Case of embryonal tumor multilayered rosettes in a patient with neurofibromatosis type 1

BACKGROUND

ETMR is a unique and highly malignant brain tumor mostly occurring in infants. This report provides a comprehensive overview of the clinical presentation, histological aspects, radiological features, and therapeutic options of ETMR. Being the first report on the co-occurrence of NF1 with ETMR, it highlight the challenges of managing a patient with complex medical conditions.

CASE REPORT

We present a case of a 3 and 1/2-year-old girl with neurofibromatosis type 1 (NF1), later diagnosed with a supratentorial brain tumor reported as an embryonal tumor with multilayered rosettes (ETMR), along with possible co-occurrence of constitutional mismatch repair deficiency (CMMRD) on immunohistochemistry (IHC); however, germline testing was not performed. Even though NF1 can be associated with tumors such as gliomas, the literature has no previous case reports of ETMR coexisting with NF1.

CONCLUSION

Exploring the link between NF1 and ETMR with CMMRD is crucial to improving and establishing more treatment protocols. Therefore, reporting each case's unique features would be essential in developing appropriate treatment protocols.

Clinical and biological landscape of constitutional mismatch-repair deficiency syndrome: an International Replication Repair Deficiency Consortium cohort study

BACKGROUND

Constitutional mismatch repair deficiency (CMMRD) syndrome is a rare and aggressive cancer predisposition syndrome. Because a scarcity of data on this condition contributes to management challenges and poor outcomes, we aimed to describe the clinical spectrum, cancer biology, and impact of genetics on patient survival in CMMRD.

METHODS

In this cohort study, we collected cross-sectional and longitudinal data on all patients with CMMRD, with no age limits, registered with the International Replication Repair Deficiency Consortium (IRRDC) across more than 50 countries. Clinical data were extracted from the IRRDC database, medical records, and physician-completed case record forms. The primary objective was to describe the clinical features, cancer spectrum, and biology of the condition. Secondary objectives included estimations of cancer incidence and of the impact of the specific mismatch-repair gene and genotype on cancer onset and survival, including after cancer surveillance and immunotherapy interventions.

FINDINGS

We analysed data from 201 patients (103 males, 98 females) enrolled between June 5, 2007 and Sept 9, 2022. Median age at diagnosis of CMMRD or a related cancer was 8·9 years (IQR 5·9-12·6), and median follow-up from diagnosis was 7·2 years (3·6-14·8). Endogamy among minorities and closed communities contributed to high homozygosity within countries with low consanguinity. Frequent dermatological manifestations (117 [93%] of 126 patients with complete data) led to a clinical overlap with neurofibromatosis type 1 (35 [28%] of 126). 339 cancers were reported in 194 (97%) of 201 patients. The cumulative cancer incidence by age 18 years was 90% (95% CI 80-99). Median time between cancer diagnoses for patients with more than one cancer was 1·9 years (IQR 0·8-3·9). Neoplasms developed in 15 organs and included early-onset adult cancers. CNS tumours were the most frequent (173 [51%] cancers), followed by gastrointestinal (75 [22%]), haematological (61 [18%]), and other cancer types (30 [9%]). Patients with CNS tumours had the poorest overall survival rates (39% [95% CI 30-52] at 10 years from diagnosis; log-rank p<0·0001 across four cancer types), followed by those with haematological cancers (67% [55-82]), gastrointestinal cancers (89% [81-97]), and other solid tumours (96% [88-100]). All cancers showed high mutation and microsatellite indel burdens, and pathognomonic mutational signatures. MLH1 or MSH2 variants caused earlier cancer onset than PMS2 or MSH6 variants, and inferior survival (overall survival at age 15 years 63% [95% CI 55-73] for PMS2, 49% [35-68] for MSH6, 19% [6-66] for MLH1, and 0% for MSH2; p<0·0001). Frameshift or truncating variants within the same gene caused earlier cancers and inferior outcomes compared with missense variants (p<0·0001). The greater deleterious effects of MLH1 and MSH2 variants as compared with PMS2 and MSH6 variants persisted despite overall improvements in survival after surveillance or immune checkpoint inhibitor interventions.

INTERPRETATION

The very high cancer burden and unique genomic landscape of CMMRD highlight the benefit of comprehensive assays in timely diagnosis and precision approaches toward surveillance and immunotherapy. These data will guide the clinical management of children and patients who survive into adulthood with CMMRD.

FUNDING

The Canadian Institutes for Health Research, Stand Up to Cancer, Children's Oncology Group National Cancer Institute Community Oncology Research Program, Canadian Cancer Society, Brain Canada, The V Foundation for Cancer Research, BioCanRx, Harry and Agnieszka Hall, Meagan's Walk, BRAINchild Canada, The LivWise Foundation, St Baldrick Foundation, Hold'em for Life, and Garron Family Cancer Center.

Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S

Introduction

Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant.

Methods

We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints.

Results

A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three.

Discussion

The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

Lymphomatosis Cerebri: A diagnostic dilemma

Background

Lymphomatosis cerebri (LC) is a rare manifestation of primary central nervous system lymphoma (PCNSL) with only a few cases reported in the literature, appearing as diffuse infiltrating process rather than a solitary mass. It is a non-Hodgkin's type of lymphoma and is usually of the B-cell type origin.

Purpose

We intend to report this unique case of LC which came across as a diagnostic challenge.

Methods

A 53-year-old gentleman presented with complaints of two episodes of seizures 24 h apart followed by postictal confusion for 10-15 min. He underwent multiple MRI scans and underwent a biopsy of the lesion which reported infection, but he did not benefit from the treatment.

Result

The imaging was reviewed, suspicion of LC was raised and a review of histopathology was requested which later confirmed primary CNS lymphoma.

Conclusion

LC is a rare but established manifestation of PCNSL which mimics multiple other conditions. Understanding of the imaging pattern is important in making the diagnosis and differentiating it from other mimic conditions.

