Solitary Ganglioneuromatous Hamartoma Tongue in a Newborn - A Rare Entity

Ganglioneuromatous hamartoma is a benign tumour of autonomic ganglia with very few cases reported in head and neck region. In this report, we are presenting a case of ganglioneuromatous hamartoma in a 20 day old female child who presented with a tongue mass. She underwent a surgical excision and the definitive diagnosis was made by histopathology. This case reports discusses presentation and management of a case of ganglioneuromatous hamartoma.

Paediatric Hemophagocytic Lymphohistiocytosis: A Case Series With a Diverse Spectrum From a Resource-Limited Setting

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by cytokine storms leading to multi-organ dysfunction and is a highly fatal disease. Infectious diseases are the most common cause of secondary HLH. A wide variety of infections can lead to secondary HLH.  In this case series, we report five cases of HLH which had different therapeutic approaches and varied clinical courses, with one of them diagnosed as a rare entity of coronavirus disease 2019 (COVID-19)-associated HLH of multisystem inflammatory syndrome in children (MISC) spectrum, one case each of idiopathic HLH, staphylococcal infection-associated secondary HLH, leptospirosis with secondary HLH and dengue-associated HLH. The case of idiopathic HLH required initiation of immunosuppressive therapy but had a fatal outcome while others were treated successfully with antibiotics, steroids, intravenous immunoglobulin and supportive therapy. Our case series highlights the importance of evaluating for all possible infective causes thoroughly in HLH. Most patients can be managed without chemotherapy by treating the secondary causes of HLH, including common tropical infections and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Impact of COVID-19 Pandemic on Pathology Residency Program: An Experience from India

OBJECTIVE

To study the impact of the COVID-19 pandemic on pathology residents through a questionnaire-based survey.

MATERIAL AND METHOD

We designed a Google survey questionnaire with 20-questions and distributed it to the pathology residents across India via e-mail and WhatsApp. All the responses collected were analysed using appropriate statistical methods.

RESULTS

We received a total of 81 responses. The majority (n=55, 68.8%) of the residents were aged 26-30 years with a male-female ratio of 1:2.2. Residents reported a significant decrease in classes as compared to pre-covid times. However, most institutions (90%) shifted to the virtual method for various teaching sessions. About 94.7% of the residents felt a fall in the quality of training due to Covid. A significant number of junior residents (76.92%) reported an inability to complete the target thesis enrolment. The residents saw a substantial decrease in the number of peripheral smears, bone marrow, cytology, and histopathology cases compared to pre-Covid times (p value < 0.001 for all). An overwhelming 83.8% of the pathology residents were posted for COVID-19 duties. About 48.8% turned Covid positive. About 77.5% (n=62) of residents felt that the necessary training period would be extended.

CONCLUSION

The COVID-19 pandemic has immensely affected the training and teaching of pathology residents in India. Similarly, this pandemic must have affected pathology residents all across the globe. Therefore, institutions can consider offering an extended period of up to one year, depending upon residents' requests.

Anaplastic Rhabdomyosarcoma of Upper Lip in a 3-Year-Old Girl

Rhabdomyosarcoma is an aggressive malignant striated muscle neoplasm commonly seen in children involving orbit, paranasal sinuses, cheek, tongue, and rarely upper lip. The anaplastic subtype is further rare and associated with poor prognosis. Herein, we report a 3-year-old female with this uncommon variant at an uncommon site.

Gastrointestinal mucormycosis in the pediatric age group: an evolving disease

BACKGROUND

Mucormycosis is a devastating opportunistic fungal infection resulting in significant mortality, especially in pediatric patients with predisposing risk factors.

MATERIALS & METHODS

Biopsies and surgical specimens reported and proven as Mucormycosis in children under 12 years of age were retrieved from the records for three years (January 2018 to January 2021). Complete data, predisposing factors, treatment, and clinical outcome were recorded.

RESULTS

15 cases were identified, ranging from 9 days to 5 years. The male-female ratio was 3:1; three children were preterm. Fourteen children were diagnosed with gastrointestinal Mucormycosis (14/15), and one had palatal and sinusoidal involvement. Abdominal pain with distention was the most typical complaint. On microscopy, biopsies and surgical specimens showed extensive liquefactive necrosis with broad aseptate fungal hyphae. An intraoperative diagnosis was rendered in two cases. All neonates underwent exploratory laparotomy with surgical debridement and were administered Liposomal Amphotericin B. However, only two neonates survived out of the fifteen cases, one with disease limited to the appendix and pouch colon. The others succumbed to the disease despite antifungal therapy and surgical debridement. Thus, the overall mortality in the current study was calculated to be 86%, with neonatal mortality of 75%.

CONCLUSION

Gastrointestinal involvement is more common in neonates and infants with a male preponderance. The diagnosis relies on direct microscopy, histopathology, and fungal culture. Intraoperative tissue may be sent in all suspected cases for direct microscopic examination for rapid diagnosis and treatment.

Neonate with Congenital Duodenal Obstruction and Ectopic Hepatic Parenchyma

BackgroundThe presence of hepatic parenchyma at ectopic locations is infrequently reported in neonatal age. Case details: A male neonate presented with clinical signs and symptoms of duodenal obstruction. At exploration, an annular pancreas was found as the causative factor and he underwent a Kimura's duodeno-duodenostomy. A pedicled cyst was attached to the stomach's greater curvature, was excised, and histologically was a mesothelial-lined cyst with ectopic liver, complete with bile ducts, in the cyst wall. Conclusion: Ectopic liver tissue may be clinically silent and found within the wall of a mesothelial cyst. Long-term complications of this ectopic tissue are not known.

