Diagnostic accuracy of fine needle aspiration cytology in hepatic tumours

To determine the diagnostic accuracy of fine-needle aspiration cytology [FNAC] in liver masses to isolate malignant from benign tumours and hepatocellular carcinoma [HCC] from metastatic tumours. Cross-sectional, observational. Department of Histopathology, Combined Military Hospital, Peshawar, from June 2004 to June 2005. All the patients with liver masses confirmed by ultrasonography, irrespective of age and gender, were included. Patients with inflammatory lesions were excluded from the study. Selected patients underwent fine-needle aspiration under ultrasound guidance followed by needle biopsy. The cytological slides were stained by haematoxylin and eosin [H and E] stain, while Papanicolaous stain was employed in selective cases. Needle biopsy fragments were fixed in formalin followed by paraffin embedding and staining with H and E stain. Sensitivity and specificity of FNAC in the diagnosis of liver masses was determined using histological diagnosis on liver biopsy as gold standard. There were one hundred subjects. The mean age at presentation was 55 +/- 12 years with male to female ratio of 1.7:1. Cytological diagnosis in 19 cases was benign/non-neoplastic and 81 was malignant. Out of the latter, 49 [60.49%] were HCC and 32 [39.51%] were metastatic tumours on cytology. The overall sensitivity, specificity and accuracy of FNAC in the diagnosis of malignant lesions was 95.2%, 100% and 96% respectively using histological diagnosis on liver biopsy as gold standard. Sensitivity of FNAC to differentiate HCC from metastatic tumours in liver was 96% while specificity was 100% having a diagnostic accuracy of 97.5%. The discrepancy in cyto-histological comparison was mainly seen in well-differentiated and poorly-differentiated HCCs. FNAC of the liver masses is a simple, safe, accurate, economical screening test without significant morbidity that can be used to identify the vast majority of hepatic neoplasms of primary or metastatic nature with high sensitivity, specificity and diagnostic accuracy

Comparison of serum lipid profile in ishaemic and haemorrhagic stroke

To compare serum lipid profile between patients of ischaemic and haemorrhagic strokes. Cross sectional, comparative study. Military Hospital, Rawalpindi, from August 2004 to February 2005. Patients with diagnosis of stroke comprising 100 consecutive patients each of ischaemic and haemorrhagic strokes were included in the study while patients on lipid lowering therapy were excluded from study. To determine the subtype of stroke, clinical examination followed by CT scan of brain was done. A serum sample after 8 hours of overnight fasting was taken on the next day of admission for both groups of patients. Total serum cholesterol, triglycerides, LDL-cholesterol, VLDL-cholesterol and HDL-cholesterol was determined, using enzymatic colorimetric method. Statistical analysis was done by comparison of lipid profile in two subgroups, using proportion test for any significant difference. The mean age at presentation of patients with stroke was 64.2 +/- 12 years with a male to female ratio of 3.6:1. In 100 ischaemic stroke patients, raised serum total cholesterol was seen in 42, triglyceride in 04, LDL-cholesterol in 05 and VLDL-cholesterol in 07 patients. Serum HDL- cholesterol was below the normal reference in 31 cases. On the other hand, serum total cholesterol and triglycerides was raised in 05 patients each, LDL-cholesterol in 09 and VLDL-cholesterol in 03 patients of haemorrhagic stroke. Serum HDL-cholesterol was below normal in 04 patients of haemorrhagic stroke. On comparison, there were significantly greater number of patients with raised srum cholesterol and low HDL-cholesterol in ischaemic stroke than haemorrhagic stroke [p < 0.05]. No statistical significance was found on comparing serum values of ischaemic and haemorrhagic stroke for triglycerides, LDL-cholesterol and VLDL-cholesterol. Ischaemic stroke patients had high serum total cholesterol and lower HDL-cholesterol levels as compared to haemorrhagic stroke. High risk patients of stroke may be screened using srum lipid profile and further studies are suggested to evaluate the effect of lipid lowering therapy in terms of morbidity and mortality in ischaemic stroke patients

Allergic broncho-pulmonary aspergillosis presenting as flitting opacities on chest radiograph

