Survival benefit of exenteration in COVID-19-associated rhino-orbital mucormycosis.

PURPOSE: There has been a sudden increase in the number of rhino-orbital mucormycosis cases, primarily affecting patients recovering from COVID-19 infection. The local health authorities have declared the current situation an epidemic. In this study, we assess the role of exenteration in preventing disease progression and improving survival in patients with rhino-orbital mucormycosis. METHODS: The patients undergoing exenteration were grouped into the exenteration arm and those denying exenteration were grouped into the nonexenteration arm. The patients were followed at 1 month and 3 months. The 6-month survival data were collected telephonically. Continuous data were presented as Mean ± SD/Median (IQR) depending on the normality distribution of data, whereas the frequency with percentages was used to present the categorical variables. Kaplan-Meier survival curves were created to estimate the difference in survival of patients with exenteration in rhino-orbital mucormycosis versus those without exenteration. RESULTS: A total of 14 patients were recruited for our study based on the inclusion and exclusion criteria. All the patients were qualified for exenteration; however, only eight patients underwent exenteration and six patients did not consent to exenteration. At the end of 3 months in the exenteration group, four (50%) patients died. Two patients died within a week of exenteration, whereas two patients died after 2 weeks of exenteration. The deaths in the first week were attributed to septic shock and the deaths happening beyond 2 weeks were attributed to severe meningitis. The Kaplan-Meier survival analysis showed the cumulative probability of being alive at 1 month in the exenteration arm to be 85%, and it decreased to 67% by 53 days and subsequently remained stable until the end of 3 months. CONCLUSION: The Kaplan-Meier survival analysis did not show a survival benefit of exenteration at 3 months and 6 months in COVID-associated rhino-orbital mucormycosis.

Cytohistological correlation and risk stratification of salivary gland lesions using the Milan System for Reporting Salivary Gland Cytopathology: A tertiary care centre experience.

INTRODUCTION: Salivary gland neoplasms account for approximately 5% of head and neck tumours. The cytomorphology of fine needle aspiration material helps determine the preoperative assessment and risk stratification. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was developed to improve communication between the laboratory and treatment provider. AIMS AND OBJECTIVE: In the present study, we stratified all salivary gland lesions according to the MSRSGC and evaluated each category's concordance and risk of malignancy (ROM). MATERIALS AND METHODS: This was a 5 year retrospective study. First, all cases were assigned to one of the six MSRSGC categories. Then, following cytohistological correlation, the concordance rates and ROM were calculated based on the final histopathology report. RESULTS: A total of 354 cases were identified, with ages ranging from 2 to 88 years and the commonest age group was the 3rd to 4th decades. Categories I, II, III, IVA, IVB, V, and VI comprised 5.37% (19/354), 26.84% (95/354), 1.13% (04/354), 51.41% (182/354), 1.98% (07/354), 1.13% (04/354), and 12.15% (43/354) of the cases, respectively. The overall concordance rate between the cytological and histopathological diagnoses was 81.25% (65 out of 80 cases), with the sensitivity, specificity, positive predictive value, and negative predictive value at 43.48%, 96.49%, 83.33%, and 80.88%, respectively. CONCLUSION: The MSRSGC provides a better objective and structured way to communicate with the health care provider. In our study, the overall concordance rate was observed in 62/80 cases, with maximum concordance seen in categories III, IVB, and V of the MSRSGC.

Parasitic larvae in bronchoalveolar lavage fluid in a non-immunocompromised patient.

Strongyloides stercoralis is responsible for a significant human parasitic infection known as strongyloidiasis. In addition, pulmonary strongyloidiasis is one of the most critical signs of disseminated strongyloidiasis. In this instance, S. stercoralis was unexpectedly discovered in bronchoalveolar lavage fluid.

Microfilaria in cervicovaginal Pap smears: A common parasite hiding in an unusual site: Short series of four cases with literature review.

