Low-grade appendiceal mucinous neoplasms: Histomorphological spectrum in a tertiary care hospital.

BACKGROUND: Low-grade appendiceal mucinous neoplasms (LAMNs) are benign non-invasive epithelial proliferations of the appendix. These usually present clinically as mucoceles and these rarely exceed 2 cm in diameter. Lesions confined to the lumen are labelled as LAMN; however those in which mucin spreads outside the peritoneum are labeled as pseudomyxoma peritonei (PMP). AIMS AND OBJECTIVE: A retrospective study was conducted over a period of three years and all cases of appendectomies were studied. Twelve cases of LAMN were identified, which is a diagnostic dilemma for the pathologists and clinicians. RESULTS: LAMN was identified based on the histopathological features. Out of the 12 cases, 9 were classified as LAMN and 3 as appendiceal neoplasm with PMP. There was villous or flat proliferation of epithelial lining, loss lymphoid aggregates, and dissecting mucin within muscularis. CONCLUSION: LAMNs are rare neoplasms of the appendix, with clinical presentation similar to acute appendicitis. Mucinous collections within the appendiceal wall should be extensively searched for mucosal changes and, if found, should prompt a careful search for pushing invasion of LAMNs. A thorough and vigilant gross examination can be of great help. Appendicectomy is the treatment of benign and grossly intact mucinous neoplasm.

Primary mucosal malignant melanoma (PMMM) of nasal cavity: A report of two cases.

ABSTRACT: Primary mucosal malignant melanoma of the nasal cavity is a rare tumor with aggressive behavior and a dismal prognosis. An extremely rare tumor that accounts for 0.7% to 1% of all melanomas in Caucasian populations and between 4% and 8% of malignant tumors of the nasal cavity and paranasal sinuses. Taking into account the rarity, it is important to note that malignant melanoma should be considered when making a differential diagnosis of tumors of the nose and paranasal sinuses. Two cases of primary malignant melanoma of the nasal cavity both arising in females, one in a 60-year-old and the other in a 64-year-old, both of whom presented with nasal obstruction and brief symptomatic epistaxis are being presented here. The diagnosis being confirmed by a histopathological examination along with an immunohistochemical analysis by using S100 and HMB45.

Cytological diagnosis of cutaneous granular cell tumor: Rare tumor with rare presentation.

ABSTRACT: Granular cell tumors (GCTs) are uncommon soft tissue tumors, which are difficult to diagnose merely by clinical examination. Fine-needle aspiration cytology (FNAC), being an effective first-line investigation, plays a significant role in the preoperative diagnosis of GCT. However, the tumor can mimic certain other lesions; hence, a cytopathologist needs to be aware of its characteristic morphology. We report here a case of GCT, presented as a subcutaneous nodule in the first finger web. A differential diagnosis of lipoma/neurofibroma was made clinically. FNAC was done and showed characteristic features of granular cell tumor along with intranuclear inclusions and subsequently, it was confirmed on histopathology.

Prevalence and patterns of post-COVID-19 symptoms in recovered patients of Delhi, India: a population-based study.

BACKGROUND: Post-coronavirus disease 2019 (COVID-19) symptoms were widely reported. However, data on post-COVID-19 conditions following infection with the Omicron variant remained scarce. This prospective study was conducted to understand the prevalence, patterns, and duration of symptoms in patients who had recovered from COVID-19. METHODS: A prospective study was conducted across 11 districts of Delhi, India, among individuals who had recovered from COVID-19. Study participants were enrolled, and then returned for post-recovery follow-up at 3 months and 6 months interval. RESULTS: The mean age of study participants was 42.07 years, with a standard deviation of 14.89 years. The majority of the participants (79.7%) reported experiencing post-COVID-19 symptoms. The most common symptoms included joint pain (36.0%), persistent dry cough (35.7%), anxiety (28.4%), and shortness of breath (27.1%). Other symptoms were persistent fatigue (21.6%), persistent headache (20.0%), forgetfulness (19.7%), and limb weakness (18.6%). The longest duration of symptom was observed to be anxiety (138.75±54.14 days), followed by fatigue (137.57±48.33 days), shortness of breath (131.89±60.21 days), and joint pain/swelling (131.59±58.76 days). At the first follow-up visit, 2.2% of participants presented with abnormal electrocardiogram readings, but no abnormalities were noticed during the second follow-up. Additionally, 4.06% of participants exhibited abnormal chest X-ray findings at the first followup, which decreased to 2.16% by the second visit. CONCLUSION: The most frequently reported post-COVID-19 symptoms were joint pain, dry cough, anxiety and shortness of breath. These clinical symptoms persisted for up to 6 months, with evidence of multi-system involvement. Consequently, findings highlighted the need for long-term follow-up during the post-COVID-19 period.

