Outcomes Following Excision of Toe Glomus Tumors.

BACKGROUND: Glomus tumors are uncommon tumors and their occurrence in the foot is even less common. Glomus tumors of the toes are often missed, causing delays in diagnosis and treatment. We report an ambispective observational study of glomus tumors of the toes that were treated at our institution. METHODS: We reviewed the records of all the patients who underwent excision of toe glomus tumors in our department from January 2010 to September 2022. The follow-up data were collected from the outpatient records and by telephonic interview. Single Assessment Numeric Evaluation (SANE) score, Foot and Ankle Outcome Score (FAOS), and the Foot Function Index (FFI) were collected. RESULTS: Out of all the patients treated for glomus tumors, we found that 7 patients had glomus tumors of the toes. Of the 7 patients, 6 were women and 1 was a male. The mean follow-up of our patients was 66.4 months (range, 7-109 months). Of the 7 patients, 1 presented with recurrent glomus tumor 30 months following the primary operation, for which she underwent excision again, after which she was symptom free. Another patient who developed recurrent symptoms on telephonic interview refused any further treatment. Among the 6 patients who were symptom-free at follow-up (including the patient who underwent excision for the recurrent tumor), the median SANE score, and FFI were 99.5 (IQR, 96-100) and 0.5 (IQR, 0-2) respectively. The mean FAOS was 96 (SD, 3.3). CONCLUSION: Surgical excision of the subungual toe glomus tumors can be curative. Recurrence of toe glomus tumors was noted in 2 patients (29%), one of whom refused further surgery. Re-excision in the other patient resulted in complete resolution of symptoms. LEVEL OF EVIDENCE: Level III, ambispective observational study.

En Bloc Excision and Bone Grafting for Monostotic Multiple Intraosseous Glomus Tumors of the Distal Phalanx: A Case Report.

CASE: Glomus tumors of the hand are rare tumors that occur predominantly in the subungual region. Though multicentric glomus tumors have been reported in the subungual region involving the nailbed, monostotic multiple intraosseous glomus tumors have not been reported so far. We report a case of a 36 year-old woman who presented with a 5-year history of intermittent thumb pain, aggravated with exposure to cold or pressure. A glomus tumor of the thumb was excised, but symptoms returned 3 months later. She ultimately underwent curettage with bone grafting of a recurrent glomus tumor at the same site, and has been free of symptoms for 1.5 years. CONCLUSION: Intraosseous glomus tumors may present as multiple synchronous lesions. This, to the best of our knowledge, is the first case report of monostotic multiple intraosseous glomus tumors.

Nonvascularized Double Metatarsal Transfer After Excision of Epithelioid Hemangioma of Hand: A Case Report.

CASE: Epithelioid hemangioma (EH) is an uncommon, benign, locally aggressive neoplasm, and it may present as multifocal lytic lesions with soft tissue involvement in the hand. We report the midterm follow-up of a patient with recurrent EH of the hand that was reconstructed successfully, with a nonvascularized double metatarsal transfer, after tumor excision. To the best of the authors' knowledge, this is the first case report where a nonvascularized double metatarsal transfer has been used successfully after tumor resection. CONCLUSION: Osteoarticular replacement with matched metatarsal transfer after en bloc resection may be used successfully for reconstruction, after the resection of EH involving the metacarpal.

Computed Tomography-Guided Spinal Biopsy in Suspected Infective Spondylodiscitis: An Institutional Review of Its Utility.

