Grossing and reporting of radical prostatectomy specimens: An evidence-based approach.

Radical prostatectomy (RP) constitutes the primary treatment option for patients with clinically localized, biopsy-proven prostate cancer that requires local treatment with curative intent. Accurate reporting of radical prostatectomy specimens is required to guide further risk stratification and management of patients. Hence, for the handling and reporting of RP specimens, a standardized protocol should be followed. Many general pathologists may not be well-versed with the guidelines for the handling of radical prostatectomy specimens. This article discusses a detailed approach to grossing techniques, including specimen description, fixation requirements, gross cut-up, and reporting of the grade and stage of RP specimens. This will enable the pathologist to aid in multidisciplinary management.

The mystery behind a 1000 day fever in a young male.

This case is of a 23 year old diabetic male who presented with fever and splenic lesions. He continued to have fever off and on over the next 3 years despite empirical antibiotics and anti-tubercular therapy. No definitive diagnosis could be made despite exhaustive investigations. Finally, a splenectomy resulted in sustained defervescence. The splenic histopathology showed caseating granulomas but aerobic cultures, Xpert MTB/Rif ULTRA, TB and fungal cultures were negative. A final diagnosis of splenic melioidosis was made based on the clinical features, radiology, histopathology, literature review and absence of an alternative diagnosis.

Mutational Analysis of EGFR Mutations in Non-Small Cell Lung Carcinoma-An Indian Perspective of 212 Patients.

Lung cancer is the world's leading cause of cancer-related deaths. Epidermal growth factor receptor (EGFR) is one of the critical oncogenes and plays a significant role in tumor proliferation and metastasis. Patients with sensitizing mutations in the EGFR gene have better clinical outcomes when treated with tyrosine kinase inhibitors (TKI). This study expands our knowledge of the spectrum of EGFR mutations among lung cancer patients in the Indian scenario. This is a retrospective descriptive study of all newly diagnosed patients with lung cancer in tertiary care hospital in India. All the samples were subjected to real-time PCR (q-PCR) analysis and confirmation of rare novel mutations was done using Sanger sequencing. Clinicopathological characteristics, mutational EGFR status, and location on the exon and metastatic sites were evaluated. An analysis of total 212 samples showed mutations in 38.67% of cases. Among these, five (5.9%) samples had mutations in exon 18, 41 (48.8%) samples had mutations in exon 19, 12 (14.28%) samples had mutations in exon 20, and 26 (30.95%) samples had mutations in exon 21. Eleven (13.41%) were found to be uncommon EGFR mutations. Additionally, six (21.4%) samples that had EGFR mutations were also positive for brain metastasis. Future testing on bigger panels will help to characterize the incidence of genetic mutations and to determine the appropriate targeted treatment choices for NSCLC patients.

Robotic Freyer's prostatectomy: Operative technique and single-center experience.

INTRODUCTION: Transurethral resection of prostate replaced open surgery and remained the gold standard in surgical management of benign prostatic hyperplasia (BPH). Holmium laser enucleation and bipolar resection of prostate managed even larger glands. Open simple prostatectomy remains an option for large glands and concurrent pathologies. Minimally invasive laparoscopic simple prostatectomy lacks general acceptance. Surgeons have now started exploring the robotic platform due to its advantages. Herein, we present the technique and initial outcomes of robotic Freyer's prostatectomy (RFP). MATERIALS AND METHODS: Thirteen transperitoneal RFPs were performed using the DaVinci Xi platform. We evaluated perioperative characteristics and functional outcomes. RESULTS: Median patient age was 67.8 years and the mean prostate volume was 105.8 ml. The median International Prostate Symptom Score (IPSS) and American Urological Association quality of life (AUA-QoL) score was 19.6 and 5.3. There were no intraoperative complications or conversion to open surgery. The mean console time and estimated blood loss were 107.30 min and 92.5 ml, respectively. One patient required redo-surgery by robotic technique due to urine leak (Clavien-Dindo Grade 3b complication). Mean hospital stay and catheter duration were 4.9 days and 5.2 days, respectively. Change (preoperative vs. postoperative) in IPSS (19.6 vs. 4.67 points), maximum flow rate (6.8 vs. 15.1 ml/s), AUA-QoL score (5.3 vs. 2.2 points) and PVR (179.4 vs 7.1 ml) were significant (P < 0001). CONCLUSIONS: RFP is a safe and effective option for managing BPH, especially for large glands. It confers minimally invasive surgery benefits with good functional outcomes.