An unusual case of respiratory epithelial cyst of orbit presenting as a lid swelling in a child

This case highlights the importance of histopathological examination in all cases of choristoma undergoing excision.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

AB1438 CARDIOVASCULAR RISK STRATIFICATION FOR TOFACITINIB PATIENTS IN A LARGE TEACHING HOSPITAL

Background

Tofacitinib is an oral JAK-Inhibitor often reserved for patients with treatment-resistant Rheumatoid Arthritis and Psoriatic Arthritis. Tofacitinib modulates cytokines crucial to the inflammatory response which characterises the above conditions, and inhibits certain pathways in the inflammatory response cascade. Rheumatoid and Psoriatic Arthritis are linked with an inherent increased risk for major cardiovascular events. Recent emerging data has evidenced increased cardiovascular risk associated with long-term use of tofacitinib.

Objectives

To identify all patients currently undergoing Tofacitinib treatment across all sites at King’s College Hospital NHS Foundation Trust.​

To risk-stratify all patients into three categories; low risk of developing major cardiovascular events, moderate risk of developing MACE (patients with modifiable risk factors​, eg. high cholesterol or a borderline blood pressure), and high risk of developing MACE (unmodifiable risk factors​).

To switch patients at high risk onto another treatment or alternative JAK-inhibitor.​

Methods

Patient data was obtained through electronic patient records including age, blood pressure reading, full lipid profile, smoking status, and comorbidities (hypertension, diabetes, chronic kidney disease, previous cardiovascular history and history of malignancy). A QRISK3 score was calculated.

Modifiable risk factors with a lower QRISK3 score were categorised as moderate risk.

Patients were considered at high risk if they had a previous cardiovascular event, or a QRISK3 score of more than 10%.

Results

A total of 40 patients were on tofacitinib; 64% with RA, 31% with PsA, and 5% for other reasons (interstitial lung disease and colitis). Of the rheumatoid arthritis cohort: 36% of patients were at high risk, 40% at moderate risk, and 24% low risk. Of the psoriatic arthritis cohort: 67% at high risk, 25% at moderate risk, 8% at low risk.

Figure 1.

Conclusion

A significant number of patients were deemed at moderate and high risk. Patients with moderate risk were advised to undergo lifestyle changes, like exercise and diet modification and smoking cessation.

Patients at high risk were discussed at the trust-wide Rheumatology local clinical governance meeting, and advised to switch onto an alternative treatment or alternative JAK-inhibitor.

A repeat audit will be made in a few months’ time to assess the impact of lifestyle changes and alteration of drugs on cardiovascular risk.

References

[1]MHRA/CHM advice: Tofacitinib: new measures to minimise risk of major adverse cardiovascular events and malignancies (October 2021)

Disclosure of Interests

None declared

Neuroblastoma: Application of International Neuroblastoma Pathology Classification on fine needle aspiration cytology smears

BACKGROUND

Neuroblastoma (NB) is the fourth most common tumor of childhood. There is a paucity of literature on its subtyping of cytology and prognostic utility.

AIMS

We aimed to study the cytopathological features of NB on the aspirated material, subtype it, and assess the role of International Neuroblastoma Pathology Classification (INPC) classification on cytology smears in the preoperative prognosis of NB.

MATERIALS AND METHODS

Fifteen cases of NB reported on fine-needle aspiration cytology (FNAC) in the past 3 years were included. Detailed clinical, radiological, and cytological features were noted. Smears were assessed for characteristics such as cellularity, neuroblasts (cytoplasmic, nuclear details), rosettes, neuropil, Schwann cells, fibroblasts, calcification, and necrosis. Afterward, cases were categorized as undifferentiated (UD), poorly differentiated (PD), and differentiating (D) subtypes. Mitotic-karyorrhectic index (MKI) was calculated and correlated with histopathology. Follow-up was done to date.

RESULTS

The age ranged from 19 days to 10 years with an M: F ratio of 3:1. Twelve cases were retroperitoneal, two cervical, and one mediastinal. Metastatic disease was seen in six cases, one to the cervical, four to the bone marrow, and two to the scalp. The International Neuroblastoma Risk Group (INRG) staging system was available in all cases, out of which three were in stage L1, six in stage L2, four in stage M, and two in stage Ms. On cytology, four cases were differentiating NB, five PD NB, and six UD NB. The MKI was high (>4%) in 80% of UD, intermediate (2-4%) in 100% of PD, and low (<2%) in 75% of D cases. MKI corroborated in both histology and cytology, except in one case.

CONCLUSION

NB can be subtyped on cytology on the basis of characteristics of neuroblasts, presence of neutrophils, rosettes, and necrosis. UD NB has a high MKI and is associated with a poor prognosis. A preoperative comprehensive reporting of NB on cytology can be very useful in guiding appropriate chemotherapy with some increment in survival. However, larger studies are needed to validate the calculation of MKI on FNA smears.

Pediatric Colorectal Carcinoma: A Series of Seven Cases

Introduction

Colorectal carcinoma (CRC) accounts for <1% of all the neoplasms of children. Unfavorable histology and delayed diagnosis often result in poor outcome. This study aimed to investigate the clinical characteristic and prognosis of pediatric patients with CRC.

