Quest to develop a standard screening method for urothelial carcinoma using liquid-based cytology (The Paris System) and CK20

Background

Bladder cancer, the most common malignancy of the urinary tract is a leading cause of morbidity and mortality. But cystoscopy, which is till now the mainstay of screening, is an invasive, high-cost method with low sensitivity especially for flat lesions.

Aim

To find a non-invasive and effective screening method with liquid-based cytology (LBC) using The Paris System (TPS) and CK20 immunocytochemistry.

Materials and Methods

It was a prospective study including the patients with clinical or cystoscopic diagnosis of urinary bladder space occupying lesions (SOL). Both conventional (CC) and liquid-based cytology slides were prepared from urine samples. Slides were evaluated by two trained pathologists and categorized according to TPS guidelines. CK20 immunocytochemistry (ICC) was also performed. Consequent formalin-fixed paraffin embedded sections were blindly examined by another pathologist and was taken as gold standard for comparison.

Statistical Analysis

All the statistical analysis were done using MedCalc version 15.8 [Mariakerke, Belgium: MedCalc Software 2015].

Results

The study included 150 cases with a mean age of 62.4 years. Five cases revealed unsatisfactory smears. Rest of the cases were categorized as the following: 18.1% as NH-GUC, 8% as LGUN, 22.1% as AUC, 15.4% as SH-GUC, 32.9% as HGUC. Kappa value of CC and LBC were strong (0.854). LBC alone showed very low specificity (58%) and PPV (74.8%) which improved on application of ICC (specificity: 97.4%, PPV: 96.3%).

Conclusion

We conclude that CK20 ICC offers potential for accurate, non-invasive detection and surveillance of bladder cancer and is a better tool when combined with liquid-based cytology, reported using The Paris System.

Spectrum of renal vascular lesions among patients with lupus nephritis: An experience from a tertiary care center

Background

Lupus nephritis (LN) is the assemblage of glomerular, tubulointerstitial and vascular changes. Despite the fact that glomerular changes are overemphasized in pathological classification and scoring system, but the existence of vascular damage negatively impact the clinical course.

Aims and Objective

This study was conducted to determine the clinicopathological spectrum of renal vascular lesions in lupus nephritis.

Materials and Methods

Renal microvascular lesions in biopsy proven lupus nephritis were classified into 5 major categories-thrombotic microangiopathy, true vasculitis; lupus vasculopathy, uncomplicated vascular immune deposits, and arterial. Clinical details, laboratory parameters and histopathological variables were compared among all groups. Summary of chronic changes was also assessed.

Results

Biopsies from 56 patients revealed thrombotic microangiopathy (2), lupus vasculopathy (3), uncomplicated vascular immune deposit (6), PAN type vasculitis (1) and arterial sclerosis (13). No renal vascular lesions were found in 35.18% of patients. At the time of biopsy, arterial sclerosis or lupus vasculopathy patients were older Nephritis subtype. Activity indices were higher in lupus vasculopathy group whereas patients with arteriosclerosis showed highest chronicity index.

Conclusions

Renal vascular lesions are common in systemic lupus erythematosus patients with nephritis and may be associated with aggressive clinical course.

The curious case of T-cell mediated renal allograft rejection after Covid-19 infection

ABSTRACT

Our case illustrates the possible explanation of renal allograft rejection in a patient who had recovered from Covid-19 infection in the post-transplant period, which ultimately led to the death of the patient. A 27-year-old male patient received renal allograft from his mother, with an uneventful post-transplant period. Three years after the transplantation he contracted Covid-19 infection. The patient recovered from Covid-19 infection after being treated according to the treatment protocol. Subsequently, in the next 2 weeks, he presented with heavy proteinuria and a rise in serum creatinine level. Renal biopsy examination showed features of acute T-cell mediated rejection (TCMR) without any evidence of antibody-mediated rejection. He was given all due care but he deteriorated quickly leading to his death. This case highlights the inter-relation between Covid-19 infection and acute TCMR of the renal allograft, where renal biopsy serves as an indispensable tool in understanding its pathophysiology.

Clinico-Hematological Profile in Hemoglobin SE Disease: A Case Series from a Tertiary Care Centre

Hemoglobin SE (HbSE) disease are rare globally and there is paucity of literature regarding this condition. Cases reported in the Indian scenario so far have been limited to the tribal populations. This case series aims to highlight the rarity of this double heterozygous state and to raise awareness of its community prevalence beyond the tribal population. This is a case series over a 5-year observation period with six cases of double heterozygosity for HbS and HbE in our tertiary care centre. Four cases were in the 8-15 years' age group and 2 cases of 24-25 years' age group reported for initial evaluation due to easy fatigability and weakness: Two cases were siblings with history of consanguineous marriages in the family. Mild Pallor, variable icterus, spleen was just palpable in three of the cases and low MCV recorded in all cases. Sickling tests were positive and high performance liquid chromatography (HPLC) revealed both HbS > 50% and HbE fractions ≥ 25%. It's important to detect this rare condition, prevalent in consanguineous marriages as dreaded complications like sickling crisis may manifest during pregnancy and air travel. Detection and genetic counselling is important for prognosis, planning follow up and therapy for this uncommon double heterozygous state.

Heavy chain deposition disease in a case of clear cell renal cell carcinoma- A jack in the box

Renal cell carcinoma (RCC) is the most common subtype of adult renal tumors, and its detection rate in the early stages has been increased in the dawn of advanced imaging modalities. Nephrectomy is the mainstay of treatment; determination of tumor category and staging is the primary concern of oncopathologists. Non-neoplastic renal parenchyma is overlooked majority of times and thus misses the opportunity to detect concomitant medical renal diseases which also predict the renal outcome in the postoperative era. Although any kind of glomerular or extraglomerular pathology may be encountered, vascular changes in the form of arterionephrosclerosis are the commonest one. Here, we take the opportunity to report an unusual association of heavy chain deposition disease (HCDD) with clear cell subtypes of renal cell carcinoma in a 48-year-old male of Indian ethnicity.

