Spectrum of malignancies in human immunodeficiency virus - positive patients at a Tertiary Care Centre in South India

CONTEXT

India has a very large number of patients living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Opportunistic infections in these patients are commonly encountered. However, malignancies in such patients also do occur.

AIM

The aim was to study the spectrum of malignancies in HIV-positive patients at a tertiary health care center.

SETTINGS AND DESIGN

Retrospective study.

MATERIALS AND METHODS

The cases were retrieved from pathology record files at our Institute from January 2003 to December 2008. The follow-up was obtained from Medical oncology records. The morphology of each case was reviewed along with immunohistochemistry wherever done.

RESULTS

There were 61 such cases (51 males, 10 females). The age range was 7-78 years with a median of 35 years. The clinical presentation varied according to the malignancy. The largest group was non-Hodgkin lymphoma (18 nodal, 23 extra-nodal). The others included carcinoma breast (4), chronic myeloid leukemia (3), Burkitt Leukemia (2), squamous cell carcinoma anal region (2), multiple myeloma (2) and one each of miscellaneous malignancies (7).

CONCLUSION

Malignancies in HIV positive individual occurred in younger individuals. Non-Hodgkin lymphomas, especially extra-nodal lymphomas, were the most common malignancy. There were no cases of proven Kaposi's sarcoma or invasive cervical carcinomas. There were two cases of multiple myeloma which are infrequently reported.

Expanding the antibody-mediated component of plasma cell-rich acute rejection: A case series

Renal allograft rejection is mediated by T-cells (T-cell mediated rejection) or by donor-specific antibodies (DSAs) (antibody mediated rejection, ABMR). Plasma cell-rich acute rejection (PCAR) is a unique entity due to its peculiar morphology and poor prognostic behavior. All allograft biopsies done at our center from January 2013 to October 2014 were reviewed, and seven were identified with a diagnosis of PCAR with antibody mediated rejection (ABMR). The allograft biopsies were classified as per the Banff 2007 schema. Immunohistochemistry with C4d, SV 40, CD3, CD20, CD138, kappa and lambda light chain was performed. Total 210 allograft biopsies were performed in the study period of which seven biopsies (3.3%) were diagnosed as PCAR with ABMR. All these were late ABMRs (more than 6 months) with median posttransplant duration of 17 months. The allograft biopsy showed features of PCAR along with glomerulitis, peritubular capillaritis, and positive C4d. DSA was positive in six patients. All the patients were treated with standard therapeutic measures of acute cellular rejection (ACR) and ABMR including steroids, plasma exchange, rituximab and intravenous immunoglobulins. All the patients had persistent graft dysfunction or graft loss on follow-up.

A clinicopathologic study of malignant melanoma based on cytomorphology

CONTEXT

Melanoma accounts for 1-3% of all malignancies. It is usually diagnosed as metastasis in the draining lymph nodes, that is inguinal lymph node. Due to paucity of cytological studies on melanoma in India, the present study was undertaken.

AIM

To study the cytomorphology of malignant melanoma and to correlate the cytological diagnosis with histopathology and clinical details.

SETTINGS AND DESIGN

Sixteen cytomorphological features were studied and analysed from the cases diagnosed as melanoma on cytology with histopathological correlation.

MATERIALS AND METHODS

Thirty patients diagnosed with malignant melanoma on fine-needle aspiration cytology (FNAC) were studied over a period of 10 years and compared by histopathology. Papanicolaou (Pap)- and May Grunwald Giemsa (MGG)-stained smears were studied and analysed for the cytomorphological spectrum of melanoma.

RESULTS

Among the 30 patients studied, males were 19 and females were 11 (M:F:1.7:1) with a mean age of 49.3 years. The commonest primary site was foot followed by maxilla and thigh. The most common site for metastasis was inguinal lymph node. All 30 cases had histopathological correlation. Pigmented melanophages (83%) was the predominant feature followed by presence of melanin pigment (77%) and pseudo-inclusions (73%). Condensed chromatin was observed in the majority of the patients (53%). Smooth and irregular nuclear contours were seen in combination in 37% of the cases. A combination of nuclear placement, that is eccentric and central was observed as a predominant feature (53%). Spindle cell pattern was the predominant shape. Among cytoplasmic features, melanin granules and vacuoles were equally distributed (50%). Mixed pattern, that is singly scattered plasmacytoid cell pattern and cell clusters was the predominant cell architecture.

