Reporting Pancreatic FNAC using the Papanicolaou System: Still a Diagnostic Challenge

Introduction

The Papanicolaou Society of Cytopathology System for reporting Pancreaticobiliary Cytology (PSCPC) is a reliable method to classify pancreatic fine needle aspiration cytology (FNAC) smears. However, it is not without practical problems which can diminish the diagnostic accuracy of the cytological diagnosis.

Aims and Objectives

To determine the diagnostic pitfalls while reporting cytomorphology of pancreatic lesions according to PSCPC on correlating FNAC findings with histopathology.

Materials and Methods

Retrospective analysis of pancreatic FNAC smears received in the Department of Pathology of our tertiary care institute over a period of 2 years was done. The cytological diagnoses were classified according to the Papanicolaou Society of Cytopathology system of reporting pancreaticobiliary cytology and correlated with histopathology. The reasons of cyto-histological discordance were analyzed.

Results

Out of 50 cases in which both FNAC and biopsy of pancreatic lesions were done, 34 cases were positive/malignant (Category VI), eight cases were suspicious for malignancy (Category V), three cases were neoplastic (Category IV), two cases were atypical (Category III), two cases were negative for malignancy (Category II), and one case was non-diagnostic (Category I). Out of 50 cases, histopathology was non-diagnostic due to inadequate material in six cases. The cytological diagnoses were compared with histopathology in the remaining 44 cases. Categories III, IV V, and VI were considered as positive for neoplastic pathology. The sensitivity of FNAC to predict neoplastic pathology was 97.5%, while the specificity was 25%. The positive predictive value was 92.9%. Two cases reported as atypical (Category III) turned out to be adenocarcinoma on histopathology. One case reported as neuroendocrine tumor and two cases reported as adenocarcinoma on cytology displayed features of chronic pancreatitis on histology. One case reported as neoplastic mucinous cyst (Category IV) turned out to be adenocarcinoma on histology (limited concordance).

Conclusion

The cytopathologist needs to be wary of the potential pitfalls to improve the diagnostic accuracy of FNACs.

Is mediastinal fine needle aspiration cytology required or redundant? A single institution-based correlation study with core needle biopsy

INTRODUCTION

Fine Needle Aspiration cytology (FNAC) and core needle biopsy (CNB) are rapid, minimally invasive and useful techniques to evaluate mediastinal lesions.

OBJECTIVES

To compare cytopathology with histopathology of mediastinal lesions and analyse reasons for discordance.

MATERIAL & METHODS

Retrospective analysis was done in a tertiary care centre in North West India over a period of seven and half years from 1stJuly 2016 to 31st December 2023. Only those patients who had undergone FNAC and trucut biopsy of mediastinal masses were included. The cytopathology and histopathology slides were studied to analyse causes of discordance. Sensitivity, specificity, positive and negative predictive values of FNAC were calculated keeping histopathology as gold standard.

RESULTS

Out of 57 cases analysed, eight cases were non diagnostic on cytology. Cytology could effectively classify a lesion as non neoplastic (7) or neoplastic (42). For further subtyping, histopathology and Immunohistochemistry (IHC) were required. Out of 27 cases of cytological - histopathological discordance, 8 cases had sampling error, 15 cases had limited concordance where FNAC could predict possibility of tumor and 4 cases were discordant where subtyping of malignancy varied on CNB. Sensitivity of FNAC to predict definite diagnosis was 90.2 %, specificity was 50 %, positive predictive value of FNAC to give a definite diagnosis was 93.9 %, negative predictive value was 37.5 %.

CONCLUSION

Evaluation of mediastinal masses requires combination of cytology, histopathology and ancillary techniques like IHC. FNAC and CNB are complementary modalities and both are essential for rapid, accurate and comprehensive diagnosis.

Look Out for Fever: Clinical Profile of Dengue in Young Adults in a Tertiary Care Center in North India

Background Dengue fever (DF) is a common viral disease, clinical manifestations of which vary from influenza-like illness (DF) to life-threatening dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). The aim of this article was to study the clinical profile of DF in young adults.

Material and Methods This was an observational study conducted in the department of medicine over a period of 2 years (January 1, 2013—December 31, 2014). Patients aged between 18 and 30 years with serology proven (nonstructural protein 1 [NS1]/dengue immunoglobulin M [IgM]) DF were included in this study. The clinical and laboratory data was recorded and analyzed.

Results Out of 418 cases, the incidence of DF, DHF, and DSS was 87.32, 7.66, and 5.02%, respectively. The most common presentations were fever (99.76%) followed by vomiting (29.43%), pain abdomen (17.94%), myalgias (13.16%), petechial rash (12.92%), and bleeding (10.29%). Dengue NS1 and IgM antibodies were positive in 87.3% and 88.12% of the patients, respectively. Ascites, splenomegaly, hepatomegaly, pleural effusion, gall bladder wall edema, and pericardial effusion were present in 8.13, 6.94, 6.70, 5.98, 2.63, and 0.72% of the patients, respectively. Complications included bleeding (10.29%), acute respiratory distress syndrome (1.67%), myocarditis (1.44%), seizures (1.44%), hemarthrosis (0.24%), and encephalopathy (0.24%). The mortality rate was 3.35% with death of 14 patients. Shock, bleeding, and elevated serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase levels predicted adverse outcome.

Conclusion DF can present with a plethora of clinical manifestations in endemic areas. Adverse outcome is more likely if patients have elevated SGOT levels, shock, and bleeding. Continuous seroepidemiological surveillance is essential to control outbreak and minimize morbidity and mortality.