Background Infectious spondylodiscitis is a debilitating condition and evidence-based medicine dictates confirming the diagnosis before treatment. Computed tomography-guided spinal biopsy plays a major role and hence we would like to determine its utility in current clinical practice. Purpose The purpose of this study is to determine the percentage of confirmatory positives of CT-guided spinal biopsy in patients who were clinicoradiologically diagnosed with infectious spondylitis. Material and Methods A retrospective analysis of patients who underwent CT-guided biopsy for suspected infectious spondylodiscitis from 2017 to 2021 in a tertiary medical center was done. The data were filtered and obtained from the electronic database of the institution. Results In all, 259 patients underwent CT-guided biopsy of the spine. The procedure provided confirmatory results in 149 (57.5%) biospecimens. Histopathology examination was confirmatory in 95 (36.6%) of the 241 biospecimens sent. The Mycobacteria Growth Indicator Tube (MGIT) was confirmatory in 51 (19.9%) of the 250 biospecimens sent and drug resistance was seen in 6/51 (11.7%) biospecimens. Xpert TB provided confirmatory results in 72 (27.8%) of the 254 biospecimens sent and rifampicin resistance was seen in 16/72 (22.2%) biospecimens. Bacterial culture was confirmatory in 29 (11.2%) of the 250 biospecimens sent. The complication documented in this study was 0.3%. Conclusion CT-guided spinal biopsy for suspected vertebral osteomyelitis is a safe and effective minimally invasive procedure. It demonstrates a positive yield in more than half of the patients. Knowing the outcome, the patients can be appropriately counseled prior to the procedure. CT-guided biopsy results were affected by prior administration of ATT (antitubercular therapy) in suspected tuberculous spondylitis patients.

Special AT-rich sequence-binding protein 2 (SATB2) in the differential diagnosis of osteogenic and non-osteogenic bone and soft tissue tumors.

BACKGROUND: The diagnosis of osteosarcoma (OSA) depends on clinicopathological and radiological correlation. A biopsy is considered the gold standard for OSA diagnosis. However, since OSA is a great histological mimicker, diagnostic challenges exist. Immunohistochemistry (IHC) can serve as an adjunct for the histological diagnosis of OSA. Special AT-rich sequence-binding protein 2 (SATB2) was recently described as a reliable adjunct immunohistochemical marker for the diagnosis of OSA. METHODS: We investigated the IHC expression of SATB2 in 95 OSA and 100 non-osteogenic bone and soft tissue tumors using a monoclonal antibody (clone EPNCIR30A). The diagnostic utility of SATB2 and correlation with clinicopathological parameters were analyzed. RESULTS: SATB2 IHC was positive in 88 out of 95 cases (92.6%) of OSA and 50 out of 100 cases (50.0%) of primary non-osteogenic bone and soft tissue tumors. Of the 59 bone tumors, 37 cases (62.7%) were positive for SATB2, and of the 41 soft tissue tumors, 13 cases (31.7%) were positive for SATB2. The sensitivity of SATB2 as a diagnostic test was 92.6%, specificity 50%, positive predictive value 63.8%, and negative predictive value 87.7%. CONCLUSIONS: Although SATB2 is a useful diagnostic marker for OSA, other clinical, histological and immunohistochemical features should be considered for the interpretation of SATB2.

Aspergillus flavus costochondritis following coronary artery bypass grafting: a case report and a brief review of literature.

Bacterial sternal wound infections following cardiac surgery are not uncommon. However, sternal wound infection by a fungus is a rarity, and it warrants a correct diagnosis followed by specific treatment. We report a case of Aspergillus sternal wound infection with costochondritis following cardiac surgery, and briefly review the relevant literature.

P16INK4a/ki67 Immunocytochemistry in Improving the Predictive Value for High Grade Cervical Intraepithelial (≥CIN2) Neoplasia in Pap Smear.

INTRODUCTION: Cervical cytology has limited sensitivity to detect cervical pre-cancerous lesions. High-risk human papillomavirus (hr-HPV) DNA testing has high sensitivity but its specificity is limited. This study was done to assess the utility of p16INK4a/ki-67 dual stained cytology in improving the predictive value for high-grade cervical (CIN2+) lesions. AIM/OBJECTIVE: To assess the significance of P16/Ki-67 immunocytochemistry in improving the predictive value for high-grade cervical intraepithelial (≥CIN 2+) lesions on Pap smear. MATERIAL AND METHODS: This was a prospective diagnostic study that included 93 patients with ASC-US/LSIL/ASC-H and HSIL on thin prep cervical smears and who also underwent hr-HPV DNA test and colposcopy-guided biopsy. Biopsy was the gold standard against which the performance of P16INK4a/Ki-67 and hr-HPV results were compared. RESULTS: In women of all ages, sensitivity of (96.8%) hr-HPV test and p16/Ki-67 dual immunocytochemistry (≥1 positive cell) were similar and negative predictive value (NPV) was (97.1% vs. 97.9%) but the latter test showed better specificity (69.4% vs. 53.2%) and positive predictive value (PPV, 61.2% vs. 50.8%) for ≥CIN 2 lesions. A higher cut off of at least 10 positive cells gives a higher specificity and PPV, with slightly decreased sensitivity and NPV. CONCLUSION: Because high-risk HPV test has a high sensitivity and NPV, whereas P16/Ki-67 dual immunocytochemistry (≥10 positive cells) has a high specificity and PPV, the latter can be recommended as an ancillary test in hr-HPV-positive women to reduce the number of women going for colposcopy and biopsies.