Leiomyoma of the Nipple: A Rare Entity at Rare Site.

Cutaneous leiomyomas are benign and rare smooth muscle tumors. Genital leiomyoma includes leiomyomas located in the nipple, scrotum, areola or vulva. Nipple leiomyomas are the least common genital leiomyomas and are commonly seen to occur in middle-aged women. Here, we present a case of a 40-year-old female complaining of a growth over the right nipple for six months. On local examination, it was a 1cm x 1cm growth on the lateral aspect of the nipple. Finally, a treatment plan of complete excision was done. Grossly, it was a well-circumscribed skin-covered soft tissue bit with a skin flap measuring 0.6cm x 0.6cm and soft tissue measuring 0.6cm x 0.5cm x 0.2cm. Histopathological examination revealed a skin-covered section with dermis showing a well-circumscribed unencapsulated lesion that showed intersecting fascicles of spindle cells with no atypia or mitoses noted. Microscopically, the growth had tumor-free resection margins. Immunohistochemical confirmation with S100, smooth muscle actin (SMA) and caldesmon was done. Diagnosis of nipple leiomyoma was given with strong SMA positivity. Nipple leiomyoma is a rare, benign lesion and needs to be correctly diagnosed microscopically. Biopsy and immunohistochemistry is a confirmatory investigation that can lead to timely management of the patient.

Telangiectatic osteosarcoma of the mandible-A rare case report and an insight into differential diagnosis.

Telangiectatic osteosarcoma (TOS) is a rare variant of osteosarcoma that typically affects young individuals and long bones. The case under discussion was seen in the mandible of a 57-year-old female and had rapidly grown in size within a week. Microscopically, the tumour was characterised by large vascular cavities surrounded by anaplastic cells. Thin lacy tumour osteoid was observed at various foci. Abundant multinucleated osteoclastic giant cells along with areas of necrosis were also noted. The tumour cells were positive for SATB2, while negative for Cytokeratin AE1/3, CD 34. Ki-67 positivity was observed in more than 50% of tumour cells. A diagnosis of high grade telangiectatic osteosarcoma was thus made.

Endometrial stromal tumors: A clinico-histomorphological spectrum of endometrial stromal tumors with review of literature.

BACKGROUND: Endometrial stromal tumors (ESTs) are rare subset of mesenchymal uterine neoplasms. There are heterogeneous morphological, immunohistochemical, and genetic features. Approximately 50% of ESTs occur in perimenopausal women. In 2020, WHO sub-categorized ESTs into four groups: endometrial stromal nodule (ESN), low-grade endometrial stromal sarcoma (LGESS), high-grade endometrial stromal sarcoma (HGESS), and undifferentiated uterine sarcoma (UUS). OBJECTIVE: To review the morphological spectrum of endometrial stromal tumors. METHOD: This retrospective study reviewed the histomorphological features of 15 endometrial stromal tumors with respect to atypia, necrosis, mitosis, collagen bands, whorling around vessels, myometrial invasion, and inflammatory cells. Immunohistochemistry markers (CD10, SMA, and ER) along with special stains (Masson's trichrome, toluidine blue) were also studied. RESULTS: The age of the patients ranged from 32 to 60 years. Three patients were postmenopausal. The most common presenting symptom was vaginal bleeding. Five patients were operated with a clinical diagnosis of uterine fibroid. One patient presented with prolapse with no other complaint. All the 15 patients had total abdominal hysterectomy and salpingo-oophorectomy. One case showed necrosis, eight cases showed collagen bands, all the 15 cases showed whorling around vessels, one case showed vascular emboli, and seven cases showed inflammatory cells. In low-grade cases, one case showed focal atypia and one case showed focal coagulative necrosis indicating infarction. Thirteen cases were LGESS, and one case of ESN and HGESS. All cases were positive for ER and CD10. CONCLUSION: Endometrial stromal tumors demonstrate extensive permeation of the myometrium as irregular islands with frequent vascular invasion, whorling around vessels, collagen bands, and inflammatory cells. All these features should be observed thoroughly on microscopy by pathologists to clearly differentiate the low-grade and high-grade endometrial stromal tumors, and to understand the overlapping gray areas morphologically as it affects the prognosis of the patient.

Leiomyosarcoma of sphenoid sinus- A rare tumor at an unusual site.

