Seek the Spindle Tumor in Submandibular Space.

INTRODUCTION: Submandibular region is surgically significant in the head and neck field and a mass in this region may have multiple differential diagnoses. CASE REPORT: An elderly man came with a single 4×2.5 cm swelling in the neck on the right side, just below the lower jaw, since one month. Ultrasound showed an irregular heterogeneous hypoechoic lesion in the right submandibular space measuring 37×23 mm with mild internal vascularity. The submandibular gland appeared separate but compressed. Fine needle aspiration was suggestive of spindle cell neoplasm. The swelling was excised under general anesthesia. By histopathological examination, the lesion was diagnosed as anaplastic lymphoma kinase-negative inflammatory myofibroblastic tumor (IMT) based on focal immunoreactivity with cyclin D1. The patient then received radiotherapy 60 Gray divided into 30 fractions over 6 weeks. The case had no evidence of recurrence or residual disease six months post-surgery. CONCLUSION: Tumefactive spindle-cell lesion in the head and neck can comprise inflammatory conditions, benign and malignant neoplasms or borderline neoplasms, such as nodular fasciitis and IMT. The definitive histologic diagnosis of IMT helps in tailoring the treatment modality based on its locally aggressive biologic potential.

Neoplastic Meningitis: A Study from a Tertiary Care Hospital from Coastal India.

INTRODUCTION: Neoplastic involvement of cerebrospinal fluid (CSF) secondary to known or unknown primaries elsewhere is a poor prognostic factor and is equivalent to stage IV disease. AIM: The aim of the study is to analyse the cytological features of neoplastic meningitis in a tertiary care center. MATERIALS AND METHODS: A retrospective study of 400 consecutive CSF samples was done in the cytology laboratory of our hospital. The fluid obtained by spinal tap was sent for microbiological, biochemical and cytological evaluation. Smears that showed the presence of malignant cells were included in this study. RESULTS: Out of 400 cases, 36 (9%) showed neoplastic meningitis. Of which, 13 cases (36%) revealed leukemic infiltration, 2 (6%) lymphomatous infiltration and 21 (58%) carcinomatous meningitis. The leukemia cases included seven cases of acute lymphoblastic leukemia and six cases of acute myeloid leukemia. Among the carcinomatous meningitis cases, eight were metastasis from carcinoma breast, six from lung carcinoma and one each from malignancies of gallbladder, stomach and retinoblastoma. Four cases were metastatic adenocarcinoma from unknown primary. Pleocytosis was a significant finding seen in 58% cases (n = 21). Elevated protein and hypoglychorrhachia was noted in 68% cases (n = 18). CONCLUSION: A combined diagnostic approach including biochemical, microbiological and pathological evaluation was useful in eliminating infectious meningitis and confirming neoplastic meningitis in these cases. Cytology should be performed on cerebrospinal specimens from all patients with known or suspected malignancy with meningismus. Detection of malignant cells on cytological examination of CSF is the diagnostic gold standard for neoplastic meningitis.

Mixed epithelial and stromal tumor - A solid-cystic renal neoplasm undergoing malignant transformation: A rare case report.

We present a case of 53-year-old female who came with the complaints of mass on the right side of the abdomen noticed 3 weeks back. There was no history of localized swelling or rise of temperature, no history of weight loss, or evening rise of temperature. On examination, there was a flank mass which was bimanually palpable and tender. Routine laboratory investigations were within normal limits, except for the presence of hematuria in routine urinalysis. Computed tomography scan abdomen revealed a large multiloculated solid-cystic mass lesion with septation in the right-sided kidney. Cystic renal cell carcinoma was suspected and conventional open right radical nephrectomy was done. Grossly, the tumor was solid-cystic containing blood-tinged fluid. Microscopy revealed a complex tumor with both epithelial and stromal proliferation and with the aid of immunohistochemistry a diagnosis of mixed epithelial and stromal tumor undergoing malignant transformation was concluded.

Morphological Spectrum of Basal Cell Carcinoma in Southern Karnataka.

