4.6%) of lymphoblastic lymphomas and diffuse small non-cleaved cell lymphomas and one case of small lymphocytic lymphoma and diffuse small cleaved cell lymphoma. One case of T cell rich B cell lymphoma was also diagnosed in the thoracic spine as primary extranodal lymphoma. Eight cases were unclassifiable and in 2 cases the features were suggestive of lymphoma. Immunophenotypic analysis was performed in 20 cases, however, in 2 cases the results were inconclusive. Fifteen cases (83%) showed immunoreactivity for B cell markers and 3 cases showed T cell phenotype out of which one case was lymphoblastic lymphoma.

CONCLUSION

CNS lymphomas were uncommon tumors and comprised 4.6% of the total CNS neoplasms in our study. Moreover, these CNS lymphomas accounted for 2.2% of the total non-Hodgkin's lymphomas, including both nodal and extranodal. There was a higher incidence of location of these lymphomas within the spinal cord than brain. Most of the lymphomas were of intermediate or high grade (75%) according to the working formulation. Immunophenotypical status revealed B-cell phenotype in 84% of the lymphomas, in which it was tested (JPMA 50:141, 2000).

Frequency of malignant solid tumors in children

OBJECTIVE

To find out the frequency of malignant solid tumors in children (< 15 years).

SETTING

All cases of pediatric malignant solid tumors which were diagnosed in the section of histopathology at the Aga Khan University Hospital, Karachi during the period of two years.

METHODS

These tumors were initially evaluated on H&E stained sections and special stains were also performed whenever indicated. The undifferentiated tumors were evaluated immunohistochemically by using a panel of antibodies on sections from routinely processed, formalin fixed, paraffin embedded tissue blocks.

RESULTS

Of two hundred and fifty three (253) consecutive cases of paediatric malignant solid tumors, lymphoma (26.1%) was the most common tumor followed by central nervous system tumors (16.6%), osteosarcoma (7.5%), rhabdomyosarcoma (6.7%), neuroblastoma (5.1%), Wilm's tumor (5.1%), Ewing's sarcoma (4.7%), retinoblastoma (4.7%), germ cell tumor (4.4%) and primitive neuroectodermal tumor (4%) in order of frequency. In seven cases (2.8%), the nature of lesion remained undetermined even after immunohistochemical staining. Rest of malignant tumors (12.3%) included the rare entities like synovial sarcoma, nasopharyngeal carcinoma, leiomyosarcoma, malignant schwannoma and thyroid carcinoma, etc.

CONCLUSION

Lymphoma was the most frequent Paediatric tumor. The frequency of childhood central nervous system tumors was quite high as compared to the other series from different regions of Pakistan.

Childhood non-Hodgkin's lymphoma: an immunophenotypic analysis

OBJECTIVE

To observe the frequency of histological subtypes of childhood non-Hodgkin's lymphoma and its immunohistochemical profile.

SETTING

All cases of non-Hodgkin's lymphoma diagnosed in children (< 15 years) in the section of histopathology at the Aga Khan University Hospital Karachi during the period of three years.

METHODS

These consecutive cases were evaluated on H&E stained sections and then immunohistochemistry analysis of these tumors was performed by employing Peroxidase Anti-Peroxidase (PAP) technique.

RESULTS

The present series included 61 cases of non-Hodgkin's lymphoma. NHL was more common in males as compared to females with male to female ratio of 5.8:1. High grade NHL comprised 87% of childhood lymphoma. The mode of presentation in majority of NHL (57%) was extranodal. Burkitt's lymphoma (33%) was the most prevalent histological subtypes, followed by lymphoblastic (28%), diffuse large cell (15%), diffuse mix small and large cell (13%), small non cleaved Non-Burkitt's (7%) and immunoblastic (4%). Immunophenotypic analysis of the childhood Non-Hodgkin's lymphoma revealed that 67% of the Non-Hodgkin's lymphoma are B-cell type while 33%, are those of T-cell lineage.

CONCLUSION

NHL was more common in males. Majority of NHL in children were high grade tumors. Burkitt's lymphoma was the most frequent histological subtype. T-cell NHL comprised a significant portion of childhood lymphomas.

Spectrum of Hodgkin's disease in children and adults: impact of combined morphologic and phenotypic approach for exclusion of "look-alikes"

OBJECTIVE

To determine the prevalence of Hodgkin's disease (HD) and its various subtypes in children and adults and assess the use of immunohistochemical (IHC) studies in confirming HD cases and excluding its close mimicries/look-alikes.

MATERIAL AND METHODS

All 265 Hodgkin's disease cases diagnosed at The Aga Khan University Hospital, Karachi over the last 6 years (July 1991-July 1997) were included. Of these 219 were diagnosed on routine H&E examination while in the remaining 46 cases, diagnosis was made after a thorough IHC workup. (This group initially included 161 cases labelled as lymphoproliferative disorder with HD as one of the differentials).

