Adenomyoepithelial adenosis mimicking phylloides: A diagnostic dilemma

Benign proliferative breast diseases are well recognized in young females. Benign biphasic proliferation of epithelial and myoepithelial cells has been observed, among which adeno-myoepithelial adenosis is one of the rare morphologies published in the literature with the tendency to recur and poses a risk for low-grade malignant transformation. Here, we report a case of a young female who had a history of recurrent breast lump mimicking phyllodes tumor and eventually diagnosed as adeno-myoepithelial adenosis on histopathological examination. Benign proliferative breast diseases are well recognized in young females. Benign biphasic proliferation of epithelial and myoepithelial cells has been observed, among which adeno-myoepithelial adenosis is one of the rare morphologies published in the literature with the tendency to recur and poses a risk for low-grade malignant transformation. Here, we report a case of a young female who had a history of recurrent breast lump mimicking phyllodes tumor and eventually diagnosed as adeno-myoepithelial adenosis on histopathological examination.

Comparative assessment of cleaning efficacy of two exclusive paediatric rotary files in root canals of primary teeth: An in vitro study

BACKGROUND

Paediatric rotary file systems have recently been developed for primary teeth use.

AIM

To study the cleaning efficacies of two paediatric rotary endodontic files, the Prime PedoTM , and the Kedo-SG BlueTM against the standard H files.

DESIGN

This in vitro study included 54 freshly extracted primary molars, which were randomised into three groups (n = 18 each) and were prepared using either Kedo-SG BlueTM , Prime PedoTM or hand H files after injecting methylene blue dye into the canals. Pre- and post-operative cone beam computerised tomography (CBCT) was performed to assess change in root canal volumes. Methylene blue dye removal from canals was assessed using stereomicroscopy, and canal cleanliness was examined by scanning electron microscopy (SEM).

RESULTS

Both Prime PedoTM and Kedo-SG BlueTM files reduced significantly less dentine when compared with conventional hand filing with Prime PedoTM removing the least amount of dentine. No significant difference was found in median SEM scores among the groups in the cervical, middle and apical thirds of the roots. Stereomicroscopic assessment of root canal cleanliness using dye removal technique shows a statistically significant difference existing between Kedo-SG BlueTM and hand H files groups.

CONCLUSION

Prime PedoTM removed the least amount of dentine. Kedo-SG BlueTM performed significantly better than conventional hand filing with H files when the root canal cleanliness was assessed.

Primary Pure Intrarenal Yolk Sac Tumor in 1.5-Year-Old Boy-A Rare Case Report

Germ cell tumors primarily arise in gonads and extragonadal germ cell tumors, an uncommon entity, originates usually along the midline. Here, we report the fifth example of intrarenal pure yolk sac tumor in a 1.5-year-old boy who presented with abdominal pain and underwent excision of the mass for suspected Wilms tumor. On histopathology and immunohistochemistry, a diagnosis of a yolk sac tumor was rendered. Postoperative serum alpha-fetoprotein levels were 21 000 ng/dl. The purpose of this report is to emphasize the importance of suspecting a germ cell tumor as one of the differential diagnoses of a suspected case of Wilms tumor and the significance of evaluating serum alpha-fetoprotein levels preoperatively.

Congenital myopathy presenting as recurrent pneumonia with lung collapse and pulmonary artery hypertension

A boy presented with cough, breathlessness for 1 month, fever for 1 week with similar previous episodes without hospitalisation. He had generalised muscle wasting, acute chronic malnutrition and required immediate ventilation. Provisional diagnosis of recurrent pneumonia with failure to thrive was made. As serial chest X-rays showed recurrent lung collapse, congenital lung anomalies were ruled out. 2D-echocardiography showed pulmonary arterial hypertension. Workup for congenital immunodeficiency and cystic fibrosis was negative. There was no improvement in muscle mass despite total parenteral nutrition. He was noticed to have myopathic facies. History was reviewed when the mother reported reduced fetal movements in this pregnancy. The patient had low voice amplitude. Creatine kinase levels were normal. Muscle biopsy followed by whole exome sequencing identified frameshift duplication NM_020451.3(SELENON):c.249_250dupGG (p.Asp84Glyfs*17), thus, confirming diagnosis of SEPN1-related congenital myopathy (CM) with fibre-type disproportion. Respiratory system involvement was distracter, emphasising consideration of CM while evaluating persistent lung collapse with muscle wasting.

