Immunohistochemical expression of histone modification pattern in adult glioblastoma.

BACKGROUND: Despite the growing advances in molecular research and therapeutics, glioblastomas are still considered highly invasive aggressive tumors with a median survival of 15 months. Genetic alterations have been studied in detail; however, additionally, there is now growing evidence on the role of epigenetic alterations in glioblastoma. Recently, histone modification patterns have been found to have a significant part in gene expression and prognosis. However, further research in this field is warranted to establish its role for the betterment of these patients with the deadly disease. AIMS: To determine the immunohistochemical expression of histone modifications like histone-3-lysine-18 acetylation (H3K18Ac) and histone-4-lysine 20 trimethylation (H4K20triMe) in glioblastoma patients. MATERIALS AND METHODS: This is a retrospective study of 48 glioblastoma patients who underwent surgery. Immunohistochemistry (IHC) for tri-methyl-histone-H4 (Lys20) (H4K20triMe) and acetyl-histone-H3 (Lys18) (H3K18Ac) was performed in paraffin-embedded tissues manually, and the expression was noted. Data on the mitotic index and overall survival was collected and statistically analyzed. RESULTS: The mean age was 50 years with a M: F ratio of 1.6:1. Out of 48 cases, 60% (28 cases) demonstrated positivity for H3K18Ac and 98% (46 cases) for H4K20triMe. The pattern of expression was nuclear with increased expression adjacent to necrosis and at the invasive front. The overall median Q score for H3K18Ac was 1/12 and for H4K20triMe was 6/12. No significant statistical significance was observed between histone expression, Ki67%, and overall survival. CONCLUSION: Histone modification patterns are being explored in detail in an array of tumors. They also have a potential role in glioblastoma for risk stratification and instituting appropriate treatment based on the prognosis. Epigenetic changes like histone modification patterns, in addition to genetics, can pave the way for a better molecular understanding of glioblastomas and provide hope in the future to improve the survival of these patients with deadly diseases.

Warthin-like papillary carcinoma thyroid.

Solitary thyroid nodule should raise a suspicion of malignancy, which is very common in middle-aged females. Papillary carcinoma thyroid is the most common thyroid malignancy. Warthin-like papillary carcinoma is one of its rare variants. It has a frequent association with Hashimoto's thyroiditis. Here, we report a case of 43-year-old female who presented with swelling in the anterior aspect of neck for 1 month. Fine-needle aspiration cytology features were suggestive of papillary carcinoma thyroid and biopsy confirmed the diagnosis of Warthin-like papillary carcinoma thyroid. This variant is of great clinical and prognostic significance as it carries an excellent prognosis.

A Unique Presentation of a Thoracic Conundrum: Tracheobronchial Rests in the Esophagus.

Tracheobronchial rests are a rare congenital anomaly where ectopic respiratory tract elements may be found in an abnormal site, such as within the esophageal wall. We present a case of a late presentation of an esophageal intramural tracheobronchial rest with complaints of pain in the left chest wall, vomiting, and loss of appetite for one month. The chest X-ray and mammogram were both normal, but an endoscopy could not be performed due to luminal narrowing. A CT scan shows a well-defined, round, non-enhancing hypodense lesion measuring 2.6 x 2.7 cm in the middle one-third of the esophagus. Upon resection, histopathological examination revealed fragments of tissue lined by pseudostratified ciliated columnar epithelium with respiratory mucinous glands admixed with pools of mucin and underlying strands of skeletal muscle. The subepithelium contains esophageal submucosal glands, which confirm the esophageal origin of the choristoma. The usual presentation is congenital esophageal stenosis at birth with over half of these cases being attributed to tracheobronchial rests. Presentation beyond adolescence is even rarer with a relatively benign course and favorable prognosis. Clinical, radiological, and pathological correlation as well as a high index of suspicion are important to avoid misdiagnosis and to institute optimal treatment.

Biphasic squamoid alveolar renal cell carcinoma: A rare entity with an even rarer presentation as cutaneous metastases - A case report.

Biphasic squamoid alveolar renal cell carcinoma (BSARCC) is a newly emerging distinct and rare morphologic variant of renal cell carcinoma (RCC). Morphological, immunohistochemical, and molecular data have shown that BSARCC is closely related to papillary RCC type 1. We report a case of Biphasic squamoid alveolar renal cell carcinoma with a rare presentation as cutaneous metastases. This variant tends to show an aggressive behavior. Hence, accurate histopathological diagnosis can help in effective treatment and for close follow-up of the patients.