Contiguous Lumbar Vertebral Involvement with Vertebral Collapse in Giant Cell Tumor: A Usual Tumor with an Unusual Presentation

Giant cell tumor (GCT) is a primary bone tumor of long bones, which can rarely involve the vertebrae. Contiguous vertebral involvement by GCT is a rare presentation and poses a diagnostic dilemma on imaging. We report a case of GCT involving three contiguous lumbar vertebrae causing vertebral collapse along with a large soft tissue component. Considering the site and clinical presentation, possibilities of a round cell tumor with large extraosseous soft tissue component and malignant neurogenic tumor were suggested on initial radiological examination but histopathology confirmed the diagnosis of GCT. It is important to diagnose this entity correctly because of totally different lines of management. In our case, initial surgical management was excluded in view of high surgical morbidity and, thereby, adjuvant therapy with denosumab was planned.

Spectrum of Adrenal Lesions on Fine-Needle Aspiration Cytology: A Tertiary Care Centre Experience

Introduction Fine-needle aspiration cytology (FNAC) is an easy, quick, and specialized technique to distinguish neoplastic from non-neoplastic adrenal lesions, yet limited to tertiary care centers. It helps in analyzing symptomatic, as well as incidental adrenal lesions with high sensitivity and specificity.

Aim This study was conducted to determine the cytological spectrum of adrenal lesions in a tertiary care center.

Material and Methods This was a retrospective study which included a total of 19 cases of adrenal FNAC received from June 2017 till June 2019 in a north Indian tertiary care university hospital. All the lesions were broadly classified into non-neoplastic and neoplastic categories. The non-neoplastic lesions were divided into infective causes and cystic lesions. Neoplastic lesions were further grouped into benign and malignant lesions. Immunohistochemical findings were retrieved from the hospital records wherever accessible.

Results A total of 19 cases were aspirated, of which 16 cases (84.20%) yielded satisfactory material. Six cases (31.57%) showed non-neoplastic pathology of which one was a cystic lesion, three were infective (two histoplasmosis and one tuberculosis), and two showed only benign adrenal cortical cells in a setting of known extra-adrenal primary malignancy. The neoplastic group comprised of 10 cases (52.63%) of which 4 cases showed metastatic carcinomatous deposits from a known extra-adrenal primary malignancy and 6 cases showed primary adrenal neoplasm (one case of myelolipoma, one case of pheochromocytoma, and four cases of adrenal neoplasm) which were then subjected to biopsy and immunohistochemistry. A final diagnosis of pheochromocytoma was made in three cases, adrenocortical carcinoma in one case, and one case was inconclusive because of nonrepresentative biopsy.

Conclusion Image-guided fine-needle aspiration cytology of adrenal lesions helps to determine the exact nature of the infection, avoids unnecessary surgery, and helps in targeted management. However, histopathological evaluation with immunohistochemistry remains the diagnostic modality of choice with regard to neoplastic lesions.

Peritoneal malignant mesothelioma: Slippery like an eel to diagnose on cytology-case series of 3 cases

INTRODUCTION

Peritoneal malignant mesothelioma is an extremely rare tumor and is a difficult diagnosis to be made on cytology alone. We report 3 cases where the cytologic features were misdiagnosed as carcinoma/lymphoma but histopathology and immunohistochemistry (IHC) established the diagnosis of malignant mesothelioma.

CLINICAL DETAILS

Case 1 was a 60-year-old man with multiloculated ascites and omental caking. Peritoneal fluid was reported as malignant on cytology but was misclassified as adenocarcinoma. Case 2, a 45-year-old man with ascites and peritoneal nodularity, radiologically mimicking peritoneal carcinomatosis, was also reported positive for malignancy on ascitic fluid cytology. Fine-needle aspiration (FNAC) from omental fat revealed signet ring cells, thus misleading to cytologic diagnosis of adenocarcinoma. Case 3 was a 63-year-old man with perisplenic mass with extensive omental caking and peritoneal nodularity that was also suspected to be peritoneal carcinomatosis on radiology. FNAC smears from perisplenic mass showed sheets of plasmacytoid cells. On cytology, the differential diagnoses offered were neuroendocrine tumor or non-Hodgkin lymphoma. The diagnosis of malignant mesothelioma was established only after IHC on histopathologic sections in all these cases. None of our patients had history of prior asbestos exposure.

CONCLUSION

In such clinical scenarios, with radiology suggesting peritoneal carcinomatosis, the cytologic features need corroboration by IHC/fluorescence in situ hybridization on cell block or biopsy to correctly identify malignant mesothelioma and differentiate it from metastatic carcinomatous deposits and benign mesothelial proliferation.

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

Middle Meningeal Artery Embolization Using Combined Particle Embolization and n-BCA with the Dextrose 5% in Water Push Technique for Chronic Subdural Hematomas: A Prospective Safety and Feasibility Study

BACKGROUND AND PURPOSE

Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization.

MATERIALS AND METHODS

We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume.

RESULTS

A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post-middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume).

CONCLUSIONS

Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.

Molecular dynamics modeling of lithium ion intercalation induced change in the mechanical properties of LixMn2O4

The objective of this study is to understand the fracture mechanisms in the lithium manganese oxide (LiMn₂O₄) electrode at the molecular level by studying mechanical properties of the material at different values of the State of Charge (SOC) using the principles of molecular dynamics (MD). A 2 × 2 × 2 cubic structure of the LiMn₂O₄ unit cell containing eight lithium ions, eight trivalent manganese ions, eight tetravalent manganese ions, and 32 oxygen ions is studied using a large-scale atomic/molecular massively parallel simulator. As part of the model validation, the lattice parameter and volume changes of Li_xMn₂O₄ as a function of SOC (0 < x < 1) have been studied and validated with respect to the experimental data. This validated model has been used for a parametric study involving the SOC value, strain rate (charge and discharge rate), and temperature. The MD simulations suggest that the lattice constant varies from 8.042 Å to 8.235 Å during a full discharging cycle, in agreement with the experimental data. The material at higher SOC shows more ductile behavior compared to low SOC values. Furthermore, yield and ultimate stresses are less at lower SOC values except when SOC values are within 0.125 and 0.375, verifying the phase transformation theory in this range. The strain rate does not affect the fully intercalated material significantly but seems to influence the material properties of the partially charged electrode. Finally, a study of the effect of temperature suggests that diffusion coefficient values for both high and low-temperature zones follow an Arrhenius profile, and the results are successfully explained using the vacancy diffusion mechanism.