Leukemia cutis - A case of cutaneous manifestation of acute monoblastic leukemia

Leukemia cutis is a comprehensive terminology for dermal manifestations of any type of leukemia either with accompanied or antecedent blood or bone marrow involvement. Although both myeloid and lymphoid neoplastic leukocytes can infiltrate the skin, the frequency is higher among children with congenital myeloid leukemia. However, the underlying pathogenesis of dermal tropism is not yet established. Clinical manifestation varies regarding appearance, site, and numbers. Skin biopsy is essential for the early establishment of the diagnosis and to guide for further testing and categorical management. We report the case of acute myeloid leukemia-cutis in a 22-year-old female where cutaneous manifestation preceded the hematological diagnosis of systemic leukemia.

Utility of serum anti-phospholipase A2 receptor antibody as a biomarker in membranous nephropathy: An experience from a tertiary care center of Eastern India

Background

Membranous nephropathy (MN) is a pattern of glomerular injury. Exact categorization into primary membranous nephropathy (PMN) or secondary membranous nephropathy (SMN) is essential for treatment. An endogenous podocyte antigen, M-type phospholipase A2 receptor (PLA2R) has been discovered to be involved in the pathogenesis of PMN.

Aims and Objectives

In this article, we aimed to analyze renal tissue PLA2R and serum anti-PLA2R antibodies in MN cases and determined the diagnostic utility.

Materials and Methods

The study was of prospective type carried out from March 2019 to August 2020. Analysis of cases of MN was performed with PLA2R paraffin immunoflourescence and serum anti-PLA2R antibody ELISA.

Results

Overall sensitivity, specificity, PPV, and NPV of serum anti-PLA2R ELISA for PMN was 91.3%, 80%, 75%, and 93.3%, respectively, and of tissue PLA2R staining for PMN was 91.67%, 81.08%, 75.86%, and 93.75%, respectively. There was strong concordance between two methods. In the patients that were followed up, we found baseline serum anti-PLA2R antibody was less in complete remission group than that in non-remission group and the reduction in serum anti-PLA2R antibody was more in complete remission group than that in non-remission group.

Conclusion

Routine light and immunofluorescence examination are incapable of giving exact categorical opinion regarding PMN and SMN. Serum anti-PLA2R antibody detection and renal tissue PLA2R analysis are sensitive and specific in detecting PMN. Baseline serum anti-PLA2R antibody and anti-PLA2R antibody quantification trends are related to prognosis of PMN. So they can be incorporated as additional biomarker.

Intestinal helminths—an outlander in a case of protein losing enteropathy

Malabsorption is the major disease burden in tropical countries. Both primary and secondary forms exist and a secondary form overshadows the primary category. Intestinal parasitic infections lead to secondary form of tropical malabsorption in both native and travelers and presentation varies from mild glossitis to severe protein losing enteropathy. The underlying condition is often masked unless an endoscopic biopsy is performed. This is followed by a histopathological examination which unravels the etiology.

Three shades of black - secondary thrombotic microangiopathy

Thrombotic microangiopathy is a group of disorders characterized by microangiopathic hemolytic anemia, thrombocytopenia and organ damage. Wide age distribution and the heterogeneity in presentation demand a deeper understanding into the pathogenesis of TMA. Primary TMA is distinct from TMA associated with secondary causes and remains clinically occult till a precipitating factor aggravates it. The extent and severity of renal damage caused by each of them is also distinct. The first alerting signal could be the presence of schistiocytes on peripheral smear and arteriolar thrombi on light microscopy. Thus in secondary TMA, identification of the underlying disorder is indispensible for targeted management.

Role of light and immunofluorescence microscopy to differentiate primary and secondary membranous nephropathy

CONTEXT

Membranous nephropathy (MN) causes nephrotic syndrome, mostly primary but may be associated with SLE, infections, cancer, or drug.

AIMS

To estimate clinical, serological, light microscopic, and direct immunofluorescence (DIF) findings to differentiate primary and secondary MN.

SETTINGS AND DESIGN

Prospective, cross-sectional, single-center study in a tertiary care hospital.

METHODS AND MATERIAL

Total 51 cases from September 2019 to February 2020.

LABORATORY DATA

Blood glucose, urine analysis, urea, creatinine, albumin, cholesterol, HBsAg, Anti HCV, ASO, ANA, MPO ANCA, PR3 ANCA, dsDNA, PLA2R, C3, and C4. Clinical parameters: age, sex, BP, skin lesions, arthralgia, edema, obesity. Renal biopsies examined with H and E, PAS, silver methanamine, MT stains. DIF done with IgG, IgM, IgA, C3c, C1q, kappa, and lambda.

STATISTICAL ANALYSIS USED

Statistical software (Graph Pad PRISM 6) and Chi-square test).

RESULTS

Among 51 cases, 25 are primary and 26 are secondary MN with 22 being lupus nephritis, with 2 being post-infectious and the remaining 2 being proliferative glomerulonephritis with monoclonal immunoglobulin deposition (PGNMIDD) with kappa chain restriction. Mean age was 37 ± 12.18 and 30.69 ± 13.92 years for primary and secondary MN, respectively. Significant male preponderance in primary MN. Serum C4 significantly low in secondary MN (15.34 ± 9.59). Microscopic hematuria present in secondary MN. Mesangial and endocapillary hypercellularity are significant in secondary MN. IgG and kappa are significantly intense in primary whereas IgA, C3c, and C1q are significantly intense in secondary MN.

CONCLUSIONS

Reliable differentiation between primary and secondary MN has important therapeutic implications.

Diagnostic and prognostic utility of SF-1 in adrenal cortical tumours

BACKGROUND AND AIMS

Superior imaging techniques have increased the recognition of adrenal pathology. Distinguishing benign from malignant adrenocortical tumors is not always easy. Several criteria and immunohistochemical markers have been discovered which help to differentiate between adrenocortical adenoma (ACA) and adrenocortical carcinoma (ACC). Our aim here was to evaluate the diagnostic and prognostic role of steroidogenic factor-1 (SF-1) in adult adrenocortical tumors (ACT) diagnosed using the Weiss criteria. In this cohort, we have also analyzed Ki67 and p53 expression and the extent of agreement between SF-1 and Ki-67.