Materials and Methods

A retrospective review of medical records of all patients diagnosed of CRC between 2015 and 2020 was performed. Data regarding gender, age, location, and histopathology were collected.

Results

Seven children (5 males and 2 females) were included in the study. Age ranged between 8.6 and 11.8 years. Abdominal pain was the most common symptom. The duration between onset of symptoms to the diagnosis ranged from 5 days to 8 months. Right-sided tumors were more common than the left side. Histopathological examination showed mucinous adenocarcinoma in four/seven patients and signet cell variant was seen in 2/7. Immunohistochemistry was positive for cytokeratin and beta-catenin, however, all microsatellite instability markers were found negative. Despite surgical treatment and chemotherapy, four of our cases faced mortality and one patient was lost to follow-up.

Conclusion

CRC can present in first decade of life and often misdiagnosed. Pediatric CRC has distinct tumor biology and shares a poor prognosis. Paucity of literature from the Indian subcontinent should urge further clinicopathological trials for establishing etiology and for refining treatment recommendations in these children.

Mixed cortico-medullary adrenal carcinoma in children: looks are deceptive!!

Background

Mixed cortico-medullary adrenal carcinoma (MCMAC) is an extremely rare entity with scarce literature on its cytomorphology.

Case presentation

A 2-year-old girl presented with abdominal pain for 3 days and a past history of fever with significant weight loss. On examination, a non-tender left hypochondrial firm mass and an enlarged left supraclavicular node were found. Twenty-four-hour urinary levels of VMA were marginally high. Contrast-enhanced computed tomography of the abdomen showed a suprarenal heterogeneous mass encasing major vessels. Aspiration cytology of both mass and node showed similar features comprising a predominant population of singly scattered large cells with moderate cytoplasm, eccentric nucleus and prominent nucleolus in a necrotic background. Tumour cells expressed Synaptophysin and Melan-A. In view of increasing respiratory distress, debulking surgery was performed, and histopathology of the specimen revealed the presence of both malignant medullary and cortical components supported by immunohistochemistry making a final diagnosis of MCMAC. The patient succumbed to death in the postoperative period. The cytology slides were reviewed and were seen to show a dual cell population.

Conclusion

Coexistent malignant cortical and medullary tumour of the adrenal gland is the first case reported in the paediatric age group in the literature with only three previous case reports in adults.

Hypnosis and progressive muscle relaxation for anxiolysis and pain control during extraction procedure in 8-12-year-old children: a randomized control trial

Introduction

Hypnosis (H) and Progressive Muscle Relaxation (PMR) have proven to be effective in a variety of medical settings; there is a paucity of their practical application in paediatric dentistry. The study aimed to comparatively evaluate the role of H and PMR on anxiety, heart rate (HR), oxygen saturation (SPO₂), blood pressure (BP), pain, and analgesic requirement during extraction in children.

Materials and methods

Sixty children aged 8–12 years undergoing primary molar extractions were randomly allocated to three groups—H, PMR, and control (C). The anxiety (proposed Visual Facial Anxiety scale), HR, and SPO₂ were measured pre/post-operatively with/without interventions (H, PMR, C) at 4 intervals. The BP and pain (Wong-Baker faces pain scale) were recorded pre- and post-operatively. Need for analgesic post-operatively was assessed.

Results

Statistically significant reduction in anxiety was noted post-extraction in H (0.30 ± 0.80), PMR (0.50 ± 0.69) (p < 0.001*). HR showed a statistically significant drop after H, PMR application. (p < 0.001*) No significant difference in SPO₂ was noted in the three groups (p > 0.05). Pain control was well achieved using H (85%), PMR (70%); BP was well-regulated in the H, PMR compared to C group (p < 0.001*). Need for analgesics was reduced in H (45%), PMR (50%) versus C (100%). Both techniques H, PMR were comparable in all measures.

Conclusion

Hypnosis and PMR are effective techniques for anxiolysis and pain control in paediatric dental patients.

Association of Anti-tissue Transglutaminase Antibody Titers and Duodenal Biopsy Findings in Pediatric Patients of Celiac Disease

Aims & Objectives

To ascertain the association of serum anti-tissue transglutaminase (anti-tTG) antibody titers with the severity of duodenal mucosal damage on histology andto predict a possible cut-off value of anti-tTG antibody titers for the diagnosis of Celiac disease. Marsh grading greater than two in conjunction with clinical assessment, which may help avert an invasive endoscopic procedure, especially in medically unfit children.

Materials & Methods

A retrospective study was designed wherein demographic and laboratory data of children aged less than 12 years with raised anti-tTG antibody titers with available histopathology of duodenal biopsies were extracted from the hospital medical records and reviewed.

Results

A total of 134 children were included in the study, which showed female preponderance. Histopathological changes, characteristic of Celiac disease, were observed in 116 cases; seven among the rest showed evidence of Giardiasis, and 13 could be considered potential Celiac. Of the 116 patients, 1.7% belonged to Marsh grade I, 5.2% grade II and 8.6%, 26.7%, and 57.7% to grade IIIA, IIIB, and IIIC, respectively. A significant association was found between anti-tTG antibody titers and Marsh grading. The cut-off value of anti-tTG antibody titer levels for diagnosing Celiac disease using receiver operating characteristics (ROC) curve in predicting Marsh greater than two at histology was observed to be 84.6 U/ml with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.7%, 68.4%, 94.2%, and 59%, respectively.