Traditional Indian practices: Time to revisit and re-adopt for a healthier lifestyle

The COVID-19 pandemic has affected human life significantly. In spite of significant advancement of medical technology, management is still focused on preventive strategies due to non availability of vaccine or any definitive treatment. The preventive strategies include hand hygiene, social distancing, isolation/quarantine along with the methods for boosting immunity. The ancient literature and several traditional practices of our country guide a hygienic life style and address several preventive aspects of transmission of infection across the society. Furthermore, healthy eating habits and use of various herbs and spices as regular food ingredients has been proven for boosting the immunity. In this review, we have tried to correlate the traditional practices with the available scientific evidences.

Predictors of dengue-related mortality in young adults in a tertiary care centre in North India

Background

Outbreaks of dengue fever cause widespread mortality. There is a paucity of studies on predictors of morbidity and mortality in dengue. This observational study was performed to study the factors predicting adverse outcomes caused due to dengue fever thereby optimally manage the patient's to reduce mortality.

Methods

The study included a 1-year retrospective and 1-year prospective period were clinical, laboratory and outcome data of patients between 18-30 years of age, having serology proven (NS1/dengue IgM) dengue fever were recorded and analysed.

Results

Out of 418 patients, 404 (96.64%) recovered and 14 (3.35%) expired, resulting in a 3.35% mortality rate. Platelet count did not determine the outcome in dengue patients. The shock factor was present in 45 (11.1%) patients who recovered and 10 out of 14 patients who expired (71.4%), P value was statistically significant. Mean value of SGOT and SGPT in dengue patients who expired were 2865.43 and 1510.07 IU/L, respectively, which were significantly higher than the mean values of SGOT and SGPT in those who survived. Bleeding was present in 39 (9.7%) patients who recovered. Out of the 14 expired patients, bleeding was present in 5 (35.7%) which is statistically significant. Hence, on multivariate logistics analysis, bleeding, a higher SGOT and SGPT value and shock were found to be significant risk factors for mortality in dengue fever patients.

Conclusion

Bleeding, shock and raised SGOT and SGPT levels were identified as predictors of adverse outcomes and mortality in dengue fever. Timely identification of these risk factors and active management is important to reduce dengue-related mortality.

Cerebrospinal fluid pleocytosis in immunocompromised patients: Can it be Cryptococcus

Cryptococcal meningitis commonly affects immunocompromised cases and can have varied presentation. In some instances, the presence of a plethora of inflammatory cells on cerebrospinal fluid (CSF) in an immunosuppressed patient can lead to further investigations, which unravel the presence of cryptococcal meningitis. The aim of this retrospective study was to analyze the spectrum of CSF findings of immunosuppressed patients who were diagnosed to have cryptococcal meningitis. Retrospective analysis of CSF cytospin slides exhibiting pleocytosis and belonging to immunocompromised patients was performed, and these cases were found to have cryptococcal meningitis. Out of 932 cases of CSF (January 2016-July 2017), 10 had pleocytosis and 5 of these 10 cases demonstrated spores of Cryptococcus. Male-to-female ratio was 1:1.5. All the patients were immunocompromised and had CSF leukocytosis. Lymphocytes and monocytes were present in all samples while only one case showed plasma cells. Spores of Cryptococcus were also noted in all the cases and highlighted on India Ink Preparation and Gomori Methenamine Silver stain. All the cases were positive for agglutination-based cryptococcal antigen assay, except one where the test was not done. All immunosuppressed patients having pleocytosis in CSF were found to have cryptococcal infection. Therefore, pleocytosis in CSF in any immunosuppressed patient should raise the suspicion of cryptococcal meningitis. The pathologist and the clinician need to be vigilant in such scenarios to rule out any opportunistic infection and investigate the patient thoroughly for any underlying immunosuppression.

Pulmonary Hydatid Disease with Aspergillosis - An Unusual Association in an Immunocompetent Host

Echinococcosis is a common cause of pulmonary cavities. Aspergillus fumigatus, a saprophytic fungus, can colonise pulmonary cavities caused by tuberculosis, sarcoidosis, echinococcosis, bronchiectasis and neoplasms. Infection by Aspergillus is often seen in immunosuppressed cases. However, co-infection of Aspergillus with pulmonary echinococcosis is unexpected and very unusual, especially in an immunocompetent patient. We present the case of a 45-year-old immunocompetent male who came with non-resolving pneumonia and fever for 8 months and dyspnoea since 15 days accompanied by recurrent episodes of hemoptysis since 5 days. Chest X Ray and Computed Tomography scan showed a cystic lesion in the middle lobe of the right lung. Middle lobectomy with video-assisted thoracoscopic surgery was performed and histopathology revealed ectocyst of Hydatid cyst which was also colonised by septate fungal hyphae exhibiting acute angled branching, morphologically consistent with Aspergillus. Gomori Methanamine Silver and Periodic Acid Schiff stains highlighted the hyphae of Aspergillus as well as the lamellated membranes of ectocyst and an occasional scolex of Echinococcus. Sections from surrounding lung parenchyma also showed these fungal hyphae within an occasional dilated bronchus. Thus a diagnosis of dual infection of Aspergillosis and Pulmonary Echinococcosis was established. The possibility of dual infection by a saprophytic fungus must be kept in mind while dealing with a case of a cavitary lesion in long-standing and non-resolving pneumonia, even in an immunocompetent patient. Establishing the correct diagnosis of Aspergillosis with Echinococcosis is essential for proper and complete management.