Leimyosarcoma (lms) is a malignant soft tissue tumor of smooth muscles. The tumor arises intramuscularly and in subcutaneous locations. It is unusual to encounter lms in head and neck region, even more infrequent to discover lms in nasal and paranasal sinuses. A case of 28 years old male with leiomyosarcoma originating from sphenoid sinus with intracranial extension is being presented with aim to highlight its rarity and to highlight the differential diagnosis and the need for prudent diagnosis in the work-up of the patient.

Schwannoma-like pleomorphic adenoma: A pathological quandary.

ABSTRACT: Pleomorphic adenoma usually presents as a painless growing mass in locations of the salivary glands and is notorious for local recurrence if previous surgical resection is incomplete. Schwannoma is a benign peripheral nerve tumor with microscopic features of sheets of spindle-shaped cells with nuclear palisading. However, when a pathologist encounters a salivary gland tumor with microscopic morphological features of biphasic components with areas of schwannoma-like morphology, it is crucial to make a prudent diagnosis by differentiating Schwannoma-like pleomorphic adenoma and its differential diagnosis as they have remarkably different outcome in patients. We herein present a case of Schwannoma-like pleomorphic adenoma and discuss its approach to diagnosis and literature search.

Alveolar Rhabdomyosarcoma of the Temporal Region with Metastatic Cervical Lymph Node.

Introduction: Paediatric rhabdomyosarcoma most commonly occurs in the head and neck region. Its treatment is complex, including multi-drug chemotherapy, surgery and radiotherapy. Case report: Here, we report a case of alveolar rhabdomyosarcoma of the temporal region with a metastatic cervical lymph node, in a 15-year-old girl, and its management. The patient received ne-adjuvant chemotherapy, followed by surgery and post operative radiotherapy. Literature was also reviewed for the various treatment modalities for these rare tumours. Discussion: Rhabdomyosarcoma of the temporal region has rarely been reported in the literature. Due to the rarity of these tumours, there are difficulties in creating standardized therapeutic protocols. However, multimodality treatment, including chemotherapy, surgery and radiotherapy, has been shown to improve the overall survival rate.

Direct immunofluorescence (DIF) versus immunohistochemical (IHC) staining of complements and immunoglobulins (Ig) in pemphigus group.

INTRODUCTION: Pemphigus is a group of bullous disorders of the skin characterized by the formation of autoantibodies present in the intercellular junction of the epidermis. Diagnosis is made by clinical, histopathological examination, and DIF. As DIF needs frozen sections, fluorescent tagged antibodies, UV light microscope for examination, and trained personnel, its non-availability makes a definitive diagnosis challenging. AIMS AND OBJECTIVES: To evaluate the utility of IHC staining of complements and Ig in cases of Pemphigus. MATERIALS AND METHODS: Twenty-six diagnosed cases of Pemphigus were stained by Peroxidase immunohistochemical method using monoclonal antibody to IgG, IgA, IgM, IgG4, C3, C4 d with DAB as chromogen. Pemphigus cases include twenty of pemphigus vulgaris (PV), four cases of pemphigus foliaceous (PF), and two of pemphigus vegetans (Pveg). Positivity was defined as the deposition of Ig and complements as distinct, continuous brown staining of keratinocytes at intercellular junctions. RESULT: On IHC total of 20 PV 17 showed positivity (85%) for IgG, 11 (55%) C4d, 19 (95%) C3d, and 16 (80%) IgG4 deposits at the intercellular junction of the epidermis. All cases of PF showed a deposit of IgG, with three (75%) cases for IgG4, C3d, and C4d. Both cases of Pveg showed positivity for IgG and C4d while one case was negative for IgG4 and C3d. The overall IgG, C3, IgG4, and C4d expression for pemphigus was seen in 88%, 88%, 76.9%, and 61.5% of cases. The relation between these markers, combination of IgG and C3, was best related to each other ( P value = 0.80). The sensitivities for IgG, IgG4, and C3 were 77.8%%, 73%, and 73% resp. CONCLUSION: We conclude that IHC is a useful tool in the diagnosis of PV with the highest sensitivity of IgG and C3d. The combination of IgG and C3d could replace the DIF in almost all of our cases, so IHC on FFPE sections be used as an alternative method to DIF.

Multicystic renal dysplasia, a histomorphological spectrum: Seven years experience from a tertiary care hospital.