Conclusion

An anti-tTG antibody titer greater than 10 times the upper limit of normal (≥84 U/ml) is significantly associated with Marsh grade greater than two. Standard stool microscopy may be used as a simple tool in the workup of all children with raised anti-tTG antibody levels to rule out Giardiasis to avert unnecessary endoscopic evaluation for Celiac disease in such cases.

Kaposiform haemangioendothelioma of duodenum in a neonate

Kaposiform haemangioendothelioma, an endothelial borderline tumour, is typically seen in childhood involving extremities. It has been closely associated with a consumptive coagulopathy state, Kasabach-Merritt phenomenon (KMP). Extracutaneous involvement is uncommon. Intestinal involvement is quite uncommon and can masquerade as an acute abdomen. A 24-day-old neonate presented with bilious vomiting and fever for 5 days. Sections from the resected gangrenous duodenum contained a submucosal tumour composed of infiltrating nodules of slit-like or crescentic CD34-positive spindled-to-flattened endothelial-lined vascular spaces along with zones of fibrosis. No nuclear pleomorphism or necrosis identified. The findings were classic example of kaposiform haemangioendothelioma with an absence of any deranged coagulation profile. The index case raises interest given its congenital incidental presentation at an uncommon site, like duodenum, and absence of coexistent KMP.

Spindle cell lipoma, dorsum of hand in a 4 year old child: A rare entity

Lipogenic tumors are an uncommon entity in children. There are several variants of lipoma, of which spindle cell lipoma is an extremely rare and accounts for only 1.5% of all lipoma diagnosis. Spindle cell lipoma rarely involves distal extremities. We report a 4-year old boy with swelling over dorsum of hand operated for aesthetic purposes. The report also highlights the salient cytological features, which can help differentiate this entity from other closer mimics on aspiration cytology, guiding the surgeon for appropriate management.

Peripheral Lymphadenopathy in Children: Cytomorphological Spectrum and Interesting Diagnoses

OBJECTIVE

Peripheral lymphadenopathy is a common complaint in the pediatric outpatient department. Fine needle aspiration cytology is the first investigation of choice with a high sensitivity for diagnosis but cytology may be challenging in some cases. The study was planned to study the cytomorphological spectrum and discuss a few interesting cases.

MATERIAL AND METHOD

1890 paediatric subjects' up to 12 years of age with significant peripheral lymph node enlargement and an adequate cytology specimen were included in the study. Inadequate aspirates were excluded.

RESULTS

The majority of children presented within 4-8 years of age with a male to female ratio of 1.7:1. The anterior cervical group was most commonly affected, followed by the posterior cervical, axillary and inguinal. Reactive lymphadenitis constituted the majority of the diagnoses, followed by Tuberculosis, acute suppurative, BCG-induced lymphadenitis, Kimura disease, Rosai-Dorfmann disease and Kikuchi-Fujimoto disease. Lymphomas and metastatic malignancies were less common, and mainly consisted of Hodgkin lymphoma, non-Hodgkin lymphoma, anaplastic large cell lymphoma, and Langerhans cell histiocytosis. Cytomorphological features of a few challenging and interesting cases have been discussed.

CONCLUSION

Non neoplastic causes of lymphadenopathy predominate in the pediatric age group. A definitive diagnosis rests upon a complete clinical, radiological, microbiological, and cyto-histopathological correlation with the use of ancillary techniques wherever necessary.

Reliable cerebrospinal fluid cytology reporting over an extended period: Is it possible by adding formol saline and ethylenediaminetetraacetic acid as cell preservative?

BACKGROUND

Reporting cerebrospinal fluid (CSF) cytology within a narrow time frame is crucial as it is often indicated in critically ill patients and moreover, the cells in CSF are highly labile and tend to decline rapidly on standing. However, due to various logistic issues, delay in reporting is inevitable at times, especially if ancillary tools are required. In this study, we examine the effect of using formol saline and ethylenediaminetetraacetic acid (EDTA) as a preservative on the cellular composition of CSF at 18, 24, and 48 hours of preservation.

METHODS

Thirty CSF specimens were examined within 2 hours of collection and this reading was recorded as time zero reading. The CSF specimens were then divided in three tubes with: (a) preservative:CSF ratio of 1:1; (b) preservative:CSF ratio of 1:5; and (c) no preservative. Total and differential leucocyte counts and immunocytochemistry were performed on the three specimens at 18, 24, and 48 hours and were compared with the readings at 0 hour.

RESULTS

Preserved CSF (in the ratio of 1:5) showed no significant decrease in the number of cells at 18 hours (P = .4), 24 hours (P = .3), and 48 hours (P = .1). Cellularity decreased by 8.5%, 22%, and 40% at 18, 24, and 48 hours, respectively. Cell morphology and antigenicity were well preserved at all the three time intervals.

CONCLUSION

Formol saline and EDTA, when mixed with the CSF in the ratio of 1:5, can preserve significant cellularity for up to 24 hours.