RESULTS

Out of a total of 265 HD cases (206) 78% were males and (59) 22% were females in a ratio of 3.5:1.26% (69) cases were < 15 years while 74% (196) were > 15 years old. In both age groups, the commonest subtype proved to be Mixed Cellularity (MC) (60% of < 15 years old and 40% of > 15 years old) followed by Nodular Sclerosing (NS) (20% of < 15 years old and 27% of > 15 years old). Lymphocyte Predominant (LP) and Lymphocyte Depleted (LD) were seen less frequently. With the help of IHC studies performed on 161 cases in which HD was part of the differential diagnosis, 46 were conclusively diagnosed as HD. In the rest of the cases the main different was Non-Hodgkin's Lymphoma (NHL) that accounted for 72 of the cases.

CONCLUSION

This study shows that the most common sub-type of HD in our series in MC followed by NS. This study also suggests reasons why the more aggressive sub-type MC is predominant in Third world countries like ours compared to the better prognostic NS seen more in developed countries and why LP and LD are less and less commonly diagnosed.

Clinico-morphological pattern and frequency of bone cancer

OBJECTIVE

The present study was done to find out the frequency of malignant tumors of bone and to categorize the prevalence of various histological types of osseous malignancies with respect to age, sex and site of origin.

SETTING

This study included consecutive cases of malignant bone tumors, which were diagnosed in the department of pathology at the Aga Khan University Hospital, Karachi during the period of three years (1995-1997).

METHODS

These tumors were initially evaluated on H & E stained section from paraffin embedded tissue blocks. Special stains and immunohistochemical analysis was performed whenever required.

RESULTS

A total of 169 malignant bone tumors were diagnosed during the study period. Metastatic tumors accounted for 28.4% of all malignant tumors of bone. Osteogenic sarcoma (27.2%) was the most frequent primary tumor of bone followed by Ewing's sarcoma (12.4%), Non-Hodgkin's lymphoma (10.6%), Chondrosarcoma (8.3%), Plasma Cell Myeloma (8.3%) and other rare entities (4.8%) in order of frequency.

CONCLUSION

The most common malignant neoplasm diagnosed in osseous biopsies was metastatic tumors. Osteogenic sarcoma was the most frequent primary bone tumor in this series. The bone tumors were relatively more prevalent in males. The frequency of malignant bone tumor was relatively high as compared to developed countries.

Immunohistochemical evaluation of small round cell tumors of childhood

OBJECTIVE

This study was done to evaluate the pediatric undifferentiated small round cell tumors with immunohistochemical staining.

SETTING

The present study included consecutive cases of small round cell tumors which were diagnosed in children (< 15 years) in the section of Histopathology at the Aga Khan University Hospital, Karachi during the period of two years.

METHODS

The group of undifferentiated small round cell tumors were evaluated immunohistochemically by using a panel of antibodies on sections from routinely processed, formalin fixed, paraffin embedded tissue blocks.

RESULTS

The category of undifferentiated small round cell tumors included rhabdomyosarcoma (23.2%), primitive neuroectodermal tumor (17.9%), non-Hodgkin's lymphoma (16.1%), neuroblastoma (14.2%), Ewing's sarcoma (10.7%) in order of frequency. Osteosarcoma (Small cell variant), retinoblastoma and medulloblastoma comprised 1.8% each. In seven cases (12.5%), the immunohistochemical analysis was inconclusive.

CONCLUSION

Immunohistochemistry is a very valuable diagnostic tool which helps in distinguishing the undifferentiated tumors especially small round cell tumors. The immunohistochemical staining needs to be performed routinely for undifferentiated tumors in diagnostic histopathology.

T cell rich B cell lymphoma (TCRBCL): study of sixteen cases with review of literature

T cell rich B cell lymphoma (TCRBCL) is a recently described variant of diffuse non Hodgkin's lymphoma (NHL), the acronym of which has gained wide acceptance among hematopathologists in a relatively shorter period of time. The recognition of this entity requires immunohistochemical facilities especially on paraffin embedded tissues. TCRBCL is one of the many examples in the diagnostic anatomic pathology which emphasizes the need of immunocytochemistry and availability of this technique at least in referral laboratories. One of the differential diagnosis in this case includes lymphocyte predominance Hodgkin's disease (LPHD) which is the most favorable prognostic histologic subtype of Hodgkin's disease (HD) while TCRBCL is an aggressive B Cell NHL and should be treated as high grade large cell lymphoma. The other close differential includes peripheral T cell non-Hodgkin's lymphoma (PTCL). We reported sixteen (16) cases of TcRBCL diagnosed during a period of two and a half years (January 1995 to June 1997). HD and PTCL were the main differential diagnoses in most of these cases. The median age at diagnosis was 39 years and male to female ratio was equal. TCRBCL was nodal in location in 15 cases and a single case in extranodal site presenting as spinal tumor. The mean neoplastic B cell population was 12%, while that of reactive T cells was 82%. A significant polymorphous inflammatory cellular background was noted in 5 cases. Reed-Stenberg like cells were observed in 3 cases. Immunoglobulin light chain restriction studies were performed in fourteen cases and revealed lambda light chains in ten cases while in four cases kappa light chains were present.

