A Clinical, Dermoscopic, and Histopathological Study of Follicular Psoriasis.

Introduction: Follicular psoriasis is one of the underdiagnosed clinical types of psoriasis. Literature is grossly limited to anecdotal case reports and series. Clinical and investigational aspects are not studied in depth. Materials and Methods: A study was conducted to determine the frequency of follicular psoriasis, which includes cases with an exclusive or substantial number of follicular lesions. We analyzed the clinical, dermoscopic, and histopathological features of follicular psoriasis in a descriptive study. Results: A total of 117 patients with psoriasis were screened. An exclusive or substantial number of follicular lesions were found in 22 patients. Four patients had exclusively follicular lesions and others were psoriasis vulgaris with follicular psoriasis. Dermoscopy revealed perifollicular scaling and white homogeneous area with normal terminal hair in all cases. Vascular features were visible in 14 cases and all had dotted vessels, with four having additional globules. Twenty patients revealed one or more features suggestive of follicular psoriasis on histopathology. Conclusion: Follicular lesions can appear exclusively or can coexist with plaque type of lesions in psoriasis. They may indicate early psoriasis lesions. Dermoscopy is a useful and rapid tool to confirm the diagnosis of follicular psoriasis. Histopathology, though confirmatory, demands an astute interpretational skill. Diagnosis of follicular psoriasis can have therapeutic implications.

Myeloid sarcoma: A clinicopathological study with emphasis on diagnostic difficulties.

BACKGROUND: Myeloid sarcoma (MS) is a rare tumor composed of proliferation of myeloid precursors at extramedullary sites. They can arise de-novo or in association with hematological malignancies, most commonly acute myeloid leukemia. Clinically, it can masquerade as an abscess, cutaneous ulcer, or mass lesion. Morphologically, MS can mimic a variety of small round cell tumors including lymphomas and rhabdomyosarcoma. AIMS: (1) To study the clinical presentations and laboratory findings in patients with MS; (2) to revisit the histomorphological findings and the differential diagnosis of MS; (3) to evaluate the diagnostic role of immunohistochemistry (IHC) and determine the useful markers for accurate diagnosis of MS. MATERIALS AND METHODS: We reviewed cases of MS reported in our institution over a 10-year period from January 2004 to December 2013. The clinical presentations, laboratory data, and histopathological and immunohistochemical findings were studied. RESULTS: There were nine cases in our database, none of which were clinically suspected to be MS. Age ranged from 3 to 55 years, with a slight female preponderance. Cervical lymph nodes were the most common site involved. Histologically, the common finding was the presence of medium- to large-sized cells with fine granular chromatin, small nucleolus, and scant cytoplasm along with scattered eosinophil precursors. Myeloperoxidase was the most useful IHC marker. All cases were also positive for leukocyte common antigen contributing to the diagnostic confusion with lymphoma. CONCLUSION: The possibility of MS should be considered when dealing with unusual lymphoma-like neoplasms that cannot be categorized as any of the Non-Hodgkin lymphoma subtypes.

Juvenile Granulosa Cell Tumour: Anaplastic Variant with Omental Deposits.

Juvenile Granulosa Cell Tumour (JGCT) of ovary represents a small fraction of all primary ovarian malignancies. It is a subtype of granulosa cell tumour that is almost always found during the first three decades of life. Histologically, it differs from the typical adult type of granulosa cell tumour. It accounts for 5-15% of all granulosa cell tumours, majority being unilateral. Herein, we describe an unusual histopathological variant of JGCT with numerous large cystic spaces, anaplasia and focal syncytiotrophoblast like giant cells.

Primary Small Cell Carcinoma of The Esophagus - An Eight Year Retrospective Study.

INTRODUCTION: Primary small cell carcinoma of the esophagus is a rare and aggressive tumor. Patients present with metastatic disease and have a poor clinical outcome. The objective of the study was to correlate clinical and histopathological features of primary small cell carcinoma of the esophagus diagnosed and treated at our hospital. MATERIALS AND METHODS: A retrospective study of 11 patients diagnosed with primary small cell carcinoma of the esophagus in Kasturba Hospital, Manipal between 2006 and 2014 was done. The histopathological and immunohistochemical features were correlated with clinical and endoscopic findings. RESULTS: Eleven patients were diagnosed to have small cell carcinoma of esophagus with a male preponderance. Common presenting symptoms were dysphagia and weight loss. Majority of the patients showed mid esophageal ulceroproliferative growth. Biopsy findings were consistent with the characteristic morphology of small cell carcinoma and demonstrated immunoreactivity to neuroendocrine markers. In addition, few cases also showed adjacent squamous dysplasia/carcinoma. Most of the patients presented with metastatic disease, liver being the most common site. These patients were treated by chemotherapy and radiotherapy. CONCLUSION: Esophageal small cell carcinomas are aggressive tumors with high rates of distant metastasis. Presence of squamous dysplasia /squamous cell carcinoma in the adjacent mucosa supports the hypothesis that this neoplasm arise from pleuripotent stem cells. Presence of the latter is also useful to rule out spread from lung primary.