Lipofibromatosis: A Rare Diagnosis on Fine Needle Aspiration Cytology

Lipofibromatosis is a recently recognized slow growing rare pediatric tumor. Paucity of its cytological description in the literature leads to its pre operative misdiagnosis and further incomplete management. A twelve-month-old female presented with a rapidly progressive mass in the right thigh and buttock region. On examination, the mass was huge and involved the medial, posterior and lateral aspects of the thigh. The cytological smears showed mature adipocytes with few spindled out cells. FNA was reported as a lipoma, corroborating with the radiological presumptive diagnosis. However, histopathological and immunohistochemical features favoured a diagnosis of Lipofibromatosis. The cytological smears were reviewed and a cyto-histo correlation was established. The diagnosis of Lipofibromatosis rests upon classical cytological features in a clinically and radiologically suggestive picture. An early and accurate diagnosis if established can help the surgeon plan excision with wider margins as incomplete excision is associated with a high rate of recurrence.

Cytological diagnosis in a clinically unsuspected case of disseminated BCGosis: A case report

Bacille Calmette-Guerin (BCG) vaccine is administered worldwide to neonates and considered safe. Serious complications like disseminated BCGosis are extremely rare occurrences (<1 per million vaccinations). A 6 months male was brought to paediatric outpatient department with fever and swelling over the dorsum of the left hand for 5 days. On examination, he was febrile and had hepatosplenomegaly. X-ray of the hand showed lytic lesions in the first and second metacarpals. Provisional clinical diagnosis included Langerhans cell histiocytosis, congenital syphilis, and haematological malignancy. Fine Needle Aspiration Cytology (FNAC) was done from the swelling and showed diffuse sheets of histiocytes with both intracellular and extracellular rod-shaped unstained structures along with inflammatory cells. These ghost images stained positive with ZN stain. A cytological diagnosis of atypical mycobacteria vs leprosy was made. Child was revisited and found to have an active BCG scar. Further investigations showed low serum IgM and positive AFB culture. These bacilli were confirmed by GenoType MTBDR plus test as Mycobacterium bovis. Despite Antitubercular therapy, the patient succumbed to death. This case highlights the variable clinical presentation of BCGosis. Its occurrence may unmask any underlying immunodeficiency. If unfamiliar with the above cytological features and in absence of routinely performed special stains, the cytopathologist may miss these notorious organisms and treat such cases like suppurative lesions. To conclude, an early and definitive diagnosis of BCGosis can be established on FNAC which would ensure timely management and better outcome in this highly lethal entity.

Intraoral Foregut Cystic Developmental Malformations: Three cases with a brief review of literature

Foregut cystic developmental malformations (FCDM) are a type of rare cystic lesion. The occurrence of FCDM is exceedingly uncommon in the intraoral location. We report three cases of FCDM with intraoral location who presented at Chacha Nehru Bal Chikitsalaya, New Delhi, India, in 2016, 2017 and 2018 with symptoms of respiratory distress and feeding difficulties. Two patients were male and one was female with an age range of 29 days to eight years. The clinical differential diagnosis included mucocele, ranula, dermoid, lymphangioma, teratoma, thyroglossal duct cyst, etc. All patients were treated with simple surgical excision and diagnosed, based on histopathology, with FCDM. These should be considered as differential diagnosis of head and neck midline cystic mass lesions. This case report aimed to discuss differential diagnosis and appropriate terminology for these cystic masses as there is varied and ambiguous nomenclature.

Significance of Crushed Fragments and Eosinophils in Cytological Diagnosis of Hashimoto's Thyroiditis

Introduction Hashimoto's thyroiditis (HT) is a chronic autoimmune inflammatory disorder of the thyroid gland with a prevalence of 1%-4%. The incidence of HT seems to be increasing in recent times. If serological parameters are used as sole criteria for diagnosis, cases of HT get missed or over-diagnosed. There are established cytological features of HT but that could, at times, be seen in other thyroid disorders, making cytological diagnosis difficult. The present study was undertaken to find out the significance of crushed fragments and eosinophils along with the well-known cytological features in the diagnosis of HT. Methods This study was carried out over a period of two years and a total of 114 patients were registered for the study; 48 patients were HT cases. The control group comprised of 66 non-thyroiditis patients. Fine-needle aspiration cytology (FNAC) was performed on all patients with palpable thyroid swelling to compare cytological features of thyroiditis (study group) with aspirates of non-thyroiditis lesions (controls). Results The background lymphocytes were found to be present in all cases of the study group but in variable numbers. The lymphocytes infiltrating the follicular epithelial cells were seen in most (93.75%) of the study cases. The presence of Hurthle cells was significantly higher (83%) in the study group as compared to the control group (4.5%). The presence of crushed cells morphology (crushed fragments) were seen in 40 (83.33%) of these 48 HT cases while none in the control group showed this feature. The presence of eosinophilic infiltration shows a statistically significant association with FNA diagnosis of HT patients (P<0.05). Conclusion The crushed fragments, if visible at low power, gives a diagnostic clue for looking up for other features of HT. Also, the crushed fragments and eosinophils could avoid the false negative and misdiagnosis of neoplasm in paucicellular and highly cellular smear respectively.

Synovial Lipomatosis with Chondroblastoma in an 8-year-old Female: A Previously Unreported Entity

Introduction:

Synovial lipomatosis is a rare disease entity and a very small number of cases have been reported so far. It is characterized by villous proliferation of the synovium with expansion by mature adipose tissue. The etiology is unclear, thought cases can be seen secondary to injury, inflammation, chronic degenerative changes and neoplasms. Etiopathogenesis is still unclear, however is seen secondary to injury, inflammation, chronic degenerative conditions and neoplasms.