Feasibility of Masood's cytological index for screening breast lesions in low resource setting

Fine needle aspiration cytology has long been an accepted diagnostic modality in combination with physical examination and mammography to investigate breast lesions. In the present era, more proficient methods such as stereotactic mammographically guided breast biopsy is the preferred choice, however, in low resource setting, FNAC still remains the most cost effective and sampling modality to diagnose breast cancer. With the intention to evaluate the efficacy and limitations of FNAC in evaluation of breast lesions in low resource setting, we employed the Masood's cytological staging system to stratify the breast lesions and correlate them with histopathology wherever possible. All breast lesions aspirates were analyzed and classified according to the Masood's cytological scoring system and correlated with histopathological findings wherever adequate material was available. A total of 776 patients were studied of which 23 aspirates were unsatisfactory, 120 aspirates were categorized as inflammatory breast disease. Six hundred and thirty-three cases were classified according to Masood's cytological system. Nonproliferative breast diseases (Group I) encompassed maximum cases with 55% followed by carcinoma in situ and invasive cancers (Group IV) with 39% and proliferative breast disease without atypia (Group II) and with atypia (Group III) which had equal number of cases constituting 2.4% each. Cyto-histopathological correlation done in 102 cases revealed 100% concordance in group IV and 75% concordance in group III while it could not be performed in Group I and II as no histopathological specimen was available in those patients. Masood Cytological grading for breast aspirates is a reliable and an easily reproducible system which can be used to formulate appropriate treatment protocols in cases presenting with breast lesions.

Extensive tests for extermination: Need for incorporation of molecular detection methods of human immunodeficiency virus in screening algorithm in tertiary hospitals in India

Context:

A downward trend is being observed in the incidence of human immunodeficiency virus (HIV) infection in India due to strategic activities of National AIDS Control Organisation (NACO) in the last 24 years. Opt-out testing has consistently shown high seroprevalence in our tertiary care center.

Aim:

This study aims to audit opt-out testing and compare various commercial test kits used to detect HIV seroprevalence in patients in our tertiary care institute and suggest new algorithm for HIV testing in tertiary hospitals in India.

Materials and Methods:

Retrospective analysis of 30,021 samples tested in Department of Immunopathology using opt-out testing delinked from the NACO-sponsored testing for Integrated Counselling and Testing Centre (ICTC) was performed. Study population comprised of presurgery and emergency patients which at the time of our reporting were not included in ICTC testing.

Results:

Microlisa was the first test performed on 76% samples. 1.02% cases were reactive only with Microlisa and negative with other rapid kits hence were reported as negative, according to NACO scheme of reporting. Advanced testing algorithm followed by centre for disease control (CDC) showed that 80% of these 4^th-generation positive and rapid test-negative patients turned out to be acute HIV infections on molecular testing.

Conclusion:

Patients in tertiary referral center constitute high-risk population and should be screened with 4^th-generation enzyme-linked immunosorbent assay which incorporates p24 antigen. Those which are found indeterminate should have molecular testing by nucleic acid amplification test or real-time polymerase chain reaction, as our study has demonstrated that 1.02% of these cases may harbor acute HIV infection.

Morphological spectrum of atherosclerotic lesions in a tertiary care Institute in Punjab

Background: The incidence of coronary artery disease (CAD) has risen considerably in developing world due to industrialization, urbanisation and lifestyle changes, especially among Indians and South Asians. The onset of CAD has been seen to occur at an early age and the severity of the disease and mortality associated with CAD has also increased. The pathology of atherosclerosis needs to be re-evaluated to develop targeted therapy which can contain the disease process at the earliest stage. Aims and Objectives: Most of the morphological studies on atherosclerosis have been done on autopsy cases. In this study, we have analysed the morphological spectrum of atherosclerotic lesions in live patients. Materials and Methods:  We retrospectively analysed the histopathology slides of 85 cases whose endarterectomy plaques were received in the Department of Pathology over a period of three and half years (January 2014 to June 2017) and classified the lesions according to Modified American Heart Association classification of atherosclerosis. Results: The average age of patients was 60 years and male to female ratio of 4.3:1. Left anterior descending artery was the commonest vessel involved (52.4%). Majority of the cases had fibrocalcific plaques,followed by fibrous cap atheroma and calcified nodules. Conclusion: Coronary artery plaques were found even in patients less than 40 years old.  Aggressive lipid defense therapy needs to be the cornerstone of management of CAD.

Hepatic fine-needle aspiration cytology: The role of rapid on-site evaluation in the assessment of hepatic lesions

BACKGROUND/AIMS

Radiologically guided fine-needle aspiration cytology (FNAC) of internal organs is not cost-effective. Rapid on-site evaluation (ROSE) of smears by a cytopathologist can improve the diagnostic yield of FNACs and save time and money by reducing the need for repeat procedure/biopsy. To determine the role of ROSE in the diagnostic outcome of hepatic lesions by comparative analysis of FNAC with and without ROSE by a cytopathologist.

MATERIALS AND METHODS

Hepatic FNACs were retrospectively analyzed over two separate time periods from January 2011 to June 2013 and from January 2015 to July 2016. Smears from 2015-2016 were subjected to ROSE by a cytopathologist after staining with toluidine blue for 1 min to assess adequacy of the material. Final report was given after hematoxylin and eosin, May Grünwald Giemsa, and Papanicolaou staining were performed. Chi-square test (non-parametric) was used to determine if there was a statistically significant increase in the diagnostic yield with ROSE.