In India, filariasis is a severe and significant public health problem. It has been reported to be present in any potential site. However, cervicovaginal Pap smear cytology rarely contains microfilariae despite the widespread occurrence. The occurrence of microfilariae in cervicovaginal smears has seldom been reported, even as an accidental finding. In our retrospective study, four cases of clinically asymptomatic filariasis were diagnosed on a routine cervicovaginal Pap smear from January 2019 to July 2022. All microfilariae were characterized as Wuchereria bancrofti. In the present study, the majority of the cases present vaginal discharge, and the diagnosis was made by cytopathology. Therefore, it is crucial to consider and look for microfilariae in areas where they are not endemic.

Cytomorphology of sebaceous carcinoma of the eyelid: A short series of three cases with literature review.

BACKGROUND: Ocular sebaceous carcinoma (OSC) is a malignant and potentially lethal sebaceous gland tumor. Clinically, it masquerades as other benign and less malignant lesions, resulting in a delay in diagnosis. METHODS: In the present study, we sought to evaluate the cytomorphology of this aggressive neoplasm diagnosed by fine-needle aspiration cytology (FNAC) last year at our institute. RESULTS/FINDINGS: We report three cases of OSC diagnosed on aspiration cytology showed a cellular smear composed of sheets, 3D clusters, papillaroid, and singly scattered polygonal tumor cells having centrally located hyperchromatic pleomorphic nuclei and multiple microvacuolations in the cytoplasm. Necrosis and crushing artifact were also identified. Special stains such as Oil Red O stain on air-dried smears showed positivity, confirming the presence of lipid globules. Subsequently, the Cytological impression of sebaceous carcinoma was confirmed on histopathology. CONCLUSIONS: The article highlights the role of FNAC in the early and correct diagnosis of aggressive tumors and subsequent appropriate management to prevent recurrence and metastasis.

Development and validation of sonological classification and scoring system for uterine adenomyosis: A pilot study.

Background: Adenomyosis is a common disorder in women of reproductive age. The gold standard for diagnosis is histopathological examination of hysterectomy specimen. However, only a small percentage of women undergo surgery as treatment is primarily hormonal. Non-invasive methods of diagnosis include transvaginal sonography and magnetic resonance imaging. Patient management in adenomyosis is often based on ultrasonographic diagnosis alone, highlighting the importance of a uniform, reproducible, clinically relevant and validated sonological classification and scoring system. Although a few investigators have proposed classification and scoring system for diagnosis of adenomyosis, none of those have been validated yet. This study aimed to propose and validate a new sonological classification and scoring system for adenomyosis. Methods: This was a prospective observational pilot study. A new sonological classification and scoring system of adenomyosis was proposed based on topography, type, size and extent, which was validated by comparing the sonological reporting with histopathological reporting. The main outcome measures that were measured were rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist; and diagnostic accuracy of the sonological classification of adenomyosis. Results: This pilot study included 30 women who underwent hysterectomy over a time period of one year with ultrasonographic diagnosis of adenomyosis. The rate of agreement (Cohen's kappa) between the findings of sonologist and pathologist showed substantial agreement (0.703) for topography and almost perfect agreement for type (0.896), extent (0.892) and size (0.898). Conclusions: Our newly proposed sonological classification and scoring system for adenomyosis is valid and can be used for clinical application in interpersonal communication between clinicians, to prognosticate patients about the disease severity, to assess the candidates for surgical management and in further studies to correlate with symptoms severity and effectiveness of medical therapies.

Profile and Clinical Outcome of Children with Wilms' Tumor treated at a Tertiary Care Centre, India.