Case Report:

An 8-year-old female child presented with pain and swelling in the left knee. Radiological examination suggested of a lytic lesion in upper tibia along with reactive synovial thickening. The lytic lesion was excised and an incisional biopsy was taken from the hyperplastic synovium. Histopathological examination of the synovial tissue showed villi-like structures with mature adipose tissue expanding the synovial lining along with the presence of mild chronic inflammatory cell infiltrate. The lytic lesion showed a cartilaginous tumor comprising mineralized chicken wire matrix surrounding the chondroblasts. A final diagnosis of synovial lipomatosis with chondroblastoma was made on histopathological examination.

Conclusion:

This may be the first case report in medical literature of synovial lipomatosis coexisting with chondroblastoma in an adolescent girl. It also highlights the need for its increased awareness among young radiologists and pathologists so that an early diagnosis directs correct management and prevents further joint morbidity.

SLC28A3 genotype and gemcitabine rate of infusion affect dFdCTP metabolite disposition in patients with solid tumours

Background:

Gemcitabine is used for the treatment of several solid tumours and exhibits high inter-individual pharmacokinetic variability. In this study, we explore possible predictive covariates on drug and metabolite disposition.

Methods:

Forty patients were enrolled. Gemcitabine and dFdU concentrations in the plasma and dFdCTP concentrations in peripheral blood mononuclear cell were measured to 72 h post infusion, and pharmacokinetic parameters were estimated by nonlinear mixed-effects modelling. Patient-specific covariates were tested in model development.

Results:

The pharmacokinetics of gemcitabine was best described by a two-compartment model with body surface area, age and NT5C2 genotype as significant covariates. The pharmacokinetics of dFdU and dFdCTP were adequately described by three-compartment models. Creatinine clearance and cytidine deaminase genotype were significant covariates for dFdU pharmacokinetics. Rate of infusion of <25 mg m⁻² min⁻¹ and the presence of homozygous major allele for SLC28A3 (CC genotype) were each associated with an almost two-fold increase in the formation clearance of dFdCTP.

Conclusion:

Prolonged dFdCTP systemic exposures (⩾72 h) were commonly observed. Infusion rate <25 mg m⁻² min⁻¹ and carriers for SLC28A3 variant were each associated with about two-fold higher dFdCTP formation clearance. The impacts of these covariates on treatment-related toxicity in more selected patient populations (that is, first-line treatment, single disease state and so on) are not yet clear.

Palatal plasmacytoid myoepithelioma

Myoepitheliomas are benign neoplasms of salivary glands derived from myoepithelial cells. These tumors can occur at any age but are most common in young adults. This tumor is usually located in the parotid gland and the minor salivary glands of the soft palate and represents less than 1% of all salivary gland tumors. The myoepithelioma is classified in the follow cells types: spindle, plasmacytoid, reticular, epitheliod, and clear, additionally, mixed histological forms are described. The plasmacytoid myoepithelioma from palate salivary glands is considered as a rare entity. A 45-year-old lady presented with an asymptomatic, well-circumscribed, solid mass located on the hard palate, which was gradually increasing in size. A clinical impression of Pleomorphic Adenoma was made which on histopathological examination revealed cords, clusters, and sheets of homogenous, large cells with plasmacytoid characteristics and a prominent eosinophilic cytoplasm. Ductal and acinar differentiation were absent thus ruling out the pleomorphic adenoma, whereas, features consistent with plasmacytoid myoepithelioma were evident.

Abstract C30: Use of targeted magnetic nanoparticles for imaging in prostate cancer

Objective: Imaging techniques better than those conventionally used are needed to improve prostate cancer (PC) staging and read out of therapeutic effects in real time in treated patients. We aimed to perform preclinical evaluation of newly developed well-characterized, biocompatible, PC-targeted magnetic nanoparticles (MNPs) targeted to prostate cancer by conjugation with J591 (from N. Bander, Cornell, USA), an antibody which binds specifically to prostate specific membrane antigen (PSMA) which is expressed on the surface of ∼90% of PCs including castrate resistant prostate cancers; this binding results in internalization. The use of targeted MNPs should enhance the specificity and sensitivity of magnetic resonance imaging (MRI) to enable better staging of patients with PC and future targeted delivery of therapy.

Methods: MNPs were prepared, engineered to the appropriate size and conjugated with J591. There was no compromise in J591 cell binding or specificity for PSMA positive cells due to the conjugation, and Inductively Coupled Plasma Optical Emission Spectrometry and Prussian blue staining for iron indicated increased uptake of MNPs that were conjugated with the antibody. In vivo studies were performed in immunodepressed nude mice with subcutaneous LNCaP-LN3 (PSMA-positive) xenografts (post euthanasia using an 11.7T NMR system) or on live mice with orthotopic LNCaP xenografts, using a 16.4T MRI imaging system following intravenous injection of MNPs.

Results: Similar enhancement of MRI was obtained by NMR after injection of MNP or J591-MNP conjugates. Live imaging of mice given systemic J591-MNPs showed uptake into the prostate tumors.

Conclusions: The data indicate the promise of this technique in enabling imaging of small clusters of human prostate cancer cells. This should enable the effects of therapy to be determined by imaging in real time, improving patient management.