RESULTS

During 2011-2013, of the 160 radiologically guided FNACs for hepatic lesions, 22 were non-diagnostic, whereas during 2015-2016, of 142 radiologically guided hepatic FNACs, only six were non-diagnostic. With the application of ROSE, there was a statistically significant increase in the diagnostic yield of hepatic FNACs from 86.25% to 95.8% (p=0.015).

CONCLUSION

ROSE performed by a cytopathologist using toluidine blue can increase the diagnostic yield of hepatic FNACs and reduce the cost of healthcare by eliminating the need for a repeat procedure.

Entamoeba histolytica: A surprising coexistence with adenocarcinoma - Never brush aside brushings for biopsy

Entamoeba histolytica has been rarely reported as superadded infection over carcinomatous growth on rectal brushings. We present a case of 68-year-old male who presented with abdominal pain and bleeding per rectum who was found to have an ulceroproliferative growth on sigmoidoscopy. Rectal brushings revealed coexistence of E. histolytica with malignant cells of adenocarcinoma. No organism was detected on biopsy of the tumor, which also showed adenocarcinoma, because of possible surface colonization of the tumor by Entamoeba. This case highlights the role of rectal brushings in detecting superadded infection in a case where both brushings and biopsy were performed. It is always important to report infection superadded on malignancies for optimum management of the patients.

Role of FNA and Special Stains in Rapid Cytopathological Diagnosis of Pulmonary Nocardiosis

BACKGROUND

Nocardia, a gram-positive aerobic bacillus of the Actinomycetales family, is a significant opportunistic pathogen in immunocompromised individuals. Clinical and radiological features of pulmonary nocardiosis are nonspecific and can be misdiagnosed as tuberculosis, pneumocystis, staphylococcal or fungal infections, or as malignancy. Aspiration cytology with special stains is a quick and effective approach for accurate diagnosis.

MATERIALS AND METHODS

We present 7 cases of pulmonary nocardiosis, admitted to the pathology department in a tertiary-care hospital in Punjab. Clinical findings, immune status, laboratory tests, chest radiographs, and computed tomography scans were reviewed. Cytologically, special stains like 1% Ziehl-Neelsen (ZN), 20% ZN, periodic acid-Schiff (PAS), Grocott methenamine silver (GMS), and reticulin stains were studied along with May-Grünwald Giemsa, Papanicolaou, and hematoxylin and eosin.

RESULTS

All the patients were immunocompromised. The radiological changes were nonspecific. Cytomorphology showed acute and chronic inflammatory infiltrates with necrosis. None of the cases showed well-defined granulomas. GMS, modified 1% ZN and, Gordon and Sweet reticulin stains highlighted the delicate filamentous bacteria in all cases. PAS and 20% ZN stain for tuberculous bacilli were uniformly negative.

CONCLUSION

FNAC can provide a quick and accurate diagnosis of nocardiosis and thereby facilitate timely medical management.

Beware of Bone Marrow: Incidental Detection and Primary Diagnosis of Solid Tumours in Bone Marrow Aspiration and Biopsies; A Study of 22 Cases

BACKGROUND & OBJECTIVE

Introduction: First detection of any solid tumour as metastatic deposits in bone marrow directs clinicians to start searching for the primary tumour. Detection of bone marrow metastasis determines the stage of the malignancy, prognosis, mode of treatment, chemotherapeutic response and follow-up in case of relapse. The aim of the current study was to analyse the clinico-haematological presentation and morphological pattern of infiltration of solid tumours detected first as metastatic deposits on bone marrow examination.

METHODS

Three-year retrospective analysis of MGG-stained bone marrow aspiration smears and touch imprints of the bone marrow biopsy and Hematoxylin and Eosin (H&E) stained histopathological sections of biopsies was performed at the Department of Pathology at a tertiary care institute (January 2014 to December 2016). The morphological pattern of metastatic deposits and haematological profiles of the patients were analysed. Exclusion criterion was the presence of hematolymphoid malignancies.

RESULTS

In 22 cases, bone marrow was the first site of detection of metastasis. The age of the patients ranged from 3 years and 10 months to 82 years, with equal gender predilection. Overall, 16 cases had cytopenias, 9 cases each had leucocytosis and leukoerythroblastic presentation. The metastasis was from Ewing's sarcoma, prostate carcinoma, gastric adenocarcinoma invasive duct carcinoma breast, gallbladder carcinoma, lacrimal duct carcinoma and invasive papillary urothelial carcinoma.

CONCLUSIONS

Bone marrow examination is a cheap and reliable investigation to detect metastasis in an unsuspecting case. Bilateral trephine biopsies are recommended to increase the efficacy of detecting bone marrow metastasis.

Impact of SurePath® liquid-based preparation in cytological analysis of peritoneal washing in practice of gynecologic oncology

Context:

Peritoneal washing is performed for staging of gynecologic tumors to detect subclinical intraperitoneal metastases.

Aim:

The aim of the present study was to assess the impact of SurePath™ liquid-based cytology (LBC) in peritoneal washing in various gynecological malignancies.

Settings and Design:

An audit of peritoneal-fluid/washing (January 2012 to July 2013) was performed with corresponding gynecologic specimens. All peritoneal washings were processed using both conventional and LBC technique. Suspicious cases on cytology were reported along with gynecologic specimens.

Results:

There were a total of 393 peritoneal fluids. Eighty-three (21.1%) were positive for malignancy, and the corresponding histology was available in 352 (89.6%) cases. Sixty-nine positive samples had ovarian malignancies and 5 had uterine causes. There were 9 cases of peritoneal washings in which no histopathology was available. The most common cause of positive peritoneal cytology was ovarian serous carcinoma in 55/84 (65.5%) cases. Other causes included mucinous cystadenocarcinoma, dysgerminoma, squamous cell carcinoma in teratoma, yolk sac tumor, and granulosa cell tumor. Uterine causes included 2/45 (4.4%) cases of endometrioid adenocarcinoma, ¼ (25%) cases of clear cell carcinoma, ½ (50%) cases of carcinosarcoma, and ¼ (25%) cervix carcinoma. On review of positive cases (n = 83), 10 cases were identified, which had nil (n = 4) to low cellularity (<3 tumor clusters/smear; n = 6) on conventional smears, and were confirmed malignant on LBC.

