Evaluation of Reaction Pattern of Skin Diseases in Oman: A Study Base on Immunoflurescence and Light Microscopy Investigation Onlhy.

Aims: The aim of this study was to evaluate various reaction pattern of skin diseases in Oman using immunofluorescence and light microscopy investigation only. Methodology: A total of 187 skin biopsies were retrospectively analyzed at Sultan Qaboos University Hospital between 2006 and 2010. The presence of immune-reactants (IgA, IgG, IgM, C3 and Fibrin) and the final diagnosis by heamatoxylin and eosin stain in skin biopsy were investigated. Results: Females (59.36%) predominated over males (40.64%). Adults, aged between 26 and 44years, had the highest cases of skin diseases. The most frequent diagnosis were vesiculo bullous (n=71), lichenoid (n=69), vasculopathic (n=19) and epidermal disease (n=13) groups. Vesiculo bullous group showed different deposits of IgA, IgG, IgM, C3 and Fibrin with 19.72%, 23.94%, 8.54%, 21.13%, 11.27%, respectively. Psoriasis (n=2) and reactive condition (n=1) groups were the lowest pattern of skin diseases. IgG was positive in one case of psoriasis and there is a total absence of positive immune-reactants in epidermal disease and reactive condition groups.Conclusion: Based on the findings of this study, this retrospective study showed that vesiculo bullous group followed by lichenoid group were the most common skin disease groups detected by immunofluorescence in Oman, while psoriasis and reactive condition groups were the least frequent. Although all immune-reactants were low in their positivity, they were an important component in the final diagnosis of skin biopsies.

Inter-observer agreement in reporting HER 2 Neu protein over expression by immunohistochemistry.

Introduction: HER 2 Neu protein overexpression and its detection by immunohistochemistry (IHC) has become quiet critical because of its relevance in regards to Herceptin treatment. This peer review was done at a tertiary care center, which aimed at determining the inter-observer variation among fi ve pathologists and evaluating the degree of agreement between them. Aims: The aim of our study was to determine the reproducibility of HER 2 Neu system of reporting in breast cancer cases and determine inter-observer variability among fi ve pathologists at a tertiary care center. To compare the results with similar studies done at other centers. Settings and Design: Retrospective descriptive study. Materials and Methods: Hematoxylin and Eosin (H and E) and IHC stained slides of 104 cases of carcinoma breast, on which HER 2 Neu status had been reported were reviewed. The time period for selection was from January 2010 to December 2011 (2 year period). Five pathologists reviewed the H and E and IHC slides independently and scored the results on a specially designed work sheet. Kappa values for inter-observer variation and Cornbach’s alpha for internal consistency were calculated. Statistical Analysis Used: SPSS 20.0 (IBM). not known. Results: Complete agreement was seen between all fi ve pathologists in 70 cases (70/104) = 67%. Agreement between four pathologists was seen in 78 cases (78/104) = 75%. Agreement between three pathologists was seen in 92 cases (92/104) = 88%. The global value for kappa co effi cient for agreement between two pathologists was 0.706 and Cornbach alpha for internal consistency of reporting in the department was 0.987. Conclusion/ Key Messages: Our departmental peer review indicated that there is good inter-observer concordance (agreement between two pathologists) and there is strong overall internal consistency of reporting for HER 2 Neu reporting by IHC. Our results are comparable to International reported data of similar studies.

Study of parameters to ensure quality control in histopathology reporting: A meta-analysis at a tertiary care center.

Context : When surgical pathology reports are dispatched to patients and clinicians, sometimes they are discovered to have errors, and it is a common practice for the pathologists to issue amended reports. Measuring the rate at which surgical pathology reports are amended can be used as a tool for assuring quality control in histopathology. Aim : The aim of this study was determine the parameters that can be used as an assessment tool to minimize errors in histopathology. Materials and Methods : This study was carried out at a major histopathology center. The duration of this study was from January 2001 through January 2011(ten years). Following parameters were looked for: Interpretational errors, permanent and frozen section correlation, intradepartmental consultation and cases sent for second opinion, cases brought in tissue committee meetings, audits, and cases discussed in hospital meetings. Results : A total of 28,1931 surgical pathology cases were signed out during the ten-year period. On these, addendums were issued on 5730 cases (2.0%). Additional report issued on 3521 (1.3%). Addendum/corrected report issued for 2209 cases, which was 0.7%, representing the true interpretational error. And out of this number, a second opinion was taken for 5980 cases, and 78 were sent abroad for second opinion. Conclusion : Review by a second pathologist is a strong tool to minimize errors in surgical pathology reporting. This may be done prior to or after the report is dispatched and the case is discussed in the hospital for treatment purposes. This analysis concludes that true interpretational error occurred only in 0.7% of cases, which is an attribute to the strong peer review in the department.