CONCLUSION

A spectrum of cytomorphological features in correlation with clinical details leads to greater precision in diagnosis and helps to avoid pitfalls in diagnosing melanoma.

Identification of urinary proteins potentially associated with diabetic kidney disease

Diabetic nephropathy (DN) is the most common cause of chronic kidney disease. Although several parameters are used to evaluate renal damage, in many instances, there is no pathological change until damage is already advanced. Mass spectrometry-based proteomics is a novel tool to identify newer diagnostic markers. To identify urinary proteins associated with renal complications in diabetes, we collected urine samples from 10 type 2 diabetes patients each with normoalbuminuria, micro- and macro-albuminuria and compared their urinary proteome with that of 10 healthy individuals. Urinary proteins were concentrated, depleted of albumin and five other abundant plasma proteins and in-gel trypsin digested after prefractionation on sodium dodecyl sulfate polyacrylamide gel electrophoresis. The peptides were analyzed using a nanoflow reverse phase liquid chromatography system coupled to linear trap quadrupole-Orbitrap mass spectrometer. We identified large number of proteins in each group, of which many were exclusively present in individual patient groups. A total of 53 proteins were common in all patients but were absent in the controls. The majority of the proteins were functionally binding, biologically involved in metabolic processes, and showed enrichment of alternative complement and blood coagulation pathways. In addition to identifying reported proteins such as α2-HS-glycoprotein and Vitamin D binding protein, we detected novel proteins such as CD59, extracellular matrix protein 1 (ECM1), factor H, and myoglobin in the urine of macroalbuminuria patients. ECM1 and factor H are known to influence mesangial cell proliferation, and CD59 causes microvascular damage by influencing membrane attack complex deposition, suggestive their biological relevance to DN. Thus, we have developed a proteome database where various proteins exclusively present in the patients may be further investigated for their role as stage-specific markers and possible therapeutic targets.

Granulomatous interstitial nephritis: Our experience of 14 patients

Granulomatous interstitial nephritis (GIN) is a rare condition. Drugs, infections, immune processes, and foreign body reaction are the main causes. We identified a total of 14 patients with GIN during a period of 13 years in 2798 renal biopsies. There were 8 males and 6 females in the age range of 20-70 (mean 35 ± 12) years. The serum creatinine at presentation was 6.7 ± 3.8 (range: 2.3-14.7) mg/dl. In nine patients tuberculosis was the causative agent. Drugs (n = 2) and Wegener's granulomatosis (n = 1) were other etiologies. Systemic lupus erythematosis (SLE) and Immunoglobulin A nephropathy (IgAN) were seen in one patient each. Patients with tuberculosis were treated with antituberculous therapy and three of them improved. Four out of six patients who required dialysis at presentation remained dialysis dependent, one of whom underwent renal transplantation. Two patients progressed to end stage renal disease after 7 years and 9 years each. The patients with drug induced GIN had improvement in renal function after prednisolone treatment. Patients with SLE, and Wegener's granulomatosis responded to immunosuppression. Patient with IgAN was on conservative management. Finally, six patients were on conservative management for chronic renal failure.

Renal allograft pathology with C4d immunostaining in patients with graft dysfunction

Renal allograft biopsy is the gold standard for diagnosis of rejection. Incorporation of C4d as a marker for humoral rejection is a major addition for Banff Schema, 2005. We evaluated the pattern of C4d staining in indicated renal allograft biopsies from January 2005 to December 2009. Of the 67 biopsies analyzed, 21 were C4d-positive. They were 11 cases of acute rejection, seven chronic rejection and one biopsy each of acute tubular necrosis, BK virus nephropathy and normal biopsy. Morphologic features like peritubular capillary dilatation, tubulitis and interstitial inflammation were seen more frequently in C4d-positive biopsies and this was statistically significant. C4d positivity was noted in 50% of the chronic rejection cases indicating a humoral component in the pathogenesis of chronic rejection. There was no significant difference in the serum creatinine levels of C4d-positive and -negative patients, either at the time of biopsy or during the follow-up. This study supports the role of C4d immunostaining in confirming histologically diagnosed acute and chronic humoral rejections and in detecting histologically unsuspected cases.