Shear bond strengths of bur or Er:YAG laser prepared dentine to composite resin with or without low-level laser conditioning: an in vitro study

This study aims to compare the different modes of cavity preparation while evaluating the effect of low-level laser therapy (LLLT) on dentine before bonding in terms of shear bond strength between composite resin and dentine. Fifty human molar teeth were mounted on acrylic blocks and dentine specimen were prepared after which they were randomized into four equal groups. Cavity preparation mode differed in respective groups. After etching, bonding; composite resin was placed and polymerized on the prepared dentine surfaces. The specimens were kept in an environment simulating oral cavity and then shear tested in a universal testing machine. The failure surfaces of the specimen teeth were subjected to SEM micrographic evaluation. The cavity prepared with diamond abrasive points had a higher shearing load at failure that was statistically significantly different from the ones prepared with laser. That with diamond abrasive points followed by LLLT of the cavity surface with Nd:YAG laser had a higher bond strength than the ones prepared with just Er:YAG laser and there was no statistically significant difference between these and the ones prepared with diamond abrasive points alone. SEM analysis of the failure mode in bur-cut dentine showed the presence of a hybrid layer at the interface. Surface conditioning of the same with Nd:YAG laser before etching suggested a recrystallisation of dentine due to the heat produced. Cavity preparation with Er:YAG laser leads to reduced shear bond strength to adhesive restorative materials when compared with that using burs and high-speed handpiece.

A Hospital Based Observational Study to Detect Non-Alcoholic Steatohepatitis by Acoustic Radiation Force Impulse in Individuals with Diabetes Mellitus and Metabolic Syndrome

Non-alcoholic fatty liver disease (NAFLD)/ non-alcoholic steatohepatitis (NASH) is a rising epidemic with a potential for life threatening complications, especially in individuals with diabetes mellitus (DM) and metabolic syndrome. Though liver biopsy remains the recommended gold standard for diagnosing liver fibrosis, due to its technical feasibility and requirement of trained personnel, methods to develop non-invasive diagnostic tools for liver fibrosis have recently been underway. One such non-invasive method to diagnose liver fibrosis, point shear wave elastography using Acoustic Radiation Force Impulse (ARFI)-Imaging has gained remarkable results. This research was carried out to assess non-alcoholic steatohepatitis by acoustic radiation force impulse in individuals with diabetes and metabolic syndrome. Between March 2020 and October 2021, 140 patients with DM and metabolic syndrome, were identified. Demographic profile as well as reports of complete blood count, liver function tests, renal function tests, serum lipid profile, fasting blood sugar and postprandial blood sugar of the study participants were collected and recorded. Point shear wave liver elastography using ARFI imaging was performed for each of the study participant. NAFLD fibrosis score was determined in all of the study participants using appropriate software. Continuous and categorical variables were expressed as mean ± standard deviation and percentages respectively. Two-sided p values were considered as statistically significant at p value <0.05. Chi square test was done to see the association of clinical symptoms with fibrosis or non fibrosis. Independent t test was done to compare test variables and lab parameters between fibrosis and no fibrosis. Among the 140 study participants, 83 were males (59.29%) and 57 were (40.71%) females. On analysing the mean velocities measured by using ARFI elastography,30 participants (21.43%) had mean velocities >2.2m/s suggesting the presence of liver fibrosis and 110(78.57%) participants had mean velocities <2.2m/s did not have fibrosis. Among 83 males, 20(24.1%) had fibrosis and among 57 females, 10(17.5%) had fibrosis (p>0.05). Mean age of the 'Fibrosis' group was 54.53 (SD12.42) and that of the 'No fibrosis' group was 56.20(SD 11.76). Majority of the participants were between 56 and 65 years of age (50 participants). The mean height, weight and BMI of the 'Fibrosis' group was 152.84(±41.29), 73.33(±8.41), and 27.37(±2.73) respectively and that of the 'No fibrosis' group was 157.31(26.47), 70.89(12.46) and, 27.10(4.22) respectively (p>0.05). In the 'Fibrosis' group, majority (60%) were in the Obese 1 group and in the 'No fibrosis' group as well, majority were in the Obese 1 group (47.3%) (p=0.286). The mean (±SD) NAFLD- fibrosis Score was -1.54±1.06 in the 'No fibrosis' group and -0.61±1.81 in the 'Fibrosis' group (p value=0.012). There was no significant difference between fasting blood sugar, postprandial blood sugar, triglyceride and HbA1c levels among the 'Fibrosis' and 'No Fibrosis' groups. Among the 2 groups, there was no statistically significant difference between waist circumference, presence of hypertension, dyslipidaemia or other co-morbidities, in our study. None of the 30 individuals in the 'Fibrosis' group were on insulin (p=0.032), showing a significant difference in insulin usage among the 2 groups. There were significantly higher mean values of NAFLD-Fibrosis score in the individuals with fibrosis as compared to those with no fibrosis (p<0.05). NAFLD, diabetes mellitus and metabolic syndrome are part of the same spectrum. Individuals with diabetes mellitus and metabolic syndrome have a higher risk of developing liver fibrosis. Though in our study, parameters such as age, gender, hypertension, deranged blood sugars and lipid profile values were not significantly associated with liver fibrosis, NAFLD fibrosis score was found to have a significant association with liver fibrosis in these individuals.