Imprint Cytology of Thoracoscopic Pleural Biopsy Tissue for Early Etiological Diagnosis of Pleural Effusion: A Pilot Study From India.

Thoracoscopic pleural biopsy provides the highest diagnostic yield in both malignant and tubercular pleural effusions. However histopathologic report takes 3 to 5 days to provide the diagnosis, resulting in a delay of further management plans like pleurodesis or chest tube removal. Imprint cytology of biopsy tissue can provide early information about the etiological diagnosis. Thus, we conducted this pilot study in 66 patients of exudative pleural effusions undergoing medical thoracoscopy. One or 2 biopsy pieces obtained during medical thoracoscopy from pleural nodules were used to prepare imprint cytology slides in the thoracoscopy suite. In comparison to thoracoscopic pleural biopsy, the diagnostic yield of imprint cytology of pleural tissue was 92% (49 of 53 cases) in cases of malignant pleural effusion and 75% (9 of 12 cases) in cases of tuberculosis pleural effusions. Imprint cytology provided a definite idea about the type of diagnosis, about 2.5 days before the histopathology results. By providing early etiological diagnosis, it may also decrease the duration of hospital stay and health care expenditure. A large prospective trial has been planned in our center to confirm this hypothesis.

An uncommon cause of polyarthralgia.

Tumour induced osteomalacia (TIO) is a paraneoplastic syndrome characterized by renal phosphate wasting and hypophosphatemic osteomalacia, caused by FGF-23 (Fibroblast growth factor-23) producing mesenchymal tumours. Here, we report the case of a 40 year old lady referred by her family physician for multiple joint pains of 2 years duration. There was no evidence of inflammatory arthritis. Biochemical investigations revealed low phosphorus, with raised alkaline phosphatase and high levels of FGF-23. As a TIO was considered likely, functional imaging with a DOTATATE PET scan was done, which revealed a DOTA avid lesion in the right foot. Following surgical excision of the tumour, there was significant relief in symptoms and gradual recovery of phosphate to normal levels. It is relevant and important for family physicians as in subjects with symptom like polyarthralgia, a simple measurement of analytes like phosphate, calcium and alkaline phosphatase in primary care setting will help to arrive at a cause and referral for further evaluation as this condition is potentially treatable.

An Insight into the Utility of Sub-Categorisation of Atypia of Undetermined Significance for Risk Stratification: A Retrospective Study on an Indian Cohort with Histopathological Correlation.

BACKGROUND: Atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) criterion in thyroid fine-needle aspirates (FNAs) has been a heterogeneous entity with much inter-observer variation. Sub-categorisation of AUS/FLUS has been observed to play an effective role in risk stratification. We aimed to validate AUS/FLUS sub-categorisation in correlation with the spectrum of malignancy. STUDY DESIGN: Subjects included patients with AUS/FLUS diagnosed between January 2015 and December 2016. AUS/FLUS cases were sub-categorised into those exhibiting (1) architectural atypia, (2) cytological atypia, (3) architectural and cytological atypia, (4) AUS with Hürthle cells, and (5) AUS not otherwise specified (AUS-NOS). Each sub-category was correlated with their corresponding incidence of malignancy in surgical resections. RESULT: The overall incidence of AUS/FLUS in our centre was 13% (132/1,018). On retrospective review of 117 patients with AUS/FLUS, smears with cytological atypia showed a higher incidence of malignancy (78.3%) than those with architectural atypia (75.3%). AUS/FLUS cases with both cytological and architectural atypia had a malignancy rate of 71.4%. CONCLUSION: AUS/FLUS cases with cytological atypia had a higher risk of malignancy than those with architectural atypia. The sub-categorisation of AUS/FLUS is diagnostically important for the proper risk stratification of patients.