Differentiation of urothelial carcinoma in histopathology images using deep learning and visualization.

Artificial Intelligence is a tool poised to transform healthcare, with use in diagnostics and therapeutics. The widespread use of digital pathology has been due to the advent of whole slide imaging. Cheaper storage for digital images, along with unprecedented progress in artificial intelligence, have paved the synergy of these two fields. This has pushed the limits of traditional diagnosis using light microscopy, from a more subjective to a more objective method of looking at cases, incorporating grading too. The grading of histopathological images of urothelial carcinoma of the urinary bladder is important with direct implications for surgical management and prognosis. In this study, the aim is to classify urothelial carcinoma into low and high grade based on the WHO 2016 classification. The hematoxylin and eosin-stained transurethral resection of bladder tumor (TURBT) samples of both low and high grade non-invasive papillary urothelial carcinoma were digitally scanned. Patches were extracted from these whole slide images to feed into a deep learning (Convolution Neural Network: CNN) model. Patches were segregated if they had tumor tissue and only included for model training if a threshold of 90% of tumor tissue per patch was seen. Various parameters of the deep learning model, known as hyperparameters, were optimized to get the best accuracy for grading or classification into low- and high-grade urothelial carcinoma. The model was robust with an overall accuracy of 90% after hyperparameter tuning. Visualization in the form of a class activation map using Grad-CAM was done. This indicates that such a model can be used as a companion diagnostic tool for grading of urothelial carcinoma. The probable causes of this accuracy are summarized along with the limitations of this study and future work possible.

A huge retroperitoneal Castleman's disease - rare entity.

ABSTRACT: Castleman's disease is a rare angio-follicular lymph node hyperplasia[1,2] have varying presentation and can mimic malignancy. The common locations are mediastinum, neck, axilla, and pelvis but extra nodal sites can also be affected.[3] A 56-year-old patient incidentally found to have mass in the retroperitoneal region by Contract-enhanced computerized tomography (CT). Positron emission tomography scan showed well defined intensely enhancing fluorodeoxyglucose (FDG) avid lesion in the left iliac region with vascularity. Surgery was performed, and pathological diagnosis was hyaline vascular type-stroma-rich variant of Castleman disease. Here, we report a case of huge retroperitoneal Castleman's disease in a 56-year-old female patient.[4].

Immunohistochemical expression of beta-catenin in hepatoblastoma and its clinical significance.

Background: Primary hepatic malignancies account for 0.5-2% of all solid tumours in childhood. Hepatoblastoma, a rare embryonic tumour in the general population, represents the most frequent primary hepatic malignancy in the paediatric age group, with an incidence of one new case per million under 15 years of age, median age at diagnosis being 1 year. Aberrant activation of the Wnt/beta-catenin signalling pathway is likely to result in tumorigenesis of hepatoblastoma. The nuclear and intra-cytoplasmic accumulations of beta-catenin correlate with the likely prognosis of the disease. Nuclear expression of beta catenin is associated with a shorter survival, higher stage, and seen in embryonal/undifferentiated types. Aim: To study the expression of beta-catenin in hepatoblastoma by immunohistochemistry and correlate it with the tumour histology and survival outcome. Materials & Methods: This is a retrospective study of 11 children over a period of 5 years with the diagnosis of hepatoblastoma. These children underwent partial hepatectomy or liver transplantation at the Department of Paediatric Surgery. The clinical, histological and survival data were collected. Immunohistochemical analysis with beta-catenin was done and analysed. Results: Mean birth weight of the children was 2.75kg.63.6% had an epithelial type of histology.Beta catenin expression by IHC was studied in 11 cases and found to be positive in 4 cases. Nuclear positivity was noted in 2/4 cases of embryonal type and Cytoplasmic and membranous positivity was seen in the other 2/4 cases. Normal liver showed a membranous pattern of positivity in one case. Negative staining was seen in 6 out of 11 cases. Conclusion: Beta catenin is considered to be an useful tool for assessing the prognosis of patients with hepatoblastoma and its expression is associated with a poor survival outcome. There are no validated biomarkers for prognosis so far. However, larger studies incorporating molecular profiling is warranted to establish prognostic factors for planning effective treatment strategies.

