Frequency of IgA nephropathy presenting at a tertiary care hospital in Pakistan

Objective: to determine the frequency of IgA nephropathy presenting at a tertiary care hospital

Study Design: a cross sectional, observational study

Place and Duration of Study: Pakistan Institute of Medical Sciences, Islamabad and Shifa International Hospital, Islamabad, Pakistan, from November 2008 to November 2014

Methodology: this was a retrospective analysis of renal biopsies for the diagnosis of nephropathy during the study period. Biopsies were stained with fluorescence isothyocyanate [FITC] labelled antibodies against IgG, IgA, IgM, C3, C4 and C1q for fluorescent microscopy. For histopathological examination, the specimens were stained with hematoxylin and eosin, Periodic acid Schiff and methanamine silver stains for light microscopy

Results: out of total 1,658 renal biopsy cases, 142 [8.6%] were diagnosed as IgA nephropathy on light and immunofluorescence microscopy. Majority of IgA nephropathy patients were young [mean age = 33.2] and presented with proteinuria. The frequency rose from 2% in 2008 to 9.4% in 2014

Conclusion: IgA nephropathy was present in younger population and has a rising trend in our population

Primary intraosseous solid carcinoma of the mandible: a case report and review of literature

A primary intraosseous carcinoma [PIOC] arising de-novo is an extremely rare tumour that is limited to the jaws. The majority of the reported cases of PIOC have their origin from the odontogenic cysts, those arising de-novo are rarely illustrated. The definite diagnosis of PIOC is often difficult as the lesion must be differentiated from other primary and metastatic squamous cell carcinomas of jaws. We report an uncommon case of PIOC arising de-novo in a 25 years old man. The clinical, radiological and histological features are described. This infrequent lesion should be considered in the differential diagnosis of any jaw radiolucency

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

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

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

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

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

Epithelioid hemangioendothelioma of the liver

Epithelioid hemangioendothelioma is an intermediate grade malignant neoplasm of vascular origin. The tumor involves the liver and lungs, but other organs are affected too. The key to the diagnosis is identification of cells of endothelial origin containing Factor VIII R antigen. Surgical resection of isolated lesions is the treatment of choice; with unpredictable results reported for chemotherapy, radiotherapy, and resection of multiple lesions. The prognosis is very variable, and ranges from few months to more than 25 years

Clinician's responsibility in pre-analytical quality assurance of histopathology

To ascertain the adequacy of information provided by clinicians when requesting a histopathology investigation and to study the quality control parameters of the specimen containers. This is an observational descriptive study which was carried out at Armed Forces Institute of Pathology in December 2006 on 500 specimen requests for histopathology. Out of 500 specimens, age was not mentioned in 29 [5.8%] cases. No clinical history or differential diagnosis was given in 170 [34%] cases. Site of biopsy was absent in 65 [13%] cases and the name of requesting clinician or any contact information was present in only 115 [23%] of request forms. One hundred forty three [28.7%] containers were inadequate relative to the size of the specimen. Adequate volume of fixative was absent in 176 [38.2%] samples. There were 22 [4.3%] samples which did not have any sort of label mentioning either patient's name or type of specimen. Injection bottles constituted the highest number of containers [n=204; 40.8%] used to submit the histopathology specimen. Clinicians of all grades and specialties must be educated and made aware of their primary responsibility to request the service appropriately for the benefit of the patient and patient care

Usefulness of crush smears in intraopertive consultation of neurosurrgical biopsies