METHODOLOGY

This was a retrospective, observational study comprising 24 cases of adult ACT over 10 years. Immunohistochemical staining for SF-1, Ki67, and p53 was done in all the cases, and the results correlated with the morphological diagnosis made using Weiss criteria.

RESULTS

SF-1 was 100% sensitive and 80% specific as a marker of malignancy. Increased SF-1 expression correlated with worse survival. There was a moderate degree of agreement between Ki-67 labeling-index and SF-1 as a marker of malignancy with the kappa coefficient being 0.75. The sensitivity of p53 was lower than Ki67 in diagnosing ACC.

CONCLUSION

In adult ACTs, SF-1 has diagnostic significance and prognostic implication. SF-1 is a crucial, dosage-dependent survival factor in ACC. There is a moderate extent of agreement between Ki-67 and SF-1 as a marker of malignancy.

Clinicopathological Spectrum of Henoch-Schönlein Purpura Vasculitis: An Experience from a Tertiary Care Center

Henoch-Schönlein purpura (HSP) is a small vessel vasculitis with multiorgan involvement. Renal involvement is the key factor predicting morbidity. We have aimed to analyze the clinicopathological spectrum of HSP vasculitis and HSP nephritis to assess the risk factors associated with kidney involvement. This retrospective study was performed in the department of pathology with collaboration of department of dermatology and department of nephrology of a tertiary care center. All clinical details along with biopsy findings were retrieved. Starting materials of the study were cases of leukocytoclastic vasculitis with only perivascular IgA deposit of more than ++ in the absence of other immunoglobulin and trace complements. To investigate the possible factors that are influential on the development of biopsy-proven HSP nephritis, we divided the whole study population in two groups -group 1: with and group 2: without biopsy-proven nephritis. One-way analysis of variance was carried out during comparative analysis between two groups using IBM SPSS statistics software, version 19 and MedCalc software, version 12.3.0.0. HSP vasculitis comprised 11.6% (n = 19) of total cutaneous vasculitis in 2 years (164 cases) with a mean age of 13.52 ± 8.10 (range: 4-33 years). Three cases developed de novo kidney disease (15.79%). A correlation analysis revealed that predictors were seasonal variation (P = 0.018), severe gastrointestinal involvement (P = 0.03), and subcutaneous edema (P = 0.005). Various clinical and laboratory parameters were associated with renal consequences. Occult nephritis was the most common presentation with crescent as a constant histopathological feature.

Fine-needle aspiration cytology of juvenile granulosa cell tumour: A case report with summary of prior published cases

Juvenile granulosa cell tumours (JGCT) are uncommon tumours of the ovary and can present diagnostic difficulty both on histology and cytology because of its rarity. Here we present the fine-needle aspiration cytology (FNAC) findings of a 4 year-old girl who came with a large abdominal mass and bleeding per vaginum. FNAC from the mass showed features suggestive of granulosa cell tumour (GCT) and which was later confirmed on histology to be of juvenile type. Only two cases of cytological findings of JGCT have been described earlier, both of which were recurrent cases and at metastatic sites. The main cytological feature in our case was presence of thick colloid like fluid containing apparent bubbles along with small clusters of uniform cells with eosinophilic cytoplasm and fine vacuolation. The presence of these secretions corresponding to the macrofollicles on histology has not been reported earlier.

Utility of tru-cut biopsy in diagnosis of palpable pediatric soft tissue neoplasms

CONTEXT

Soft tissue neoplasms are infrequent in children with sarcomas accounting for approximately 7% of all pediatric malignancies. Morphologic diagnosis is challenging due to overlapping features. Subtyping and categorization of these lesions are difficult on fine-needle aspiration cytology (FNAC) alone owing to tumor heterogeneity and limited material in some cases. Tru-cut biopsies obtain adequate tumor tissue for ancillary studies besides conventional histology.

AIM

The study aims to explore the role of tru-cut biopsy to arrive at a definitive diagnosis. The study also highlights the correlation between FNAC and histopathology on tru-cut biopsy besides explaining the significance of a panel of immunohistochemistry (IHC) markers for histological categorization and subtyping.

MATERIALS AND METHODS

A total of 61 children from infancy to 18 years were included in the study. Closed biopsy procedures like FNAC and tru-cut biopsy were performed, and the tru-cut biopsy specimen was subjected to a panel of immunohistochemical markers.

RESULTS

Fisher's exact test for sensitivity and specificity towards detection of malignancy was 83% and 86%, respectively for FNAC. For tru-cut biopsy, sensitivity was 94% and specificity was 91%. The two-sided P value (<0.0001) was extremely significant. Cohen's Kappa coefficient value for tru-cut biopsy was 0.772 suggesting a substantial strength of agreement. Tru-cut with IHC had a Kappa value of 0.866 suggesting greater agreement with histopathology.

CONCLUSION

Tru-cut biopsy is a simple, safe, and reliable adjunct to the FNAC. Instead, immunohistochemistry enhances the diagnostic accuracy.

Histoplasmosis masquerading as tuberculosis: A report of three cases in immunocompetent children

The most common cause of granulomatous lymphadenitis in countries like ours is mycobactrium tuberculosis followed by atypical mycobacterial infection, fungal infections, parasitic infection, cat scratch disease, lymphogranuloma venereum (inguinal lymphadenopathy), and leprosy Here, we present three cases of lymphadenopathy due to histoplasmosis in immunocompetent children. Two of them presented with fever, lymphadenopathy, initially diagnosed as granulomatous lymphadenitis consistent with tuberculosis on FNAC and were put on antitubercular drugs. However, their condition gradually became worse. As the patients continued to deteriorate, subsequent lymph node biopsies were done and diagnosed as histoplasmosis. Third case presented with acute loss of vision with hepatosplenomegaly and lymphadenopathy. Initially considered as acute leukemia, but eventually established as histoplasmosis. Histoplasmosis should be considered as one of the possible causes of granulomatous lymphadenitis in children.