Primitive neuroectodermal tumor of the penile urethra.

Primitive neuroectodermal tumor (PNET)/Ewing's sarcoma tumors are a group of highly malignant tumors composed of small, round cells showing neuroectodermal differentiation that commonly affects soft tissue and bone. PNET involving the genitourinary system is rare and PNET of the penile urethra is rarer still. It exhibits a highly aggressive biological behavior with poor prognosis. We report a case of a 27-year-old male presenting with penile swelling and difficulty in passing urine. Examination revealed a firm penile urethral mass. Pathological and immunohistochemical results of the specimen obtained from urethroscopic biopsy followed by total penectomy confirmed the diagnosis of PNET of the urethra. He received combination chemotherapy: ifosfamide and etoposide (IE) + vincristine, Adriamycin, and cyclophosphamide (VAC). In conclusion, PNET has to be considered in the differential diagnosis of a penile urethral mass in young patients.

Comparative study of perioperative and survival outcomes after video endoscopic inguinal lymphadenectomy (VEIL) and open inguinal lymph node dissection (O-ILND) in the management of inguinal lymph nodes in carcinoma of the penis.

Open inguinal lymph node dissection (O-ILND) is the gold standard in the management of lymph nodes in carcinoma penis; however, video endoscopic inguinal lymphadenectomy (VEIL) is performed in some centers. Our primary objective is to compare perioperative and survival outcomes in patients undergoing VEIL with O-ILND, as very few studies have reported long-term survival outcomes till date. We analyzed patients who underwent O-ILND and VEIL (laparoscopic or robot-assisted) from January 2009 to January 2020 in our institute for carcinoma of the penis. Patient details, perioperative complications, and survival outcomes were analyzed. Perioperative outcomes were analyzed by logistic regression and survival outcomes by log-rank and Cox regression methods. We analyzed 79 patients (32 O-ILND, 47 VEIL) with a median follow-up of 51 (IQR 25.5-75.5) and 42 months (IQR 21-62). Wound complications were common in O-ILND group (65.6%) compared to VEIL group (27.7%) (p = 0.001), predominantly skin flap necrosis in 14 groins (23.73%) after O-ILND and none after VEIL. Median overall survival was 80 and 88 months (p = 0.840) with five-year survival of 65% and 66.8% (p = 0.636) and five-year DSS of 76.6% and 73.9% (p = 0.96) in O-ILND and VEIL, respectively. Multivariate analysis showed that grade and pathological node status were significant (HR-2.650, p = 0.040; HR-3.218, p = 0.024) factors for survival. The retrospective nature of the study design is the limitation. Management of inguinal lymph nodes in carcinoma penis by VEIL is safe, associated with lesser wound-related complications, and equivalent survival outcomes compared to O-ILND. It should be considered as an alternative option for inguinal lymph node dissection.

Gross reporting of adult kidney tumor specimens: A comprehensive evidence-based review.

Renal tumors comprise a wide spectrum of benign and malignant tumors. The important prognostic factors in renal cell carcinoma include pathological stage, tumor grade, morphological type, sarcomatoid/rhabdoid differentiation, and tumor necrosis. Therefore, the pathologist needs to be fully aware of how to gross nephrectomy specimens to be able to accurately provide the above prognostic information while reporting adult kidney tumors. With the advent of nephron-sparing surgeries, due diligence should be exercised to assess and sample the parenchymal surgical margin. This article discusses the approach to grossing nephrectomy specimens, elaborates the significance of every step, and also sheds light on the importance of clinical and radiological information in providing a holistic approach to the diagnosis and staging of adult renal tumors.