Laparoscopic cystectomy of endometrioma: Good surgical technique does not adversely affect ovarian reserve.

BACKGROUND: The damage to ovarian reserve inflicted by surgery for endometriosis represents a major concern in the balance between reproductive benefits and risks. AIM: To evaluate the ovarian reserve in sub fertile women after laparoscopic endometriotic cystectomy. SETTINGS AND DESIGN: Prospective study, done in Department of Obstetrics and Gynecology, tertiary care hospital between August 2010-2012. MATERIALS AND METHOD: Laparoscopic cystectomy performed by stripping technique for endometriotic cysts. Endometriosis was staged according to revised American Society of Reproductive Medicine classification (rASRM). Ovarian reserve assessed by comparing FSH and LH levels, measurement of residual ovarian volume, antral follicle counts and stromal blood flow on second day of menses pre and postoperatively. Cyst wall was evaluated histologically to note the presence of normal ovarian tissue in resected tissue. STATISTICAL ANALYSIS: SPSS for Windows version 16.0 (SPSS Inc., Chicago, IL) was used for statistical calculations. Wilcoxon signed test and Pearson Chi - Square test were applied. Significance level was P < 0.05. RESULTS: Incidence of minimal, mild, moderate, and severe endometriosis was 4.1%, 21.9%, 28.7%, 45.3% respectively. Ovarian reserve was assessed both by ultrasound and biochemical parameters on day 2 of menses; pre and post-operatively. Preoperative and post-operative values; FSH (7.24 ± 1.21, 7.23 ± 1.51 m IU/ml), LH levels (6.37 ± 1.8, 6.6 ± 2.3 m IU/ml), residual ovarian volume (8.5 cm(3) ± 5.3, 7.4 cm(3) ± 5.8), antral follicle count(3.3 ± 1.9, 4.1 ± 1.5) and stromal blood flow (6.8 cm/sec ± 4.57, 7.1 cm/sec ± 3.55) were statistically not significant. Loss of follicle was seen in 27.2% cyst walls on histopathological examination while 72.73% had no loss. CONCLUSION: Laparoscopic cystectomy when performed for endometriotic cysts with accurate surgical technique leads to no significant ovarian tissue removal.

Objective assessment of endogenous collagen in vivo during tissue repair by laser induced fluorescence.

Collagen, a triple helical protein with the primary role of mechanical function, provides tensile strength to the skin, and plays a pivotal task in tissue repair. During tissue regeneration, collagen level increases gradually and therefore, monitoring of such changes in vivo by laser induced fluorescence was the main objective behind the present study. In order to accomplish this, 15 mm diameter excisional wounds were created on six to eight week old Swiss albino mice. The collagen deposition accelerated upon irradiation of single exposure of 2 J/cm2 He-Ne laser dose immediately after wounding was recorded by laser induced autofluorescence in vivo along with un-illuminated and un-wounded controls. Autofluorescence spectra were recorded for each animal of the experimental groups on 0, 5, 10, 30, 45 and 60 days post-wounding, by exciting the granulation tissue/skin with 325 nm He-Cd laser. The variations in the average collagen intensities from the granulation tissue/skin of mice were inspected as a function of age and gender. Further, the spectral findings of the collagen synthesis in wound granulation tissue/un-wounded skin tissues were validated by Picro-Sirius red- polarized light microscopy in a blinded manner through image analysis of the respective collagen birefringence. The in vivo autofluorescence studies have shown a significant increase in collagen synthesis in laser treated animals as compared to the un-illuminated controls. Image analysis of the collagen birefringence further authenticated the ability of autofluorescence in the objective monitoring of collagen in vivo. Our results clearly demonstrate the potential of laser induced autofluorescence in the monitoring of collegen synthesis during tissue regeneration, which may have clinical implications.

Tuberculous mediastinal lymphadenopathy in an adult.