Changes in Peripheral Brachial Blood Pressure from Supine to Lateral Decubitus Position in Hypertensive and Normotensive Subjects

Arterial blood pressure is crucial for supplying the nutritional demands of the all body tissues and is also under tight control for the same. The day to day stress impacts the blood pressure (BP), which is effectively corrected by the baroreceptors mechanism. The effect of lateral decubitus position on the blood pressure with respect to supine position needs to be evaluated as it impacts the haemodynamics. The peripheral brachial blood pressure changes are studied among the normotensives and hypertensives with its significance from change in supine to lateral decubitus position. Sixty (60) normotensives and 60 hypertensive subjects were evaluated for arterial blood pressure measurement using mercury sphygmomanometer by gold standard auscultatory method in the supine, right and left lateral decubitus position. The same observer measured the blood pressure at the similar point of time for all the participants. The Supine and lateral decubitus Systolic and diastolic blood pressure (Mean±SD) parameters were recorded and compared using the paired 't' test (Supine Normotensives SBP 112.5±16.9, DBP 70.1±17.7 mm of Hg; Hypertensives Stage I SBP 130.2±14.5, DBP 85.2±2.8 mm of Hg; Hypertensive Stage II SBP 152.6 ±17.5, DBP 98.4±9.5mm of Hg). The mean and percentage change in systolic and diastolic BP for Normotensives from supine to right lateral position- SBP 11.6 mm of Hg (10.3%), DBP 8.8 mm of Hg (12.5%) and supine to left lateral position SBP 12.5mm of Hg (11.1%), DBP 9.9 mm of Hg (14.1%) p<0.05, for Hypertensives Stage I supine to right lateral position SBP 13.8 mm of Hg (10.5%), DBP 14.8 mm of Hg (17.37%) and supine to left lateral position SBP 13.5 mm of Hg (10.3%), DBP 12.3 mm of Hg (14.13%) p<0.05 and for Hypertensive Stage II from supine to right lateral position SBP 22.6 mm of Hg (14.8%), DBP 16.6 mm of Hg (16.8%), form supine to left lateral position SBP 12.3mm of Hg (8%), DBP 14.7mm of Hg (14.9%) p<0.01) changed significantly among the all the groups with respect to change from supine to lateral decubitus position. The fall in diastolic BP was of greater magnitude than the systolic BP. The right lateral decubitus position was dominant among the hypertensives for producing the change as compared to left lateral decubitus position. However among the normotensives it was left lateral decubitus which produced greater reduction in blood pressure. The lateral decubitus position definitively reduces the blood pressure as compared to supine position and the changes produced can't be simply ascribed to the hydrostatic effect of gravity on blood column. Sleeping on lateral side could thus be advantageous in reducing the arterial blood pressure.

Mucocutaneous manifestations of COVID-19-associated mucormycosis: A retrospective cross-sectional study

Background Cutaneous mucormycosis has shown a significant upsurge during the COVID-19 pandemic. Due to the rapid progression and high mortality of cutaneous mucormycosis in this context, it is important to identify it early. However, very few studies report detailed clinical descriptions of cutaneous mucormycosis in COVID-19 patients. Objectives To describe mucocutaneous lesions of COVID-19-associated mucormycosis based on clinical morphology and attempt to correlate them with radiological changes. Methods A retrospective cross-sectional study was conducted at a tertiary care centre from 1st April to 31st July 2021. Eligibility criteria included hospitalised adult patients of COVID-19-associated mucormycosis with mucocutaneous lesions. Results All subjects were recently recovering COVID-19 patients diagnosed with cutaneous mucormycosis. One of fifty-three (2%) patients had primary cutaneous mucormycosis, and all of the rest had secondary cutaneous mucormycosis. Secondary cutaneous mucormycosis lesions presented as cutaneous-abscess in 25/52 (48%), nodulo-pustular lesions in 1/52 (2%), necrotic eschar in 1/52 (2%) and ulcero-necrotic in 1/52 (2%). Mucosal lesions were of three broad sub-types: ulcero-necrotic in 1/52 (2%), pustular in 2/52 (4%) and plaques in 1/52 (2%). Twenty out of fifty-two patients (38%) presented with simultaneous mucosal and cutaneous lesions belonging to the above categories. Magnetic resonance imaging of the face showed variable features of cutaneous and subcutaneous tissue involvement, viz. peripherally enhancing collection in the abscess group, "dot in circle sign" and heterogeneous contrast enhancement in the nodulo-pustular group; and fat stranding with infiltration of subcutaneous tissue in cases with necrotic eschar and ulcero-necrotic lesions. Limitations The morphological variety of cutaneous mucormycosis patients in a single-centre study like ours might not be very precise. Thus, there is a need to conduct multi-centric prospective studies with larger sample sizes in the future to substantiate our morphological and radiological findings. Conclusions COVID-19-associated mucormycosis patients in our study presented with a few specific types of mucocutaneous manifestations, with distinct magnetic resonance imaging findings. If corroborated by larger studies, these observations would be helpful in the early diagnosis of this serious illness.