Paediatric choroid plexus carcinoma: a retrospective case series from Karachi

The objective of this study is to report clinical, radiological, and histopathological characteristics of three paediatric patients diagnosed as Choroid plexus carcinoma seen at our hospital, between 2015 and 2020. Three patients were diagnosed with choroid plexus carcinomas between 2015 and 2018. The mean age at diagnosis was 1.3 years (range 8 months to 1.5 years). All the three patients had subtotal resection and received adjuvant chemotherapy. One patient also received adjuvant radiotherapy. Despite these treatment measures, residual disease was noted in all three patients and two patients were subsequently treated on palliative care grounds. The average duration of follow-up after the first surgery for all three patients was approximately 33 months. Attaining satisfactory outcome in patients with CPC is challenging. Our case series reflects the difficulty in achieving gross total resection and ensuring that the disease does not recur.

Pakistan National Guidelines for Pediatric High-Grade Gliomas

Pediatric high-grade glioma (pHGG) is highly malignant central nervous system tumor and constitute 10% of the pediatric gliomas. Effective treatment needs a functioning multi-disciplinary team including pediatric neuro oncologist, neurosurgeon, neuroradiologist, neuropathologist and radiation oncologist. Despite surgical resection, radiotherapy and chemotherapy, most HGG will recur resulting in early death. A significant proportion of HGG occurs in context of cancer predisposition syndromes like Constitutional Mismatch Repair Deficiency (CMMRD) also known as Biallelic Mismatch Repair Deficiency (bMMRD) characterized by high mutational burden. The incidence of HGG with CMMRD is one per million patients. bMMRD is caused by homozygous germline mutations in one of the four Mis Match Repair (MMR) genes (PMS2, MLH1, MSH2, and MSH6). The use of TMZ is now avoided in CMMRD related HGG due to its limited response and known ability to increase the accumulation of somatic mutations in these patients, increasing the risk of secondary tumors. HGG should be managed under the care of multidisciplinary team to receive optimum treatment. This is particularly important for low middle-income countries (LMIC) with limited resources like Pakistan.

Postoperative radiotherapy for high-grade primary cardiac spindle cell sarcoma: a rare entity

A patient in her early 20s presented with blood-stained sputum and shortness of breath. Initially, she was treated for pneumonia. Later, upon exacerbation of symptoms, further investigations were done which exhibited a left atrial mass causing compression of contralateral atrium. She underwent surgical resection of the mass, which was initially mistaken as myxoma. However, histopathological correlation revealed spindle cell sarcoma with focal myogenic differentiation. This case report highlights the role of Radiation Therapy in adjuvant setting with promising impact on improving local control after R2 resection. Cardiac spindle cell sarcoma, being one of the rarest cardiac tumours reported to date, warrants establishment of a Rare Tumour Multidisciplinary Team for management of such malignancies.

Building the ecosystem for pediatric neuro-oncology care in Pakistan: Results of a 7-year long twinning program between Canada and Pakistan

BACKGROUND

Low- and middle-income countries sustain the majority of pediatric cancer burden, with significantly poorer survival rates compared to high-income countries. Collaboration between institutions in low- and middle-income countries and high-income countries is one of the ways to improve cancer outcomes.

METHODS

Patient characteristics and effects of a pediatric neuro-oncology twinning program between the Hospital for Sick Children in Toronto, Canada and several hospitals in Karachi, Pakistan over 7 years are described in this article.

RESULTS

A total of 460 patients were included in the study. The most common primary central nervous system tumors were low-grade gliomas (26.7%), followed by medulloblastomas (18%), high-grade gliomas (15%), ependymomas (11%), and craniopharyngiomas (11.7%). Changes to the proposed management plans were made in consultation with expert physicians from the Hospital for Sick Children in Toronto, Canada. On average, 24% of the discussed cases required a change in the original management plan over the course of the twinning program. However, a decreasing trend in change in management plans was observed, from 36% during the first 3.5 years to 16% in the last 3 years. This program also led to the launch of a national pediatric neuro-oncology telemedicine program in Pakistan.

CONCLUSIONS

Multidisciplinary and collaborative efforts by experts from across the world have aided in the correct diagnosis and treatment of children with brain tumors and helped establish local treatment protocols. This experience may be a model for other low- and middle-income countries that are planning on creating similar programs.

Giant Central Nervous System Aspergilloma Mimicking Butterfly Neoplasm of the Corpus Callosum

Radiological presentation of central nervous system (CNS) aspergillosis is variable and depends on the immune status of the patients. Typical features of meningoencephalitis, infarction, abscess, and mycotic aneurysms commonly occur in immunocompromised patients. A rare mass-like or tumoral form of cerebral aspergillosis has been described mostly in immunocompetent patients which results in a diagnostic dilemma, thus potentially causing a delay in the management. We present a case of a large CNS aspergilloma mimicking an infiltrative callosal neoplasm in a young immunocompetent patient. Careful evaluation of imaging features, anatomical location, enhancement pattern, concomitant sinonasal and orbital extension, and angio-aggressive nature of the mass lesion with a high index of suspicion can help diagnose CNS aspergillosis in such patients.

Lung Findings in Minimally Invasive Tissue Sampling (MITS) Examinations of Fetal and Preterm Neonatal Deaths: A Report From the PURPOSe Study

BACKGROUND

Complete diagnostic autopsy (CDA) is considered to be the gold-standard procedure that aids in determination of cause of death in stillbirths and neonatal deaths. However, CDA is not routinely practiced in South Asian countries due to religious beliefs, lack of expertise, and lack of resources. Minimally invasive tissue sampling (MITS) has been recommended as a less mutilating and less expensive alternative to CDA for obtaining tissues for analysis. The present study aims to evaluate the yield of lung tissue and histological findings using MITS as part of a cause of death analysis for stillborns and preterm neonatal deaths.

METHODS

Data were collected during an observational multicenter prospective study called the Project to Understand and Research Preterm birth and Stillbirth (PURPOSe) conducted in India and Pakistan. After obtaining written informed consent from parents, the eligible stillbirths and neonatal deaths were subjected to MITS using a standard protocol. The tissues were obtained from both lungs for histological and microbiological analysis.