Conclusions:

The most common ovarian malignancy causing positive peritoneal cytology is papillary serous carcinoma. Endometrioid adenocarcinoma rarely leads to positive peritoneal cytology. LBC technique leads to concentration of tumor cells causing reduction in false negative cases, especially in hemorrhagic and low-cellular cases.

Parotid or carotid? Misled by site

We present an interesting scenario where a 64 years old male presented with a long standing painless, infra-auricular swelling, which had progressively increased in size. Based on the site, the clinical impression was of a salivary gland lesion and FNAC was performed. The smears were unusually cellular and had necrotic background. The cytological diagnosis was a cystic neoplasm of salivary gland, possibly mucoepidermoid carcinoma. Warthin's tumor was also kept in differential. However, the radiological investigations, which were made available after the FNAC report were conflicting with cytological diagnosis of a malignancy and were characteristic of a carotid body tumor, generally a benign neoplasm. Surgical excision of the tumor with regional lymph node sampling was done and histopathological examination solved the puzzle by revealing metastasis of paraganglioma to right posterior triangle lymph nodes. This case is unique because of the unusual presentation of a malignant paraganglioma as an infra-auricular swelling, which was clinically considered as a parotid tumor. The clinician as well as the pathologist need to be aware of such diagnostic pitfall. Diagn. Cytopathol. 2017;45:569-573. © 2017 Wiley Periodicals, Inc.

Nodular Cystic Basal Cell Carcinoma of the Trunk: a Diagnostic Dilemma in an Unsuspecting Youth

Basal cell carcinoma (BCC) commonly affects the elderly and is mostly confined to the head and neck region. Only 10% of all cases occur on the trunk. We presented a case of bullous lesion on the abdomen in a young male, initially diagnosed by clinicians as a vascular nevus. Histopathological examination and immunohistochemistry (IHC) revealed it to be Nodular cystic variant of BCC. This rare variant of BCC morphologically resembles benign skin adnexal tumor of Eccrine syringofibroadenoma. Ber Ep4 positivity on IHC established the correct diagnosis. This case highlights that nodular cystic variant of BCC can be a diagnostic dilemma for clinicians and pathologists.

Cytohistological discordance on gastrointestinal brushings: Facts unfolded

Introduction:

Brush cytology is a rapid, cost-effective, and reliable tool to diagnose gastrointestinal tract (GIT) lesions in low-resource settings. Most of the studies on GIT brushings have focused on upper GI lesions. We have studied the diagnostic accuracy of brush cytology in the entire length of GIT and correlated the cytological diagnosis with histopathology. The aim of this study is to study diagnostic utility of brush cytology of GIT lesions in the context of correlation with biopsy and study the factors responsible for cytohistological discordance.

Materials and Methods:

A retrospective analysis of 101 cases of prebiopsy brush cytology samples of GIT lesions was done over a period of 1 year (June 2014 to May 2015). The cytological diagnosis was compared with histopathological diagnosis and percentage of correlation was calculated. The reasons for discordance were noted and studied.

Results:

The cytological diagnosis of 79 (78.2%) correlated with histopathological diagnosis. There was discordance in cytological and histological diagnosis in 22 cases (21.8%). Inadequacy of cytological sample and overlap of nuclear atypia caused by regenerative changes and malignancy were significant factors for cytohistological discordance.

Conclusion:

The diagnostic accuracy of brush cytology can be improved by taking appropriate measures to eliminate factors responsible for fallacies in cytological diagnosis.

Disseminated Histoplasmosis: A Fatal Opportunistic Infection in Disguise

Histoplasma capsulatum is no longer confined to certain geographic areas and should always be considered in the differential diagnosis of lymphadenopathy and organomegaly in HIV-positive patients. We present an unusual case of a 20-year-old immunocompromised male of African origin presenting with fever, jaundice, hepatosplenomegaly, and retroperitoneal and cervical lymphadenopathy. Fine needle aspiration (FNA) smears from the cervical lymph node revealed numerous yeast forms of histoplasma in macrophages. The patient succumbed to the fulminant infection. Postmortem liver biopsy also revealed infiltration by histoplasma, confirming the diagnosis of disseminated histoplasmosis. This case highlights the variable nature of the clinical presentation of disseminated histoplasmosis which can mimic tuberculosis, leishmaniasis, or lymphoma. FNA cytology is a rapid, cost-effective, and reliable diagnostic tool for early detection and prompt management of histoplasmosis.

Microstructural and Compositional Characterisation of Electronic Materials

<p class="p1"> </p><p class="p2"><span class="s1"> </span>Microstructural and compositional characterisation of electronic materials in support of the development of GaAs, GaN, and GaSb based multilayer device structures is described. Electron microscopy techniques employing nanometer and sub-nanometer scale imaging capability of structure and chemistry have been widely used to characterise various aspects of electronic and optoelectronic device structures such as InGaAs quantum dots, InGaAs pseudomorphic (pHEMT), and metamorphic (mHEMT) layers and the ohmic metallisation of GaAs and GaN high electron mobility transistors, nichrome thin film resistors, GaN heteroepitaxy on sapphire and silicon substrates, as well as InAs and GaN nanowires. They also established convergent beam electron diffraction techniques for determination of lattice distortions in III-V compound semiconductors, EBSD for crystalline misorientation studies of GaN epilayers and high-angle annular dark field techniques coupled with digital image analysis for the mapping of composition and strain in the nanometric layered structures. Also, <em>in-situ </em>SEM experiments were performed on ohmic metallisation of pHEMT device structures. The established electron microscopy expertise for electronic materials with demonstrated examples is presented.</p>

A Five-Year Study of Intrapleural Fibrinolytic Therapy in Loculated Pleural Collections

BACKGROUND

Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural ibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage.