INTRODUCTION: Basal Cell Carcinoma (BCC) is the most common skin cancer worldwide, which appears over sun-exposed skin as slow-growing, locally invasive lesion that rarely metastasizes. Many phenotypic presentations are possible. BCCs are more common in males and tend to occur in older people. Majority is found on the head and neck. Many histopathological subtypes have been defined including nodular, micronodular, cystic, superficial, pigmented, adenoid, infiltrating, sclerosing, keratotic, infundibulocystic, metatypical, basosquamous and fibroepitheliomatous. Mixed patterns are common. AIM: The aim was to study morphological spectrum of BCC in a tertiary care hospital in southern Karnataka. MATERIALS AND METHODS: This was a retrospective analysis of 100 cases of BCCs reported in the Department of Pathology over a 9-year period from 2006 to 2014. RESULTS: The mean age of presentation was 62 years. There was slight female preponderance (56%). The most common location was face (65%) and the most common presentation was ulceration (45%). Of the 100 BCCs, 50% were nodular, 13% infiltrating, 6% basosquamous, 4% superficial, 3% keratotic, 3% multinodular and 1% mixed. CONCLUSION: BCC, besides being the commonest cutaneous cancer, is also known for its numerous histological patterns which are shown to have prognostic implications. This study reveals the frequency of the various histological patterns of BCC in southern Karnataka, where it has been rarely studied before.

Nescient Aetiology of Splenic Laceration - An Enigma Unveiled.

Malaria is a common endemic disease prevalent in developing countries like India that presents with wide spectrum of clinical symptoms and complications. Splenic rupture is an uncommon but life-threatening complication which can be either spontaneous or as a result of trauma. We present a case of 50-year-old man with left upper quadrant pain following a polytrauma. Based on the radiological evidence of laceration and rupture of markedly enlarged spleen, emergency splenectomy was performed. Postoperative haematological evaluation established the co-infection of Plasmodium falciparum and vivax with high parasitaemia and marked thrombocytosis. The incidences of splenic rupture due to malaria are under-reported. In endemic areas, the management of splenic rupture in malaria should be focused on splenic preservation, thereby reducing the risk of future attacks of malaria in those patients who are highly susceptible to Plasmodium species and also reducing the incidence of overwhelming sepsis.

Fat infiltration of left ventricle - a rare cause of sudden cardiac death.

Cor adiposum is a rare disorder of the heart, where the normal heart tissue is replaced by fibro-fatty infiltrates. We report one such case of a middle-aged female who was declared dead shortly after a syncopal episode. At autopsy, the pericardium was intact and firmly adhered to the heart. Histopathology revealed fatty infiltrates extending into the left ventricle of the heart. A post-mortem diagnosis of Cor adiposum was made which is an uncommonly reported cause of sudden cardiac death.

Unusual lesions of the mediastinum.

OBJECTIVES: To study unusual lesions in the mediastinum, which do not originate from the thymus, lymph nodes, neural tissues or germ cells, and tissues that normally engender pathologic lesions in the mediastinum. MATERIALS AND METHODS: Of the 65 cases seen, 12 unusual lesion were encountered in a 5½ year period from 2006 to 2011. RESULTS: Two cases of nodular colloid goiter and one each of the mediastinal cyst, undifferentiated carcinoma, and Langerhans cell histiocytosis (LCH) affected the anterosuperior mediastinum. In the middle mediastinum, one case each of the mesothelioma, malignant gastrointestinal stromal tumor (GIST), squamous cell carcinoma (SCC), solitary fibrous tumor (SFT), and pleomorphic sarcoma (PS) was seen. One case of meningeal melanocytoma (Mme) and primary pleural liposarcoma (PL) involved the posterior mediastinum. Persistent disease was seen in LCH after 2 years. Of all the cases with malignant lesions, only the patient with SCC was alive after 1 year. CONCLUSION: The cases of primary and SCC, LCH, melanocytoma, liposarcoma and PS, and GIST are unexpected and very rarely have paradigms in the mediastinum. Radiologic impression and knowledge of the compartment where these lesions arose from hardly assisted in arriving at a definitive opinion as the lesions were not typical of this location. A high index of suspicion and the immunohistochemical profile facilitated the final diagnosis.

Reticulum vs Inclusions: A Learning Experience in Haemoglobin H Disease.