RESULTS

At both sites, a total of 453 stillbirths and 352 neonatal deaths underwent MITS. For stillbirths and neonatal deaths, the yield of lung tissue using MITS was high (92%). Intrauterine fetal distress and respiratory distress syndrome were the leading lung pathologies reported in stillbirths and neonatal deaths, respectively.

CONCLUSIONS

MITS appears to be a reasonable alternative to CDA in obtaining and evaluating lung tissue to inform accurate cause of death analysis in stillbirth and preterm deaths.

The many faces of glioblastoma: Pictorial review of atypical imaging features

Glioblastoma is an aggressive primary central nervous system tumour that usually has a poor prognosis. Generally, the typical imaging features are easily recognisable, but the behaviour of glioblastoma multiforme (GBM) can often be unusual. Several variations and heterogeneity in GBM appearance have been known to occur. In this pictorial essay, we present cases of pathologically confirmed GBM that illustrate unusual locations and atypical features on neuroimaging, and review the relevant literature. Even innocuous-looking foci, cystic lesions, meningeal-based pathology, intraventricular and infra-tentorial masses, multifocal/multicentric lesions and spinal cord abnormalities may represent GBM. We aim to highlight the atypical characteristics of glioblastoma, clarify their importance and list the potential mimickers. Although a definitive diagnosis in these rare cases of GBM warrants histopathological confirmation, an overview of the many imaging aspects may help make an early diagnosis.

Histopathological effects on stomach, liver and kidney associated with Cedrus deodara root oil in ulcer induced rats (Wistar strain)

Cedrus deodara have been used traditionally in ayurvedic system against peptic ulcer. Present work is concerned with the determination of histopathological effects in ethanol induced ulcer on rats (Wistar Strain) treated with Cedrus deodara root oil at a dose of 200mg/kg and comparison of its antiulcer activity against control, positive control and standard anti-ulcer drug (Omeprazole). The aim was to find out the antiulcer effect of Cedrus deodara root oil and to observe histopathology of liver, kidney as well. 120 Albino rats were taken and divided into four groups i.e. A, B, C and D designated as control, positive control, standard and treated groups respectively. Normal and intact general architecture of mucosa and submucosa layers of stomach observed. No significant changes observed in thickness of epithelium, no inflammatory cells were present on the mucosa and submucosal layer and gastric glands were normal. Liver of albino rats, showed no dilation and congestion in central as well as portal vein. Kidney of albino rats exhibited no shrinkage in glomeruli, no congested and dilated renal corpuscles, neither hemolysis nor congested and dilated renal tubules were seen. It is concluded that C. deodara root oil has anti-ulcer properties without effecting kidney and liver tissues.

Reliability of chest radiograph interpretation for pulmonary tuberculosis in the screening of childhood TB contacts and migrant children in the UK

AIM

To determine interobserver agreement between paediatric radiologists interpreting tuberculosis (TB) screening chest radiographs (CXR) in children in the UK, and the TB detection rate.

MATERIALS AND METHODS

A retrospective review was undertaken of electronic request, notes, and CXRs (>7 years) in children exposed to an infectious case of TB and new entrants to the UK, at a tertiary children's hospital. Included were those with positive Mantoux/interferon gamma release assay (IGRA), positive culture, or high clinical suspicion of TB. CXR reports were categorised as normal, abnormal without features of TB, or abnormal with features of pulmonary TB. Three paediatric radiologists from a dedicated paediatric radiology department evaluated available CXRs, aware of the TB screening indication, using a published CXR reporting tool and blinded to the initial CXR report and to each other. A majority decision was collated, and considered lymphadenopathy and miliary nodules as diagnostic of primary TB. Interobserver agreement was calculated using Cohen's kappa.

RESULTS

One hundred and forty-eight children underwent TB screening with a CXR. One hundred and twenty-five had available CXR reports and case notes, which indicated 20/125 (16%) had CXR features of TB. One hundred and twenty-one of the 125 had CXRs available to for panel review. Twenty of these 121 (17%) yielded a majority decision of pulmonary TB. Inter-reader agreement was moderate in all aspects (kappa 0.4-0.6).

CONCLUSION

The high percentage of pulmonary TB on CXR (16% original reports; 17% by panel review) suggests that it is worthwhile investigating childhood TB contacts; however, the routine use and recommendation for CXR is questionable because of only moderate interpretation reliability (kappa 0.5), even by experts.

Intra-abdominal Follicular Dendritic Cell Sarcoma (FDCS): Series of 18 cases of a rare entity from Pakistan

OBJECTIVES

Follicular Dendritic Cell Sarcoma (FDCS) is a rare neoplastic proliferation of dendritic cells which are immune accessory cells found in both lymphoid and non-lymphoid organs. FDCS can thus occur in lymph nodes as well as non-lymphoid organs. Intraabdominal FDCS is even rarer. Our aim was to describe the clinical and morphological features of intra-abdominal FDCSs diagnosed in our practice and to review published literature on FDCSs including intra-abdominal FDCSs.

METHODS

All cases of FDCSs diagnosed between January 1, 2008 and December 31, 2019 were included in the study. Slides of the cases were reviewed and clinical follow up was obtained.

