Ruptured Metastatic Pheochromocytoma: A Nightmare to the Surgeon.

Pheochromocytoma is a neuroendocrine tumor arising from the adrenal medulla, which often causes an adrenalin rush in the treating surgeon and the anesthesiologist. The tumor rupture presenting as acute abdomen and shock is a rare and life-threatening event. We present a case report of ruptured metastatic pheochromocytoma in a 37-year-old patient whose signs and symptoms included acute abdomen and shock. The exact mechanism causing the spontaneous rupture of a tumor is not clearly understood although some theories are proposed. CT scan is the most important investigation in this emergency. A high index of suspicion is needed to diagnose rupture in a known case of pheochromocytoma presenting with acute abdomen and shock. Ruptured pheochromocytoma is a rare emergency, and timely and precise diagnosis and initial primary nonsurgical approach followed by elective surgical resection are to be practiced whenever possible. When emergency exploration is imminent, a multi-specialty team should be prepared with a well-equipped ICU, rapid hemodynamic monitoring and corrections, massive blood transfusion protocol, and timely resuscitation.

Role of CD44 as cancer stem cell marker in triple-negative breast cancer and its association with histological grade and angiogenesis.

Introduction: Cancer stem cells (CSC) within the tumors play a central role in tumorigenesis. It is, thus, of utmost importance to identify these cells to develop effective cancer therapy. Triple-Negative Breast Cancer (TNBC) is an aggressive molecular subtype of breast cancer associated with poor patient outcomes. The role of CD44 immunohistochemistry (IHC) as a putative CSC in breast carcinomas, particularly of the TNBC-subtype is ambiguous, with equivocal results. Aims and Objectives: The present study aims to assess the role of CSC in breast carcinoma by immunohistochemical analysis of CD44 expression in TNBC. The association of TNBC expressing CSC with histological grade as well as with angiogenesis (using CD34 IHC) has been studied. Materials and Methods: Biopsy samples from 58 patients with infiltrating ductal carcinoma, NST were studied. The histology of the tumor was sub-classified into grades 1-3. Based on immunohistochemical analysis (ER, PR, HER2/Neu), the cases were divided into TNBC and NTNBC groups. The tissue sections were also subjected to analysis for CD44 to identify the CSC-phenotype and CD34 to evaluate angiogenesis, to determine the microvascular density (MVD). Results: Out of the 58 cases in the study, 28 were TNBC and 30 were NTNBC. CSC phenotype (CD44 positive) was expressed significantly higher in the TNBC (78%) versus the NTNBC (53%) (p-value 0.043). The MVD estimated using CD34 IHC was lower in the TNBC group in our study, though the difference was not statistically significant. A larger proportion of cases in TNBC showed a higher histological grade (35%) in comparison to NTNBC (27%). However, statistically, it was not significant. Conclusion: Our study demonstrated that CD44 as a CSC marker is seen significantly more in the TNBC category of invasive ductal carcinomas. Further large-scale studies, to confirm these findings, will be of potential therapeutic and prognostic value.

Mucinous carcinoma of the gallbladder- two rare case reports.

Gallbladder carcinomas are uncommon with female predominance in the sixth or seventh decades. Mucinous carcinomas of the gallbladder are rare with few cases documented in the literature. We present two cases of mucinous carcinoma of the gallbladder one of which was incidentally detected. The first case is a 65-year-old female who was diagnosed clinically with a suspected case of carcinoma of the gallbladder with the help of contrast-enhanced computed tomography. Microscopy showed extensive areas of mucin pools (>90% of the tumor), atypical cells in three-dimensional clusters, and scattered singly in the mucin pools. Immunohistochemistry revealed a strong expression of MUC2 by the tumor cells. The second case is a 60-year-old female who was diagnosed clinically with a case of chronic cholecystitis; however, the cholecystectomy specimen showed a mucinous growth in the fundus and body of the gallbladder, microscopy of which showed extensive mucin pools (>90% of the tumor) along with scattered signet-ring cells. Both the cases were reported as mucinous carcinoma of the gallbladder. Mucinous carcinoma of the gallbladder exhibit more aggressive behavior than conventional gallbladder carcinomas. Documentation of these rare cases will encourage further research to find out their true incidence and adequate management of the patient.

Staging a great escape -Incidentally detected renal urothelial carcinoma with extensive squamous metaplasia presenting as pyonephrosis.

Incidentally, detected upper urinary tract urothelial carcinoma is a rare entity. We report the case of a 70-year-old female patient who presented with flank pain, pyuria, fever, and a unilateral nonfunctioning kidney with nephrolithiasis and pyonephrosis on pyelography. Routine imaging failed to identify a mass lesion. In an Indian setting, the clinical differential of tuberculosis was considered likely. A nephrectomy was performed in view of the poor perfusion and functional status of the right kidney. Histopathological examination of the kidney showed a tumor of urothelial origin arising at the renal pelvis displaying extensive squamous metaplasia. Such a near total metaplastic change is rare and has hitherto been undescribed in the renal pelvis. Activation of pleuripotent urothelial stem cells in the setting of chronic irritation and inflammation may be the pathogenetic process behind such an occurrence.

Metastatic Epithelioid Malignant Peripheral Nerve Sheath Tumor in a Known Case of Neurofibromatosis-1, Cytomorphological Appearance, and Critical Analysis of Immunohistochemistry.

Malignant peripheral nerve sheath tumors (MPNSTs) are rare soft tissue tumors commonly arising from nerve roots in the extremities with a predilection in neurofibromatosis (NF) patients. MPNSTs are known to behave aggressively, with worse prognosis in nonresectable cases, and a 5-year survival of about 52% and 15% in resectable and unresectable cases, respectively. Although cytological diagnosis in a known case of NF-1 is possible, however, in the absence of any associated syndrome in a sporadic case, it is very challenging to accurately diagnose this tumor. Till date, to the best of our knowledge, only three cases of epithelioid MPNST correctly diagnosed on cytological examination have been described. We are presenting another case of epithelioid MPNST in a 40-year-old patient with stigmata of NF-1 since childhood, diagnosed on fine-needle aspiration cytology from the left flank mass with subsequent histopathology from left inguinal lymph node metastasis.

Abdominal tuberculosis: A retrospective analysis of 45 cases.

Abdominal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal organs with Mycobacterium tuberculosis. The peritoneum and the ileocaecal region are the most likely sites of infection and are involved in the majority of the cases by haematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. Pulmonary tuberculosis is apparent in less than half of the patients. Patients usually present with abdominal pain, and the cause is usually identified through a combination of radiologic, endoscopic, microbiologic, histologic and molecular techniques. Anti-microbial treatment is the same as for pulmonary tuberculosis. Surgery is occasionally required.