Haemoglobin H disease, also known as the alpha-thalassaemia is characterized by the presence of HbH inclusions in red blood cells, detectable on supra-vital stain. We present a case of a previously asymptomatic 31-year-old male, who insidiously developed anaemia and had prominent splenomegaly. Peripheral smear examination revealed microcytic hypochromic anaemia with numerous spherocytes and moderate polychromasia. In reticulocyte preparation with Brilliant cresyl blue, HbH inclusions were mistakenly identified as granulofilamentous reticulum of reticulocytes, giving a spuriously high reticulocyte percentage. After the literature review, repeat assessment was performed and with the aid of high performance liquid chromatography result, it was possible to delineate the HbH inclusions.

Retroperitoneal schwannoma: an atypical presentation.

Schwannoma is a rare tumour arising from Schwann cells in myelinated neural sheath of the nerves. They can arise in various places like head, neck, extremities, adrenal, retro peritoneum, psoas muscle. We here present a case of 33-year-old male who came with features of acute pancreatitis, with incidentally detected mass in presacral region on ultrasonography. Investigations like CECT and MRI were suggestive of neurofibroma, radical excision of the mass was done which showed solitary encapsulated tumour and cut sections showed areas of necrosis, and histopathologically it was proven as schwannoma. Most of the schwannoma's are benign, but rarely malignant transformation can occur. It can be associated with von Recklinghausen disease. Benign tumours have excellent prognosis, malignant tumours can present at later date with metastasis after excision also. Radiology plays a key role in diagnosis and follows up. Treatment is radical excision of tumour; recurrence is most common and has to be carefully followed up.

A clinicopathological study of interface dermatitis.

BACKGROUND: Interface dermatitis (ID) refers to a pattern of skin reaction characterized by an inflammatory infiltrate that appears to obscure the dermo-epidermal junction when observed at low power examination and referred to as lichenoid tissue reaction. A wide range of inflammatory skin diseases exhibits interface change with considerable overlap of histological features. The aim of the present study was to study the clinical features and microscopic features of ID. MATERIALS AND METHODS: The material for the present study consisted of skin biopsy samples collected from patients attending the outpatient Department of Dermatology. The study was conducted for a period of 3 years from 2007 to 2010. During this period, a total of 125 cases was studied. RESULTS: In the present study, a total of 125 cases of ID was studied which presented clinically as papulosquamous disorders. Majority of the cases of ID were seen in women (57.6%). Majority of ID were lichen planus (LP) and its variants (63.2%). Clinicopathological concordance was seen in 109 cases (87.2%) and discordance in 16 cases (12.8%). CONCLUSION: The mere presence of an interface lichenoid inflammatory reaction should not be the sole criterion for the diagnosis of LP or one of its many variants, as now seems to be the case. A clinicopathologic correlation is absolutely essential for a conclusive diagnosis of ID.

Clinical, biochemical & cytomorphologic study on Hashimoto's thyroiditis.

BACKGROUND & OBJECTIVES: Despite, the extensive salt iodization programmes implemented in India, the prevalence of goiter has not reduced much in our country. The most frequent cause of hypothyroidism and goiter in iodine sufficient areas is Hashimoto's thyroiditis (HT). This study records the clinical presentation, biochemical status, ultrasonographic picture and cytological appearance of this disease in a coastal endemic zone for goiter. METHODS: Case records of patients with cytological diagnosis of HT were studied in detail, with reference to their symptoms, presence of goiter, thyroid function status, antibody levels and ultrasound picture. Detailed cytological study was conducted in selected patients. RESULTS: A total of 144 patients with cytological proven HT/lymphocytic thyroiditis were studied. Ninety per cent of the patients were females and most of them presented within five years of onset of symptoms. Sixty eight per cent patients had diffuse goiter, 69 per cent were clinically euthyroid and 46 per cent were biochemically mildly hypothyroid. Antibody levels were elevated in 92.3 per cent cases. In majority of patients the sonographic picture showed heterogeneous echotexture with increased vascularity. Cytological changes were characteristic. INTERPRETATION & CONCLUSIONS: Our study showed predominance of females in the study population in 21-40 yr age group with diffuse goiter. We suggest that in an endemic zone for goiter, all women of the child bearing age should be screened for HT.