Primary synovial sarcoma of kidney: a rare case report with review of literature

Background

Synovial sarcoma is a rare type of sarcoma with a predilection for extremities in young adults. Very rarely this tumor can originate from kidney.

Case presentation

A 22-year-old female presented to us with complaints of right flank pain and a large mass in the right side of abdomen for the last 6 months. A provisional diagnosis of renal cell carcinoma was made and right radical nephrectomy was done. However on histopathological examination the tumor was composed of spindle cells arranged in hemangiopericytoma-like vascular pattern. Immunohistochemistry and FISH confirmed the diagnosis of synovial sarcoma of kidney. The patient had no signs of recurrence or metastasis at six months of follow-up.

Conclusion

Renal synovial sarcomas, though rare, should be considered as a differential in young adults who present with extremely large renal mass. Surgical extirpation is the treatment of choice. Ifosfamide- and doxorubicin-based chemotherapy can be given in non resectable and metastatic cases.

Atypical presentations of cutaneous tuberculosis: Series of 10 cases

Cutaneous tuberculosis classically presents as Lupus vulgaris, scrofuloderma, tuberculosis verrucose cutis and tubercular abscess. Hypersensitivity reaction to the bacilli leads to Lichen scrofulosorum and papulonecrotic tuberculids. At the same time, it can have myriad of clinical presentations, many of which are still undescribed. It is important to regularly update ourselves with these unusual manifestations so as to ensure early treatment and reduction of overall morbidity. In this case series tuberculosis manifesting as rapidly progressing diffuse facial granulomas, sporotrichoid tuberculosis, tuberculosis mimicking squamous cell carcinoma, scrofuloderma as tubercular ulcer, lupus vulgaris with nasal septal perforation, lupus vulgaris resembling furuncle, psoriasis, dermatitis and BT Hansen are described in immunocompetent individuals. These cases highlight the importance of recognition of atypical forms of cutaneous tuberculosis to minimize scarring and dissemination of bacilli.

Plantar Lichen Planus: An Atypical Presentation at a Young Age

Lichen planus is a chronic lichenoid dermatosis commonly encountered by dermatologists worldwide, affecting skin, mucosa, and scalp. The current case describes a rare variant of lichen planus, plantar lichen planus, in a 17-year-old male who presented with erythematous scaly plaques on the sole for two years associated with walking discomfort. The lesion was subjected to skin biopsy and a diagnosis of lichen planus was made considering the histopathological and clinical findings. Plantar lichen planus can often be misdiagnosed. Treating plantar lichen planus can be a therapeutic challenge and, thus, more insight is needed regarding treatment protocol or outcome of such cases.

Electron microscopy of juvenile nasopharyngeal angiofibroma: clinical and histopathological correlates

BACKGROUND

The histological and electron-microscopic (EM) characteristics of juvenile nasopharyngeal angiofibroma (JNA) have been described but no study has compared them with one another or with clinical features. The objective is to compare ultrastructural characteristics of JNA with clinical parameters.

METHODS

This prospective study included histology of 21 samples of which only 13 underwent transmission-EM. Four clinical parameters (age, duration, epistaxis, recurrence), three radiological-staging, 13 histological and 15 EM characteristics were considered. A descriptive analysis for association of these characteristics and also with clinical parameters was attempted. Furthermore statistical analysis of clinical and radiological categories with respect to frequencies of ultrastructural characteristics was also undertaken.

RESULTS

Dense-intranuclear-inclusions (DNI) and peripheral-nuclear-irregularities were universally encountered while other very prominent features were nuclear-blebs-and-pockets, myoid-features, thin-vessel-wall (TnVW), irregular-vascular-contour (IVC) and fibrous-stroma (FS). Statistical significance was obtained between recurrence with histology (p = 0.04) and Fisch staging with EM (p = 0.001). While muscle-in-vessel-wall, thick-vessel-wall, mast-cells, stellate-stromal-cells and cellular-stroma predominated in recurrent cases, the upfront disease showed predominance of scar-like-stroma, fusiform-stromal-cells, IVC, TnVW, FS, organised-collagen-bundles and less-cellular-stroma. A very unique Rod-like-structures were appreciated in the cytoplasm of the fibroblast for the first time.