RESULTS

A total of 18 cases of intraabdominal FDCS were diagnosed during the study period. Age range was 17 to 55 years. Mean and median ages were 28 and 29 years respectively. Of the 18 patients, 11 were male and 7 were females. Colon was involved in 9 cases and appendix in 2 cases. 9 cases were received as resection specimens while 9 cases were received as slides and blocks for second opinion. Tumor size ranged from 2.7 to 26 cm. Average tumor size in these 9 cases was 8.2 cm and in 6 of these 9 cases, tumor size was greater than 6 cm in largest dimension. Grossly, tumors were nodular or polypoid and had a fleshy, grey white, homogeneous cut surface. Histologically, all 18 cases showed proliferation of plump to spindle shaped cells arranged in a fascicular or storiform pattern. Tumor cells had mild to moderately pleomorphic spindle to ovoid vesicular nuclei with fine chromatin and inconspicuous to variably conspicuous nucleoli, and moderate amount of pale eosinophilic cytoplasm. Mitotic activity was usually brisk. CD21 and CD23 were positive in all 18 cases. Resection margins were negative in all 9 resection specimens. Lymph nodes positive for metastases were seen in 4 cases. Follow up was available in 13 cases. Recurrence was seen in 6 patients, out of which 3 patients died of disease 15, 17- and 24-months following resection. 1 patient with appendiceal FDCS was free of disease almost 12 years after surgery but recently developed recurrence and is currently undergoing chemotherapy. 6 patients were alive and well at the time of follow-up 5 to 68 months after resection. None of them had developed recurrence or metastases at the time of follow up. 8 of the 13 patients received chemotherapy and/or radiotherapy post-surgical resection.

CONCLUSION

Colon was involved in 9 of our 18 cases. Lymph nodes were positive for metastases in 4 out of 9 resection specimens. All cases were diagnosed based on morphology supported by positivity for immunohistochemical stains CD21 and CD23. Histological factors associated with aggressive behavior were seen in 14 cases. Majority of patients had an aggressive clinical course.

Invasive Breast Carcinoma Arising in a Nipple Adenoma After 15 Years: Report of a Rare Case and Literature Review

Nipple adenoma (NA) is a rare benign breast neoplasm that seldom co-exists with breast carcinoma (BC). Majority of these BC are separate from NA, and their origin from NA is an extremely rare event. We herein describe a case of 65-year-old female who had a painless lump for 15 years which increased in size and ulcerated for last six months. Microscopic examination of the wedge biopsy of nipple showed features of NA at superficial aspect and invasive carcinoma from it at the deeper aspect. The patient underwent mastectomy and axillary clearance, which revealed a 4-cm invasive breast carcinoma, no special type with axillary lymph node involvement. The patient received adjuvant chemotherapy, radiotherapy and adjuvant hormonal therapy. The patient is alive and disease-free after 36 months.

NA should be carefully evaluated for co-existent BC because it completely changes the treatment plan and prognosis. 

LMP1 expression in bone marrow trephines of patients with multiple myeloma confers a survival advantage

Multiple myeloma (MM) is a heterogeneous disease of the bone marrow (BM). Its association with Epstein-Barr virus (EBV) remains enigmatic. Aim of our study was to determine expression of latent membrane protein 1 (LMP1), aldehyde dehydrogenase 1 (ALDH1), CD117 and their association with 5-year survival in MM patients. Seven percent of cases expressed LMP1 in MM cells with no association with survival. Whereas, LMP1 expression in CD138- non-neoplastic cells was observed in 80% of the cases, conferring a survival advantage of 1.75 years (mean 3.75 ± 0.28, 95% CI 3.19-4.3). LMP1 in CD138- non-neoplastic cells was associated with CD117 expression in MM cells. Combinatorial analysis of LMP1 and CD117 stratified patients into good prognostic group LMP1+/CD117- (mean survival 4.16 ± 0.39 years) and a worst prognostic group; LMP1-/CD117+ (mean survival 1.02 ± 0.29 years). Our study showed that LMP1 expression in CD138- non-neoplastic cells of BM in MM patients confers a survival advantage.

Expression of cyclin D1 in clear cell sarcoma of kidney. Is it useful in differentiating it from its histological mimics?

BACKGROUND

Clear cell sarcoma of the kidney (CCSK) is a rare malignant pediatric renal neoplasm with a heterogeneous histological appearance which often results in misdiagnosis. There are no specific immunohistochemical markers which can help in differentiating CCSK from other pediatric renal neoplasms. Recently Cyclin D1 has been investigated as a possible marker in this regard. In this study, we aim to determine the usefulness of Cyclin D1 in differentiating between CCSK and other pediatric renal neoplasms and to compare our results with those of recently published studies.

METHODS

A total of 48 cases of CCSK, Wilms tumor (WT), renal rhabdoid tumor, mesoblastic nephroma, renal Ewing sarcoma and neuroblastoma were included in the study. All cases were stained with cyclin D1. Extent of Cyclin D1 staining was graded according to percentage of positive tumor cells as diffuse (> 70%), focal (5 to 70%), and negative (< 5%). Intensity of Cyclin D1 staining was graded as strong or 3+, moderate or 2+ and weak or 1 + .

RESULTS

Most or all cases of CCSK, neuroblastoma and renal Ewing sarcoma demonstrated diffuse and strong positivity for Cyclin D1. Most cases of Wilms tumor (epithelial component) also demonstrated diffuse and often strong positivity for Cyclin D1. In most cases of WT, blastemal component was negative.

CONCLUSIONS

Cyclin D1 is a sensitive but not specific immunohistochemical marker for CCSK and many other pediatric renal malignant neoplasms as well as for neuroblastoma. Hence, careful examination of histological features is important in reaching an accurate diagnosis in CCSKs. However, Cyclin D1 is very helpful in distinguishing between blastema-rich WT and CCSK.

Expression of PAX-5 in B Cell Hodgkin and Non Hodgkin Lymphoma

Background:

B-cell malignancies including Precursor B-cell lymphoblastic lymphoma/leukemia and Hodgkin Lymphoma show a wide spectrum of B-cell differentiation from early stage B-cell precursors to mature B-cells ending in terminal differentiation to plasma cells. Pan-B-cell antigens routinely used for the diagnosis of B-cell lymphoma, include CD19, CD20, CD22 and CD79a.PAX-5 protein, also known as B-cell-specific activation protein is a B-cell-specific transcription factor; essential for commitment and functional maintenance used in the diagnosis of B cell Hodgkin and non-Hodgkin lymphoma. PAX-5 show nuclear positivity in B cell lymphomas and moderate (dim) positivity in Hodgkinlymphoma Reed Sternberg cells make this marker ideal for diagnosing B cell malignances. Objective: To determine the expression of PAX-5 in B cell Hodgkin and non-Hodgkin Lymphoma in order to improve the diagnosis of B-cell lymphomas.