Allergic broncho-pulmonary aspergillosis [ABPA] is hypersensitivity reaction to Aspergillus fumigatus in the bronchial tree of young asthmatic patients. A 28 years old female patient presented with one year history of fever with generalised body aches and pains and had already received treatment for pulmonary tuberculosis. Her chest radiograph showed flitting opacities in both lung fields with a TLC of 13.2 x10[9]/L having 25% eosinophils and ESR of 87 mm at first hour. Her serum IgE were markedly raised and CT scan of the chest showed dilated large and medium sized bronchi forming mucocoeles, finger in glove appearance and nodular shadowing in the lung parenchyma. Sputum also showed fungal hyphae by direct microscopy. All the findings were consistent with the diagnosis of ABPA, which responded to oral Itraconazole and Prednisolone. ABPA is a potentially destructive lung disease requiring high index of suspicion for an early diagnosis to prevent irreversible lung damage

Comparison of heat induced antigen retrieval techniques for immune-histochemical estrogen receptor expression in ductal carcinoma of breast in females

To compare immunohistochemical estrogen receptor expression on formalin-fixed, paraffin-embedded breast carcinoma tissue sections by using regular, extended microwave heating and pressure cooker technique for heat induced antigen retrieval. Quasi experimental study. Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from August 2006 to July 2007. The study was conducted on 40 cases of breast carcinoma diagnosed on histopathology and selected by convenience sampling. One section each of the tumour was separately subjected to regular microwave heating [10 minutes], extended microwave heating [20 minutes] and pressure cooker [heating for 2 minutes after reaching full pressure]. A nuclear staining of > 10% cells with moderate intensity was considered positive and frequency of ER expression by each technique was compared statistically. Sensitivity and specificity of the techniques was determined using pressure cooker technique as the gold standard for this study. Out of 40 cases, ER expression in 24 [60%] cases was seen by microwave regular heating [MRH] and in 30 [75%] cases by microwave extending heating [MEH] technique. Pressure cooker [PC] technique for antigen retrieval demonstrated 34 [85%] cases with ER expression. Out of 16 which were negative by MRH technique, 6 became positive by MEH while 10 became positive by PC. Statistically significant difference in ER expression by PC and MEH technique was seen in comparison to MRH with a p-value of < 0.05. Moreover, 4 cases which were negative by MEH technique turned positive for ER expression by PC. MRH and MEH had 100% specificity but sensitivity was 70.6% and 88.2% respectively taking PC technique as gold standard with diagnostic accuracy of MEH as 90% and MRH as 75%. Pressure cooker antigen retrieval technique is a better method than microwave heating. The increase in duration of heating improves the percentage of positive cells as well as intensity of ER immuno-staining which entitles breast cancer patient to benefit from ER positive treatment protocols which have better prognosis

Steroid hormone receptor association with prognostic markers in breast carcinoma in northern Pakistan

To determine steroid hormone receptor expression and their association with histological prognostic markers and biological profile in female breast carcinoma in Northern Pakistan. Cross sectional, observational. Department of Histopathology, Armed Forces institute of Pathology, Rawalpindi, from January 2004 to December 2007. Female patients belonging to Northern Pakistan with primary operable breast carcinoma were included in the study. Patient's age, microscopic tumour size, tumour grade, lymph node status and biological profile for Her-2/neu status were evaluated. Immunohistochemical expression for ER and PR was determined individually and conjointly for ER+PR+ and ER-PR- while their association with above prognostic markers was determined using the x[2] test for univariate analysis. Out of the 726 cases, there were 657 [90.4%] cases of infiltrating ductal carcinoma with mean age of 48 +/- 12 years and mean tumour size of 4.2 +/- 2.3 cm. Tumour was grade-Il in 65% and lymph node metastases in 71.5% cases with Her-2/neu+ in 28.1%. ER and PR expression was 74.6% and 68.3% respectively. Conjoint expression of ER+PR+ was 456 [62.8%], ER-PR- in 21.2%, ER+PR- in 86 [11.8%] and ER-PR+ in 30 [4.1%] cases. Individually, ER and PR showed positive association with age, lymph node metastasis, tumour grade and inverse association with Her-2/neu. Conjoint expression of ER+PR+ [62.8%] and ER-PR-[21.2%] showed positive association with age, tumour grade, lymph node metastasis and inverse association with Her-2/neu [p < 0.05]. Hormone receptor expression of ER and PR expression is comparable to the West with ER and PR showing inverse association with Her-2/neu and positive association with age, tumour grade and lymph node metastases

Age related association of her-2/neu with prognostic markers in female breast carcinoma