Utility of immunohistochemical expression of E-cadherin in colorectal carcinoma.

Introduction: Reduced expression of E-cadherin, an intercellular junction protein, is associated with differentiation and metastasis of multiple cancers, including colorectal cancer. Aim: To investigate the utility of the immunohistochemistry of E-cadherin as a prognostic marker for colorectal cancer (CRC). Material and methods: Immunohistochemical analysis for E-cadherin was performed on 100 paraffin blocks retrieved from resected specimens of CRC patients. The collected data were statistically analysed. Results: Among the 100 patients, men comprised 58% and the majority had tumour size of 5-10 cm (55%). Grade II CRC was more common (74%) than grade I and III (13% each). The correlation of E-cadherin expression with lymph node involvement was statistically significant, as revealed by p-value < 0.01, with about 27% in N1 and 13% in N2 stage. E-cadherin expression was significantly correlated with tumour differentiation pattern (p < 0.01), wherein out of 13 poorly differentiated carcinomas, 38.5% and 30.5% of samples showed negative and weak E-cadherin staining, respectively. Conclusions: Furthermore, a shift from membranous E-cadherin staining in normal cells to cytoplasmic and mixed staining was observed in cancer cells. The study indicates that immunohistochemical E-cadherin expression has prognostic value, as revealed by its loss of expression in poorly differentiated cells and lymph node metastasis.

The Significance of Topoisomerase II Alpha in Invasive Breast Carcinoma.

Background Topoisomerase II alpha (Top 2 A) protein has been shown to be a proliferation marker associated with tumour grade. The current study evaluated the prognostic impact of Top 2 A protein on luminal breast cancer and its utility as an independent prognostic marker. Immunohistochemical expression of Top 2 A in breast cancer and its correlation with the tumour type, size, lymph node metastases, grade and ER/PR positivity. Methodology Ethics committee approval was taken and 65 cases of Invasive breast carcinoma presenting to the Department of Pathology at a tertiary care centre in South India were studied. Patient details including age, tumour type, tumour size, tumour grading, estrogen receptor (ER)/progesterone receptor (PR)/human epidermal growth factor receptor 2 (HER2/neu) status and pathologic stage was studied. Immunohistochemistry (IHC) work-up for Top 2 A expression was done and evaluated. Results Of the 65 histological sections of breast cancers, 29/65 showed nuclear positivity for Top 2 A. Node positive tumours 17/65 stained positive for Top 2 A. Stage I tumours 2/65, stage II tumours 12/65 and stage III 14/65 stained positive for Top 2 A. Among the HER2/neu-positive tumours, 22/65 stained for Top 2 A and among ER/PR-positive 9/65 cases were positive for Top 2 A. Triple-negative tumours 5/65 stained for Top 2 A. Conclusion Higher Top 2 A expression was seen in higher stage tumours. HER2/neu-positive tumours significantly showed a correlation with Top 2 A positivity. Therefore, Top 2 A expression can be considered an individual prognostic factor in breast carcinoma.

A Rare Case of a High-Grade Astroblastoma with 5-Year Follow-up.

Astroblastoma is a very rare glial tumor derived from astroblasts. It has been controversial in terms of its features and diagnosis. The objective of this report is to present the findings of the high-grade astroblastoma with a good prognosis in a 21-year-old female who presented to us with diplopia and headache. While imaging led to the foremost differentials of pleomorphic xanthoastrocytoma and Ganglioglioma which are low-grade neoplasms, the final diagnosis was established on microscopy and immunohistochemistry after excision. Treatment protocol included surgery with postoperative radiotherapy and chemotherapy. Due to controversial and limited literature, this tumor poses difficulties in diagnosis and management. This is a rare, successfully managed case of astroblastoma with a positive outcome 5 years after the diagnosis was established. In this case report, we review the steps of diagnosis, the differentials, the pathological and histological features, and the management of this rare entity.

An Unusual Presentation of Herpes Esophagitis in an Immunocompromised Individual.