Gastrointestinal stromal tumor with skeletal muscle, adrenal and cardiac metastases: An unusual occurrence.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the bowel. It most commonly arises in the stomach, followed by the small intestine, colorectum and the esophagus. It usually spreads to the liver or the peritoneum, with bone and lung metastases being infrequent. Here, we present a case report of GIST behaving in a bizarre way. The patient presented with skeletal muscle metastasis and was initially misdiagnosed as leiomyosarcoma. On follow-up, he developed adrenal metastasis, and later, cardiac metastasis. None of the above unusual sites has previously been reported in literature to our knowledge.

Utility of p63 immunohistochemical stain in differentiating urothelial carcinomas from adenocarcinomas of prostate.

Background: Prostatic adenocarcinoma and urothelial carcinoma of the urinary bladder are common cancers in men. High grade forms of these tumors may present ambiguous morphologic features that do not permit a definite diagnosis. This distinction between the two tumors has significant staging and therapeutic implications. Hence, an accurate diagnosis is essential for optimal patient care. p63 is a new marker which can be used in this context. It is expressed in most of the urothelial carcinomas and negative in majority of prostatic adenocarcinomas. Aim: To compare the expression of p63 in urothelial carcinomas and adenocarcinomas of prostate. Materials and Methods: Comparative cross--sectional study was carried out at a tertiary cancer hospital from 15 June 2006 to 15 December 2006. Immunohistochemical stain p63 was performed on 50 cases of urothelial carcinoma and 50 prostatic adenocarcinomas. Patients' name, age, histology numbers, grade of tumor, and expression of p63 were recorded. p63 expression was seen in 44 of 50 urothelial carcinomas (88%). None of the prostatic adenocarcinomas expressed p63. The ages of patients with prostatic adenocarcinoma ranged from 49 to 86 years with a median age of 71 years and 41 to 83 years for urothelial carcinomas with a median age of 60.5 years. Conclusion: p63 can be used as a reliable marker to distinguish prostatic adenocarcinomas from urothelial carcinomas in difficult cases in conjunction with other markers like PSA.

The morphologic and immunohistochemical spectrum of 16 cases of sclerosing stromal tumor of the ovary.

Background: Sex-cord-stromal tumors of the ovary are rare neoplasms and they differ from the common surface epithelial tumors in clinical and imaging features. Patients and Methods: This study was done to evaluate the morphologic and immunohistochemical pattern of 16 cases of sclerosing stromal tumor of the ovary diagnosed at a tertiary care hospital. All patients having sclerosing stromal tumor of the ovary were included with the help of medical records using the SNOMED coding system over 10 year period i.e. 1998 to 2008. Result: Sixteen cases of the stromal tumor of the ovary were diagnosed over this 10 year period; the age range was 23 to 40 years (median age 28). In 7 out of 16 cases, serum CA 125 level was done which was raised as per the available medical records. All of these cases showed unilateral. The gross appearence of all the tumors was similar and all had unilateral involvement. Mucin was negative in all of these cases.

Primary non-hodgkin's lymphoma of bone: Experience of a decade.

Objective: To study the prevalence and characterization of primary non Hodgkin's lymphoma of bone in a major referral center of Pakistan. Methodology: All cases of primary non Hodgkin's lymphoma of bone, diagnosed at a referral center in Pakistan from January 1998 to July 2008 have been included. Patients with diagnosis of lymphoma at some other site prior to diagnosis in bone biopsy were excluded from the study. Results: Sixty cases of primary non Hodgkin's lymphoma of bone were received, with a male to female ratio of 7: 3 (42 males and 18 females). Overall, 52/60 (86.6 %) patients were diagnosed with Diffuse large B-cell non-Hodgkin's lymphoma. The largest fraction of patients was found in the pediatric group i.e. 33/60(55%) followed by elderly group i.e.15/60 (15%) and adults i.e. 12/60 (20%). The commonest sites of involvement were femur (28.3 %), hip bone (16.6%) and humerus (10%). Conclusion: Diffuse large B-cell lymphoma is the commonest type of primary non Hodgkin's lymphoma of bone in the Pakistani population. It is common in all ages. The sites most often involved are femur followed by hip bone. Primary non Hodgkin's lymphoma of bone appears to be more common in males. Our results are comparable to international data with various studies also showing that diffuse large B cell non Hodgkin lymphoma is the commonest primary bone lymphoma. However, primary Bone Lymphoma is more common in children and young adults.

Breast carcinoma grading, estimation of tumor size, axillary lymph node status, staging, and nottingham prognostic index scoring on mastectomy specimens.