Methods:

In this Prospective study, all the cases of B cell lymphoma diagnosed at The Aga Khan University Hospital, Karachi from July 2010 to July 2011were included. A panel of Immunohistochemical stain was performed in all cases along with additional PAX- 5 stain with appropriate controls.

Results:

Total 125 cases were included. Hodgkin Lymphoma (Mixed cellularity) was the commonest B-cell lymphoma subtype, 32 (25%) cases. Other common subtypes included Hodgkin lymphoma (Nodular sclerosis subtype), diffuse large B-cell lymphoma and B lymphoblastic lymphoma.

Conclusion:

This study demonstrates that PAX-5 is the most sensitive and reliable immuhohistochemicalmarker in the diagnosis of B cell Hodgkin and non-Hodgkin lymphoma.

Metachronous renal Ewing sarcoma/primitive neuroectodermal tumour in a survivor of Burkitt lymphoma

We present a case of a 14-year-old girl who was diagnosed with Burkitt lymphoma in 2014. She was managed with chemotherapy and remained in remission for 3 years. On her surveillance imaging in 2017, a left-sided renal neoplastic mass was incidentally discovered. She underwent nephrectomy and pathology of the resected specimen revealed small cell tumour of the kidney with features favouring renal Ewing sarcoma/primitive neuroectodermal tumour. Molecular genetic analysis by fluorescence in situ hybridisation was performed which showed translocation of 22q12, thereby confirming the diagnosis. This is a rare secondary malignancy and an unusual association. This case highlights the importance and diagnostic dilemmas of rare secondary tumours in patients with such haematological malignancies and discusses its possible pathogenetic aspects.

Abstract 53: Expression of EBV in the non-neoplastic cell population in trephine biopsies of patients with multiple myeloma is associated with a significant survival advantage

Introduction: Multiple myeloma (MM) is a plasma cell (PC) disorder of the elderly, affecting predominantly males. Therapeutic advancement during the last decade has improved overall survival. Crosstalk between malignant PCs and the microenvironment is considered to play an important role in the development of resistance to treatment and relapse. Epstein Barr virus (EBV) is the first B-lymphotropic herpes virus identified for its association with human tumors. Reports relating an association of EBV to MM are few and inconsistent. It has been proposed that initiation of viral lytic cycle in EBV infected B cells is preceded by X-Box binding Protein-1 (XBP-1) mediated differentiation, resulting in a subset of EBV expressing infected PCs. Increased incidence of EBV expressing MM cases have been observed in immune-compromised patients. However, the significance of EBV in the bone marrow (BM) of MM patients has not been fully elucidated. The aim of our study was to evaluate prevalence of EBV in association with MUC1, XBP-1, ALDH1, and B-cell lineage markers (CD20, CD45, CD56, and CD138) in bone marrow trephine biopsies of patients with MM and to assess if there was any association with prognosis in a cohort of 151 MM patients at a single tertiary teaching hospital institution in Pakistan.

Methodology: Formalin-fixed, paraffin-embedded trephine blocks of 151 MM cases diagnosed from 2007-2015 were evaluated for immunohistochemical (IHC) expression of MUC1, XBP-1, and EBV along with stem cell marker (ALDH1) and B-cell lineage markers (CD20, CD45, CD56, and CD138). Clinicopathologic details and follow-up data were collected from patients' medical records. Data was analyzed on SPSS 19. Five-year survival was estimated by Kaplan Meier curve for patients with follow-up available for 5 years or more (n=75).

Results: Mean age at diagnosis was 57 years (range 30-89) with male preponderance (68.2%). Women (60.4%) with MM presented at an earlier age (median age 55 years, range 42-78) and difference in age of presentation was found to be significant (p value 0.04). Bone lesions were identified in 68.9% of patients at presentation. Stage I, II, and III disease was identified in 32.4%, 23.4%, and 44.1 % of patients, respectively (ISS staging system). Relapse was observed in 79.6% of patients and was significantly correlated with the expression of XBP-1 (p value 0.035).

CD56 was expressed in 60.3% of cases and was significantly associated with cases diagnosed after the age of 57 years (p value 0.003). Expression of MUC1 was observed in 62.3% of tumors and 70% of MUC1-positive tumors also expressed XBP-1 (p value 0.06).

Although the number of cases expressing EBV in the MM tumor cell population was only 7.2%, we detected EBV in 80.2% of the cases in the adjacent non-neoplastic cells with conspicuous expression in megakaryocytes.

Five-year survival analysis (n=75) showed that expression of EBV+ in non-neoplastic cells was associated with significantly improved outcome with an advantage of 1.8 years (95% CI 3.32-4.4) as compared to EBV- cases (p value &lt; 0.005). Among the XBP-1+ tumors, lack of EBV expression in non-neoplastic cells significantly correlated with adverse outcome (95%CI, 0.70-2.6) (p value &lt; 0.005).

Conclusions: To the best of our knowledge, this is the first study reporting expression of EBV in non-neoplastic cell population in BM trephines of MM patients. Salient conclusions of our study are as follows:

1. Expression of EBV in the surrounding tumor microenvironment of trephine biopsies of patients with MM is associated with a significant survival advantage;

2. Patients with MM in Pakistan present at a comparatively earlier age;

3. XBP1 expression was associated with relapse.

Citation Format: Sheerien Rajput, Khurram Minhas, Iqbal Azam, Sadia Habib, Azhar Hussain, El-Nasir Lalani. Expression of EBV in the non-neoplastic cell population in trephine biopsies of patients with multiple myeloma is associated with a significant survival advantage [abstract]. In: Proceedings of the Second AACR Conference on Hematologic Malignancies: Translating Discoveries to Novel Therapies; May 6-9, 2017; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(24_Suppl):Abstract nr 53.