To determine age-related association of Her-2/neu expression with histological and immunohistochemical prognostic markers in female breast carcinoma. Cross sectional, observational study. Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from January 2004 to December 2007. Patients of primary operable female breast carcinoma were categorised as <40 years [pre-menopausal], 41-50 years [pen-menopausal] and > 50 years [post-menopausal] age groups. Histological type, tumour size, tumour grade and lymph node status were determined while estrogen receptor [ER], progesterone receptor [PR] and Her-2/neu expression were evaluated immunohistochemically. Association of Her-2fneu with histological and immnuohistochemical prognostic markers was determined in pre-menopausal, pen-menopausal and post- menopausal age groups using the x[2] test for uni- and multivariate analysis. Out of the 722 patients, 230 [31.9%] were in pre-menopuasal, 221 [30.6%] in pen-menopausal and 271 [37.5%] in post-menopausal age group. Infiltrating ductal carcinoma was the pre-dominant subtype in all the age groups. Mean tumour size was 4.3 +/- 2.3 cm [range 0.4-17 cm] and lymph node metastasis was seen in 310 [70.8%] cases. Her-2/neu showed association with ER in the all the age groups while PR only showed association in the pen-menopausal and postmenopausal women. Her-2/neu showed no association with tumour size, tumor grade and lymph node metastases in pre-menopausal and pen-menopausal women while it showed positive association with tumour size and lymph node metastasis in the post-menopausal women [p <0.05]. Majority [62%] patients were under 50 years as against the Western epidemiology. Association of Her-2/neu with ER, PR, tumour size and lymph node metastasis was age related as pre-menopausal, pen-menopausal and post-menopausal had variable expression of these prognostic markers with therapeutic and prognostic implications

To compare the relapse rate of artesunate with tetracycline and quinine with tetracycline in uncomplicated falciparum malaria

To determine the relapse rate of falciparum malaria treated with artesunate plus tetracycline [AT] versus quinine plus tetracycline [QT] in uncomplicated patients of malaria. A cross sectional comparative study was carried out at Combined Military Hospital, Quetta from 01 May to 30 November 2006. Ninety patients of age-sex matched group with uncomplicated falciparum malaria having parasitemia >1%, age between 14-65 yrs, either sex and with no previous malaria treatment related to the present attack were recruited from emergency department, medical wards, included in the study. One group was given quinine along with tetracycline [QT] and the other group was given artemesinin and tetracycline [AT]. The patient was discharged from the hospital when three negative blood smears were obtained. Thereafter, blood smears were taken at days 7, 14, 21 and 28 after the start of the treatment, as outdoor patients. Parasitological response was regarded as radical cure with parasite clearance by day 7 without recrudescence up to day 28. Fever and parasite clearance times were noted as the time from the initiation of treatment to the first of three consecutive normal axillary temperature readings [<37°C] or negative blood peripheral film slides, respectively. Out of 90 patients of falciparum malaria, treatment was completed in 85 patients. The cure rates using treatment with AT was effective in 35 of 45 [77.7%] while QT was effective in 34 of 45 [75.5%] of the patients without any statistically significant difference [p = 0.68]. Poor compliance with the treatment schedule was observed in 2 of 45 [4.4%] in the AT group and 4 of 45 [8.8%] QT group of patients. Cure rates of 95.5% and 91.1% would have been obtained in the AT and QT groups if only compliant patients [n = 69] were considered. Parasitemia at day two cleared faster in the AT group than the QT group [91.1% versus 44.4%, respectively; p-value <0.001]. Combination of artesunate plus tetracycline is effective in the treatment of uncomplicated falciparum malaria and may provide a useful alternative to other treatment regimens

Cytomorphological spectrum of neurosurgical lesions by crush smears cytology

To study the cyto-pathological appearance of intraoperative crush smears of neurosurgical biopsies after subsequent comparison with paraffin sections. Place and duration of study: The study was conducted at Armed Forces Institute of Pathology, Rawalpindi, for one year from February 2002 to February 2003. One hundred, neurosurgical biopsies were received for intraoperative consultation over a period of one year. Clinical information like age, gender, history, and CT scan or MRI findings were recorded. Crush smears were prepared, fixed in 95% alcohol and stained with rapid haematoxylin and eosin stains. Diagnosis was categorised into inflammatory, benign and malignant tumours considering the cyto-pathological features. Remaining tissue was fixed overnight in 10% formalin for histological sections. Permanent Haematoxylin and Eosin [H and E] sections were used as the "gold standard" for comparison. Out of 100 neurosurgical biopsies, crush smears of 94 were considered suitable for interpretation. The smears were categorised as, 8 inflammatory, 41 benign and 41 malignant tumours. Four cases were labelled as inconclusive. Eighty four of the crush smears diagnosis agreed with the histological diagnosis, cyto-morphology of the lesions on crush smear is discussed. Crush smears are useful in the intraoperative diagnosis of space occupying lesions of central nervous system as majority of the cases have typical diagnostic yield and cyto-morphology. We found crush smear cytology highly reliable, rapid and inexpensive mode of intraoperative diagnosis