CONCLUSIONS

While histological parameters of recurrence need further validation, a larger sample may better define histopathological surrogate for predicting intracellular dynamics that may further correlate with underlying cellular stresses. Hence an 'ultrastructural staging' may better customise treatment protocol and prognosis. Furthermore 'characteristic' unique rods need to be further investigated along with validation of viral aetiology for DNI.

Case Report of Cutaneous Squamous Cell Carcinoma at the Wrist Joint and the Public Health Crisis of Arsenicosis

CONTEXT

Arsenicosis is caused by long term (6 months plus) ingestion of arsenic above a safe dose, characterized by skin lesions and possible involvement of internal organs. Arsenicosis is common in India and Bangladesh where naturally occurring high concentrations of arsenic in the earth's crust contaminate ground water, causing adverse health effects.

CASE PRESENTATION

We report a case of a 55-year-old Indian male, resident of a known arsenic endemic region of Uttar Pradesh who suffered from characteristic pulmonary and cutaneous features of chronic arsenic toxicity which included radiological findings of interstitial lung disease, hyperkeratotic lesions over the palms and soles, rain drop like pigmentation over the trunk, and carcinomatous changes at the wrist joint. The patient was started on chelating agents (d-penicillamine) and oral retinoids (isotretinoin) followed by the surgical excision of the carcinoma.

DISCUSSION

Environmental contamination with arsenic is a well-known health hazard in South Asian countries. The main source is consumption of contaminated ground water for domestic purposes. Cutaneous lesions, internal organ involvement including interstitial lung disease and carcinomas as observed in our patient have been reported in the literature. Various mechanisms like epigenetic changes and arsenic-induced immune suppression have been proposed for the development of cutaneous carcinomas with prolonged exposure to arsenic.

RELEVANCE TO CLINICAL PRACTICE

Among the various causes of palmo-plantar hyperkeratosis, arsenicosis should be kept in mind when presenting in combination with pigmentary changes and carcinomatous growth from an arsenic-endemic region.

CONCLUSIONS

People residing in arsenic-endemic regions should be made aware of arsenic-related health hazards. Rainwater harvesting and good nutrition are the simplest measures which could be adopted by the exposed population in affected areas. Several methods have also been employed by governmental and non-government organizations to separate arsenic from contaminated water to combat arsenic-related diseases and carcinomas.

COMPETING INTERESTS

The authors declare no competing financial interests.

Promoter hypomethylation as potential confounder of Ras gene overexpression and their clinical significance in subsets of urothelial carcinoma of bladder

Overexpression of normal Ras and its aberrant CpG island methylation in the promoter regions have been shown to direct cells for uncontrolled abnormal growth and bladder tumor formation and therefore, fetched recent attention as a marker of diagnosis and prognosis to predict the biological behavior of urothelial carcinoma of bladder (UCB). Methylation pattern at CpG islands of the promoter regions of rat sarcoma (Ras) gene homologues namely Kristen-Ras (K-Ras), Harvey (H-Ras), and Neuroblastoma (N-Ras) were examined by methylation specific polymerase chain reaction (MSP). Real time-quantitative polymerase chain reaction (RT-qPCR) was done to determine transcriptomic expressions of these Ras isoforms in the prospective series of 42 NMIBC (non-muscle invasive bladder cancer) and 45 MIBC (muscle invasive bladder cancer) biopsies. CpG loci in H-Ras and K-Ras were observed to be more hypomethylated in MIBC, whereas more hypomethylation in N-Ras was noted in NMIBC. Strong association of hypomethylation index with tumor stage, grade, type and size validate them it as marker of diagnosis in UCB patients. Differential overexpression of H-Ras, N-Ras and K-Ras genes in NMIBC and MIBC and their association with patients' demographics identify them as important diagnostic markers in pathogenesis of UCB. Given the reported ability of promoter hypomethylation to activate Ras expression, correlation studies examined positive significant association between hypomethylation index and expression. Study concludes that promoter hypomethylation of N-Ras and K-Ras could be a potential confounder of their increased expression in NMIBC. Biological significance of simultaneous presence of higher expression and promoter hypomethylation of Ras gene isoforms in MIBC is difficult to resolve in a given cohort of patients.