Comparison of Frozen Section and Squash Cytology as Intra-Operative Diagnostic Tool in Pediatric CNS Tumors

BACKGROUND

Pediatric central nervous system (CNS) tumors have a different histological spectrum as compared to adults with the infantile group having even more varied and distinct histological profiles. Intra-operative diagnosis is especially important as it guides the neurosurgeon to tailor an approach which is best suited for a particular case. The aim of the study was to evaluate the diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value of frozen section (FS) and squash cytology and to find out the degree of correlation (kappa value) between the two procedures.

MATERIALS AND METHODS

A prospective study was conducted on 55 pediatric patients with clinicoradiologically diagnosed CNS lesions for a period of 2.5 years. Intra-operative squash smears and FS were made and stained with hematoxylin and eosin stain. Diagnosis made subsequently on paraffin embedded sections was taken as the gold standard.

RESULTS

Although the specificity (90%) and positive predictive value (96%) were comparable between the two procedures, sensitivity (91.4%) and negative predictive value (75%) of FS was more as compared to squash cytology. Both the diagnostic modalities showed substantial agreement (k = 0.728).

CONCLUSION

Even though the histological spectrum of pediatric CNS tumors is more varied than adults, FS gives a reasonable intra-operative diagnosis and better results when compared to squash alone.

Cutaneous Vesiculobullous Lesions: A Clinicopathologic Study

Vesiculobullous disorders could be either immunobullous or non-immunobullous. The spectrum was analyzed using histopathology, direct immunofluorescence (DIF), and salt-split technique. Among the 104 patients analyzed, 77 (74%) were immunobullous and 25 (24%) were having non-immunobullous diseases. Bullous pemphigoid (20.2%) is the commonest among immunobullous lesions, and epidermolysis bullosa (11.5%) was the most frequent non-immunobullous lesion. Involvement of the hair and nail and a positive family history were common relationships for non-immunobullous disorders. Immunobullous lesions showed DIF positivity whereas non-immunobullous lesions were DIF negative. Perilesional DIF was more sensitive and specific than lesional DIF. The commonest antibody was immunoglobulin G (IgG) (78.9%) followed by complement 3c (C3c) (38.1%), immunoglobulin A (IgA) (25%), and immunoglobulin M (IgM) (6.6%). No lesion should be considered non-immunobullous unless both lesional and perilesional DIF results were negative.

Clinicopathological Study of Primary Pediatric Gastrointestinal Lymphomas

Background:

Primary gastrointestinal lymphomas (PGIL) are uncommon in children and account for <5% of all pediatric malignancies. The objective of our study was to analyze the prognostic factors of pediatric PGILs with reference to its histological subtypes, stage, and outcomes using immunohistochemistry.

Materials and Methods:

Twenty cases were studied over 11 years. Clinicopathological profiles, histological details, and immunohistochemical (IHC) profiles were analyzed.

Results:

The mean age at the presentation was 6 years. Using IHC stains (CD CD10, CD19, CD20, CD3, terminal deoxynucleotidyl transferase, BCL 2 and 6, PAX 5, and MUM1), diffuse large B-cell lymphoma (DLBCL) was most prevalent (45%), followed by Burkitt lymphoma (35%) and lymphoblastic lymphoma (20%). DLBCLs (9) were classified using the Han's algorithm. Six were activated B-cell and 3 were germinal center B-cell subtypes. The cases of lymphoblastic lymphoma and those in Stage I disease had the best prognosis.

Conclusion:

Pediatric PGILs have variable presentation, outcomes, and diverse treatment modalities depending on the histological subtypes. A panel of IHC stains can be a useful adjunct for the categorization and prognosis of pediatric PGILs.

Pediatric lupus nephritis - An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India

Context

Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease.

Aims

To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score].

Settings and Design

Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India.

Subjects and Methods

We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies.

Statistical Analysis Used

Kruskal-Wallis and χ² tests.

Results

Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity.

Conclusions

Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.

Genetic and acquired blistering disorders of pediatric age group: An experience from Eastern India

Introduction

Blistering or vesiculobullous disorders in pediatric population are either immunobullous or mechanobullous. Spectrum was analyzed using demographic details, clinical features, histopathology, direct immunofluorescence (DIF) and Immunofluorescence mapping (IFM).

Methodology

This was a single institution based observational study in children below 18 years. The demographic details were collected using proforma containing particulars of the patient, history, complaints, and other parameters. Punch biopsy of the skin lesion was done. Biopsy samples were examined under light microscope followed by DIF using fluorescent conjugated polyclonal antibody against immunoglobulins IgG, IgM, IgA, and complement C3. The salt-split technique was also used in particular cases. IFM was done using anticytokeratin (CK) 5 & 14, antilaminin 332, anticollagen VII, and anticollagen IV antibodies.

Results

Out of total 50 cases, linear IgA bullous dermatosis (LABD) was the commonest. The average concordance between clinical and final diagnosis (histopathological examination + DIF) was 87.5% and discordance was 12.5%. The agreement between histopathological examination and DIF was found to be substantially significant (κ = 0.6892). IFM depicted epidermolysis bullosa simplex with reduced CK 14 expression, dystrophic epidermolysis bullosa with reduced Collagen VII expression and junctional epidermolysis bullosa with absent laminin 5 expression.

Conclusion

The spectrum of bullous lesions in childhood was properly delineated and subcategorization of EB was done. Histopathological examination showed the hallmarks that were conclusive in most of the cases except in LABD and EB. DIF and IFM proved indispensable in those cases. Thus, DIF is not a substitute for histopathology but complementary to it.

IgG4 tubulointerstitial nephritis - An uncommon enemy!

IgG4-related disease (IgG4-RD) is an evolving entity characterized by immune mediated multisystem involvement in the form of fibro inflammatory lesions like sclerosing pancreatitis, dacryoadenitis, Reidel thyroiditis, or chronic sclerosing sialadenitis. Barely, the lesions are restricted to kidney (IgG4-RKD: IgG4-related kidney disease) involving either glomerular or extraglomerular compartment. It is challenging to identify and demands an awareness regarding the entity to reduce the number misdiagnosis and missed diagnosis. Here, we report a case of a 45-year-old woman with IgG4 tubulointerstitial nephritis (IgG4-TIN) who presented with unexplained renal dysfunction as her initial manifestation. This is the first case of IgG4-RKD reported from our tertiary care center among 1864 native renal biopsy in the last two years.