Synchronous and Metachronous Malignant Epithelial and Lymphoid Tumors: a Clinicopathologic Study of 10 Patients from a Major Tertiary Care Center in Pakistan

Case reports and case series documenting unfortunate patients with more than one malignant neoplasm are rare but well established. While majority of such patients have two malignancies, cases with three or even four malignant neoplasms in the same patient have been published in literature. A number of factors influencing carcinogenesis have been implicated in such cases including exposure to large amounts of radiation, chemotherapy for the original malignancy; prolonged history of heavy smoking and exposure to other environmental carcinogens; aging; and underlying genetic alterations. Concomitant multiple malignant neoplasms may be synchronous-two or more malignant neoplasms histologically distinct from each other, arising in the same site and detected simultaneously (for example during the same hospital admission) or detected one after the other in sequence in a period less than 6 months; or metachronous-two or more malignant neoplasms of similar or distinct histologic type detected at different times (after an interval of greater than 6 months) in different anatomic sites. Any combination of malignant tumors can occur in the same patient for example carcinomas with other carcinomas, carcinomas with Non-Hodgkin or Hodgkin lymphomas, carcinomas with mesotheliomas, carcinomas with sarcomas etc. We have reported several cases with multiple malignancies during our practice, and these cases were composed of the different combinations described above. The aim of the present study is to document 10 such cases of combined carcinoma and Non Hodgkin lymphoma in the same patient which were diagnosed in our section.

Commonest Cancers in Pakistan - Findings and Histopathological Perspective from a Premier Surgical Pathology Center in Pakistan

CONTEXT

There are no recent authoritative data about incidence and prevalence of various types of cancers in Pakistan.

AIM

To determine the frequency of malignant tumors seen in our practice and provide a foundation for building a comprehensive cancer care strategy.

MATERIALS AND METHODS

10,000 successive cases of solid malignant tumors reported in 2014 were included. All cases had formalin fixed, paraffin embedded specimens available and diagnosis was based on histological examination of H and E stained slides plus ancillary studies at the Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi. The latest WHO classifications were used along with the latest CAP protocols for reporting and the most updated TNM staging.

RESULTS

There were 9,492 (94.9%) primary tumors while 508 (5.1%) were metastatic. Some 5,153 (51.5%) were diagnosed in females and 4,847 (48.5%) in males. The commonest malignant tumors in females were breast (32%), esophagus (7%), lymphomas (6.8%), oral cavity (6.7%) and ovary (4.8%), while in males they were oral cavity (13.9%), lymphomas (12.8%), colorectum (7.9%), stomach (6.9%) and esophagus (6.6%). Malignant tumors were most common in the 5th, 6th and 7th decades. About 8% were seen under 20 years of age.

CONCLUSIONS

Oral cavity and gastrointestinal cancers continue to be extremely common in both genders. Breast and esophageal cancers are prevalent in females. Lung and prostate cancer are less common than in the west. Ovarian cancer was very common but cervix cancer was less so.

MALT lymphoma of the base of the tongue: a rare case entity

Lymphoma is a malignant tumour arising from lymphoid tissue, with the majority of cases being in the lymph nodes, however, in 1/4th of cases, these tumours are found in extralymphoid tissue. Lymphoid tissue is also found in organs having mucosa, such as the digestive tract, salivary gland and in tracheal tissue. This collection of lymphoid tissue is known as mucosa-associated lymphoid tissue (MALT), and non-Hodgkin lymphoma involving this extralymphoidal lymph tissue is known as MALT lymphoma. It was first reported by Isaacson and Wright in 1983, however, it was not included as a working diagnosis in clinical use until it was reclassified as 'marginal zone B-cell lymphoma' in a 1994 Revised European American Lymphoma (REAL) classification. It is rarely seen in the head and neck region, and we report the sixth case of MALT lymphoma of the base of the tongue. A 61-year-old man presented with dysphagia and the feeling of a lump in his throat for 5 months.

Epidemiologic Data, Tumor Size, Histologic Tumor Type and Grade, Pathologic Staging and Follow Up in Cancers of the Ampullary Region and Head of Pancreas in 311 Whipple Resection Specimens of Pakistani Patients

AIM

To report the histologic findings on Whipple resection specimens and thus determine the extent and spread of carcinomas of ampullary region and head of pancreas in our population.

SETTING

Section of Histopathology, Department of Pathology, Aga Khan University Hospital (AKUH), Karachi, Pakistan.

MATERIALS AND METHODS

A case series of 311 consecutive Whipple resection specimens received between January 1,2003 and December 31, 2014. Specimens processed for histologic sections and representative sections submitted and histologically examined as per established and standard protocols. All relevant tumor parameters including histologic type, histologic grade, pathologic T and N stage and tumor size were assessed. Epidemiologic data were also recorded. All findings were analysed using SPSS 19.0 software.

RESULTS

Ampullary (periampullary) carcinomas were much more common than carcinomas of the head of the pancreas, especially in males, with an average age of 53 years. Mean tumor size was 2.5 cms, over 54% were well differentiated. A large majority were pT2 or pT3 and N0. Carcinomas of pancreatic head were also more common in males, mean age was 55 years, mean tumor size was 3.5 cms, and over 65% were moderately differentiated. The majority were T2 or T3 and pN1. Prognostically, significant statistical correlation was seen with tumor grade and pathologic T and N stage (p values statistically significant). However, tumor size was not statistically significant.

CONCLUSIONS

Ampullary carcinomas are more common compared to pancreatic carcinomas. Majority of ampullary carcinomas were well differentiated while majority of pancreatic carcinomas were moderately differentiated. Large majority of both types of cases were pT2 or T3. Histologic tumor grade and pathologic T and N stage are significantly related to prognosis in Pakistani patients with ampullary and pancreatic cancers.

Congenital (infantile) fibrosarcoma of the scalp: a case series and review of literature

INTRODUCTION

Congenital infantile fibrosarcoma (CIFS) is a soft tissue sarcoma of infants mainly involving lower extremities usually presenting during the first year of life. A subset of cases occur in the head and neck, but scalp involvement is exceptionally rare.