Mutational analysis of Ras hotspots in patients with urothelial carcinoma of the bladder

BACKGROUND

Mutational activation of Ras genes is established as a prognostic factor for the genesis of a constitutively active RAS-mitogen activated protein kinase pathway that leads to cancer. Heterogeneity among the distribution of the most frequent mutations in Ras isoforms is reported in different patient populations with urothelial carcinoma of the bladder (UCB).

AIM

To determine the presence/absence of mutations in Ras isoforms in patients with UCB in order to predict disease outcome.

METHODS

This study was performed to determine the mutational spectrum at the hotspot regions of H-Ras, K-Ras and N-Ras genes by polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing followed by their clinical impact (if any) by examining the relationship of mutational spectrum with clinical histopathological variables in 87 UCB patients.

RESULTS

None of the 87 UCB patients showed point mutations in codon 12 of H-Ras gene; codon 61 of N-Ras gene and codons 12, 13 of K-Ras gene by PCR-RFLP. Direct DNA sequencing of tumor and normal control bladder mucosal specimens followed by Blastn alignment with the reference wild-type sequences failed to identify even one nucleotide difference in the coding exons 1 and 2 of H-Ras, N-Ras and K-Ras genes in the tumor and control bladder mucosal specimens.

CONCLUSION

Our findings on the lack of mutations in H-Ras, K-Ras and N-Ras genes could be explained on the basis of different etiological mechanisms involved in tumor development/progression, inherent genetic susceptibility, tissue specificity or alternative Ras dysfunction such as gene amplification and/or overexpression in a given cohort of patients.

Clinicohistopathological implications of phosphoserine 9 glycogen synthase kinase-3β/ β-catenin in urinary bladder cancer patients

BACKGROUND

Aberrant activation of phosphorylated form of glycogen synthase kinase-3β [pS9GSK-3β (Serine 9 phosphorylation)] is known to trigger Wnt/β-catenin signal cascade but its clinicohistopathological implications in bladder carcinogenesis remain unknown.

AIM

To investigate the diagnostic and prognostic relevance of expressions of pS9GSK-3β, β-catenin and its target genes in the pathobiology of bladder cancer.

METHODS

Bladder tumor tissues from ninety patients were analyzed for quantitative expression and cellular localization of pS9GSK-3β by immunohistochemical (IHC) staining. Real time-quantitative polymerase chain reaction and IHC were done to check the expression of β-catenin, Cyclin D1, Snail and Slug at transcriptome and protein level respectively. Clinicohistopathological variables were obtained from histology reports, follow up and OPD visits of patients. Expressions of the markers were statistically correlated with these variables to determine their significance in clinical setting. Results were analysed using SPSS 20.0 software.

RESULTS

Aberrant (low or no membranous/high nuclear/high cytoplasmic) expression of pS9GSK-3β was noted in 51% patients and found to be significantly associated with tumor stage and tumor grade (P = 0.01 and 0.04; Mann Whitney U test). Thirty one percent tumors exhibited aberrant co-expression of pS9GSK-3β and β–catenin proteins and showed strong statistical association with tumor stage, tumor type, smoking/tobacco chewing status (P = 0.01, 0.02 and 0.04, Mann-Whitney U test) and shorter overall survival probabilities of patients (P = 0.02; Kaplan Meier test). Nuclear immunostaining of Cyclin D1 in tumors with altered pS9GSK-3β/β–catenin showed relevance with tumor stage, grade and type.

CONCLUSION

β–catenin and pS9GSK-3β proteins are identified as markers of diagnostic/prognostic significance in disease pathogenesis. Observed histopathological association of Cyclin D1 identifies it as marker of potential relevance in tumors with altered pS9GSK-3β/β-catenin.

The Significance of ERG and Androgen Receptor Expression in Adenocarcinoma Prostate

Background Fusions of transmembrane protease, serine 2 (TMPRSS2) with erythroblast transformation specific transcription factors have been found in prostate cancer. The v-etserythroblastosis virus E26 oncogene homologue (ERG) is a proto-oncogene of the erythroblast transformation specific transcription factor family. TMPRSS2-ERG fusion is the most common molecular alteration present in about 50% of prostatic adenocarcinomas. Androgen receptor (AR) plays a key role in prostate development and is involved in the progression of prostate cancer. Objective To evaluate the significance of combined ERG and AR expression in cases of prostatic adenocarcinoma. Method The study was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. Formalin fixed-paraffin embedded archival prostatic tissue specimens were obtained. A total of 10 cases of prostatic adenocarcinoma were included in the study. Immunohistochemistry for Androgen receptor was done by the standard protocol. Multiplex immunohistochemical staining was done for ERG+CK5 using a primary antibody cocktail of mouse and rabbit antibodies. Result Specific AR immunostaining was exclusively nuclear and was present in all 10 cases in varying intensity. Specific ERG immunostaining was nuclear and was present in seven cases (70%) and absent in three cases (30%). The three cases that were negative for ERG had a Gleason score of ≤ 6 and the AR staining was strong and present in about 90% of the cells. Gleason score was directly related to the ERG staining while AR staining was inversely related to the ERG staining. Conclusion The prognostic value of combined ERG and AR over-expression, its associated genes should be further investigated as potential therapeutic targets in prostate cancer progression. Preliminary data is being presented. Larger prospective studies with survival analysis are essential for prognostic significance.