Hairy Projections on Non Hairy Cells- A Case Report

Adult T-Cell Leukaemia/Lymphoma (ATLL) is a mature T-cell neoplasm. It is caused by human retrovirus Human T-cell Lymphotropic Virus Type 1(HTLV-1). The neoplastic cells after monoclonal integration begin to express T-cell associated antigens namely CD2, CD3 and CD5. These leukaemic cells are highly pleomorphic in light microscopic appearance and also they have a highly variable clinical presentation ranging from acute to lymphomatous to chronic to smouldering. There is a chance of missed or miss diagnosis due to their morphological and clinical heterogeneity and specialised test like immunophenotyping or flow cytometry is essential for exact categorisation. Authors hereby, report a case of 45-year-old female patient suffering from ATLL whose peripheral smear showed leukaemic cells with unusual hairy projections resembling hairy cell leukaemia posing diagnostic dilemma.

Composite phaeochromocytoma with malignant peripheral nerve sheath tumour: A case report with summary of prior published cases

Composite phaeochromocytomas (CP) are extremely uncommon adrenal medullary tumours where phaeochromocytoma coexists with another adrenal medullary tumour also of neural crest origin. CP includes combination of phaeochromocytoma along with a component of neuroblastoma, ganglioneuroblastoma, ganglioneuroma, benign nerve sheath tumour or a malignant peripheral nerve sheath tumour (MPNST). Here we describe the morphological and immunohistochemical details of a case of CP with MPNST in a 30 years old lady, without history of neurofibromatosis. Only 6 cases of CP with MPNST have been reported so far. We have tabulated a summary of these prior published cases of phaeochromocytoma with MPNST. To our knowledge, this is the first literature review describing the clinico-pathological characteristics of these rare tumours.

Sertoli-Leydig cell tumor of ovary in children: A report of two cases, including retiform variant

Sertoli-Leydig cell tumors (SLCTs) are rare and heterogeneous group of ovarian neoplasms which belong to the sex cord-stromal category of tumors. SLCTs are classified into well, intermediate, and poorly differentiated types. Retiform growth pattern and heterologous elements are commonly found in moderately and poorly differentiated tumors. SLCTs are usually encountered in the third decade of life and patients most often present with virilization. Here, we report two cases of SLCTs of the ovary, both in 2-year-old girls without any hormonal symptoms. The first case was a retiform variant of Sertoli-Leydig cell tumor and the second was a well-differentiated SLCT. Because of its wide spectrum of morphology, several tumors enter in the differential diagnosis and the presence of heterologous elements further complicates the diagnosis. Here, we have described the morphological characteristics of these tumors and discussed their differential diagnoses. SF-1, WT1, and α-inhibin are useful immunostains in establishing the diagnosis and differentiating these from the more the common ovarian germ cell tumors in children.

A tale of tripartite: An experience from a tertiary care center of Eastern India

Background

Crescentic glomerulonephritis (Cr GN) is pattern of glomerular injury resulting from wide range of diseases sharing a common pathogenesis.

Objectives

The objective of our study was to analyze the clinicopathological spectrum and outcome of Cr GN with special reference to its immunopathological subtypes using a panel of immunofluorescence stains.

Materials and Methods

Native renal biopsies with crescentic pattern of injury were included. Detailed Clinical and laboratory variables were analyzed along with the treatment protocol and renal outcome, wherever available. Renal biopsy slides were evaluated for various glomerular and extraglomerular features. Both qualitative and quantitative data were analyzed.

Results

A total of 57 cases of Cr GN were included; majority (47.36%) of cases were pauci-immune in nature. Among clinical features, ranges of proteinuria and creatinine level were significantly different between subgroups. The various light microscopic parameters, including proportion of cellular crescents and capillary wall necrosis were different. Presence of arteriolar changes also showed association with unfavorable outcome. Three unusual associations, including IgA nephropathy, membranous glomerulonephritis and Hepatitis B infection were detected. Adequate follow-up information was available in 35 of the patients. Of these, 14 were dialysis-dependent at the last follow-up.

Conclusions

Type III Cr GN (pauci-immune Cr GN) was the commonest cause of Cr GN in our population. Adult patients required renal replacement therapy more frequently than pediatric cases those are chiefly infection associated. Critical appraisal of clinical, histopathological and immunofluorescence finding help to identify individual subtypes as treatment and outcome varies accordingly.

Utility of cell block preparation in diagnosis of paediatric abdominal neoplasms

BACKGROUND

Paediatric abdominal neoplasms are fairly common. Fine needle aspiration cytology (FNAC) is used for the initial evaluation of paediatric abdominal neoplasms. However, sometimes FNA interpretation can be difficult on limited material, owing to tumour heterogeneity and overlapping features. Therefore, we attempted to obtain additional information using cell block (CB) preparation from residual aspiration material along with immunohistochemistry (IHC) to enhance the diagnostic accuracy.

AIM

To evaluate the correlation between CB preparation and FNAC in diagnosis of paediatric abdominal tumours with the help of an extended panel of IHC markers and to highlight some of the diagnostic difficulties.

MATERIALS AND METHODS

A total of 113 cases of paediatric abdominal masses were studied. In addition to routine FNA smears, CBs were prepared from the residual material for IHC analysis as considered appropriate.

RESULTS

This study included a total of 113 children with abdominal masses. Histopathology following surgical resection was available in 53 cases. Histology was taken as gold standard to measure the diagnostic accuracy with reference to sensitivity (Sn), specificity (Sp), positive predictive value and negative predictive value. The Sn of FNA alone was 87.5% and Sp was 97.78%. The Sn and Sp increased with use of CB alone and were 100% and 97.78% respectively. The highest Sn and Sp were observed when CB was combined with IHC where both the values were 100%.

