Effectiveness of vascular markers [immunohistochemical stains] in soft tissue sarcomas

Objective: To ascertain the effectiveness of IHC markers of vascular origin like CD31, CD34, FLI1 and ERG in vascular soft tissue sarcomas including angiosarcomas, Kaposi sarcomas, epithelioid hemangioendothelioma and a non-vascular soft tissue sarcoma [Epithelioid sarcoma]. Study Design: Descriptive study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from 2011 to 2017

Methodology: Diagnosed cases of angiosarcomas [n=48], epithelioid hemangioendothelioma [n=9], Kaposi sarcoma [n=9] and epithelioid sarcoma [n=20] were selected. Immunohistochemical staining as performed on formalin fixed paraffin embedded sections. The sections were stained for the following markers: CD34 [VENTANA clone Q Bend 10], CD31 [Leica clone 1 A 10], FLI1 [CELL MARQUE clone MRQ-1] and ERG [CELL MARQUE clone EP111]

Results: A complete panel of CD34, CD31 and ERG was applied on 8/48 cases of angiosarcomas with triple positivity in 6 cases. Eight cases showed positivity for only CD31 and ERG and 2 cases showed positivity for only ERG. A complete panel of CD34, CD31 and ERG was applied on 3/9 cases of epithelioid hemangioendothelioma with positivity for all markers in 2 cases. Combined positivity for ERG and CD34 was seen in 2 cases and on 4 cases only CD31 immunohistochemical was solely applied with 100% positivity. FLI1 was not applied on any case. Among 9 cases of Kaposi sarcoma, ERG, CD34 and CD31 in combination were applied on only 1 case with triple positivity. Remaining cases show positivity for either CD34, CD31 or FLI1. Majority of cases of epithelioid sarcomas were diagnosed on the basis of cytokeratin and CD34 positivity with loss of INI1. The other vascular markers showed negativity in all cases

Conclusion: Among these four markers, ERG immunohistochemical stain is highly effective for endothelial differentiation due to its specific nuclear staining pattern in normal blood vessel endothelial cells [internal control] as well as neoplastic cells of vascular tumors and lack of background staining

Clinicopathological study of solid pseudopapillary tumor of pancreas

Objective: To study the morphological and immunohistochemical features of solid pseudopapillary tumor of pancreas. Study Design: Retrospective study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital and Research Centre from Jun 2016 to Mar 2017

Material and Methods: Sixty-four patients [n=64] including 61 females and 3 males with pathological diagnosis of solid pseudopapillary tumor were selected from archives of Shaukat Khanum Memorial Cancer Hospital and Research Center for the period of 2000-2017. For the sample selected, their morphological features and immunohistochemical profile were reviewed and analyzed. The morphological features are considered as gold standard for the diagnosis

Results: The mean age was 33 years [range 8-50 years]. Immunohistochemical stains were performed on formalin fixed paraffin embedded section of 55 cases. Pancytokeratin was performed on 8 cases, out of which only 2 cases showed positivity. CD10 was performed on 14 cases, out of which only 12 cases showed positivity. Neuron specific enolase [NSE], CD56, vimentin, progesterone receptor [PR] and beta catenin were performed on 8, 5, 3, 13 and 16 cases respectively and showed positivity in majority of cases. Neuroendocrine markers [chromogranin and synaptophysin] were performed on 25 and 6 cases, from which it showed weak positivity in 3 cases. CD99 was performed on 19 cases and showed characteristic dot like staining

Conclusion: Among the immunohistochemical stains, CD99 had a specific dot like staining pattern and was used as a first line marker in diagnosis

Correlation of histological risk assessment/ scoring system with lymph node metastasis and recurrence/progression of diases in oral squamous cell carcinoma

To correlate the scoring system using histopathologic parameters; worst pattern of invasion [WPOI], lymphocytic host response [LHR] and peri-neural invasion [PNI], with disease recurrence, overall survival and cervical lymph node metastasis in OSCC patients. Study Design: Cross sectional. Department of Histopathology, Shaukat Khanam Memorial Cancer and Research Hospital, Lahore in collaboration with Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. Study completed in 2 years. A "Risk Scoring system" was applied to 50 cases of OSCC with 2 years follow-up data, based on histopathologic parameters WPOI, LHR and PNI. The cases were divided into High risk and Non- High risk categories according to the specified parameters and then correlated with disease recurrence, overall survival and cervical lymph node metastasis. Results: There were 7 low risk, 17 intermediate risk and 26 high risk cases. No correlation was seen between the risk groups and disease recurrence, overall survival or cervical lymph node metastasis. However, when assessing the individual parameters, significant correlation was observed between PNI with disease recurrence [p = 0.03], and between WPOI and overall survival [p = 0.02] and cervical lymph node metastasis [p = 0.005]. The individual parameters, peri-neural invasion and worst pattern of invasion are observed to be significant prognostic indicators in OSCC patients. A study with a larger number of cases is required to truly assess the value of the scoring system in Pakistani patients

Paraffin-based immunohistochemistry in the evaluation of glomerular diseases in renal biopsies