PATIENTS AND METHODS

We report clinicopathological features of three cases of CIFS involving the scalp diagnosed between 2011 and 2012.

RESULTS

The ages of the three patients at the time of diagnosis ranged from 12 to 90 days (mean 48 days). All were males and presented with scalp swelling at birth which grew rapidly in size. The tumor was located in the left temporal region in two cases and the right temporoparietal region in one case. On imaging, underlying bone involvement was noted in two cases. The mean size of the resected tumors was 8 cm. All cases exhibited a cellular tumor arranged in sheets of uniform oval to spindle cells, increased mitosis, and hemangiopericytoma-like vessels. All patients are alive after a mean follow-up of 39.6 months. Recurrence was seen in one case due to incomplete excision. No metastasis was seen in any of the cases.

CONCLUSION

CIFS of the scalp is rare and carries a good prognosis. Underlying bone erosion is rare but was noted seen in two of our cases. A male predominance was seen in our cases.

Sarcoidosis presented as retroperitoneal and lung mass

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology characterised pathologically by the presence of non-caseating granulomas in involved organs. Sarcoidosis most frequently involves the lungs followed by eye and skin. Presentation as retroperitoneal and lung mass is rare in sarcoidosis. We describe an unusual case of sarcoidosis where the patient presented with large retroperitoneal and lung masses, and was treated as tuberculosis.

How our practice of histopathology, especially tumour pathology has changed in the last two decades: reflections from a major referral center in Pakistan

Continued advances in the field of histo-pathology (and cyto-pathology) over the past two decades have resulted in dramatic changes in the manner in which these disciplines are now practiced. This is especially true in the setting of a large university hospital where the role of pathologists as clinicians (diagnosticians), undergraduate and postgraduate educators, and researchers has evolved considerably. The world around us has changed significantly during this period bringing about a considerable change in our lifestyles and the way we live. This is the world of the internet and the world-wide web, the world of Google and Wikipedia, of Youtube and Facebook where anyone can obtain any information one desires at the push of a button. The practice of histo (and cyto) pathology has also evolved in line with these changes. For those practicing this discipline in a poor, developing country these changes have been breathtaking. This is an attempt to document these changes as experienced by histo (and cyto) pathologists practicing in the biggest center for Histopathology in Pakistan, a developing country in South Asia with a large (180 million) and ever growing population. The Section of Histopathology, Department of Pathology and Microbiology at the Aga Khan University Hospital (AKUH) in Karachi, Pakistan's largest city has since its inception in the mid-1980s transformed the way histopathology is practiced in Pakistan by incorporating modern methods and rescuing histopathology in Pakistan from the primitive and outdated groove in which it was stuck for decades. It set histopathology in Pakistan firmly on the path of modernity and change which are essential for better patient management and care through accurate and complete diagnosis and more recently prognostic and predictive information as well.

Pleomorphic lobular carcinoma of the male breast with axillary lymph node involvement: a case report and review of literature

Background

Carcinoma of the male breast is responsible for less than 1% of all malignancies in men but the incidence is rising. Invasive ductal carcinoma is the most common histological subtype while invasive lobular carcinoma is responsible for only 1.5% of the total cases of which pleomorpic lobular carcinoma is an extremely rare variant. We report the case of a gentleman with node positive, pleomorphic lobular carcinoma of the breast.

Case presentation

An elderly gentleman with a past history of type 2 diabetes and long term ethanol use presented to us with a self-discovered palpable lump in the left breast. Physical examination revealed bilateral gynaecomastia along with a well circumscribed subareolar mass and palpable lymphadenopathy in the ipsilateral axilla. The breast nodule revealed atypical cells on fine needle aspiration biopsy and the patient underwent a modified radical mastectomy after systemic surveillance was negative for metastatic disease. The lesion was reported as grade III pleomorphic lobular carcinoma with a lack of E-cadherin expression on immunohistochemistry and the neoplastic cells exhibited strong positivity for estrogen receptor in the absence of Her2 gene amplification. Six out of the eleven dissected regional lymph nodes showed evidence of disease. The patient completed 4 cycles of adjuvant chemotherapy without evidence of recurrent disease and was subsequently lost to follow up.

Conclusions

Although invasive lobular carcinomas comprise 12% of all female breast cancers, they are very rare in males due to lack of acini and lobules in the normal male breast. Pleomorphic lobular carcinoma, an aggressive variant of ILC is even rarer in males.

Chronic consumption of ethanol by our patient may have resulted in some degree of hepatic impairment with resultant hyperestrogenism. This in theory may have been the cause of his gynaecomastia, resultant breast cancer and is a plausible explanation for development of the invasive lobular subtype in a male. The prognosis and clinicopatholocial features of pleomorphic lobular carcinoma in men are less clearly defined due to its rarity. Additional studies are hence necessary to improve our understanding of this disease in males.

Gastrointestinal, liver and biliary tract pathology: a histopathological and epidemiological perspective from Pakistan with a review of the literature

AIM

To present an epidemiological and histological perspective of diseases of the gastrointestinal tract (including liver and biliary tract) at the Section of Histopathology, Department of Pathology, AKUH, Karachi, Pakistan.

MATERIALS AND METHODS

All consecutive endoscopic biopsies and resections between October 1 and December 31, 2012 were included.

RESULTS

A total of 2,323 cases were included. Carcinoma was overwhelmingly the commonest diagnosis on esophageal biopsies (69.1%); chronic helicobacter gastritis (45.6%) followed by adenocarcinoma (23.5%) were the commonest diagnoses on gastric biopsies; adenocarcinoma (27.3%) followed by ulcerative colitis (13.1%) were the commonest diagnoses on colonic biopsies; acute appendicitis (59.1%) was the commonest diagnosis on appendicectomy specimens; chronic viral hepatitis (44.8%) followed by hepatocellular carcinoma (23.4%) were the commonest diagnoses on liver biopsies; chronic cholecystitis was the commonest diagnosis (over 89%) on cholecystectomy specimens.