CONCLUSION

CB with IHC is a useful adjunct to the routine FNA smears that further contributes to enhance the accuracy of the cytopathological diagnosis and is useful for choosing pre-operative chemotherapeutic regimen.

Correlation between Thyroid Imaging Reporting and Data System and Bethesda System of Reporting of Thyroid Cytopathology of Thyroid Nodule: A Single Center Experience

Background:

The incidence of thyroid cancer has been increasing worldwide. Thyroid imaging reporting and data system (TIRADS) has been proposed for risk stratification of thyroid nodules to improve categorical management. Fine needle aspiration cytology based on Bethesda system for reporting of thyroid cytopathology (BSRTC) plays a fundamental role in the evaluation of thyroid nodule microscopically. Both the systems, the TIRADS and the latest revised BSRTC 2017, are widely recommended and practiced all over the world, but the correlation between the two systems has not been established.

Aims and Objectives:

This study was conducted to assess the risk of malignancy (ROM) in the intermediate Bethesda categories of thyroid lesions and their correlation with the corresponding TIRADS categories.

Materials and Method:

It was a prospective cross-sectional study over 1 year including 69 patients aged 18 years or older having solitary thyroid nodules. All cases were triaged using both TIRADS and BSRTC 2017 and the diagnostic performances were compared with subsequent paraffin sections to evaluate ROM. Correlation between TIRADS and BSRTC systems was expressed as kappa value.

Result:

Good concordance was observed between TIRADS and BSRTC systems in the evaluation of benign thyroid nodule lesions (category 2-II). There was discordance in follicular lesions (category 4-IV). The kappa value generated (0.411) revealed moderate agreement between the two risk stratification systems.

Conclusion:

Careful application of both grading systems is essential for the proper segregation of thyroid nodules to facilitate effective clinical and surgical management. However, universally acceptable protocols need to be developed to avoid the heterogeneous approach.

An unexpected host in a soft-tissue lesion of thigh

Rhinosporidiosis is an enigmatic entity and poses a major health problem in the developing countries of South-East Asia. A soft friable polypoid nasal mass is the most common presentation, while sparse literature is available on extranasal involvement. We describe the case of a 35-year-old female patient who presented with a slow-growing soft-tissue swelling with ulceration over the thigh. On clinical and radiological examination, a provisional diagnosis of soft-tissue neoplasm was made. After resection, histopathological sections showed a closely packed cyst with innumerable endospores. The present case report documents the rare occurrence of an incidentally detected cutaneous rhinosporidiosis causing diagnostic difficulty.

Diagnostic utility of cytology smears and cell block in adrenal lesions

BACKGROUND

Cytology of the adrenal gland is a less performed technique even in tertiary care centres; yet cytological evaluation is an important diagnostic tool for assessment of adrenal lesions. Our objective was to evaluate the diagnostic utility of FNAC smears and cellblock with immunohistochemistry (IHC) in lesions of the adrenal.

MATERIAL AND METHODS

We had a total of 50 cases over a period of 2 years where both FNAC smears and cellblocks were taken. The smears and cellblocks were examined for adequacy. They were subsequently categorised into four groups: unsatisfactory, benign, suspicious of malignancy and malignant. The diagnostic accuracy of FNAC smears and cellblock with IHC were evaluated and compared, taking histopathology, wherever available, as the gold standard, RESULT: We had 50 cases with age ranging from 6 to 53 years with a median of 7.5 years. Of these, 54% were cytologically malignant and neuroblastoma was the commonest lesion. Histopathology was available in 23 cases only, where the diagnostic accuracy was evaluated. The sensitivity and specificity of FNAC smear was 100% and 85.71%, respectively whereas the sensitivity and specificity of cellblock with IHC was 100% and 92.86%, respectively.

CONCLUSION

Cellblock together with IHC provides a higher degree of specificity, reduces the unsatisfactory rate and improves the diagnostic accuracy in lesions of the adrenal gland. Immunohistochemistry is an important adjunctive tool.

Immunohistochemistry-based comparative study in detection of Hirschsprung's disease in infants in a Tertiary Care Center

BACKGROUND:

Hirschsprung's disease (HD) is the major cause of pediatric intestinal obstruction with a complex pattern of inheritance. The absence of ganglion cells along with an analysis of hypertrophy and hyperplasia of nerves in the nerve plexus of submucosa and muscularis mucosae is regarded as a potential hallmark for its diagnosis.

AIMS AND OBJECTIVES:

This study was undertaken to ascertain the (1) clinical profile, (2) mode of presentation, and (3) to compare the role of calretinin immunostaining with acetylcholinesterase in the diagnosis of HD.

MATERIALS AND METHODS:

This prospective and observational study was conducted in the Department of Pathology, IPGME & R from June 2014 to May 2015. One hundred and four patients clinically and radiologically diagnosed with HD underwent surgery were included in the study. The data of every patient including age, sex, and presenting symptoms were recorded. Eventually, histopathological, calretinin, and acetylcholinesterase immunohistochemical examination were done.

RESULTS:

Total numbers of cases studied were 104, which aged between 0 days and 365 days. Male preponderance (76.92%) was noted. The overall sensitivity, specificity, positive, and negative predictive value of acetylcholinesterase were 100%, 86.44%, 84.91%, and 100%, respectively. The concordance of detection of ganglion cells and nerve fibers, and thereby diagnosis of Hirschsprung's and non-HD using calretinin and the gold standard was statistically in strong agreement (κ = 0.749, 95% confidence interval: 0.635–0.863).

CONCLUSIONS:

Calretinin stands out as the single and indispensable tool that differentiates HD from other mimickers.

Membranoproliferative Glomerulonephritis- A Disease or a Pattern of Injury?

