Diagnostic Approach to Thyroid Nodules.

Derangement of thyroid function is a common clinical problem, with variable clinical presentations ranging from subtle, incidentally discovered disorders to overt disease, with frank disturbances of hormone levels and visible thyroid enlargement. In addition, there are the autoimmune thyroid disorders, and the neoplastic enlargements which result in palpable nodules. A large amount of new information has become available in recent times. They provide a comprehensive approach to diagnosis of thyroid nodules, ranging from initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, and their management. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease. We went through the published literature available electronically and assessed the various studies and their results. The results were reviewed carefully and interpreted in order to analyse the approach to diagnosis of thyroid swellings, especially in the Indian context. Although a detailed review is outside the scope of this paper, we will attempt to discuss some of these guidelines, especially in light of the scenario in our region.

Malignant Melanoma of Anal Canal – A Diagnostic Dilemma

A 50-year-old male presented with major complaints of bleeding per -rectum and generalized weakness for past one and a half month. Digital rectal examination (DRE) and colonoscopy revealed a thrombosed internal haemorrhoid, which was surgically excised. Histopathological examination (HPE) was pointing towards anal malignant melanoma, which was further confirmed by positive immunohistochemistry (IHC) for HMB-45. As the patient had no secondaries or lymph node enlargement, he was referred for loco-regional radiotherapy. Primary ano-rectal melanoma is a rare but locally aggressive neoplasm capable of early metastasis. Owing to its non-specific clinical presentation it may be mistaken for benign conditions like haemorrhoids and may prove fatal.  Surgical treatment may range from wide local excision (WLE) to abdomino-perineal resection (APR) with controversial role of chemo-radiation in advanced cases. Prognosis is usually bleak with a 5-year survival rate of less than 20%. Owing to the rarity of ano-rectal melanoma and importance of its early detection and management, this case is being reported here.

Chediak Higashi Syndrome with Recurrent Upper Respiratory Tract Infection.

A four-year old child presented with history of recurrent infections since birth, mostly upper respiratory tract infections or sino-pulmonary involvement and moderate grade fever with symptomatic relief on antibiotics and antipyretic medications. We present this case which was diagnosed as respiratory tract infection with neutropenia consistent with Chediak-Higashi syndrome(CHS), with a brief review of this rare genetic clinical entity.

The significance of microbiopsies in cytological smears.

Background: The role of fi ne needle aspiration cytology (FNAC) in the diagnosis of malignant lesions is well documented. Conventionally obtained fi ne needle aspiration (FNA) smears frequently contain well preserved viable intact tissue fragments (microbiopsies). Aims: The present study was aimed at evaluating the microbiopsies and carrying out further cyto-histopathologic correlation in order to assess what additional information they could provide. Materials and Methods: A total of 116 FNA smears from clinically suspected malignant lesions were examined, of which 81 smears (70.0%) contained representative tissue fragments of the tumors. Histopathological details were available in 75 cases. Immunocytochemistry (ICC) was applied in selected smears as and when required. Results: Tumors in which microbiopsies aided in diagnosis chiefl y included soft tissue malignancies (12 cases), typed into malignant peripheral nerve sheath tumor, fi brosarcoma, spindle cell sarcoma and malignant melanoma; lung tumors (14 cases) classifi ed as small cell carcinoma, large cell carcinoma, squamous carcinoma and adenocarcinoma; breast tumors (08 cases), typed into ductal, medullary and lobular carcinoma; and lymph node metastasis (19 cases) from primaries in lung, larynx and thyroid. The cyto-histopathologic concordance was raised from 81.2% in the absence of microbiopsies to 93.2% in their presence. Conclusions: FNA smears containing microbiopsies are of ample help in establishing fi rm diagnosis, tumor typing, and predicting possible primary sites in metastatic tumors which were not possible by cytology alone. Hence, this technique can be utilized to enhance the diagnostic accuracy of FNAC, if put into practice in evaluation of routine cytology smears, without increasing any fi nancial burden on patients.

Osteosarcoma of the Clavicle in an Adolescent Child.

Clavicle is an unusual site for any primary bone tumour, including osteogenic sarcoma. Although a rare site of affection, most clavicular tumours tend to be malignant. We present a case report of osteosarcoma of the clavicle in a twelve-year-old male child who presented with a huge swelling of the left clavicle for the last six months.

Percutaneous Needle Biopsy-An Assertive Tool In The Diagnosis of Bone Tumors in Under Developed Countries.

Our study on 106 cases of bone tumors aims at correlating the clinical, radiological and cytological findings of benign and malignant tumors of bone and evaluating the usefulness of percutaneous biopsy as a diagnostic tool in underdeveloped countries. Giant cell lesions were the most common benign tumor, 42 cases (84%) and giant cell tumor was the most common giant cell lesion in our study, 27 (64.3%). Round cell tumor appeared to be the most common malignant tumor of bone, 20 cases (35.7%). Osteosarcoma represented 15 cases (14.2%) of all bone tumors and 26.8% of all malignant bone tumors in our study. Final histopathological diagnosis was available only in 54 cases. Out of which 53 cases showed concordance with previous cytological diagnosis. Only a single case of chondrosarcoma was misdiagnosed as chondroma on FNAC (false negative). The sensitivity and specificity of FNAC was 96.0% and 100% respectively while positive predictive value and negative predictive values were 100% and 96.7% respectively. The diagnostic accuracy in our study was 98.1%.