To determine sensitivity and specificity of paraffin-based immunohistochemistry in the evaluation of glomerular diseases in renal biopsies using immunofluorescence as gold standard. Cross-sectional analytical study. Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from August 2008 to August 2009. Seventy renal biopsy specimens fulfilling the inclusion criteria for light microscopy and immunofluorescence during the study period were evaluated. Antibodies to immunoglobulins [IgG, IgA, and IgM] and components of complement system [C3] were applied on 70 formalin-fixed paraffin-embedded renal biopsy specimens previously classified by means of light microscopy and immunofluorescence [IF]. Staining for these antibodies was recorded as positive and negative for immunohistochemistry [IHC] and IF in paired proportions presuming IF as gold standard test. The sensitivity, specificity, positive predicitive value and negative predicitive value of individual antibody were calculated. Of 70 patients, mean age was 33 +/- 18 years ranging from 2 to 80 years. Forty five [64%] were males and 25 [36%] were females. The sensitivity, specificity and predictive values of individual antibodies to IgG, IgA, IgM and C3 were very low and generally in the range of 40 - 60%. The sensitivity, specificity and predictive values of immunohistochemistry on formalin-fixed paraffinembedded renal biopsy specimens were very low and therefore, not suitable for evaluation of renal biopsies in currentcircumstances

Morphological characterization of renal tumours according to decades of life: experience at AFIP Rawalpindi, Pakistan

To evaluate morphological characterization of renal tumours according to decades of life and to compare it with other national and international studies. Descriptive study Place and duration of study: The retrospective study was carried out in the Department of Histopathology, Armed Forces Institute of Pathology [AFIP] Rawalpindi during the years 2005 to 2008. Data of 236 nephrectomy specimens diagnosed as renal tumours during the years 2005 to 2008 was retrieved from tumour registry of AFIP, Rawalpindi. The morphological characterization of these tumours according to decades of life was done and compared with the international data. Of 236 cases of renal tumours, 169 [72%] were males and 67 [28%] were females. The mean age of the patients was 50 years [SD=18.5] ranging from 1 to 80 years. The most common histological diagnosis in adults was conventional renal cell carcinoma in 172 [73%] patients followed by papillary renal cell carcinoma in 20 [8.5%] patients. Among children Wilm's tumour was the most common in 21 [9%] of patients. Conventional renal cell carcinoma was most commonly diagnosed in the patients aged between 51 to 60 years [52 cases] where as 17 out of 21cases of Wilm's tumour were diagnosed in the age group of 1 to 10 years. Renal cell tumours are diagnosed in all ages. Conventional renal cell carcinoma and papillary renal cell carcinoma are the most common types in non pediatric age group whereas Wilm's tumor is most common type in pediatric age group. The chromophobe renal cell carcinoma was very rare in our study. Males had a greater incidence as compared to females and incidence of renal tumours has the trend of increase over the years

Gunshot wounds - autopsy findings at AFIP Rawalpindi

To provide information about details of firearm injuries as observed during autopsies performed at the Department of Histopathology AFIP, Rawalpindi, Pakistan. This was a descriptive study. A total of 300 autopsies carried out during the years [Sep 2005 - Dec 2008] were retrieved from the autopsy record of Armed Forces Institute of Pathology, Rawalpindi. Out of these, 28 autopsies were performed after death due to firearm injuries. The variables selected were: age of deceased, time of death, weapon used, number and site of entry and exit wounds, mode of death and distance of the used firearm from the body at the time of gunshot as indicated in circumstantial evidence. Out of total of 300 autopsies, 28[9.33%] died of gunshot injuries. Most deaths occurred in the 3[rd] decade [67.9%]. Most of the subjects had single [60.7%] entry wound while half had a single [50%] exit wound. Most of the entry wounds [60.7%] had diameter < 2cm and exit wounds [35.7%] had a maximum diameter in the range of 2-5cm. Most frequent used weapon was rifle [82.1%]. Anterior chest [n=12] [42.9%] sustained the highest number of injuries. In suicidal deaths, heart and left lung [n= 4] [57.14%] were most commonly hit anatomical site. The weapon was in contact with the body at the time of gunshot in all suicidal deaths. The distance was less than ten meters in accidental deaths [7.1%]. Out of 6 [21.4%] homicidal deaths, distance was in the range of 100-200 meters in 3[50%] cases and 300-400 meters in remaining 3[50%] cases. Mode of death [suicidal/homicidal/accidental] could not be determined on postmortem examination only. Circumstantial evidence was necessary in the assistance of these findings. All details of firearm wounds including site, size, shape and appearance of surrounding tissue are required to be documented in autopsy reports to ascertain the exit and entry wounds. The detailed description of wounds provided additional information to ascertain possible distance of weapon from body and help in confirming mode of death