Pritanjali SinghBackground Wilms' tumor (WT) is the most common kidney tumor of the pediatric age group. The outcome of WT has improved due to the evolution of the treatment approach. A prospective observational study was conducted at All India Institute of Medical Sciences (AIIMS), Patna, to analyze the clinical profile along with the response and outcome to neoadjuvant chemotherapy according to the International Society of Pediatric Oncology (SIOP) protocol. Materials and Methods In total, 28 patients of WT visited the radiotherapy department from January 2015 to December 2019. Results Gender distribution showed male preponderance with a median age at diagnosis was 31 months. The abdominal lump was the dominant clinical presentation. The median volume of tumor at diagnosis was 359.48 mL (52.67-1805.76). Radiological staging workup shows that stage I, II, III, IV, and V were 7.1%, 39.3%, 39.3%, 10.7%, and 3.6% respectively. Neoadjuvant chemotherapy (NACT) was received by all patients. Also, 71.4% of patients showed > 50% of tumor volume reduction, while 28.6% of patients showed < 50% of tumor mass reduction. There was a statistically significant decrease in the tumor volume reduction following neoadjuvant chemotherapy ( p < 0.001). There was a statistically significant stage down ( p = 0.018) of the disease. Bivariate correlation studies showed recurrence was correlating statistically significantly with age < 24 months ( p = 0.049), locoregional lymph nodes ( p = 0.008), histopathological subtypes ( p < 0.001), stage of the disease ( p = 0.003), and risk groups ( p < 0.001). In addition, 25% of patients developed recurrence during the median follow-up of 25 months. The median disease-free survival (DFS) and overall survival (OS) were not reached. The mean DFS and OS were 48 and 59.13 months, respectively. One- and 3-year DFS were 100% and 64.1%, respectively. One- and 3-year OS were 100% and 75% respectively. Conclusion Our study suggests that most of the patients presented at an advanced stage, thus rendering most of the cases difficult to undergo surgery at presentation. Neoadjuvant chemotherapy followed by surgery may be considered a well-balanced approach with a comparable response and survival outcomes.

The International Academy of Cytology standardized reporting of breast fine-needle aspiration biopsy cytology: A 2 year's retrospective study with application of categories and their assessment for risk of malignancy.

OBJECTIVES: Breast cancer is the most common cancer in women worldwide. The fine-needle aspiration biopsy (FNAB) may be used as the first-line pathological investigation for evaluation and early diagnosis of the breast lesion. The FNAB helps to differentiate malignant from benign lesions. In the present study, we categorized the breast FNAB cases according to the International Academy of Cytology Yokohama System (IACYS) for reporting breast FNAB cytology and to assess the risk of malignancy (ROM) for each category. MATERIAL AND METHODS: A retrospective data of breast lesions were retrieved from the archives of pathology department between January 2018 and December 2019. The study got approval from the Institutional Ethics Committee. Only 123 cases with cytology and histopathological correlation were included in this study. The cytological category was given according to IACYS for reporting breast FNAB cytology. RESULTS: The FNAB results were include as insufficient material 3.25% (4/123), benign 46.34% (57/123), atypical 12.2% (15/123), suspicious for malignancy (SM) 4.88% (6/123), and malignant 33.33% (41/123). The ROM was 50%, 7.27%, 40.0%, 83.33%, and 97.5% for NS, benign, atypical, SM, and malignant, respectively. CONCLUSION: FNAB is an important tool in the diagnosis and management of breast lesions, especially in financial constrained developing countries like India with limited resources, where practice of core needle biopsy is limited. The 5-tier IACYS for reporting breast FNAB improves the reproducibility of cytology reports across the world and helps in triaging the breast lesion patients.

Outcome of routine histopathological examination of gallbladder specimen following elective laparoscopic cholecystectomy.

BACKGROUND: Gallstone disease is one of the commonest surgical ailments encountered in our setup. Its prevalence in India varies from 2% to 29%. Although cholelithiasis accounts for more than 95% of gall bladder related disease, routine histopathological examination (HPE) is vital. It reveals a myriad of benign as well as the malignant surgical pathology of the gallbladder (GB). This part of the world is considered as an endemic region for GB carcinoma as well as gallstone disease. This study intends to evaluate the outcome of the routine HPE of laparoscopic cholecystectomy specimens. METHODS: This retrospective observational study evaluated the results of the routine HPE of elective laparoscopic cholecystectomy specimens of single tertiary care center. Patients suspected or diagnosed with carcinoma gall bladder were excluded. Demographic data such as age, sex, and pathology results were recorded. RESULTS: From January 2017 to December 2019, HPEs of 921 patients who had undergone laparoscopic cholecystectomy specimens were analyzed. 97.6% specimens had benign lesion of which chronic calculus cholecystitis was predominantly high (95.01%) followed by cholesterosis (9.9%) and xanthogranulomatous cholecystitis (6.51%). Incidental carcinoma gall bladder was observed in 17 specimens accounting for 1.85%. Mean age of patients who underwent cholecystectomy was 43.10 ± 13.90 with female to male ratio of 3.23:1. CONCLUSION: Chronic calculus cholecystitis was the most common gall bladder disease with high female preponderance to all GB pathologies. This study affirms the importance of routine HPE after cholecystectomy as early incidental detection of carcinoma gall bladder alters the postoperative management approach and patients are expected to have a better outcome with it.