Clinico-pathological profile and outcome of inhalational burns

To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. Case-series. The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area [TBSA] involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickess skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. There were 19 patients of inhalational burns, 8 [42%] of whom expired. The mean percentage of TBSA in 11 surviving patients was 50 +/- 10.87 and 70 +/- 15.46 in fatal cases. The mean haemoglobin [Hb] on admission was 15.8 +/- 1.6 g/dL and after fluid resuscitation it became 11.4 +/- 1.5 g/dL. The mean Total Leucocyte Count [TLC] in surviving patients was 9.6 +/- 6.1x10[9]/L and 1.5 +/- 2.3x10[9]/L in fatal cases [p=0.001]. The mean platelet count of surviving patients was 205 +/- 63x10[12]/L while in fatal cases was 58 +/- 48x10[12]/L [p=0.05]. The serum urea levels in surviving patients was 4.3 +/- 2 mmol/L while in fatal cases was 8.6 +/- 0.9 mmol/L [p=0.05]. The serum creatinine levels were 98.2 +/- 16.5 micro mol/L in the survivor group and 249.5 +/- 76 micro mol/L in the mortality group [p=0.05]. The serum total protein in surviving patients was 63 +/- 8 g/dL while in mortality cases it was 57 +/- 7 g/L. Serum albumin in the survivor group was 36.7 +/- 5 g/L and 35 +/- 4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival

Primary perisplenic hydatid cyst

Splenic parasitic cysts due to flat worm Ecbinococi resuling in hydatid disease are a rare presentation as primary site even in the endemic regions. Primary splenic parasitic cysts have an incidence of 0.5-4%. A 21-year-old male with pet dogs at home, presented with 3 months history of gradually increasing discomfort in the left hypochondrium and tender splenomegaly. He had marked eosinophilia with normal liver function tests and positive serum IgM Echinococcus antibodies. Ultrasonography showed a cyst in the hilar region of spleen having septations with internal echos. An upper midline laparotomy was performed and a perisplenic cyst was removed along with spleen from the sub-diaphragmatic location. Histopathological examination confirmed acellular fibrous wall of hydatid cyst with germinal layer and scolices in the centre. Postoperatively, patient was continued on oral Albendazole for one month

Ruptured ovarian teratoma presenting as peritonitis

A 55-year-old lady reported to the surgical OPD with clinical findings of acute peritonitis. Emergency laparotomy was performed. The peritoneal cavity was full of purulent material, however, the gut was normal. An 8 x 6 cm thick walled cyst was found in the left ovary with a minute perforation and purulent fluid coming out of it. Thorough peritoneal lavage along with left oophorectomy was performed. The postoperative recovery was smooth. Histopathology confirmed benign cystic teratoma of ovary

Morphological profile and association of HER-2/Neu with prognostic markers in breast carcinoma in northern Pakistan

To determine the morphological profile and association of HER-2/neu expression with histological prognostic markers and hormonal receptor expression in female breast carcinoma in Northern Pakistan. Cross-sectional, observational study. Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from January 2004 to May 2007. A total of 535 patients of primary operable female breast carcinoma with hormonal profile and biological status were included in the study. Patient`s age, microscopic tumour size, tumour grade, lymph node status, Estrogen Receptor [ER], Progesterone Receptor [PR] and joint ER/PR status were evaluated and their association was determined with HER-2/neu expression using the x2 test for univariate analysis. Out of 535 cases, there were 481 [89.9%] cases of infiltrating ductal carcinoma with mean age of 48 years and mean tumour size of 4.4 cm. Tumour grade II was seen in 68% cases and lymph node metastases were present in 65% cases. HER-2/neu expression was seen in 31% cases, while ER and PR expression was seen in 72.3% and 62.6% respectively. ER and PR showed inverse association with HER-2/neu while positive association was seen with lymph node metastases [p < 0.05]. No association was seen between tumour size and tumour grade. Joint ER and PR expression also showed a higher number [73.5%] of HER-2/neu negative cases. HER-2/neu, ER and PR expression is comparable to the West with inverse association with ER and PR and positive association with lymph node metastases. Since HER-2/neu expression is variable in carcinomas with different tumour characteristics, it is not possible to predict hormone receptor expression in all the cases