OBJECTIVES: Multicystic dysplastic kidney (MCDK) is defined as the presence of multiple noncommunicating cysts of various sizes, detected sonographically, without evidence of functioning renal parenchyma on dimercaptosuccinic acid renal scan. It has an incidence of 1:4000 live births. They are more commonly diagnosed in boys, usually on the left side, but may also be bilateral. There is the presence of primitive ducts surrounded by fibromuscular connective tissue. These are because of the disturbed connection of the ureteric bud with renal blastema and abnormal division at the stage of metanephros, resulting in an abnormal metanephros differentiation. MATERIALS AND METHODS: Thirty cases of MCDK were included to study their histomorphology along with their clinical features. Cases were retrieved from the last seven years (2015-2021) from the Department of Pathology, Maulana Azad Medical College. RESULT: Age ranged from 10 days to 18 years. The cases were between 1 years and 5 years of age. Six out of 30 cases (20%) were infants with three of them being neonates. Twenty-one cases were males. All the cases had unilateral kidney involvement with the left kidney being involved in 20 out of 30 cases. Twenty-eight cases underwent nephrectomy in view of small contracted nonfunctional kidneys with one of them being horseshoe shaped. Five cases had associated hydronephrosis (two ipsilateral and three bilateral). One case had Hirshprung's disease, four had anorectal malformation, two had posterior urethral valves with vesicourethral reflux, one had duplex moiety, and one had undescended testes. On histopathological examination, all of them showed the presence of immature disorganized tubules surrounded by a collarette of immature mesenchymal stroma. One of the cases showed osteoid formation and four had areas of immature cartilage. Normal kidney parenchyma was seen at the periphery in four cases. CONCLUSION: This series has been presented to highlight the various histomorphological features of MCDK. MCDK can be managed conservatively in most of cases due to autoinvolution and, hence, needs to be differentiated from other close differentials like polycystic kidney disease, cystic nephroma, and cystic partially differentiated nephroblastoma in order to avoid unnecessary surgical intervention.

Sebaceous carcinoma with apocrine differentiation arising in a known case of basal cell carcinoma: A rare entity.

Sebaceous carcinoma is a ra malignant tumor of adnexal origin arising from sebaceous glands. It is most commonly seen arising from the eyelids and head and neck. It is predominantly seen in females with an average age of around 65 years. Apocrine differentiation in sebaceous carcinomas is rare but has been reported in the literature. Here, we present a case of sebaceous carcinoma with apocrine differentiation in a 62-year- old female who was a diagnosed case of basal cell carinoma.

Sarcomatoid Carcinoma of Larynx: A Rare Case.

Sarcomatoid carcinoma is a rare tumour consisting of both sarcomatous and carcinomatous elements. It accounts for less than 1% of laryngeal malignancies. This case report describes sarcomatoid carcinoma of the larynx in a 54-year-old male managed by total laryngectomy with post operative radiotherapy. Surgery is the treatment modality of choice for this rare entity. However, early stage sarcomatoid carcinoma tumours are better treated with radiotherapy alone similar to early stage squamous cell carcinoma of the larynx with favourable results.

Metaplastic breast carcinoma: Analysis of clinical and pathologic features, a five-year study.

Background: Metaplastic carcinoma breast (MCB) is a rare tumor comprising of both glandular and non-glandular patterns with epithelial and or mesenchymal components. Due to their varied clinicomorphological features, diagnosis has been challenging. Aim: To study the clinicopathological and histomorphology of cases of metaplastic carcinoma breast diagnosed in a tertiary care hospital along with literature review. Materials and Methods: This is a retrospective study including data of 11 patients who were diagnosed with MCB either on trucut or mastectomy specimens conducted between January 2014 and December 2018. Results: The study includes 11 patients, out of which 10 were diagnosed on mastectomy while one on trucut specimen. All the patients were women with the mean age of presentation being 43.8 years. The most common presentation was palpable breast lump with mean tumor size of 7.3 cm in greatest dimension. Skin involvement was seen in 36.3% of cases. While eight cases (72.7%) were classified as epithelial, three (27.2%) were classified as mixed. Amongst epithelial variety, in eight cases, squamous component was seen along with infiltrating ductal carcinoma (IDC) while one was pure squamous type. In mixed variety, one case showed spindled areas along with squamous areas and areas of IDC. Other two showed focal sarcomatous and cartilaginous areas in one and angiosarcomatous, bone and cartilage formation admixed with areas of IDC in other case. Conclusion: MCB are rare breast tumors with aggressive course and are characterized by their large size and rapid growth rate. Recently, there has been an upsurge in the cases of MCB due to increase in recognition of this entity. It has to be distinguished from other tumors by the pathologists so as to guide proper treatment.