Spinal cord compression: histologic spectrum of lesions

Histologic diagnosis ultimately determines the prognosis and treatment of lesions causing spinal cord compression. Modern imaging techniques have revolutionized the procedure of localizing lesions presenting with signs and symptoms of spinal cord compression. As a result, these lesions are more accessible for fine needle aspiration and biopsy. A quick diagnosis is possible if cytologic preparation is made. Similarly, intraoperative frozen section facility not only provides rapid diagnosis, but also offers opportunity of appropriate management decision there and then. Histology in many cases needs help of special stains and immunocytochemistry. This study looks at the histologic spectrum of these lesions, gender distribution and age range in Pakistani population.

Soft tissue sarcomas: pattern diagnosis or entity?

Soft tissue sarcomas (STS) are a diverse and heterogeneous group of tumours. The sub-classification of these tumours is of importance for both prognosis and treatment. Classically, sub-categorization is based purely on histomorphological grounds, but as new techniques evolve, a more conclusive and accurate diagnosis can be made. This study describes the prevalence of soft tissue sarcomas in adults diagnosed at The Aga Khan University Hospital (AKUH) and the impact of immunohistochemistry (IHC) on the precise sub-categorization of these tumours. The study included 364 adults (age 16+) who were diagnosed as soft tissue sarcoma in the past six years (May 1991-July 1997) at the Histopathology lab of the AKUH. Where indicated, tumours were stained with a panel of antibodies using the PAP technique. Of these, 237 (65%) were male and 127 (35%) were female. The median age at which all sarcomas were diagnosed was 39.5 years. The most common site was the lower extremity (29%). The most frequently diagnosed sarcoma was leiomyosarcoma (13%), followed by malignant nerve sheath tumour (12%), rhabdomyosarcoma (10%) and liposarcoma (10%). Cases were further analyzed by dividing them into two groups, each group comprised of all sarcomas diagnosed during the specified period. In the period 1991-1994, only 16% of cases were further analyzed using IHC, while in the period 1995-1997, IHC was performed on 59% of cases. In the 1991-1994 group, a conclusive diagnosis was made in 57% of the cases and in the 1995-1997 group in 78%. A Chi-square test was performed, which proved that these results were statistically significant. Soft tissue sarcoma is one of the key areas in surgical pathology where immunohistochemistry plays an important role in both precise diagnosis and sub-categorization.

Diagnostic evaluation of fine needle aspiration cytology in the management of palpable breast lesions

A total of 113 fine needle aspirates of the breast masses were evaluated in which the subsequent biopsy or mastectomy specimen were also available for histological examination. The age ranged from 16 to 80 years with a mean of 42 years. In benign conditions the mean age was 34.7 years while in malignant cases it was 48 years. The cytological diagnoses were compared with the histological results which revealed that the specificity and sensitivity of fine needle aspiration cytology in the palpable breast lesions was 86.1% and 89.2% respectively with a positive predictive value of 93% and efficiency of 88.2%. Similar statistics from other series in which the cytological results of breast lesions were compared with histological results, revealed almost same results which suggest that fine needle aspiration cytology is an effective and accurate technique for the diagnosis and management of palpable breast lumps.

Changing patterns and re-distribution of antigen in poorly differentiated carcinomas: its implications in tumour diagnosis

The variability of expression of tumour-associated antigens via either antigenic heterogeneity or antigenic modulation presents a basic problem in immunohistochemical diagnosis of poorly/undifferentiated tumours. This work was designed to study antigenic expression on human resected epithelial tumours by a panel of most widely used antibodies (EMA, CEA, AUAI & Cytokeratin) in relation to tumour differentiation and polarization. It was observed that poorly differentiated carcinoma with loss of polarity show homogeneous membrane staining (with antibodies against EMA, CEA & AUAI) in contrast to either apical (luminal) or basolateral membrane staining in well differentiated counterparts. Biochemical studies have shown that apical and basolateral epithelial cell membrane domains have a characteristic set of glycoproteins. Tight junctions are essential for maintaining this functional polarization. It was concluded that structural and functional abnormalities of tight junctions in poorly differentiated carcinomas results in loss of polarity with progressive invasion of the cell surface by antigenic glycoprotein and resultant homogeneous individual cell antigenic expression in poorly differentiated carcinomas. This study demonstrates that antigenic expression on tumour cells is not static, but dynamic and heterogeneity of antigenic expression may well be due to biological factors such as spatial configuration of the lesion.