Acute acalculous perforated cholecystitis

A case of acute acalculous perforated cholecystitis with acute generalized peritonitis in a middle aged cachectic man, presenting late in a moribund condition, is reported. He underwent emergency laparotomy [subtotal cholecystectomy], went into multi-organ failure and was managed accordingly. The patient recovered in about 2 weeks and was followed-up regularly

Second opinion in pathology of lymphoid lesions- an audit

Errors in medical practice remain under intense scrutiny because of their human costs in terms of disability and suffering. Second opinion in histopathology is a safeguard against misdiagnosis before instituting major therapeutic endeavor. Lymphoid lesions are peculiar for their diagnostic evaluation as they require ancillary techniques and expertise in most cases. This review was undertaken to assess the magnitude of diagnostic discrepancies in lymph node lesions of surgical pathology. Forty cases of lymph node lesions initially reported from different centres and referred for second opinion during the year 2005 were included in the study. Special stains and immunohistochemistry were applied and initial diagnosis was compared with the review diagnosis. The discrepancies were divided into different categories keeping in view the implications on patient management. Of the 40 cases included in the study, there was agreement with the initial diagnosis on review in 11 cases. There was discrepancy between the initial and review diagnosis in 29 cases. Review is a sensitive and effective method for quality control and to identify areas of disagreement. Mandatory second opinion is a good policy in patient management where crucial therapeutic decisions are involved. It is highly suggested in cases where the histpathologist initially reporting the case does not have requisite ancillary techniques like immunohistochemistry

Biphasic synovial sarcoma of oral cavity

Synovial sarcoma is a mesenchymal spindle cell tumour, which is unrelated to synovium and shows variable epithelial differentiation. Typically, synovial sarcoma arises in the soft tissues of the extremities but cases in the head and neck region are less common and oral cavity involvement is extremely rare. A 17-year-old girl presented with a gradually increasing swelling on the right cheek for 2 years, which on biopsy, revealed a biphasic tumour comprising fascicles of spindle shaped cells with gland formation by epithelial cells and scattered masts cells. Histological diagnosis of biphasic synovial sarcoma was confirmed on immunohistochemistry by strong positivity for EMA, S-100 and CD-99 in both epithelial as well as spindle cell areas

Retroperitoneal masses: different clinical scenarios

We present two cases of retroperitoneal masses with different presentations and outcomes. The first case was a 22 years old primigravida lady who underwent emergency caesarean section for preterm premature rupture of membranes with breach. On the operating table, a large retroperitoneal mass was identified and the biopsy confirmed Burkitt's lymphoma. Post operative chemotherapy did not have a favourable result and the patient had a fatal outcome. The other case was a 15 years old boy who had a progressively increasing retroperitoneal mass. Exploratory laparotomy revealed a hard, fixed, unresectable tumour extending into the mesentery of the small gut, biopsies were taken which showed tuberculosis. Post operative antituberculosis treatment had a marked response and the tumour disappeared after 6 months

Paroxysmal nocturnal hemoglobinuria

Paroxysmal Nocturnal Hemoglobinuria [PNH] literally means to have episodes of hemoglobin in the urine during the night. It is a Coomb's negative rare hemolytic disorder characterized by non-malignant clonal expansion of haemopoietic stem cells due to acquired genetic mutations. A 30 years old male patient presented with 5 years history of transfusion dependent anemia with intermittent episodes of passing dark colored urine in the morning. Blood complete picture showed decreased hemoglobin and reticulocytosis upto 30%. Coomb's test was negative with unconjugated hyperbilirubinemia and markedly raised serum LDH. Urine analysis showed marked hemosiderinuria and flow cytometry revealed 60% RBCs deficient for CD-59, confirming the diagnosis of paroxysmal nocturnal hemoglobinuria. The management of the patient depends on whether anemia is due to hemolysis or as consequence of impaired erythropoiesis. Corticosteroids at a dose of 0.25-1 mg/kg/day was selected as it is amongst the various treatment options in patients with predominant hemolysis