Introduction:Membranoproliferative Glomerulonephritis (MPGN) is a pattern of glomerular injury resulting from wide range of diseases sharing a common pathogenesis and thus, presented with large spectrum of clinical presentation starting from slowly progressive subnephrotic range proteinuria to nephritic syndrome and Rapidly Progressive Glomerulonephritis (RPGN). Aim: The aim of the study was to do reanalysis of the aetiological classification of MPGN and its prognostic outcomes. Materials and Methods: A retrospective, cohort study was conducted including the patients of all age groups with MPGN pattern of injury, from February, 2018 to August, 2018 at a Tertiary Healthcare Centre of West Bengal, India. All specimens were examined by two nephropathologists at the institute using both light microscope and immunofluorescence microscope. Haematoxylin and Eosin (H&E), Periodic Acid-Schiff (PAS), silver methanamine, Masson’s Trichrome (MT) stained smears were prepared for light microscopy. Specimens for immunofluorescence microscopy were stained using Fluorescein Isothiocyanate (FITC) conjugated polyclonal rabbit anti-sera against human IgG, IgM, IgA, C3, C1q, kappa, lambda. Correlations were evaluated using Spearman’s rank correlation. A p<0.05 was considered as statistically significant. GRAPHPAD PRISM 5 was used for statistical analysis. Results: From a total of 47 cases, 41 cases in immunoglobulin associated group, 4 cases in C3 nephropathy group and 2 cases in pauci-immune group were found. Autoimmune diseases had the strongest association followed by infections and dysproteinemia. Severity and chronicity parameters were more prevalent in the immunoglobulin positive group. The pauci-immune group showed maximum vascular involvement, indicating it to arise from a vascular pathology. Conclusion: Membranoproliferative Glomerulonephritis is not a single disease entity instead this pattern of injury could be seen in a variety of diseased condition.

Granulomatous Interstitial Nephritis - A Series of Six Cases

Granulomatous interstitial nephritis is an uncommon variant accounting for about 6% of all tubulointerstitial nephritis. The etiology can be drugs such as antibiotics and nonsteroidal anti-inflammatory drugs and infections such as tuberculosis, sarcoidosis, and fungal infections. Renal biopsy remains the gold standard for establishing the diagnosis. Here, we present a series of six cases of granulomatous interstitial nephritis, of which two cases were associated with lupus nephritis and another two cases with crescentic glomerulonephritis. Focal segmental glomerulosclerosis and mesangiosclerosis with chronic tubulointerstitial nephritis were detected in the rest of the cases. Most of the patients presented with features of nephrotic syndrome. Urine analysis showed albuminuria in all cases. In renal biopsy, interstitial epithelioid cell granuloma was a constant feature along with which there were foci of necrosis and moderate fibrosis in few cases. But none of our cases had any relevant history of prolonged drug intake. Tuberculosis and fungal infections were also ruled out. Thereby in this case series, we subgroup all the cases into two category four cases associated with granulomatous nephritis and two cases with idiopathic granulomatous nephritis.

A cytohistological correlation in salivary gland swelling with special reference to the proposed Milan system

Context and Background

Cytological grading of salivary gland lesion, which is a simple, cost-effective, and reproducible method, can be used as a tool for the selection of treatment modality. The proposed Milan classification establishes one guideline for reporting of salivary gland cytology and thus helps in individualized treatment and follow-up.

Aims and Objectives

(1) The aims and objectives of this study were to establish the validity and reliability of the Milan classification of cytological grading in salivary gland swelling and (2) to calculate the malignancy risk.

Materials and Methods

This prospective study was designed in clinically diagnosed salivary gland swelling at the Department of Pathology of a tertiary care referral hospital. Fine-needle aspiration (FNA) was done, and stained smears were examined under light microscope and cytological findings were noted according to the Milan classification. Tissue for the histopathological study was obtained in 119 cases. The previous cytological findings were compared to subsequent histopathology report.

Results

: Among 119 FNAs, 2.5% were nondiagnostic and 55.4% were nonneoplastic. While no samples were placed in the atypia of undetermined significance category, benign tumors accounted for 25.2%. About 1.7% was grouped in the salivary gland neoplasm of uncertain malignant potential, 2.5% of cases were categorized as suspicious of malignancy, and 12.6% of cases comprised as malignant tumors. Overall, malignancy risk was observed to be the highest (93.3%) in Category 6 and lowest (3.0%) in nonneoplastic category.

Conclusions

The six-tier diagnostic categories of the Milan classification scheme help in segregating patients with salivary gland lesions into the management categories of follow-up, conservative surgery, and radical surgery with/without chemotherapy.

Diagnostic and prognostic utility of SF1, IGF2 and p57 immunoexpression in pediatric adrenal cortical tumors

BACKGROUND

Adrenocortical tumors (ACT) are uncommon in the pediatric age group. Using the standard Weiss criteria in pediatric tumors leads to overdiagnosis. This has led to the development of newer systems such as Weineke criteria. Ki67 labeling index aids in differentiating adenomas from carcinomas. We aim to evaluate the diagnostic and prognostic role of Ki67 labeling index, along with immunoexpression of steroidogenic factor-1, insulin like growth factor 2 and p57, in pediatric ACTs diagnosed using Weineke criteria.

METHODS

We have studied 25 cases of pediatric ACTs. Immunohistochemical staining for Ki67, SF-1, IGF2 and p57 was done in all cases and the result was correlated with the morphological diagnosis using the Weineke criteria.

RESULTS

Ki67 labeling index showed complete concordance with the morphological diagnosis. SF-1 and IGF2 showed similar correlation with the diagnosis, with IGF-2 proving to be a more specific marker. Increased Ki67, SF-1 and IGF2 immunostaining also correlated with worse survival. p57 was more specific in determining benign status of a tumor.

CONCLUSION

SF-1 and IGF2 are highly sensitive markers of malignancy in pediatric ACTs and can be used in combination with Ki67 expression for optimal diagnostic and prognostic assessment of pediatric ACTs.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Thyroid Bethesda Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance (AUS/FLUS): A Heterogenous Group

Background:

The Bethesda system of reporting thyroid cytopathology (BSRTC) was introduced in 2007. The third category of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) poses difficulties for the pathologist, and different papers have been published varying the risks of malignancy.