Herpes simplex infection remains the third most common cause of esophagitis following gastric reflux disease and candida infection. This disease usually occurs in immunocompromised individuals; however, it has been frequently reported in healthy individuals. We present a case of a 39-year-old man who presented to the ER with symptoms unusual of herpes esophagitis. He was presumed to be immunocompromised due to uncontrolled diabetes mellitus and chronic alcohol use. Endoscopy revealed features in favor of candidiasis; however, histopathology displayed characteristic features of herpes infection. Herpes esophagitis should thus be suspected in immunocompromised patients with an independent underlying pathology and treated early with antiviral agents like acyclovir to prevent impending complications.

Detection of Human Leukocyte Antigen B27 by Flowcytometry in Patients With Suspected Ankylosing Spondylitis in a Tertiary Care Centre.

Introduction Human leukocyte antigen B27 (HLA-B27) is strongly implicated in the pathogenesis of ankylosing spondylitis (AS). Hence, HLA-B27 testing is routinely used in the diagnosis of AS. Objectives We aimed to establish the frequency of HLA-B27 in AS patients by flow cytometry and relate the differences between B27+ and B27- cases to the serum concentrations of rheumatoid arthritis factor (RA), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Methods  The study population included a total of 210 patients who visited the tertiary health care center. The peripheral blood samples obtained from AS patients were subjected to a qualitative two-color direct immunofluorescence method using the HLA-B27/CD3 antibody for the rapid detection of HLA-B27 antigen expression in erythrocyte-lysed whole blood in FACSCalibur flow cytometer (Becton Dickinson, USA). Results Out of 210 AS patients, the distribution of HLA-B27 positivity was observed only in 46 (22%) patients. The remaining 164 patients (78.1%) were negative for HLA-B27. Of the 46 HLA positive patients, 39 (25.34%) were males and only seven (12.5%) were females. In both sexes, HLA-B27 frequency was significantly higher in the age group 21-30 years, followed by 41-50 years. The current study also revealed a significant association between sex and age of onset of HLA­B27 detection in patients with suspected AS. Disease activity was not significantly correlated with RA, ESR, and CRP. Conclusions The detection of HLA-B27 by flow cytometry proved to be a reliable test in the screening of AS in the Indian population.

Clinical Evaluation of Proline, Glutamic acid, and Leucine-Rich Protein 1 Expression in Astrocytomas and Correlations with the Proliferation Marker Ki-67.

Malignant astrocytomas presenting in humans of any age group are a challenge to diagnose and treat. Hence, there is a quest for new markers to ascertain their grades and predict disease outcomes. Proline, glutamic acid, and leucine-rich protein 1 (PELP1), a nuclear receptor co-regulator, is an oncogene found in various cancers. We postulate that by screening for PELP1, its correlation with survival outcomes of patients across various grades can indicate a plausible novel diagnostic marker and a potential therapeutic target in gliomas. Immunostaining of 100 cases of astrocytomas for PELP1 was performed on paraffin-embedded sections. Results showed that PELP1 expression increases with higher grades; the mean H-score of PELP1 in grade-I astrocytomas was determined to be 112.3, whereas in grade-IV it was 235.1 (P value = 0.0001). Survival analysis of patients with H-score of 200-300 was only 8.8% and 68.8% in patients with scores of 0-100. PELP1 expression in high-grade astrocytomas is an important factor in determining the outcomes. Graphical abstract Evaluation of molecular expression of PELP1 along with Ki-67 LI signifies a linear increase in its expression pattern among different grades of astrocytomas from low- to high-grade tumors, which can serve as a potential prognostic molecular marker in differentiating various types of astrocytomas in humans.

Clinical Evaluation of P21 Activated Kinase 1 (PAK1) Activation in Gliomas and Its Effect on Cell Proliferation.

Glioblastomas are the primary malignant tumors of brain tissues with poor prognosis and highly invasive phenotypes. Till now Ki-67 LI has emerged as a well-studied proliferation marker that aids in tumor grading, but labeling index alone cannot predict overall survival in gliomas. P21 activated kinase 1 (PAK1) - a serine/threonine kinase has been shown to function as downstream nodule for various oncogenic signaling pathways that promote neoplastic changes. This study is designed to evaluate the expression of PAK1 across various grades and its correlation with Ki-67 LI and overall survival rates among a total number of 140 clinical brain tumors of glioma patients. We also studied the activation status of phospho PAK1 in glioma tissues and established the role of PAK1 in proliferation of glioblatoma cell lines under γ-irradiation.This study provides molecular evidence signifying the role of PAK1 and its activation status in the progression of Gliomas to more aggressive phenotypes.