Introduction: Breast carcinoma is the most common malignant tumor and the leading cause of cancer death in women. In western countries, a sharp increase in the detection of breast carcinoma, largely due to widespread use of mammography, has recently led to a fall in breast cancer mortality. This, however, is not true for less developed countries, in which mortality continues to rise. Objective: The aim of this study was to acquire information about the extent and spread of breast carcinoma in our patients by grading the tumors, determining the tumor size, and axillary lymph node status, staging of the tumors and Nottingham Prognostic Index (NPI) scoring on the available material. Materials and Methods: One hundred and twenty consecutive mastectomy specimens with axillary lymph node sampling removed for breast carcinoma and received in the section of histopathology, Aga Khan University, in the year 2005, were included in the study. Standard protocols were used for the processing of the specimens, and reporting was done using a standard format incorporating all relevant tumor parameters. NPI was applied to the cases. Results: Out of the 120 cases, 5 (4.17) were grade 1, 91 (75.83) were grade 2, and 24 (20%) were grade 3. Also, 9 cases (7.5%) were T1 (4 were T1b, and 5 were T1c); 53 (44.16%) were T2; 50 (41.66%) were T3; and 8 (6.66%) were T4. Axillary lymph nodes were available in 107 cases. In 13 cases, no lymph nodes were recovered. Out of 107 cases 27 (25.23%) lymph nodes were negative for metastases pN0; 29 (27.10%) cases were pN1; 26 (24.30) were pN2; and 25 cases (23.36%) were pN3. Extranodal spread was present in 56 (70%) out of the 80 cases in which lymph nodes were positive. The average microscopic size of nodal metastasis was 1.7 cms. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). Tumor necrosis was present in 76 out of 120 cases (63.33%). Vascular invasion was present in 43 out of 120 cases (35.83%). NPI scores were greater than 5.4 in 60 out of 107 cases (56.1%) indicating poor prognosis. Conclusion: The large majority of the cases were grade 2 tumors. Most cases (all grades) were T2 or T3, and were axillary lymph node positive. Large majority of cases with nodel metastases showed extra nodal spread. The majority of patients had NPI scores greater than 5.4 indicating poor prognosis. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). The findings show extensive and advanced disease trends in our patients.

In-house daily consensus conference: An important quality control/quality assurance activity - Experience at a major referral center.

Background: For every practicing histopathologist, improvement of diagnostic accuracy is an important objective. Personal consults are an important component of quality control (QC)/quality assurance (QA) in our Section of Histopathology. In addition, the College of American Pathologists recommends a daily in-house consensus conference, which is a prospective system by which all difficult and problematic cases are reviewed and discussed and signed out by consensus. Design: In-house consensus conference is held daily using a multi-headed microscope. This collegial session is run by the seniormost consultant in the section and is attended by all histopathology consultants and residents. The consultants and residents present cases of their choice for discussion. The cases may be selected due to diagnostic difficulty, unusual nature of a case, management purposes such as performance of additional biopsies, special studies, etc., or request on the part of clinician or patient. Cases may be shown once or, in case of lack of consensus or difficulty in diagnosis, more than once after additional work-up suggested by the conference. Results: In a 4-month period, 774 (4.1%) cases of a total of over 14,000 well-mixed surgical cases were brought to the in-house daily consultation conference. Four hundred ninety-three cases (63.7%) were conclusively decided the first time while 198 cases (25.5%) were decided by consensus after being shown twice. In 83 cases (10.7%), a definite diagnosis could not be given. The cases on which a definite diagnosis was not possible represents 0.59% of all cases received in the department during the study period. The most common cases were shown from the gastrointestinal tract (115 cases or 14.8%), lymph nodes (110 cases or 14.2%) and soft tissue (82 cases or 10.6%). In most cases in which a definite diagnosis could not be given, the main reason was scanty material or crushed nature of the tissue. Conclusion: The in-house daily consensus conference is an extremely useful QC/QA exercise, which is very important in reaching an accurate diagnosis in difficult and challenging cases and minimizing diagnostic errors.

Spectrum of malignancy in mixed tumors of salivary gland: a morphological and immunohistochemical review of 23 cases.

Malignancy arising in mixed tumors of the salivary gland is a distinct entity that can occur sporadically or in association with a background of pleomorphic adenoma. Carcinoma arising with a background of pleomorphic adenoma is well documented. However, there are rare occurrences of aggressive de novo carcinosarcomas of the parotid that have been reported. Various cell lineages such as the epithelial glandular cells and the stromal spindle cells are involved. We report 23 cases of tumors of the salivary gland comprising 18 cases of carcinoma ex pleomorphic adenoma, four cases of carcinosarcoma of the parotid and one case of benign metastasizing pleomorphic adenoma. The occurrence of various malignancies suggests that this phenomenon is not very uncommon and should be looked for when reporting a mixed tumor.

Myofibroblastoma of breast.

Soft tissue neoplasms of breast thought to be derived from Myofibroblasts have been classified as myofibroblastomas. Myofibroblasts are spindle shaped mesenchymal cells derived from fibroblasts. These are rare neoplasms (more often seen in the male breast) and have same structural and immunohistochemical characteristics as those of solitary fibrous tumors. We present a case of an adult female presenting as firm breast lump diagnosed as myofibroblastoma and confirmed by diffuse positivity of CD34 immunohistochemical stain.