Grossing and reporting of testicular tumor specimens : An evidence-based approach.

The majority of testicular tumors are germ cell tumors (GCTs), but there are numerous other types, making testicular tumors one of the most diverse areas of human pathology, despite their relative rarity. Testicular tumors are usually diagnosed only after radical surgery, as biopsies are not performed. Further management of the patient is dependent on the diagnosis at microscopy, which itself is based on the sections taken at the time of grossing the specimen. Many pathologists often aren't well versed with guidelines for handling of orchiectomy specimens and for microscopy. This article discusses, in detail, the approach to grossing of a testicular tumor specimen and elaborates of the reasons as to why we do what we do at the initial "cut-up". It explains the logic behind the reporting guidelines for testicular tumors and offer a clinical primer to the pathologist as to why we do what we do while grossing testicular tumor specimens.

Extremely rare case of retropharyngeal space benign plexiform schwannoma - Excised through Smith- Robinson Approach.

BACKGROUND: Approximately 25-45% of schwannomas are typically slow-growing, encapsulated, and noninvasive tumors that occur in the head-and-neck region where they rarely involve the retropharyngeal space. Here, we report deep-seated benign plexiform schwannoma located in the retropharyngeal C2-C5 region excised utilizing the Smith-Robinson approach. CASE DESCRIPTION: A 30-year-old male presented with dysphagia and impaired phonation attributed to an MR documented C2-C5 retropharyngeal schwannomas. On examination, the lesion was soft, deep seated, and extended more toward the right side of the neck. Utilizing a right-sided Smith-Robinson's approach, it was successfully removed. The histopathology confirmed the diagnosis of a plexiform schwannoma. CONCLUSION: Retropharyngeal benign plexiform schwannomas are rare causes of dysphagia/impaired phonation in the cervical spine. MR studies best document the size and extent of these tumors which may be readily resected utilizing a Smith-Robinson approach.

An Overview of Liver Transplant Pathology: Data from a Tertiary Referral Centre in Western India.

INTRODUCTION AND AIM: 1. Study of liver explants - Etiologic types of end-stage chronic liver disease (ESCLD) and acute liver failure (ALF) in adults and children. 2. Assessment of donor steatosis and incidental granulomas. 3. Post-transplant liver biopsies. MATERIAL AND METHODS: Specimens of 180 explant hepatectomies, 173 donor wedge and 30 core liver biopsies, and 58 post transplant liver biopsies received in our department from April 2013 to March 2017. RESULTS: 1. Most common causes of ESCLD in adults were: alcohol related (30.32%), hepatitis virus related (18.71%) and non-alcoholic steatohepatitis related (18.06%); and in children ≤ 12 years were: biliary atresia (27.27%), autoimmune disease (18.18%) and Wilson's disease (18.18%). Most common causes of ALF in adults and children were anti-tubercular therapy induced and idiopathic respectively. 2. Prevalence rate of moderate steatosis (between 30-60%) was 4.28%. Incidental granulomas were seen in 5 cases. 3. Most common diagnoses of post-transplant biopsies in adults included acute cellular rejection (ACR) (36.17%), recurrence of viral disease (8.51%) and moderate non-specific portal triaditis (8.51%). Among children ≤ 12 years, most common diagnoses included unremarkable liver parenchyma, ACR and ischemia/reperfusion injury. CONCLUSION: 1. Alcohol- and hepatitis- virus related ESCLD, and biliary atresia are leading indications for liver transplantation in adults and children respectively. 2. Prevalence of 4.28% of moderate steatosis, is much lower than that documented in western literature. Only 5 cases of incidental granulomas is unexpectedly low in a country endemic for tuberculosis. 3. Most common diagnoses of post-transplant liver biopsies in adults has been acute rejection, which is similar to the findings from much larger published series.