Ischemic jejunal stricture in patients with extrahepatic portal vein obstruction.

Ischemic jejunal stricture due to mesenteric vein thrombosis (MVT) rarely occurs in patients with extrahepatic portal vein obstruction (EHPVO). This is because the thrombus often occludes only a short segment of superior mesenteric vein adjacent to splenoportal confluence, facilitating development of collateral veins that protect bowel from ischemia. However, ischemic strictures can develop when the thrombus involves jejunal veins, venous arcades or vasa recta. We report three patients with EHPVO, who developed jejunal strictures due to MVT. They presented with symptoms of proximal bowel obstruction. Two of these patients had evidence of recurrent deep vein thrombosis (DVT), suggesting possibility of an underlying prothrombotic state. One of them had completely occluded bilateral iliac veins and inferior vena cava following DVT, 10 years ago. At the same time, he was identified as having a portal cavernoma. Contrast-enhanced computed tomography showed portal cavernoma together with MVT in all the patients. The thrombus was identified in the jejunal veins in two patients and in the entire superior mesenteric vein up to splenic vein in one patient. All three patients were found to have a tight concentric stricture involving a long length of proximal jejunum. Two patients required urgent surgical intervention and one died.

Cotyledonoid dissecting leiomyoma: an uncommon form of a common disease.

Leiomyomas are benign uterine smooth muscle neoplasms with varied morphology that are well known to undergo secondary changes. Cotyledonoid dissecting leiomyoma is a rare and distinct form of leiomyoma that poses a diagnostic challenge for clinicians, radiologists, and pathologists and can be confused with malignant uterine neoplasms. Only a few cases have been reported so far in the literature. Here we report a case of a cotyledonoid dissecting leiomyoma in a 60-year-old woman, emphasize its gross and histological features, and provide a review of the literature.

Is fine needle aspiration cytology (FNAC) useful in skin adnexal masses? A study on 5 cases of pilomatixoma.

Superficial cutaneous/subcutaneous nodules, caused by a variety of inflammatory, benign and malignant pathology of diverse origin, are tempting lesion for fine needle aspiration cytology (FNAC). Amongst these, adnexal tumor show considerable overlap, both in clinical manifestation as well as in histopathology. Archieval records of clinical findings, FNAC smears and reports pertaining to 5 histologically proved cases of pilomatricoma (PMX) were analyzed. Different cytological findings were graded + to +++. Pre FNAC clinical diagnoses were sebaceous cyst, tuberculous lymphadenopathy, dermatofibroma, reactive lymphadenopathy and lipoma. PMX was diagnosed on FNAC in 3 cases on finding groups of basaloid cells, ghost epithelial cells, pink fibrillary material and calcium deposits. Other cases were diagnosed as epidermal inclusion cyst with the differential diagnosis of well differentiated squamous cell carcinoma and skin appendageal tumor of undetermined origin in one case each. In all the cases, FNAC established epithelial nature of the lesion, excluding clinically mimicking inflammatory/neoplastic lesions of other origin. FNAC should be followed by excision biopsy to accurately type the epithelial neoplasm.

A rare presentation of invasive rhino-orbital mucormycosis in an immunocompetent young girl: a case report.

A 18 year young, healthy, immunocompetent girl presented with proptosis of left eye, referred to eye OPD, suspected clinico-radiologically as malignancy. This presentation with suspicion of malignancy resulted into extensive surgical debridement with removal of left eye, which was diagnosed as mucormycosis on histopathological examination. Her eye could have been saved if the mucormycosis was highly suspected initially, because of the good general health and immunocompetency led to misdirected thought.