Ultrasound-guided Fine-needle Aspiration Cytology along with Clinical and Radiological Features in Predicting Thyroid Malignancy in Nodules ≥1 cm.

AIMS AND OBJECTIVES: The aim of the study is to examine the adequacy and accuracy of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in thyroid nodules ≥1 cm and to analyze the clinical, sonological, and cytological features in predicting thyroid malignancy. MATERIALS AND METHODS: US-FNAC was done on 290 patients from December 2013 to December 2014 by the radiologist. The Thyroid Imaging Reporting and Data System (TIRADS) was used to record the sonological features. FNAC samples were reported by a dedicated cytopathologist. Accuracy was calculated by comparing US-FNAC, clinical features and ultrasound (US) features for those who had final histopathology till April 2017. RESULTS: The adequacy of US-FNAC in this study was 80.2%. Thyroidectomy was performed in 128/290 (44.1%). The sensitivity and specificity of US-FNAC in this study is 83.9 and 76.3%, respectively, with a positive predictive value of 85.2%, negative predictive value of 74.4%, and an accuracy of 81% in predicting malignancy in thyroid nodules ≥1 cm. The malignancy rate in benign FNAC sample was 25% (10/40), and was 69% (8/13) in those with a follicular lesion of undetermined significance (FLUS). Around 80% of benign and 89% of FLUS had follicular variant of papillary carcinoma of thyroid (FVPTC). US-FNAC, a high TIRADS score, and US features such as marked hypoechogenicity, taller than wide, irregular margins, microcalcification, and clinical features, such as hard in consistency and significant cervical lymph nodes, were important in predicting malignancy (P < 0.001). CONCLUSIONS: The accuracy of US-FNAC in this study is 81%. The US-FNAC, a high TIRADS score, a hard thyroid nodule, and significant cervical lymph nodes are important in predicting malignancy. The accuracy rate in benign and atypia undetermined significance categories needs to improve in this study. Further research to help in decreasing false negative rates of FVPTC will help in increasing the accuracy of US-FNAC in the present study.

Paget's Disease of Bone: An Entity Still Exists in India.

BACKGROUND: Paget's disease of bone (PDB) is uncommonly reported from India. We attempted to study the clinical and imaging features and management of participants who presented with PDB. MATERIALS AND METHODS: In this retrospective study, clinical and imaging profile, biochemistry, and treatment outcomes of participants with PDB (n = 48) were obtained. RESULTS: The mean age was 60 ± 11.3 years and 35% were women. Twenty percent were asymptomatic. Many (87%) had polyostotic involvement. Sixty percent (n = 29) underwent treatment with zoledronic acid and rest with oral bisphosphonates, and all achieved remission. CONCLUSION: Most of the pagetic participants had polyostotic disease and one-fifth were asymptomatic. All participants had disease remission following treatment.

Undifferentiated thymic carcinoma with intracranial metastasis in a two-year-old.

Thymic carcinoma with central nervous system involvement is very rare in children. A 27-month-old girl presented with a unilateral squint, vomiting, and behavioral changes. Imaging studies showed a silent anterior mediastinal mass and a large metastatic mass at the base of the skull. Biopsy of the anterior mediastinal mass confirmed an undifferentiated tumor consistent with thymic carcinoma. The child died within 3 months of the onset of symptoms, due to progression of the disease. These lethal tumors of unknown histogeneses and etiology are aggressive in nature, resistant to therapy, and have a rapidly fatal course.

Clinicopathological Study of 18 Cases of Inflammatory Myofibroblastic Tumors with Reference to ALK-1 Expression: 5-Year Experience in a Tertiary Care Center.