Aims:

(1) Evaluation of the cytological features of thyroid lesions according to BSRTC. (2) After resection, correlation with histopathological report to evaluate the risk of malignancy (ROM) and the risk of neoplasm (RON). (3) Division of category III into six subgroups based on cytological findings and assessment of ROM and RON.

Materials and Methods:

A total of 282 patients with diagnosed thyroid lesions underwent fine-needle sampling under ultrasound guidance. Smears were prepared and stained with May–Grunwald–Giemsa stain and Papanicolaou stain.

Results:

Of 282 cases, there were 9 cases (3.1%) of category I, 157 cases (55.8%) of category II, 24 cases (8.5%) of category III, 20 cases (7.1%) of category IV, 14 cases (4.8%) of category V, and 58 cases (20.7%) of category VI. The RON was 60, 17.1, 63.1, 77.7, 91.7, and 98.2% and the ROM was 60, 14.3, 26.3, 38.9, 91.7, and 96.3% in categories I, II, III, IV, V, and VI, respectively. The RON was 0, 75, 50, 100, 66.6, and 100% and the ROM was 0, 25, 50, 100, 16.6, and 0% in subgroups 1, 2, 3, 4, 5, and 6, respectively. We have proposed a system of subgrouping AUS/FLUS that may help to dispel the confusion generated by an AUS/FLUS report, and provide with a more exact and reproducible diagnostic and prognostic tool.

Correlation of Gleason Grading and Prognostic Immunohistochemistry Markers (Human Epidermal Growth Factor Receptor 2/neu and Androgen Receptor) in Prostatic Core Needle Biopsy: A Study in a Tertiary Care Center

Background: Worldwide prostate cancer is the most common cause of cancer and the second leading cause of cancer death among men. Transrectal ultrasound-guided core needle biopsies are the diagnostic modalities which help in proper categorization and grading of prostatic carcinoma, thus facilitating individualized treatment. These biopsies are the primary source for performance of additional diagnostic immunohistochemical testing for basal cell-associated markers to rule out the morphological mimicker and prognostic markers such as androgen receptor (AR) and human epidermal growth factor receptor 2 (HER2)/neu. Materials and Methods: A prospective, observational study was conducted in the department of pathology in collaboration with department of urosurgery of a tertiary care hospital. One hundred and nineteen patients diagnosed with prostatic nodules were included in this study. Values of serum prostate-specific antigen were recorded. Tissue for histopathological study was obtained in the form of core needle biopsy, and Gleason grade was calculated in all malignant cases. Immunohistochemistry for p63 and alpha-methylacyl-CoA racemase was performed as an additional test in premalignant cases. Prognostication of the prostate cancer cases was done using AR and HER2/neu. Results: A total of 119 cases aged between 20 and 90 years were included in this study. Malignant lesions reveal an increase in the percentage of AR staining in comparison to the benign glandular structure. The Gleason score with higher value (8–9) showed increased expression of HER2/neu receptor. Conclusion: Critical histopathological analysis of core needle biopsy along with immunohistochemical evaluation maximizes the diagnostic accuracy in prostate cancer cases and also helps in prognosis assessment.

A Clinicopathological and Immunofluorescence Study of Intraepidermal Immunobullous Diseases

Context:

Autoimmune blistering diseases (AIBDs) are characterized by autoantibodies directed against antigens of skin. Direct immunofluorescence (DIF) study helps in confirming the diagnosis where histopathology alone is noncontributory.

Aims:

This study aimed to evaluate the clinicopathological and DIF features of intraepidermal AIBD and to assess their relative diagnostic significance.

Materials and Methods:

It was an institution-based observational study. A total of 34 patients were studied over a period of 1½ years in the Department of Pathology in collaboration with the Department of Dermatology of a tertiary care hospital. The clinical, pathological, and DIF features were evaluated and documented.

Statistical Analysis:

Data were analyzed by statistical tests using GraphPad InStat.

Results:

Pemphigus vulgaris (PV) was the predominant type with 18 (53%) cases followed by 15 (44%) cases of pemphigus foliaceus (PF) and a single case of pemphigus erythematosus (PE). The age of the patients ranged from 17 to 85 years. Overall, there was a female preponderance in the study group. The most common presenting feature was pruritus (58.82%). Tzanck smear showed the presence of acantholytic cells in thirty (88.24%) patients. Characteristic histopathological features were present in all the cases of PV and PF except one case of PF which was found to be a case of PE. DIF study showed intraepidermal deposition of intercellular immunoglobulin G (IgG) and C3 both in PV and PF. The case of PE showed epidermal “antinuclear antibody” staining with IgG.

Conclusion:

Immunofluorescence study may be used as an additional tool for confirmation of diagnosis where histopathology alone is inconclusive.

Fatigue in systemic lupus: the role of disease activity and its correlates

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM).

METHODS

A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables.

RESULTS

Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (β 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (β 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (β 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (β 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue.

CONCLUSION

Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Utility of intraoperative squash cytology in diagnosis of paediatric central nervous system lesions

BACKGROUND

Role of squash cytology in intraoperative diagnosis of central nervous system lesions has been well established. Intraoperative diagnosis is especially important in paediatric CNS lesions as decision regarding gross total resection or near total resection or subtotal resection is crucial and radiotherapy and chemotherapy are best avoided in this age group. The aim of this study was to evaluate the utility of squash cytology of CNS lesions in paediatric age group and to assess its diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value.

MATERIALS AND METHODS

A prospective study was conducted on 42 paediatric patients with clinico-radiologically diagnosed CNS lesions. Intraoperative squash smears were stained with haematoxylin and eosin (H&E) stain. Diagnosis made subsequently on paraffin sections was taken as gold standard.

RESULTS

The overall diagnostic accuracy of intraoperative squash cytology of CNS lesions in paediatric age group was 73.80%. The sensitivity, specificity, positive predictive value and negative predictive value of this modality were 92.31%, 87.50%, 96.00% and 77.78%, respectively.

CONCLUSIONS

The spectrum of CNS lesions in paediatric age group is different from that in adults. Though the sensitivity and specificity of squash cytology in paediatric tumours are less than that of adults, it is an important tool for intraoperative diagnosis that guides regarding the extent of resection.