Androgen Receptor Expression in Hypospadias.

INTRODUCTION: The exact mechanism behind the development of hypospadias is unclear. Research studies on androgen receptor (AR) expression are controversial with results stating all possible outcomes - AR elevated, similar, or reduced when compared to normal. AIMS: The aim is to study the AR expression and hormone levels in hypospadias patients and compare them with children having normal genitalia. METHODS: Group 1 (controls) involved patients who underwent circumcision for phimosis while Group 2 involved hypospadias patients who did not receive any preoperative testosterone. Preoperative hormonal assay included luteinizing hormone, follicle-stimulating hormone, and free testosterone levels in all the patients. The foreskin specimen was analyzed for AR expression using immunohistochemistry (anti-AR antibody PathnSitu, clone R441, 1/100 dilution). AR staining was expressed as H score. The H score was calculated by multiplying the intensity of staining and the percentage of stained cells showing cytoplasmic positivity at high power (×40). RESULTS: There were 27 patients in Group 1 while 16 in Group 2 (distal 10; proximal 6).There was no significant difference in the age distribution. The mean H score was significantly higher (189.5) in hypospadias patients compared to controls (97.5) and was significantly higher in proximal (220) compared to distal (159) hypospadias. There was no significant difference in hormone levels between groups. CONCLUSION: AR expression was significantly elevated in hypospadias patients. It was higher in proximal compared to distal hypospadias, probably due to end-organ overexpression. Further larger trials are likely to through light into this controversial subject.

Primary leiomyosarcoma of the penis: a case report.

Primary leiomyosarcoma of the penis is a very rare tumour. Only 46 cases have been reported in the English medical literature. We are presenting this case of a 59-year-old patient with a ulceroproliferative growth in his penis. Histopathology was a high grade spindle cell sarcoma, which was proved by immunohistochemistry to be a leiomyosarcoma.

The role of immunohistochemistry in the analysis of the spectrum of small round cell tumours at a tertiary care centre.

CONTEXT: The term, "Small Round - Cell Tumours" (SRCT) describes a group of highly aggressive malignant neoplasms which are composed predominantly of small and monotonous undifferentiated cells with high nucleocytoplasmic ratios. Immunohistochemistry (IHC) plays a crucial role in catagorizing the small round - cell tumours. AIMS: This study was done to analyse the spectrum of small round cell tumours over a period of five years at a tertiary care centre and to study the relevance of immunohistochemistry in making precise diagnoses of the small round cell tumours. MATERIAL AND METHODS: Formalin - fixed, paraffin - embedded sections of tumours which were diagnosed as small round cell tumours on small biopsies and resected specimens were retrieved from the files of the Department of Pathology of Sri Ramachandra Medical College and Research institute, in the period from January 2005 to December 2009. This study was confined to the bone and the soft tissues. Decalcification was performed on the bony tissues before the routine processing was done. The patients belonging to all age groups were included in this study. The small round cell tumours of the bone marrow, the spleen and the lymph node was excluded from our study. Immunohistochemical stains were performed to differentiate and categorise the small round blue cell tumours. The immunomarkers which were utilised in this study included CD45/LCA (the lymphocyte common antigen), CD20, CD3, CD99 (cluster of differentiation 99 also known as MIC2), desmin, EMA (epithelial membrane antigen), CK(cytokeratin), synaptophysin, chromogranin and GFAP (Glial fibrillary acidic protein). RESULTS: Forty three cases of small round cell tumours were analysed, which included 19 cases of NHL (non Hodgkin's lymphoma), 6 cases of Ewing/PNETs (primitive neuroectodermal tumours), 3 cases of atypical carcinoid, 3 cases of olfactory neuroblastoma, 2 cases each of rhabdomyosarcoma, Wilms tumour, neuroblastoma and synovial sarcoma and 1 case each of small cell osteosarcoma, small (oat) cell carcinoma, medulloblastoma and hepatoblastoma. By using a panel of monoclonal antibodies, we could arrive at a final diagnosis for all the 40 cases in which immunohistochemistry was performed. CONCLUSION: Our study showed that the use of immunohistochemistry was extremely beneficial. A majority of the small round cell tumours occurred between the ages of 15-45 years and the most common small round cell tumour was Non-Hodgkins lymphoma (extra lymphoreticular).