Alteration in lipid composition differentiates breast cancer tissues: a 1H HRMAS NMR metabolomic study

INTRODUCTION

Breast cancer is the most frequent diagnosed cancer among women with a mortality rate of 15% of all cancer related deaths in women. Breast cancer is heterogeneous in nature and produces plethora of metabolites allowing its early detection using molecular diagnostic techniques like magnetic resonance spectroscopy.

OBJECTIVES

To evaluate the variation in metabolic profile of breast cancer focusing on lipids as triglycerides (TG) and free fatty acids (FFA) that may alter in malignant breast tissues and lymph nodes from adjacent benign breast tissues by HRMAS ¹H NMR spectroscopy.

METHODS

The ¹H NMR spectra recorded on 173 tissue specimens comprising of breast tumor tissues, adjacent tissues, few lymph nodes and overlying skin tissues obtained from 67 patients suffering from breast cancer. Multivariate statistical analysis was employed to identify metabolites acting as major confounders for differentiation of malignancy.

RESULT

Reduction in lipid content were observed in malignant breast tissues along with a higher fraction of FFA. Four small molecule metabolites e.g., choline containing compounds (Chocc), taurine, glycine, and glutamate were also identified as major confounders. The test set for prediction provided sensitivity and specificity of more than 90% excluding the lymph nodes and skin tissues.

CONCLUSION

Fatty acids composition in breast cancer using in vivo magnetic resonance spectroscopy (MRS) is gaining its importance in clinical settings (Coum et al. in Magn Reson Mater Phys Biol Med 29:1-4, 2016). The present study may help in future for precise evaluation of lipid classification including small molecules as a source of early diagnosis of invasive ductal carcinoma by employing in vivo magnetic resonance spectroscopic methods.

Retroperitoneal teratoma simulating giant adrenal myelolipoma: a diagnostic puzzle

Teratoma is a germ-cell tumour that is common in para-axial regions. Retroperitoneal teratoma is rare and comprise only about 1% of all teratomas. We present a 21-year-old female who presented with a lump in the abdomen. After radiological investigations, she was diagnosed as case of adrenal myelolipoma which on excision turned out histologically to be retroperitoneal teratoma. Our case highlights the limitation of radiological investigations in preoperative diagnosis of teratoma.

Establishing a deceased donor program in north Indian region: lessons learnt

INTRODUCTION

Living-related donors are the source of almost all organ transplants in India. However, these donations fall far short of current needs, and there remains a huge disparity between demand and supply of organs. In the last five yr, a consistent increase in deceased donor transplant activity has been observed in some southern Indian states. This report describes our experience of establishing a new deceased donor program in the state of Uttar Pradesh in north India.

METHODS

We describe our experience on counseling families of all brain-dead patients admitted to our center from October 2013 to September 2014 and data on retrieving and transplanting organs.

RESULTS

A total of 99 brain-dead patients were identified, of which 67 were medically eligible as donors. Fourteen patients developed cardiac arrest before the counseling could begin. Only eight families agreed for multi-organ donation.

CONCLUSION

Lack of consensus among the family members, mistrust of the medical system, fear of mutilation of the body, and delay in the funeral were identified as the main reasons behind negative consent. Conversely, mass media campaign, proper ICU care of brain-dead patients, rapport with the family and streamlining all medico legal processes were associated with positive consent.

Molecular profiling of ETS and non-ETS aberrations in prostate cancer patients from northern India

BACKGROUND

Molecular stratification of prostate cancer (PCa) based on genetic aberrations including ETS or RAF gene-rearrangements, PTEN deletion, and SPINK1 over-expression show clear prognostic and diagnostic utility. Gene rearrangements involving ETS transcription factors are frequent pathogenetic somatic events observed in PCa. Incidence of ETS rearrangements in Caucasian PCa patients has been reported, however, occurrence in Indian population is largely unknown. The aim of this study was to determine the prevalence of the ETS and RAF kinase gene rearrangements, SPINK1 over-expression, and PTEN deletion in this cohort.