To evaluate accuracy of intraoperative crush smears diagnosis of neurosurgical biopsies. Cross-sectional study. The Armed Forces Institute of Pathology, Rawalpindi, from February 2002 to February 2003. One hundred, neurosurgical biopsies were received for intraoperative consultation over a period of one year. Clinical information regarding age, gender, history, and CT scan or MRI findings were recorded. Crush smears were prepared, fixed in 95% alcohol and stained with rapid haemotoxylin and eosin [H and E] stains. Diagnosis was categorized into inflammatory, benign and malignant tumours. Remaining tissue was fixed overnight in 10% formalin for histological sections. Permanent H and E sections were used as the gold standard. The average time required for intraoperative cytological diagnosis was 8 minutes. Out of 100 neurosurgical biopsies, crush smears of 94 were considered suitable for interpretation. There were 8 inflammatory, 41 benign and 41 malignant tumours, including 4 inconclusive. Eightyfour of the crush smears diagnosis agreed with the histological diagnosis. Overall diagnostic accuracy of crush smears was 93.3%. Diagnosis of inflammatory, benign and malignant tumours showed specificity of 98.7%, 96% and 94%, and a sensitivity of 70%, 97.5% and 95% respectively. Crush smears are useful in the intraoperative diagnosis of space occupying lesions of central nervous system. The crush smears cytology was found highly reliable, rapid and inexpensive mode of intraoperative diagnosis

pattern of malignant tumours: Tumour registry data analysis, AFIP, Rawalpindi, Pakistan [1922-2001]

To provide information regarding frequency of malignant tumours through data retrieved from pathology based tumour registry of AFIP, Rawalpindi, Pakistan. All malignant tumours recorded with the AFIP tumour registry over a period of 10 years [1992-2001] were analysed in terms of age group, gender and type of tumour with relation to site. A comparison with the previously published material from same setting, national and international studies were also done. The total malignant tumours in the 10 years period were 21,168. Out of these, 12584 [59.5%] were seen in male patients while 8584 [40.5%] were in females. Total malignant tumours in pediatric age group were 927 [4.4%]. The common malignant tumours in males in order of decreasing frequency were, those of prostate, skin, lymph node, leukaemia, urinary bladder, colorectum, bone, lung, stomach and liver. In females, breast carcinoma was on top followed by skin, leukaemia, ovary, coloretum, lymph node, bone, liver, cervix and gall bladder. In females, contrary to the Western studies and India, ovarian tumours were more frequent than cervical cancers. Comparison of this analysis with our previous analysis, national and international studies showed some interesting features. It was found that in males, tumours of the prostate were the most frequent as compared to the previous study, which showed lymphomas and leukemias to be the most common. On the other hand in females, tumours of the breast remained to be consistently most frequent

Urothelial neoplasia of the urinary bladder - comparison of interobserver variability for WHO classification 1972 with WHO/ISUP consensus classification 1998

Classification of urothelial bladder tumours is an important factor in the treatment and prognosis of these lesions. Over the years many classifications have been proposed for this purpose. The objective of this study was to classify urothelial neoplasms of the urinary bladder using the latest WHO/ ISUP Consensus Classification 1998 and WHO Classification 1972 and compare the two regarding interobserver variability. This study included 100 consecutive biopsy specimens of urothelial neoplasms of the urinary bladder diagnosed at the department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. These were classified according to WHO Classification 1972 and WHO/ISUP Consensus Classification 1998 by 2 groups of pathologists independently. The tumour categories for WHO classification 1972; papilloma, and transitional cell carcinoma [TCC] grades I, II and III were compared with the WHO/ISUP Consensus Classification entities of papilloma, papillary neoplasm of low malignant potential, low grade and high grade papillary carcinomas. Kappa statistics were used to evaluate interobserver variability. Chi square test was used to calculate significance. There was agreement on 80 tumours between the two groups of histopathologists when using WHO classification 1972 while there was agreement on 95 tumours using WHO/ISUP consensus classification. The value of Kappa for WHO Classification was 0.68 [good agreement] whereas for WHO/ISUP Consensus Classification it was 0.91 [excellent agreement]. The difference between the two systems was statistically significant [p<0.001]. Kappa values were less for benign and borderline lesions using both systems. WHO/ISUP Consensus Classification 1998 showed less interobserver variability than WHO Classification 1972 in the evaluation of bladder tumours. It was found easier to apply by both groups. There was less agreement on the benign and borderline lesions using both the classifications