OBJECTIVE

To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies.

METHODS

A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution.

RESULTS

There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases.

CONCLUSIONS

Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

Study of Self-Induced Growth of AlGaAs Nanoneedles on Silicon Substrates Using Metal Organic Chemical Vapor Deposition Technique

A simple catalyst free growth method was used for the growth of single crystalline AlGaAs nanoneedles on Si substrate by metal organic chemical vapor deposition (MOCVD) technique. The growth mechanism of catalyst free growth of nanoneedles was investigated. The effect of growth rate, growth temperature and V/III ratio was studied in detail. The growth of nanoneedles required a careful optimization of the growth conditions. The formation of well-faceted nanoneedles with hexagonal cross-section was found to be influenced by the growth parameters. Based on these studies, the growth mechanism has been explained using nucleation theory. The growth of nanoneedles was believed to proceed via Vapor-Solid (VS) growth mechanism after the initial AlGaAs cluster formation depending on the growth conditions.

Subcutaneous Axillary and Scalp Metastases from Non-Gynecological Retroperitoneal Leiomyosarcoma: An Unusual Presentation After Surgical Resection

Retroperitoneal leiomyosarcomas are rare sarcomas, with an incidence of less than 2 per million population. Cutaneous metastases from sarcoma account for only 1-2.6% of metastatic skin lesions. Cutaneous and subcutaneous metastasis from retroperitoneal leiomyosarcoma is a very rare entity. We present a case of 72-year-old male with scalp nodule and subcutaneous swelling in left posterior axillary fold. Fine needle aspiration cytology from both these sites revealed a sarcoma, which was positive for Smooth Muscle Actin and negative for S100 on cell block immuno-histochemistry (IHC). The past history revealed surgical resection of a retroperitoneal mass in 2010 which was diagnosed on histopathology and IHC as leiomyosarcoma. A final diagnosis of metastatic deposits from leiomyosarcoma was made. Retroperitoneal leiomyosarcoma presenting as scalp and subcutaneous metastasis is an unusual presentation. Adequate clinical history and a high index of clinical suspicion is required to detect cutaneous and subcutaneous metastatic deposits occurring five years after surgical resection.

Myeloid Sarcoma: An Unusual Case of Mediastinal Mass and Malignant Pleural Effusion with Review of Literature

Myeloid sarcoma is an extramedullary tumor seen most commonly in patients with acute myeloid leukemia and less frequently in chronic myeloid leukemia, myelodysplastic syndrome and rarely, in an isolated form without any other underlying malignancy. Malignant pleural effusion in hematological malignancies is rare when compared with solid tumors. We present an unusual case of myeloid sarcoma in which a mediastinal mass with pleural effusion was the initial presentation. A 27 year old gentleman presented with complaints of fever, chest pain and swelling in the anterior chest wall for 6 months. Examination revealed a lump measuring 5 × 5 cm on the left side of the chest wall. Hematological evaluation showed hemoglobin-14.2 g/dL, platelet count-233 × 10(9)/L, TLC-117 × 10(6)/L with normal differential counts. Contrast enhanced computerised tomography (CECT) confirmed the presence of a soft tissue mass in the superior mediastinum abutting against the chest wall. Core biopsy was suggestive of myeloid sarcoma and immunohistochemistry was positive for myeloperoxidase and negative for CD3, CD 20 and CD 23. Pleural fluid analysis showed the presence of malignant cells. Bone marrow examination did not show an excess of blasts. A final diagnosis of extramedullary myeloid sarcoma with malignant pleural effusion was made. The patient was given induction chemotherapy (3 + 7 regimen) with daunorubicin and cytosine arabinoside. Repeat CECT done on day 28 showed complete resolution of pleural effusion and significant reduction in the size of mediastinal mass. The patient has successfully completed three cycles of consolidation therapy following which there has been complete resolution of the mass. He remains asymptomatic on close follow up.

Prospective glioma grading using single-dose dynamic contrast-enhanced perfusion MRI

AIM

To evaluate the sensitivity and specificity of single-dose dynamic contrast-enhanced (DCE) perfusion magnetic resonance imaging (MRI) in prospective evaluation of glioma grading and to correlate the relative cerebral blood volume (rCBV) values with mitotic and ki-67 indexes obtained at histopathology.

MATERIALS AND METHODS

A total of 53 histologically proven patients with glioma were included in this study. DCE-MRI perfusion with a single dose of contrast medium was included in brain tumour protocol and prospective grading of glioma into low and high grade was done based on a previously reported rCBV cut-off value of 3. Tumours with rCBV ≥ 3 were considered to be high grade and rCBV < 3 were considered to be low grade. The sensitivity and specificity of the cut-off value were estimated. Ki-67 and mitotic indexes were also obtained on histopathological analysis along with histological grading.

RESULTS

Based on pre-defined rCBV cut-off values, prospective grading of low- and high-grade glioma was achieved with a sensitivity and specificity of 97.22% and 100%, respectively. Significant correlation was found between the mitotic/ki-67 indexes and rCBV values when data for high- and low-grade tumours was combined.

CONCLUSION

DCE-MRI performed with a single dose of contrast medium is as effective as a protocol with a double-dose of contrast medium for glioma grading using 3 T MRI and could be added to the routine evaluation protocol of brain tumours.