Orquitis tuberculosa aislada / Isolated tuberculous orchitis

Presentación de un caso poco frecuente de tuberculosis genital aislada, en un hombre de 28 años, no fumador, sin antecedentes clínicos significativos...

Pindborg Tumor in an Adolescent- An Atypical Presentation.

Calcifying epithelial odontogenic tumor (Pindborg tumor), is a rare benign odontogenic neoplasm representing about 0.4-3% of all odontogenic tumors. This tumor more frequently affects adults in an age range of 20- 60 years, with a peak incidence in the 5th decade of life. Calcifying epithelial odontogenic tumour has a much lower recurrence rate than ameloblastoma and malignant transformation with metastasis is rare.

Primary neuroendocrine carcinoma of the breast.

Primary neuroendocrine carcinoma of the breast is rare-only about 30 cases have been reported in literature. Immunohistochemical examination showing expression of chromogranin and/or synaptophysin confirms evidence of neuroendocrine differentiation. Usually foci of neuroendocrine differentiation can be seen in breast carcinoma and are reported to be present in about 2-5% of breast cancer cases. Here, we report a case of breast carcinoma in which most of the areas studied on the tissue section showed neuroendocrine differentiation.

Microfilariae in Testicular Fine Needle Aspiration Biopsy.

Filariasis due to Wucheria bancrofti is endemic to Southern Asia. While the laboratory diagnosis has been conventionally made by demonstrating microfilariae in peripheral blood smears, these have also been occasionally diagnosed on aspiration cytology of various organs. This paper reports the finding of microfilariae in material obtained from the testicular mass in an eighteen year old male by fine needle aspiration (FNA) cytology.

Actinomycosis - Left Post Chest Wall.

A forty year old female of weak body built presented with recurring small hard lumps in let posterior chest wall for 3 years and discharging ulcers for 3 months duration. Clinically, the provisional diagnosis was malignancy with secondary infection. FNAC showed features suggestive of dysplasia but histopathology confirmed the diagnosis as actinomycosis. The present case is reported due to rare incidence of actinomycosis at post chest wall with muscle involvement.

Ocular manifestations of cysticercosis: a case report.

Ocular and extraocular cysticercosis is a commonly encountered manifestation of the disease caused by the cysticercus cellulosae. Any region of the eye may be afflicted including the subconjunctival space. We present the case ofa young female who developed a small mass at the medial canthus of the left eye, which was diagnosed as conjunctival cysticercosis subsequent to excision and histopathological examination.

Ultrasound Guided Fine Needle Aspiration Biopsy of Abdominal Masses

Ultrasound guided fine needle aspiration biopsy of abdominal masses. Material Methods: 200 patients with abdominal lump were subjected to fine needle aspiration biopsy by a 20-22 G needle and smears prepared were stained with H & E and Papanicolaou stains. Histopathological specimens were processed and stained with H & E stain and a cytohistological correlative study performed. 128 (74%) were females and 72 (36%) were males. 83 cases (41.5%) had a mass in the hepatobiliary region, out of which 53 (63.9%) had a mass in the gall bladder. Malignant lesion constituted the commonest cytologic diagnostic category 115 cases (57.5%). Adenocarcinoma gall bladder was found in 31 cases (37.3%) followed by metastatic adenocarcinoma liver in 12 cases (14.5%) and hepatocellular carcinoma in 8 cases (9.6%). Adenocarcinoma stomach 8 cases (18.6%) was the commonest GI malignancy followed by adenocarcinoma intestine 7 cases (16.3%). Serous cystadenocarcinoma comprised the commonest ovarian cancer, 5 cases (12.5%) followed by mucinous cystadenocarcinoma, 2 cases (5.1%). Overall sensitivity of 94.11%, specificity of 100% and diagnostic accuracy of 95.7% was found in the present cytohistological correlative study.

Mammography-guided stereotactic fine needle aspiration cytology of breast lesions.

The purpose of the present study was to evaluate the efficacy of mammographic guided stereotactic fine needle aspiration cytology in 136 patients with breast lesions including mammographic features, cytomorphological findings and nuclear grading in malignant cases. Majority of the cases were predictable correctly by combination of the three modalities of diagnosis viz, clinical examination, mammography and cytology.