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

Endometrial biopsy findings in infertile patients

To evaluate the etiopathological factors in infertile patients, detectable on endometrial biopsy. A total number of 100 endometrial biopsies were studied which were obtained from the patients undergoing investigations for infertility over a period of two years from Jan 2003 - Dec 2004, at Histopathology department Combined Military Hospital Sialkot, to find out the cause of infertility in these cases. All these patients were in fertile age group and were between 25 - 35 years of age. All of these biopsies were taken in premenstrual phase. The most common finding was late secretory endometrium [40%] which was consistent with the phase at which the biopsy was taken. Proliferative endometrium indicating anovulatory cycles was noted in 25% cases. Among the pathological findings, the most common was chronic non specific endometritis [15%] followed by endometrial hyperplasia [8%], chronic granulomatous endometritis of tuberculous etiology [5%] and endometrial polyp [3%]. 4% of the biopsies showed mid secretory endometrium which was also out of phase for the time at which biopsy was taken. Although endometrial biopsy is not the only diagnostic tool in women having infertility, however the confirmation of hormonal changes consistent with ovulation can be very helpful in management of these patients. The presence of out of phase endometrium and other endometrial patterns may direct the physician toward appropriate therapy. In addition, the therapy can be directed according to a specific etiology, if detected

Clinicopathological evaluation of nasal biopsy specimens- and afip experience

To evaluate the presence and frequency of clinically significant microscopic diagnosis in cases under going nasal polypectomy/biopsy. Cases of nasal polypectomy/biopsy reported from department of histopathology during last five years [2004-2008] were retrieved from records and evaluated microscopically for detailed histological diagnosis. A total of 383 cases were reviewed. Most frequent age was 5[th] decade. Nasal polepectomy comprised 54.73% [n=214]. Nasal Biopsy not otherwise specified comprised 21.99% [n=86]. Suspicious of growth was indicated in 23.27% [n=84] cases. Among all types of biopsy, 60.04% [n=230] were inflammatory nasal polyps, 10.44% [n=40] malignant neoplasm, 5.48% [n=21] were inverted papilloma. Rest of the cases [24.03%] showed benign inflammatory changes and benign neoplastic lesions. Although frequency of neoplastic lesion in routine polypectomy specimen as mentioned in literature is low. Our study reveals significant number of malignant cases. Considering the prognostic significant of early histological diagnosis and appropriate post considered essential. Large scale studies are required to evaluate clinicopathological correction of nasal biopsy specimens in our setup

Case report co-existing endometrial stromal sarcoma and leiomyoma-uterus - a case report

Leiomyoma of the uterus is an extremely common neoplasm with overall incidence of 4-11% and nearly 40% in women over the age of 50 yrs [1]. Endometrial stromal tumors tend to occur in middle aged women with average age of 45 years. Endometrial stromal sarcomas constitute about 10-15% of uterine malignancies with mesenchymal component [2]. Combined smooth muscle-stromal tumor is a rare entity and it is also called as stromomyoma in old literature [3]. We labeled our case as CO-EXISTING ENDOMETRIAL STROMAL SARCOMA [ESS] AND LEIOMYOMA-UTERUS PRESENTING AS SEPARATE MASSES which is different from combined smooth muscle-stromal tumor as evident from discussion below

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

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

Malignant tumors of the minor salivary glands in northern Pakistan: a clinicopathological study

Malignant tumors of the minor salivary glands comprise a small but significant proportion of oral cancers. We analyzed this group of tumors in our population. The records of all cases of malignant minor salivary gland tumors diagnosed at the Armed Forces Institute of Pathology [AFIP], Rawalpindi, Pakistan, during a period of 10 years [1994-2003] are described. The institute receives biopsy material from armed forces and public and private sector hospitals in northern Pakistan as well as referrals for second opinion. A total of 21168 tumors were recorded at the AFIP Tumor Registry during the study period. These included 70 malignant minor salivary gland tumors. Twenty-three of these [32.8%] arose in the palate while the remaining tumors originated at other sites in the oral cavity. The commonest histological type was adenoid cystic carcinoma, constituting 30 cases [42.8%]. The next most common type was mucoepidermoid carcinoma; comprising 26 [37.1%] cases. The mean age of cases was 43.4 years and the male-to-female ratio was 1:1.4 There were 2 cases each of polymorphous low-grade adenocarcinoma and clear cell adenocarcinoma. The remaining cases included undifferentiated carcinomas, adenocarcinomas [not otherwise specified] and a few other rare tumors. Adenoid cystic carcinoma was the commonest malignant neoplasm of the minor salivary gland followed by mucoepidermoid carcinoma. The palate was the commonest location of these tumors

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

Ossifying fibromyxoid tumor of oral cavity

Ossifying fibromyxoid tumor is a rare tumor of mesenchymal origin with varied presentation at different sites including head and neck. Clinically these are slow growing lesions and patients have a variable age at presentation. A 14 years old girl presented with a slowly enlarging gingival swelling, which on radiological examination showed increased rarefaction in the mandible with a provisional diagnosis of an inflammatory lesion. Microscopically, the tumor had spindle to oval shaped cells in a fibromyxoid background with a peripheral shell of lamellar bone. Histological diagnosis of ossifying fibromyxoid tumor was made after immunohistochemical stains for vimentin and S-100 protein. Recurrence, metastasis and histologically increased mitotic count are indicative of atypical or malignant ossifying fibromyxoid tumors

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