Citation Format: Pamela J. Russell, C Soekmadji, B Thierry, G Cowin, T Strait-Gardner, N Verma, Wang Xiaochun, A Khatri. Use of targeted magnetic nanoparticles for imaging in prostate cancer [abstract]. In: Proceedings of the AACR Special Conference on Advances in Prostate Cancer Research; 2012 Feb 6-9; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2012;72(4 Suppl):Abstract nr C30.

CD147/EMMPRIN and CD44 are potential therapeutic targets for metastatic prostate cancer

Prostate cancer (CaP) is a major health problem in males in Western countries. Current therapeutic approaches are limited and many patients die of secondary disease (metastases). There is no cure for metastatic castration-resistant prostate cancer (CRPC). Targeting tumor-associated antigens is fast emerging as an area of promise to treat late stage and recurrent CaP. Extracellular matrix metalloproteinase inducer, EMMPRIN (CD147) is a multifunctional glycoprotein that can modify the tumor microenvironment by activating proteinases, inducing angiogenic factors in tumor and stromal cells, and regulating growth and survival of anchorage-independent tumor cells (micrometastases) and multidrug resistance (MDR). CD44 is a multifunctional protein involved in cell adhesion, migration and drug resistance, and is a primary receptor for hyaluronan (HA), a major component of the extracellular matrix (ECM) with a critical role in cell signaling and cell-ECM interactions in cancer. Our recent studies indicate both CD147 and CD44 are involved in cancer drug resistance and play very important roles in CaP metastasis. Thus, CD147 and CD44 may be ideal therapeutic targets to control metastatic and CRPC disease. This review will discuss their putative roles in CaP metastasis and MDR, and give an overview of literature regarding their expression on human CaP tissues. Additional focus will be on the potential of therapeutic strategies targeting CD147 and CD44 to prevent CaP metastasis and overcome drug resistance.

Molecular and traditional chemotherapy: a united front against prostate cancer

Castrate resistant prostate cancer (CRPC) is essentially incurable. Recently though, chemotherapy demonstrated a survival benefit ( approximately 2months) in the treatment of CRPC. While this was a landmark finding, suboptimal efficacy and systemic toxicities at the therapeutic doses warranted further development. Smart combination therapies, acting through multiple mechanisms to target the heterogeneous cell populations of PC and with potential for reduction in individual dosing, need to be developed. In that, targeted molecular chemotherapy has generated significant interest with the potential for localized treatment to generate systemic efficacy. This can be further enhanced through the use of oncolytic conditionally replicative adenoviruses (CRAds) to deliver molecular chemotherapy. The prospects of chemotherapy and molecular-chemotherapy as single and as components of combination therapies are discussed.

Palliative care services for those with chronic lung disease

Excellent palliative care is available for patients with advanced lung cancer. Whether the same services are available for those with nonmalignant respiratory disease is less clear. A questionnaire was sent to 210 named respiratory physicians, each representing a major hospital in England, Wales, and Northern Ireland. A total of 107 replies were received; the response rate was 51.0%. Respondents cared for patients with chronic obstructive pulmonary disease, asbestosis, and diffuse parenchymal lung disease but only a third had responsibility for cystic fibrosis. Physicians were supported by a mean of 3.4 respiratory nurse specialists per department and 73.8% had a specialist lung cancer nurse. In only 16 cases (20.3%) did that nurse extend care to those with nonmalignant disease. Only a minority reported easy access to hospice in-patient care or day care. About 21.5% of the respondents had formal policies in place for care of patients with chronic respiratory disease nearing the end of life, but 87.9% of respondents had no formal process for initiating end of life discussions with those with terminal respiratory illness. Patients with advanced nonmalignant respiratory disease have less universal access to specialist palliative care services than do those with malignant lung disease, and in the majority of hospitals there is no formalized approach to end of life care issues with patients with chronic lung disease.

Reflecting the scope and work of palliative care teams today: an action research project to modernise a national minimum data set

The Minimum Data Set (MDS) for UK specialist palliative care services was developed in 1995 to provide annual data on palliative care services. Data collected is used for local and national purposes including service management, monitoring and audit, the commissioning of services and the development of national policy. The emergence of Payment by Results and HealthCare Resource Groups, which will have an impact on the funding processes, together with identified limitations of the current MDS resulted in a project to revise the MDS. An action research approach was used for the project and had distinctive phases including modifying the MDS, a pilot phase and an expert panel consultation. Modifications to all the sections of the MDS and changes to terminology were made. The action research approach enabled revisions made based upon a national consensus and met the changing provision of specialist palliative care services for the UK.

Comparative evaluation of shear bond strength of conventional composite resin and nanocomposite resin to sandblasted primary anterior stainless steel crown

To evaluate and compare the shear bond strength of conventional composite resin and nanocomposite resin to sandblasted primary anterior stainless steel crown. The study samples consisted of 30 primary anterior stainless steel crowns (Unitek TM, size R4), embedded in resin blocks with crown, in test groups of 15 samples each. Mounting of the crown was done using resin block with one crown each. Sandblasting was done and the bonding agent Prime and Bond NT (Dentsply) was applied on the labial surface of the primary anterior sandblasted crown. The composite resin and nanocomposite resin were placed into the well of Teflon jig and bonded to Stainless Steel Crowns. The cured samples were placed in distilled water and stored in incubator at 37 degrees C for 48 hours. Shear bond strength was measured using universal testing machine (Hounsefield U.K. Model, with a capacity of 50 KN). Independent sample 't' test revealed a nonsignificant (P < 0.385) difference between mean shear bond strength values of conventional and nanocomposite group. The bond strength values revealed that nanocomposite had slightly higher mean shear bond strength (21.04 +/- 0.56) compared to conventional composite (20.78 +/- 0.60). It was found that conventional composite resin and nanocomposite resin had statistically similar mean shear bond strength, with nanocomposite having little more strength compared to conventional composite.