Fine Needle Aspiration Cytology in the Management of Tumors and Tumor like Lesions of Bone

FNAC should be considered as the part of routine preliminary investigation of orthopaedic patients presenting with musculoskeletal tumorous lesions. A total of 110 cases were screened cytologically in the background of clinical, radiological findings and biochemical tests. Primary malignant tumor formed the major entity accounting for 56% of the cases, while benign tumors comprised 8% only. Overall success rate of needle aspiration cytology in diagnosing tumors and tumor like lesions was 92%. Giant cell tumors of bone was the most common malignant lesion observed in 15 cases (30%), followed by Ewing's Sarcoma in 5 cases (10%). Cytologic diagnosis was completely compatible with the final histopathologic diagnosis in 82.3% of cases.

Bilateral lower zone shadows on chest radiograph - A clinicopathological profile.

Background: The initial suspected diagnosis in bilateral lower zone lung involvement made clinically can be compared and correlated with the final diagnosis obtained after percutaneous FNA cytology, BAL fluid examination and transbronchial biopsy. Aim: To study diseases presenting with bilateral lower zone shadow on chest radiograph and compare the initial clinical diagnosis to the final diagnosis. Methods: Fifty six patients were studied by routine hematological, sputum and pleural fluid examination along with PCNA and TBNA cytology, bronchial aspirate/ BAL fluid examination and transbronchial biopsy after a detailed clinical history and thorough physical examination. Results: Initially suspected diagnosis included tuberculosis in 32.1% cases, pneumonia in 30.4%, malignancy in 10.7%, pulmonary oedema in 5.4%, bronchiectasis in 8.9%, ILD in 7.1%, TPE in 3.6% and bilateral hydatid disease of lung in 1.7% of cases. The final diagnosis revealed tuberculosis in 25.0% cases, pneumonia in 23.2%, malignancy in 16.1%, bronchiectasis in 8.9%, pulmonary oedema and ILD in 7.1% each, sarcoidosis and TPE in 3.6% each, while pulmonary candidiasis, pulmonary alveolar proteinosis and bilateral hydatid disease of the lung in 1.7% case each respectively. Conclusion: Majority of cases can be diagnosed by a detailed clinical profile along with a chest radiograph. However, FNAC and fibreoptic bronchoscopy are of high value for pathological and microbiological confirmation of the diagnosis and provides a significant yield.

Study of Fine Needle Aspiration Cytology in Lymphadenopathy with Special Reference to Acid-fast Staining in Cases of Tuberculosis

The present study was conducted to evaluate the usefulness of FNAC as a diagnostic tool in 1000 patients of lymphadenopathy. Fine needle aspiration was performed in all the patients following through clinical examination and slides were stained with H & E, PAP and Ziehl Neelsen stains. The results of FNAC were further correlated with paraffin embedded sections of tissue blocks. Eight hundred and sixty-four cases (86.4%) were of benign lymphadenopathy; out of which 536 (53.6%) cases were of reactive nature and 328 cases (32.8%) were tubercular. The remaining 136 (13.6%) cases were of malignant lymphadenopathy, consisting 45 (4.5%) cases of primary malignancies i.e. lymphomas and 91 (9.1%) cases of metastasis to lymph nodes. Out of 328 cases, Z-N positivity for AFB was found in 152 cases (46.4%) and Mantoux test was positive in 180 cases (54.9%). On correlation of FNAC findings with histopathology; sensitivity and specificity was found out to be 91.6% and 99%, respectively, with diagnostic accuracy of 97.3% in cases of benign lesions. The same being 97%, 97.5% and 97.4%, respectively in tubercular lesions. The sensitivity, specificity and diagnostic accuracy was 100% each in malignant lesions. FNAC of lymphnodes is an excellent first line method, for investigating the nature of the lesions, as it is economical and convenient alternative to open biopsy.

Transbronchial needle aspiration in undiagnosed radiographic shadows.

Background: Transbronchial needle aspiration (TBNA) is diagnostic in benign and malignant pulmonary lesions. The technique of TBNA has made mediastinal and hilar nodes accessible. In addition to its usefulness in central airway lesions, TBNA has been found to increase the diagnostic yield in peripheral lesions also. Aim: To evaluate the role of transbronchial needle aspiration (TBNA) in cases of unconfirmed radiographic shadows. Material and Methods: A detailed clinical history was recorded in all the 54 patients, who presented with an unconfirmed radiographic shadow. Thereafter, fibreoptic specimens of bronchial aspirate and TBNA were collected, and subjected to Ziehl-Neelsen staining, Graim’s staining, fungal smear, culture for pyogenic organisms and acid fast bacilli and cytological examination by H & E stain and Papanicolaou staining.Bronchial biopsy was collected in cases wherever feasible and specimens were paraffin embedded cut into 3-5 mm thickness and stained with H & E stain. Results: Out of 54, 48.1% were diagnosed to be having bronchogenic carcinoma, 20.4% each pneumonia and tuberculosis, while one patient had primary fungal infection (Candida abbicaus). The overall diagnostic yield was highest with TBNA (85.2%) followed by transbronchial biopsy (48.2%) and bronchial aspiration (42.7%) cases. Conclusion: TBNA offers an unique opportunity to make a pathological diagnosis at the time of bronchoscopy. It is equally effective in diagnosing various infective conditions like pneumonia and tuberculosis.