Case report of tumour-induced osteomalacia with parotid gland tumour as a focus / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;">Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, which is characterized by overproduction of FGF23 as a phosphaturic agent leading to chronic phosphaturia and hypophosphatemia, associated with inappropriately normal or low levels of vitamin D. We describe a rare case of a 57-year-old Indian female who presented with bone pains, muscle pains and lower limb weakness. On examination she was found to have hypophosphatemia. Our work up led to the identification of a FGF23 secreting parotid tumour. The tumour responsible for symptoms was a pleomorphic adenoma of the parotid gland. Its complete resection resulted in normalisation of patient's symptoms. Laboratory parameters and microsopic examination further revealed a mesenchymal tumour of mixed connective tissue type.</p>

Dorsal spinal epidural cavernous hemangioma.

A 61-year-old female patient presented with diffuse pain in the dorsal region of the back of 3 months duration. The magnetic resonance imaging showed an extramedullary, extradural space occupative lesion on the right side of the spinal canal from D5 to D7 vertebral levels. The mass was well marginated and there was no bone involvement. Compression of the adjacent thecal sac was observed, with displacement to the left side. Radiological differential diagnosis included nerve sheath tumor and meningioma. The patient underwent D6 hemilaminectomy under general anesthesia. Intraoperatively, the tumor was purely extradural in location with mild extension into the right foramina. No attachment to the nerves or dura was found. Total excision of the extradural compressing mass was possible as there were preserved planes all around. Histopathology revealed cavernous hemangioma. As illustrated in our case, purely epidural hemangiomas, although uncommon, ought to be considered in the differential diagnosis of spinal epidural soft tissue masses. Findings that may help to differentiate this lesion from the ubiquitous disk prolapse, more common meningiomas and nerve sheath tumors are its ovoid shape, uniform T2 hyperintense signal and lack of anatomic connection with the neighboring intervertebral disk or the exiting nerve root. Entirely extradural lesions with no bone involvement are rare and represent about 12% of all intraspinal hemangiomas.

Primary non-Hodgkin's lymphoma of the spleen presenting as space occupying lesion: a case report and review of literature.

Primary splenic lymphoma (PSL) is rare with a reported incidence of less than 1%. Diffuse large cell pathology has been reported in 22-23% of the cases and is felt to have poor outcome. This study reports a 50 year old male who presented with fever and weakness. He was found to have a mass lesion in the spleen documented by CT scan. A splenectomy was performed which showed non-Hodgkin's lymphoma. Immunohistological studies showed a positivity for CD20 and CD30.

Renal angiomyolipomas--a study of 18 cases.

Angiomyolipoma is a distinctive neoplasm composed of an intimate admixture of three components, viz. mature adipocytes, smooth muscle cells and blood vessels. This study was undertaken to better define the various morphological patterns of angiomyolipoma and their immunohistochemical profile. The paraffin blocks and slides of 18 cases of renal angiomyolipoma, accessioned over a period of 8 years from Tata Memorial Hospital, were reviewed. There were 2 men and 16 women in the age range of 17 to 68 years. Pre-operative fine needle aspiration cytology (FNAC) was performed in 6 cases, of which 5 were erroneously diagnosed as renal cell carcinomal sarcoma. Histologically, 14 cases revealed conventional histology. The remaining 4 cases were particularly misleading posing diagnostic problems due to variant patterns (leiomyomatous variant-3 cases and epithelioid variant- 1 case). Apart from the usual histology, necrosis, giant cells, and varying degrees of nuclear pleomorphism were present in three of the cases. Immunohistochemistry performed in 16 cases revealed immunoreactivity for HMB45 in all the 16 tumors (100%), estrogen receptor (ER) and progesterone receptor ((PR) in 2 cases (12.5%) and 6 cases (37.5%) respectively.