Consistent cytotoxic-T-lymphocyte targeting of immunodominant regions in human immunodeficiency virus across multiple ethnicities

Although there is increasing evidence that virus-specific cytotoxic-T-lymphocyte (CTL) responses play an important role in the control of human immunodeficiency virus (HIV) replication in vivo, only scarce CTL data are available for the ethnic populations currently most affected by the epidemic. In this study, we examined the CD8(+)-T-cell responses in African-American, Caucasian, Hispanic, and Caribbean populations in which clade B virus dominates and analyzed the potential factors influencing immune recognition. Total HIV-specific CD8(+)-T-cell responses were determined by enzyme-linked immunospot assays in 150 HIV-infected individuals by using a clade B consensus sequence peptide set spanning all HIV proteins. A total of 88% of the 410 tested peptides were recognized, and Nef- and Gag-specific responses dominated the total response for each ethnicity in terms of both breadth and magnitude. Three dominantly targeted regions within these proteins that were recognized by >90% of individuals in each ethnicity were identified. Overall, the total breadth and magnitude of CD8(+)-T-cell responses correlated with individuals' CD4 counts but not with viral loads. The frequency of recognition for each peptide was highly correlated with the relative conservation of the peptide sequence, the presence of predicted immunoproteasomal cleavage sites within the C-terminal half of the peptide, and a reduced frequency of amino acids that impair binding of optimal epitopes to the restricting class I molecules. The present study thus identifies factors that contribute to the immunogenicity of these highly targeted and relatively conserved sequences in HIV that may represent promising vaccine candidates for ethnically heterogeneous populations.

Vpr is preferentially targeted by CTL during HIV-1 infection

The HIV-1 accessory proteins Vpr, Vpu, and Vif are essential for viral replication, and their cytoplasmic production suggests that they should be processed for recognition by CTLs. However, the extent to which these proteins are targeted in natural infection, as well as precise CTL epitopes within them, remains to be defined. In this study, CTL responses against HIV-1 Vpr, Vpu, and Vif were analyzed in 60 HIV-1-infected individuals and 10 HIV-1-negative controls using overlapping peptides spanning the entire proteins. Peptide-specific IFN-gamma production was measured by ELISPOT assay and flow-based intracellular cytokine quantification. HLA class I restriction and cytotoxic activity were confirmed after isolation of peptide-specific CD8(+) T cell lines. CD8(+) T cell responses against Vpr, Vpu, and Vif were found in 45%, 2%, and 33% of HIV-1-infected individuals, respectively. Multiple CTL epitopes were identified in functionally important regions of HIV-1 Vpr and Vif. Moreover, in infected individuals in whom the breadth of HIV-1-specific responses was assessed comprehensively, Vpr and p17 were the most preferentially targeted proteins per unit length by CD8(+) T cells. These data indicate that despite the small size of these proteins Vif and Vpr are frequently targeted by CTL in natural HIV-1 infection and contribute importantly to the total HIV-1-specific CD8(+) T cell responses. These findings will be important in evaluating the specificity and breadth of immune responses during acute and chronic infection, and in the design and testing of candidate HIV vaccines.

Enhanced activity in parathyroid hormone-(1-14) and -(1-11): novel peptides for probing ligand-receptor interactions

The amino-terminal portion of PTH is critical for PTH-1 receptor (P1Rc) activation. In exploring this component of the ligand receptor interaction, we recently showed that the agonist potency of the weakly active PTH-(1-14)NH(2) peptide can be enhanced by natural amino acid substitutions at several positions, including position 11 (normally leucine). Here we show that the potency of PTH-(1-14)NH(2) can be enhanced by using nonnatural amino acids that increase the length and polarizability of the position 11 side-chain. Thus, in LLC-PK(1) cells stably expressing high levels of the human P1Rc, [homoarginine([Har)(11)]PTH-(1-14)NH(2) was 30-fold more potent for cAMP production than was native PTH-(1-14)NH(2). Combining the homoarginine-11 substitution with other recently identified activity-enhancing substitutions yielded [Ala(3,12),Gln(10),Har(11),Trp(14)]PTH-(1-14)NH(2), which was 1500-fold more potent than PTH-(1-14)NH(2) (EC(50) = 0.12 +/- 0.04 and 190 +/- 20 microM, respectively) and only 63-fold less potent than PTH-(1-34) (EC(50) = 1.9 +/- 0.5 nM). The even shorter analog [Ala(3),Gln(10),Har(11)]PTH-(1-11)NH(2) was also a full cAMP agonist (EC(50) = 3.1 +/- 1.5 microM). Receptor mutations at Phe(184) and Leu(187) located near the boundary of the amino-terminal domain and transmembrane domain-1 severely impaired responsiveness to the PTH-(1-11) analog. Overall, these studies demonstrate that PTH analogs of only 11 amino acids are sufficient for activation of the PTH-1 receptor through interaction with its juxtamembrane region.