Diagnostic Utility of Biomarkers in COPD

BACKGROUND

COPD will become the third leading cause of death by 2020. There are many situations in which spirometry, the primary tool for diagnosis of COPD, cannot be performed, and thus, the staging and status of these patients cannot be determined. To date, there is no known biochemical marker used for diagnosing COPD. This study aimed to explore the utility of biomarkers for diagnosis of COPD.

METHODS

This was an observational study composed of 96 stable subjects with COPD and 96 subjects with normal lung function. Each group contained an equal number of smokers and nonsmokers. Serum levels of superoxide dismutase 3, glutathione peroxidase, catalase, ceruloplasmin ferroxidase activity, C-reactive protein, and surfactant protein D (SPD) were estimated. Ferroxidase activity was estimated by a kinetic method, whereas the other analytes were measured by enzyme-linked immunosorbent assay. The cutoff value, sensitivity and specificity at the cutoff value, and area under the curve for each analyte were determined from receiver operating characteristic curve.

RESULTS

Significantly decreased superoxide dismutase 3 and increased ferroxidase activity, SPD, glutathione peroxidase, and C-reactive protein levels were found in subjects with COPD. For all subjects and nonsmoking subjects with COPD, the area under the curve was highest for ferroxidase activity, followed by glutathione peroxidase, SPD, and C-reactive protein, with a sensitivity and specificity of > 73%. For smoking subjects with COPD, the area under the curve was highest for SPD, followed by glutathione peroxidase, ferroxidase activity, and C-reactive protein, with a sensitivity and specificity > 67%. Some combinations of markers were found to give either a sensitivity or specificity of > 95%, which can be utilized to rule in and rule out COPD.

CONCLUSIONS

Biomarkers can be reliably utilized in the diagnosis of COPD. Of all the markers, SPD appears to be the most promising in smokers, whereas ferroxidase activity shows promise in nonsmokers. To rule out COPD, ferroxidase activity or glutathione peroxidase can be potentially useful, whereas to rule in COPD, ferroxidase activity and glutathione peroxidase appear to be the most promising combination in both nonsmoking and smoking subjects.

Analysis of morphological markers of chromosomal instability in ascitic fluid

Chromosomal instability (CI) plays a major role in the carcinogenesis. Micronuclei, nuclear budding, chromatin bridges,and multipolar mitoses are the morphological markers of CI and have never been studied in routine cytological specimens. Aims of the study is to analyze the significance of morphological markers of CI in malignant and benign ascitic fluid smears. A total of sixty benign and 40 malignant ascitic fluid samples were selected for this study. All the cases with malignant ascitic fluid showed histopathological evidence of malignancy in ovary and omentum. Chromatin bridges, multipolar mitosis (MPM), micronuclei and nuclear budding were counted in 1000 cells in representative May Grunwald Giemsa (MGG) stained smears. The CI markers were correlated with the cytological diagnosis of effusion. The mean number of micronuclei, nuclear budding, chromatin bridge and multipolar mitoses found in malignant effusions were 13.2611.79, 10.1067.07, 2.5362.67, 1.964.5, respectively. The mean number of micronuclei, nuclear budding, anaphase bridges, and MPM found in benign effusion cases were 0.566761.07934, 0.516761.33, 0.66760.25, and 0, respectively. The student t test showed significant differences between malignant and benign ascitic fluid samples for each marker of CI. This is the first comprehensive study of morphological markers of CI in ascitic fluid smears. This study has shown strong correlation between markers of CI and cytological diagnosis of malignancy. In future, the knowledge of these markers can be applied to diagnose malignancy in suspected cases of effusion in difficult situations.

Bilateral sertoli-leydig cell tumor in a primigravida: a rare case

We present a unique case of incidentally discovered bilateral Sertoli Leydig cell tumour in a primigravida who displayed no features of virilization. The apha fetoprotein levels were elevated. Magnetic resonance imaging was suggestive of ovarian tumors, possibly germ cell tumor. Bilateral salpingo-oophorectomy was performed and histopathology showed features of Sertoli Leydig cell tumor with intermediate to poor differentiation. Immunohistochemistry was positive for calretinin and inhibin, while cytokeratin was negative. Four courses of bleomycin-, etoposide- and cisplatin-based chemotherapy regimen was started, but the patient aborted while receiving the second cycle of chemotherapy. She received the remaining two cycles of chemotherapy and is now on close follow up with monitoring of serum inhibin levels to detect any tumor recurrence. Bilateral Sertloli Leydig cell tumor has not been reported previously in a pregnant female. The aim of this article is to describe the clinical, radiological and pathological features and management of this rare entity.

Secretory meningioma: a diagnostic pitfall

CONTEXT

Secretory meningioma is a rare subtype of meningiomas, displaying epithelial and secretory differentiation of meningothelial cells. It has unique radiological, morphological, and immunohistochemical features, but runs a benign course. Radiological picture because of the variable degrees of peritumoral edema can be confused with aggressive neoplasms. Morphologically, it is difficult to distinguish secretory meningioma from other tumors having a clear cell appearance and aggressive clinical behavior.

MATERIALS AND METHODS

Retrospective analysis over a period of 16 years (1997-2012) brought out five cases diagnosed as secretory meningioma. The slides were restained and subject to special stains and immunohistochemistry and the clinical details were retrieved.

RESULTS

On histopathology, the tumors showed a characteristic vacuolated appearance due to the presence of variably sized intracytoplasmic lumina. Another unique feature was the presence of hyaline inclusions within these intracytoplasmic lumina and in the intercellular spaces. These inclusions were periodic acid-Schiff positive diastase-resistant, yellowish-orange on Elastic Van Giesson stain and strongly carcinoembryonic antigen positive.

CONCLUSION

Owing to its rarity and unique morphology secretory meningioma poses a diagnostic challenge to the pathologists. As this tumor follows a benign course, it is crucial to correctly diagnose this entity to avoid unnecessary over treatment.