Classification and immunophenotyping of acute leukemias: a prospective study

Over a period of 3-1/2 years, 86 cases of acute leukemia were analyzed by immunohistochemical (IHC) means on ficoll separated cytospin preparations of peripheral blood and/or bone marrow samples. Antibodies included in the panel were specific against Tdt, HLA-DR, CD19/CD20/CD22, CALLA (CD10), CD2, CD11C as well as against Ig heavy chains. Of 86 cases analyzed, 48 cases were of ALL, (25 of common pre-B ALL, 15 of pre-B/NULL and 8 of T ALL phenotype), twenty-four (24) out of 86 cases were of non-lymphoblastic (AML/AMML) type. In six cases, there was suggestion of a mixed lineage, while in 8 cases there was inconclusive diagnosis. Mean age was lower in common ALL sub-set of ALL as compared to pre-B/NULL group (i.e., 8 vs 12 years), while in non-lymphoblastic group it was 36 years. T cell phenotype was invariably seen in young adults, who usually presented with a mediastinal mass.

Immunophenotypic analysis of non-Hodgkin's lymphoma

One hundred and three cases of Non-Hodgkin's lymphoma were evaluated immunohistochemically using a panel of monoclonal antibodies which includes leucocyte common antigen (LCA), CD45R (Pan-B marker), L-26 (CD 20-Pan-B marker) and UCHL-1 (Pan-T marker). Of the total 63 cases (61.17%) showed a B-cell phenotype while 40 (38.83%) were of T-cell origin. Most B-cell neoplasms belonged to intermediate (79.36%) or high grade (15.87%) according to the International Working Formulation (WF). Most T-cell lymphomas were of either intermediate (52.5%) or high grade (32.5%) neoplasms. Some T-cell neoplasms presented as specific clinicopathological entities like lymphomatoid granulomatosis (2 cases), mycosis fungoides (1 case) and AILD type NHL (1 case). In 27 cases the immunostaining pattern of two. Pan-B markers i.e., L26 and CD45R was compared. L26 staining was expressed in all 27 cases (100% sensitivity) while CD45R showed positive reaction in 22 cases (82% sensitivity). UCHL-1 is proved to be a sensitive and lineage specific T-cell marker and in 67% cases the staining pattern was moderate (+2) to intense (+3). The mean age for the B-cell lymphomas was 49 years and 36 years in T-cell neoplasm. Male to female ratio in both types of lymphomas was 2:1. The study indicates a high prevalence of T-cell when comparing the data from western countries and lower to those from Japan and Caribbean countries.

Management of children with acute respiratory infections (ARI) by general practitioners in Multan - an observational study

A knowledge, attitude and practices (K.A.P.) survey was conducted among doctors working as general practitioners (GP) in Multan, for diagnosis and management of acute respiratory infections (ARI) in children under five years of age. GPs in Multan were not familiar with national ARI control programme and rational drug use guidelines. They rarely asked about symptoms describing severity of disease while taking patient histories and did not look for signs of severe pneumonia during physical examinations. Most patients diagnosed as URTI (upper respiratory tract infection) received oral antibiotics and those with pneumonia received injectable antibiotics. Other drugs prescribed included cough syrups, antihistamines and antipyretics. The average number of drugs prescribed per patient was 3.4. The doctors were deficient in providing home care advice for sick children to the caretakers. Average time spent by doctors on each patient was two minutes and twenty-three seconds. A combination of biomedical and social factors help to perpetuate this irrational prescribing behaviour of the GPs. Continuing education programmes for doctors in general practice about ARI management in children and rational use of drugs and health education of the public may improve the current prescribing practices.

Computed tomography appearance of malignant schwannoma of the liver

Malignant schwannoma of the liver without associated neurofibromatosis is rare. The authors present one such case in a 35-year-old woman. Computed tomography demonstrated large liver masses with contiguous involvement of adjacent stomach tissue, consistent with local invasion.

Toxic metals status in kidneys and gallstones of workers in a steel plant environment

Samples of kidney stones and gallstones obtained from patients who were workers at a steel plant, or residents of the steel plant township area and those unrelated to the steel plant and steel plant township area were analysed for the presence of toxic metals (Zn, Cr, Ni, Co, Cu, Pb, Hg, Cd and Mn) by atomic absorption spectrophotometry. Other constituents (moisture, organic matter, oxalate, phosphate, fluoride and calcium) were also determined in each sample. In most of the samples the highest occurrence of toxic metals was found in the samples obtained from workers of the steel plant who were also residents of the steel plant township area. In samples obtained from patients who were non-workers of the plant but residents of the steel plant township area, the concentrations of the toxic metals were smaller, but higher than in those cases who were unrelated to the steel plant environment.