Rare association of papillary carcinoma of thyroid with adult T-cell lymphoma/leukemia.

Papillary carcinoma is the most common malignant tumor of the thyroid, especially in countries with adequate or excess iodine in diet. Many studies indicate that a sizable number of papillary cancer cases occur in a setting of chronic thyroiditis. But the tumor that arises more frequently in thyroiditis is malignant lymphoma. We report a rare association of papillary carcinoma of thyroid in an elderly lady with adult T-cell lymphoma/leukemia. Fine needle aspiration of the thyroid, neck nodes and evaluation of the bone marrow and peripheral blood helped in the diagnosis of papillary cancer coexisting with adult T-cell lymphoma/leukemia.

Bone marrow biopsy in non-Hodgkin lymphoma: a morphological study.

CONTEXT: Bone marrow (BM) biopsy is an integral part of staging work-up for non-Hodgkin lymphoma (NHL). AIMS: To study the characteristics of BM involvement in NHL with respect to incidence, histologic pattern and morphology of infiltration and its discordance with the histology of primary anatomic site. SETTINGS AND DESIGN: Forty-nine cases of NHL in which BM biopsy was performed for staging were included in this study, the primary site being classified according to the WHO classification for NHL. MATERIALS AND METHODS: A prospective study of 49 cases was conducted. Bilateral BM biopsy was obtained from the posterior superior iliac spine. The biopsies were fixed in 10% buffered formalin solution and decalcified using 10% formal - formic acid for 4 - 6 h followed by routine processing. The serial sections were stained by hematoxylin and eosin and reticulin stains. RESULTS: BM biopsy showed involvement by lymphoma in 27 cases (55.10%). Unilateral positivity was found in four cases (14.81% cases). The overall incidence of marrow involvement by NHL was 55.1%. The incidence of involvement was higher in T-cell lymphomas when compared with B-cell lymphomas and predominant pattern of involvement was mixed. Diffuse large B-cell lymphomas had the lowest incidence in all the B-cell lymphomas. A discordant histology between BM and primary anatomic site was found in 29.63% (8/27) of the cases, where it was seen more in follicular lymphomas and diffuse large B-cell lymphomas. CONCLUSIONS: Critical examination of BM biopsies can increase the diagnostic accuracy, thereby contributing to the prognosis and appropriate treatment modalities.

Cutaneous dirofilariasis presenting as an eyelid swelling.

Dirofilariasis is a common filarial infection occurring in domestic and wild animals as a result of arthropod bites. However, it can be transmitted to humans after mosquito bites. Here, we report a case of a 54-year-old lady who developed an unilateral eyelid swelling secondary to Dirofilaria repens.

Acute haemorrhagic pancreatitis - A case of sudden death.

Sudden death in young individuals is relatively uncommon and acute haemorrhagic pancreatitis as a cause of sudden and unexpected death is a rare phenomenon. A case of sudden death due to acute haemorrhagic pancreatitis is reported in a young doctor who ignored the radiating pain of acute pancreatitis for gastritis, and resorted to self-medication. The condition was discovered only at autopsy.

Langerhans cell histiocytosis of mediastinal node.

The predominant clinical and radiological features of Langerhans Cell Histiocytosis (LCH) in children are due to osseous involvement. Extra-osseous disease is far less common, occurring in association with bone disease or in isolation. In the present study, LCH was presumptively diagnosed on Ultrasound guided Fine needle aspiration cytology (FNAC) of the mediastinal lymph node in a 18 month-old child. The diagnosis was confirmed by histological examination of the biopsy material.S-100 protein localization in the LCH cells is often positive on immunohistochemistry.

Mucoepidermoid carcinoma of lung: a case report.

Mucoepidermoid lung tumours are uncommon neoplasms comprising of 0.2% of all the lung tumours and historically included under the term bronchial adenomas. This is a case report of a bronchial tumour in the hilar region present since 3 years. The neoplasm could be easily classified as a mucoepidermoid tumour of low malignant potential, as it resembled the histologically identical lesion in the main salivary glands. The case is reported for its rarity and for the histological evaluation of the malignant potential in an apparently clinically benign neoplasm.