Enterobius vermicularis causing symptoms of appendicitis in Nepal.

This study set out to determine the prevalence of Enterobius vermicularis in surgically removed appendices and to assess the possible relation of the parasite to acute appendicitis. All 624 surgically removed appendices received in the Department of Pathology, BPKIHS, Dharan, Nepal during 2(1/2) years (August 1999-January 2002) were examined. E. vermicularis was identified in nine (1.62%) appendices from the patients with a clinical diagnosis of appendicitis. The parasite was most frequently seen in histologically normal appendices (6/71) and was rarely associated with histological change of acute appendicitis (3/539). No cases of E. vermicularis infestation occurred in appendices showing chronic inflammation or removed during the course of other surgical procedures. E. vermicularis was found more frequently in uninflamed and histologically normal appendices (8.45%) than those which were inflamed with histopathologic changes of acute appendicitis (0.56%). It may be a cause of symptoms resembling acute appendicitis although the mechanism for this does not involve mucosal invasion by the parasite.

Myeloid metaplasia in aspirates from enlarged spleens: a clue in the absence of peripheral blood findings characteristic of myelofibrosis.

OBJECTIVE: To assess the significance of finding myeloid metaplasia in splenic aspirates from patients presenting with mild to moderate firm splenomegaly, in the absence of characteristic peripheral blood findings, in diagnosing idiopathic myelofibrosis. STUDY DESIGN: Archival records pertaining to 14 patients diagnosed as having myeloid metaplasia on splenic aspirates performed between September 2000 and April 2004 were analyzed. RESULTS: The relevant findings in these 9 women and 5 men were: splenic enlargement 17-21 cm with homogeneous echotexture on ultrasonography, hemoglobin 4-10 g/dL, variable pattern of anemia, total leukocyte count 6,300-28,800/ mm3 with neutrophilia and a few late myeloid precursors on the differential count, normal platelet counts, dry bone marrow tap in 10 patients and cellular marrow aspirate with prominence of megakaryocytes dispersed in a maturing cell population of myeloid and erythroid series in 4 patients. Splenic aspirates yielded foci of trilineage hematopoiesis suggestive of myeloid metaplasia, possibly due to myelofibrosis of idiopathic type, as confirmed on trephine biopsy in all cases. CONCLUSION: Splenic aspirates may be a useful tool for detecting myeloid metaplasia suggesting myelofibrosis when peripheral blood findings are not yet characteristic of the same. The procedure was not associated with any complications.

Fine needle aspiration cytology of tubercular epididymitis and epididymo-orchitis.

OBJECTIVE: To study the role of fine needle aspiration cytology (FNAC) and ancillary studies in the diagnosis of tubercular epididymitis or epididymo-orchitis. STUDY DESIGN: Forty patients with tubercular epididymitis or epididymoorchitis diagnosed on FNAC underwent a detailed clinical workup, imaging and microbiologic studies before being started on antitubercular treatment (ATT). One patient underwent orchiectomy. RESULTS: Clinically, the disease presented in patients of all ages usually as a scrotal swelling or rarely as a scrotal sinus (3) or abscess (3) or as part of disseminated tuberculosis (2). Three patients gave a history of previous tuberculosis. Scrotal sonography confirmed the involvement of the epididymis, testis or spermatic cord in each case. FNAC was diagnostic in 27 aspirates (epithelioid cell granulomas with caseation) but nondiagnostic in the rest. Tubercular etiology was confirmed directly by detection of acid-fast bacilli (AFB) on FNA smears in 24 (60%) patients and urine samples in 11 and indirectly in 9 patients with negative AFB by using a combination of a positive Mantoux test (5 of 9), presence of caseating granulomas on FNA smears (7 of 9) and therapeutic response to ATT (9 of 9). CONCLUSION: FNA as a minimally invasive technique plays a prime role in the diagnosis of tubercular epididymitis and epididymoorchitis. It provides adequate material for cytologic and microbiologic examination and helps to avoid unnecesary orchiectomy.