CONCLUSIONS

Squamous cell carcinoma comprised 88.8% of esophageal cancers. About 67% were in the lower third and 56.5% were moderately differentiated; mean ages 49.8 years for females and 55.8 years for males; 66% cases were from South West Pakistan. Over 67% patients with gastric adenocarcinoma were males; mean ages 59 and 44 years in males and females respectively, about 74% gastric carcinomas were poorly differentiated; and 62.2% were located in the antropyloric region. About 63% patients with colorectal adenocarcinoma were males; mean ages 46.1 and 50.5 years for males and females respectively; tumor grade was moderately differentiated in 54%; over 80% were located in the left colon. In 21.2% appendicectomies, no acute inflammation was found. Acute appendicitis was most common in young people. Hepatitis C (66.3%) was more common than hepatitis B (33.7%); about 78% cases of hepatocellular carcinoma occurred in males; females comprised 76.7% patients with chronic cholecystitis; and 77.8% patients with gall bladder carcinoma. All resection specimens showed advanced cancers. Most cancers occurred after the age of 50 years.

Sarcomatoid carcinoma of prostate involving the whole lower urinary tract and rectum

Sarcomatoid carcinoma of prostate is an extremely rare but aggressive neoplasm. It is generally associated with a poor prognosis. About 100 cases have so far been reported in the English literature. We report the case of a 64-year-old male with a very rapidly progressive disease that ultimately involved the whole lower urinary tract and rectum. The management of this case along with etio-pathogenesis and literature review is discussed.

Melanotic neuroectodermal tumour of infancy: a rare brain tumour of childhood

Melanotic neuroectodermal tumour of infancy is a rare, mostly benign but locally aggressive tumour of neural crest cell origin occurring in infants. The most commonly affected anatomic site is the maxilla. Such tumours of the brain and skull are very rare. We present the case of an 8 months old baby girl whose presenting complaint was a swelling in the scalp for 6 months. She was otherwise asymptomatic. CT imaging confirmed the presence of an osteolytic tumour in the anterior parasagittal skull with dural involvement. The tumour was surgically excised enbloc. The patient has been well at 2 years follow-up without any evidence of recurrence.

Madurella mycetomatis as an agent of brain abscess: case report and review of literature

Fungal cerebral abscesses are rare and usually seen in immunocompromised individuals. We report a case and review published literature of Madurella mycetomatis as an agent of cerebral abscess. We found contiguous head and neck infections to be the principal cause of cerebral maduromycosis caused by M. mycetomatis. Early recognition of Madurella spp. as the causative agent is essential to avoid cerebral spread.

IL-4 gene polymorphisms and their association with atopic asthma and allergic rhinitis in Pakistani patients

BACKGROUND AND OBJECTIVE

Interleukin (IL) 4 is a cytokine that mediates allergic responses. Different single nucleotide polymorphisms (SNPs) can influence the immune response mediated by cytokines. The aim of the present study was to investigate the possible association between IL-4 polymorphisms and allergic rhinitis and atopic asthma.

METHODS

A total of 214 atopic patients (108 with asthma and 106 with allergic rhinitis) and 120 healthy controls from Pakistan were genotyped for IL-4 SNPs C-589T (rs2243250), T+2979G (rs2227284), and C-33T (rs2070874) using restriction fragment length polymorphism-polymerase chain reaction. Statistical analysis was performed using the statistical software package StatCalc, Epilnfo v.6.

RESULTS

The SNP rs2243250 was significantly associated with both asthma (P = .004, chi2 = 11.0) and allergic rhinitis (P < .001, chi2 = 20.2), as was T-2979G (P < .001, chi2 = 22.51 for asthma and P < .001, chi2 = 57.6 for allergic rhinitis). The most frequent genotypes in the asthma and allergic rhinitis groups were TT for SNP rs2243250, and GG for SNP rs2227284. rs2070874 was not found to be associated with either of the 2 atopic respiratory diseases analyzed in the Pakistani cohort.

CONCLUSIONS

rs2243250 and rs2227284 are significantly associated with asthma and allergic rhinitis. The results of this study indicate that in addition to environmental factors, genetic risk factors also play an important role in the development of atopic respiratory diseases.

Immunoglobulin E reactivity and allergenic potency of Morus papyrifera (paper mulberry) pollen

BACKGROUND

Paper mulberry (Morus papyrifera) pollen is considered to be one of the most clinically relevant aeroallergens in Pakistan. To date, the allergenicity of the pollen has not been investigated.

OBJECTIVE

To characterize the sensitization profile of mulberry-allergic patients and the proteins of paper mulberry pollen contributing to pollinosis in the Pakistani population.

METHODS

Proteins were extracted from mulberry pollen using different protocols. Immunoglobulin (Ig) E binding proteins to mulberry pollen was determined by ImmunoCAP testing and immunoblotting using sera from 29 mulberry pollen-allergic patients with positive skin prick test results to mulberry pollen antigens. The histamine release assay was performed in vitro to determine the allergenic potency of pollen extracts and a partially purified mulberry pollen allergen. The protein was identified using N-terminal sequencing and matrix-assisted laser desorption/ionization-time of flight spectrometry (MALDI-TOF/TOF).

RESULTS

IgE sensitization to mulberry pollen was confirmed by positive ImmunoCAP results to pollen from Morus alba (white mulberry) in 23 out of 29 mulberry pollen-allergic patients. A 10-kDa protein from the paper mulberry pollen extract was considered a major allergen, along with additional IgE-reactive proteins. Sera from 79% of the patients reacted to the 10-kDa allergen, which showed substantial capacity to trigger histamine release in 3 out of 4 patients. N-terminal sequencing and MALDI-TOF/TOF yielded an amino acid sequence with no homology to known proteins.

CONCLUSIONS

Mulberry-allergic patients are sensitized to multiple mulberry pollen allergens. We identified a novel 10-kDa protein that was a major allergen and should be further investigated for diagnostic and therapeutic purposes.