BACKGROUND: Inflammatory myofibroblastic tumor is a histopathologically distinctive neoplasm of children and young adults. According to World Health Organization (WHO) classification, inflammatory myofibroblastic tumor is an intermediate-grade tumor, with potential for recurrence and rare metastasis. There are no definite histopathologic, molecular, or cytogenetic features to predict malignant transformation, recurrence, or metastasis. METHODS: A 5-year retrospective study of histopathologically diagnosed inflammatory myofibroblastic tumors of various anatomic sites was conducted to correlate anaplastic lymphoma kinase-1 (ALK-1) expression with histological atypia, multicentric origin of tumor, recurrence, and metastasis. Clinical details of all the cases were noted from the clinical work station. Immunohistochemical stains for ALK-1 and other antibodies were performed. Statistical analysis was done using Fisher exact test. RESULTS: A total of 18 cases of inflammatory myofibroblastic tumors were found during the study period, of which 14 were classical. The female-male ratio was 1:1 and the mean age was 23.8 years. Histologically atypical (four cases) and multifocal tumors (three cases, multicentric in origin) were noted. Recurrence was noted in 30% of ALK-1 positive and 37.5% of ALK-1 negative cases, whereas metastasis to the lung, liver, and pelvic bone was noted in the ALK-1 positive group only. CONCLUSIONS: Overall, ALK-1 protein was expressed in 55.6% of inflammatory myofibroblastic tumors. There was no statistically significant correlation between ALK-1 expression, tumor type, recurrence and metastasis. However, ALK-1 immunohistochemistry is a useful diagnostic aid in the appropriate clinical and histomorphologic context.

Musculoskeletal oncogenic osteomalacia-An experience from a single centre in South India.

BACKGROUND: Oncogenic osteomalacia is an acquired form of hypophosphatemic osteomalacia where the tumour resection may lead to cure of the disease. Tumours originating from the musculoskeletal region form an important subgroup of oncogenic osteomalacia. METHODS: This was a retrospective study conducted at a tertiary care centre in south India where we analyzed the hospital records of all the patients with musculoskeletal oncogenic osteomalacia from January 2010-April 2016. RESULTS: A total number of 73 patients were diagnosed to have adult onset hypophosphatemic osteomalacia out of which 13 patients (M: F = 6:7; mean age: 45.38 ± 18.23 years) with musculoskeletal oncogenic osteomalacia were included in the study. Common presenting symptoms were bony pains, proximal myopathy and fractures. Mean duration of symptoms from the initial hospital visit was 58.46 ± 64.48 months. The initial mean fibroblast growth factor (FGF) 23 levels being 828.86 ± 113.22 RU/ml (Normal range: 22-91). Imaging modalities used for localization of the tumour: DOTATATE PET/CT (8 patients), FDG PET/CT (3 patients), 1 patient (Both DOTATATE PET/CT and FDG PET/CT) and whole body Tc 99 m Red blood cell (RBC) blood pool scintigraphy (2 patients). 9 patients underwent surgery and all achieved remission. 4 patients denied surgical consent. CONCLUSION: Musculoskeletal oncogenic osteomalacia is a major subgroup of oncogenic osteomalacia which need more extensive whole body imaging for the localization of the tumour. Surgical excision often leads to remission of the disease.

Paraneoplastic Pemphigus Associated with Follicular Dendritic Cell Tumor in the Mediastinum.

Paraneoplastic Pemphigus (PNP) is an autoimmune bullous disease characterized by severe stomatitis, polymorphous skin eruptions, and underlying neoplasms. Diagnosis of cutaneous paraneoplastic disorders requires high index of suspicion. We describe a patient with PNP associated with follicular dendritic cell (FDC) tumor in the mediastinum, a rare neoplasm originating from follicular dendritic cells. Its management requires identification of underlying malignancy and treatment of the same. Our patient showed remission of PNP upon excision of the tumor and remained disease-free for 8 years.

Osseous Hydatidosis of Femur in a Patient with Fracture Non-union: An Uncommon Entity.

Hydatid disease caused by the larval form of the parasitic tapeworm, Echinococcus granulosus, commonly affects the liver and lungs. Bone involvement by Hydatid is extremely uncommon and is reported in 1-3% of cases. It is often a dormant disease, presenting at a late stage with non-specific clinical and radiological findings. Usually they occur as an isolated entity without liver/lung involvement and a clinical suspicion of this disease is not possible. We report a rare case of Hydatid cyst of femur in a 25-year-old female, with unresolving non-union of fracture for five years. The occurrence of this disease in atypical locations and lack of a specific radiological sign makes the diagnosis challenging and it is important for the orthopaedicians and pathologists to be aware of this entity for a precise diagnosis.