METHODS

In this multi-center study, formalin-fixed paraffin embedded (FFPE) PCa specimens (n = 121) were procured from four major medical institutions in India. The tissues were sectioned and molecular profiling was done using immunohistochemistry (IHC), RNA in situ hybridization (RNA-ISH) and/or fluorescence in situ hybridization (FISH).

RESULTS

ERG over-expression was detected in 48.9% (46/94) PCa specimens by IHC, which was confirmed in a subset of cases by FISH. Among other ETS family members, while ETV1 transcript was detected in one case by RNA-ISH, no alteration in ETV4 was observed. SPINK1 over-expression was observed in 12.5% (12/96) and PTEN deletion in 21.52% (17/79) of the total PCa cases. Interestingly, PTEN deletion was found in 30% of the ERG-positive cases (P = 0.017) but in only one case with SPINK1 over-expression (P = 0.67). BRAF and RAF1 gene rearrangements were detected in ∼1% and ∼4.5% of the PCa cases, respectively.

CONCLUSIONS

This is the first report on comprehensive molecular profiling of the major spectrum of the causal aberrations in Indian men with PCa. Our findings suggest that ETS gene rearrangement and SPINK1 over-expression patterns in North Indian population largely resembled those observed in Caucasian population but differed from Japanese and Chinese PCa patients. The molecular profiling data presented in this study could help in clinical decision-making for the pursuit of surgery, diagnosis, and in selection of therapeutic intervention.

Parapelvic solitary neurofibroma of the kidney

A middle-aged man presented with intermittent gross haematuria and dull aching left flank pain for 1 month. He was a chronic smoker for 15 years. Contrast-enhanced CT scan of the abdomen detected a 4.5×3.0×2.5 cm, heterogeneous and poorly contrast-enhancing mass in the left renal sinus and upper ureteric region causing narrowing of the pelviureteric junction and upper ureter. Considering it to be a transitional cell carcinoma of upper urinary tract, the patient underwent laparoscopic radical nephroureterectomy. Histopathology revealed the mass to be a neurofibroma in the renal sinus extending around the upper ureter.

Carcinoma of breast metastasising to mandible

Metastatic tumours to oral cavity from distant sites are rarely seen. Bones are frequently involved as compared to soft tissues. Clinical presentation may vary according to site and size of metastatic tumour. We present a case of carcinoma of breast in a 50-year-old woman, metastasising to mandibular ramus, condyle and surrounding soft tissue structure presenting as osteomylitis of condyle.

Multilocular cystic renal cell carcinoma: a rare entity

Multilocular cystic renal cell carcinoma (MCRCC) is an uncommon subtype of clear cell renal cell carcinoma that appears to have a favourable prognosis. Literature reports a very low incidence of 1-2% of MCRCC among the renal neoplasms. The first such reported case was in 1957 by Robinson. In 1998, Eble et al suggested following diagnostic criterion for MCRCC: (1) an expansile mass surrounded by a fibrous capsule; (2) interior of tumour entirely composed of cysts and septa with no expansile nodule or solid component confined to more than 10% of entire tumour and (3) septa containing aggregates of clear epithelial cells. We report a case of MCRCC in a 60-year-old male patient who presented with abdominal lump and after suspicion of renal malignancy underwent nephrectomy. The patient was perfectly well till last follow-up of 3 months postoperatively.

Testicular metastasis of colorectal carcinoma: an unusual presentation

Metastasis of colorectal carcinoma to testis is rare. The authors report a case of 35-year-old man with right testicular mass. Contrast-enhanced CT scan (CECT) of testes showed testicular mass with ascitis and enlargement of retroperitoneal lymphnodes. Thus, a provisional diagnosis of disseminated primary testicular tumour was made. On subsequent high orchidectomy pathological examination revealed mucinous adenocarcinoma with CDX2 positivity thereby suggesting the possibility of metastasis from adenocarcinoma. Further, the diagnostic evaluation revealed a colorectal mass, which was inoperable (stage IV) and found to be primary colorectal mucinous adenocarcinoma. The authors conclude that occult colorectal carcinoma may rarely metastasise to testis and this unusual presentation may produce diagnostic dilemma. Although rare, metastases to testes should be considered as a differential diagnosis, especially where symptoms are unusual for primary malignancy.

Clear cell sarcoma of kidney: A rare entity

Clear cell sarcoma of the kidney is an uncommon renal neoplasm of childhood. It represents one of the most common unfavorable tumors included in National Wilms’ Tumor Study Group clinical protocols. We came across this rare tumor in a 2-year-old male child. The case report is followed by discussion, stating the differentiating features between Wilms’ and clear cell sarcoma, histological details, treatment, and prognostication.