Coexisting ovarian serous cystadenoma with fibroma: A very unusual combination.

Surface epithelial neoplasms are the most common ovarian tumors, constituting around 60% of all ovarian malignancies. They are classified as benign, borderline, and malignant. Ovarian cystadenomas are common benign epithelial neoplasms which carry an excellent prognosis. Ovarian thecoma-fibroma groups are uncommon sex cord-stromal neoplasms, constituting 1.0%-4.0% of all ovarian tumors. Most of them are benign and often found in postmenopausal patients. Combination tumors in the ovary are known. The most common combination is mucinous cystadenoma which occurs in association with Brenner tumor, mature cystic teratoma, Sertoli-Leydig cell tumor, or even a serous cystadenoma. A combination of surface epithelial and thecoma-fibroma group is very rarely encountered. A case of one such combination of serous cystadenoma and fibroma of the ovary is being presented here in a postmenopausal woman.

Correlation of ultrasound-based TIRADS and the Bethesda system for reporting of thyroid cytopathology: A study in a tertiary care centre.

BACKGROUND: The age-standardised incidence rate of thyroid cancer in India is 1 in 416 in the general population. This increased incidence has mainly been attributed to improved detection methods for small thyroid lesions. Two such methods are the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TIRADS) and the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). AIMS AND OBJECTIVES: To study the correlation between ACR TIRADS and TBSRTC, and between each system and the final histopathological report. MATERIALS AND METHODS: Thyroid cytopathology cases were retrieved for the period January 2019 to July 2022. For each case, the TIRADS score and Bethesda category were noted. Histopathology specimens were also traced. RESULTS: The study comprised 1100 cases, with 955 female and 145 male patients (M:F = 1:6.59), and ages ranging between 7 and 85 years. The TIRADS scoring was available for 1036 cases. Histopathology was available for 231 cases. There was a significant correlation between TIRADS and TBSRTC, with a p-value of 0.000 and a substantial Kappa agreement of 0.688. Both TIRADS and TBSRTC also had significant correlations with the histopathology data, with a p-value of 0.000 for each. The sensitivity values for TBSRTC and TIRADS were 69.4% and 65.8%; specificity, 99.3% and 96.5%; positive predictive value (PPV), 98.3% and 91.8%; and negative predictive value (NPV) 84.7% and 84.4%, respectively. The risk of malignancy (ROM) was also calculated and was found to be high, especially for TBSRTC II, III, IV and V (11.3%, 20%, 61.5%, 97.4% respectively) and TIRADS 2 and 3 (10.3% and 29.6% respectively). CONCLUSION: The TIRADS and TBSRTC systems of categorisation of thyroid lesions are concordant and could help improve the overall survival rate of patients with thyroid malignancies.

Histopathological response to denosumab in giant cell tumours of bone - A review of 11 cases.

Background: Giant cell tumor (GCT) of the bone is a locally aggressive primary bone tumor, that can rarely metastasize. Arising mostly in epiphysis of the long bones in young adults, the tumor is composed of mononuclear cells that are admixed with osteoclastic giant cells(OLGCs), which express RANK ligand and RANK respectively. Denosumab a monoclonal antibody against RANK ligand has been shown to reduce the tumor by causing bone lysis by inhibiting RANKL. Histological changes in 11 patients of GCT who were treated with denosumab are presented here. Materials and Methods: Clinical records and slides of 11 patients of GCT who had been administered neoadjuvant denosumab were included in the study. Evaluation of pre and post therapy GCT specimens was performed by two pathologists (RK and VM). There were 4 males and 7 females. Their mean age was 30 years. All the patients received 120 mg denosumab subcutaneously every week with additional 120 mg on days 8 and 15 of therapy. The histological slides were reviewed and following points noted: 1) degree of ossification,2) fibrosis,3) loss of osteoclastic giant cells,4) proliferation of mononuclear cells,5) atypia,6) Permeation of osteoid by malignant cells. Results: Out of 11 cases, 2 cases did not show any significant histological improvement. 7 cases showed reduction in giant cells, increased fibrosis, enhanced mononuclear cell proliferation and ossification consistent with a pathological response. Atypia and osteoid permeation were noted in 2 cases which showed transformation to osteosarcoma. Conclusion: Denosumab treated giant cell tumor show dramatic histological changes. The post therapy lesions may bear no resemblance to pretherapy lesion. There may be complete resolution or may be confused with benign or malignant lesions Rarely they may show sarcomatous transformation. It is imperative that the pathologist is aware of these changes to prevent diagnostic pitfalls as it poses therapeutic and prognostic implications.