We describe a patient who presented to us with fever, decreased appetite, weight loss and dry cough for 1 month with no abnormalities on examination. A chest radiograph showed a mediastinal shadow. CT of the chest revealed multiple mediastinal lymph nodes. Bronchoalveolar lavage was negative for acid-fast bacilli and cytological examination did not show malignant cells. Serum ACE levels were high (93 U/L). Bone marrow aspiration and biopsy did not reveal any pathology. Mediastinoscopy-guided mediastinal lymph node biopsy showed features of granulomatous lymphadenitis. This case report summarises an unusual presentation of tuberculosis in an adult.

A guise of osteosarcoma: chondroblastoma-like.

Osteosarcoma (OS) is a rare tumor arising from immature bone forming cells or through neoplastic differentiation of other immature mesenchymal cells into osteoblasts. Chondroblastoma-like OS is one of the rare forms of OS to be seen in jaw bones. Aggressive clinical behavior, osteolytic areas in the radiograph and histological presentation of chondroblastoma such as cells with grooved nuclei, typical chicken-wire calcification along with areas of tumor osteoid, implied the diagnosis as chondroblastoma-like OS. Use of reticulin stain further confirmed the diagnosis. A case of chondroblastoma-like OS is reported, emphasizing the importance of early diagnosis of aggressive jaw lesions with the help of routine radiography, histopathology, and special stains.

Extragenital aggressive angiomyxoma of the axilla and the chest wall.

Aggressive angiomyxomas are uncommon mesenchymal tumours which most often arise in the perineal and the pelvic regions in women. Extragenital aggressive angiomyxonas are extremely rare. We are reporting a young male with an aggressive angiomyxoma which involved the axillary region and extended into the anterior chest wall, which demonstrated its characteristic histomorphological features. The diagnosis was confirmed by immunohistochemistry. A careful histological examination, along with immunohistochemistry, aids in diagnosing this lesion and differentiating it from tumours which have similar histologies.

Use of cautery as a therapeutic modality in skin metastasis due to renal cell carcinoma.

Renal cell carcinoma commonly metastasises to the lungs, lymphatics and bone; it uncommonly metastasises to the skin. Several studies and reports have noted skin metastasis to be an indicator of high death rates. The best treatment for a single skin metastasis is surgical excision. However, local radiotherapy has been found to be equally effective. We present a case report where cautery was used at the site of skin metastasis, with good results.

Primary paratesticular ganglioneuroma: a rare case in an adult.

Ganglioneuroma is a benign tumor, affecting the central nervous system, commonly seen in children and young adults. Non-cranial ganglioneuromas are seen predominantly in the posterior mediastinum and retroperitoneum. Paratesticular neoplasms are extremely rare and are susceptible to clinical misinterpretation as malignancy. Tumors of nerve origin are a rarity in the paratesticular region, with a few cases of schwannoma and malignant peripheral nerve sheath tumor being reviewed in the literature. A rare case of ganglioneuroma involving the paratesticular region in an adult is presented.

Immunohistochemical phospho tensin tumor suppressor gene staining patterns in endometrial hyperplasias: a 2-year study.

BACKGROUND: Endometrial carcinoma is a common neoplasm associated with the female genital tract with considerable morbidity. Endometrial hyperplasias have been widely regarded as precursor lesions. It is of importance to the pathologist to identify the subset of hyperplasias or the associated factor which could be a possible forerunner of malignancy. Phospho tensin gene (PTEN) has gained importance as one of the factors responsible. AIM: To determine the variability in PTEN expression patterns in different types of endometrial hyperplasias. SETTINGS AND DESIGN: The study was undertaken on samples received at the Department of Pathology from 2005 to 2007. MATERIALS AND METHODS: One hundred samples with 76 showing hyperplasias of different types formed the core "study group" with simple hyperplasia without atypia predominating. The rest belonged to the control groups. PTEN intensity and percentage positivity, variability in patterns of glandular and stromal expression, the number and type of PTEN null glands in different types of hyperplasia were evaluated. Statistical analyses used were Fisher's exact test based on Monte Carlo test and chi-square test. RESULTS: Complex hyperplasia was associated with a reduction in number of strongly PTEN positive glands, with an increase in null glands, seen in clusters. Co-existing atypia was associated with the weakest staining and in fewer glands. CONCLUSIONS: PTEN expression in endometrial hyperplasias can be used as an early warning of heightened cancer risk and a potential target for preventive treatment. However, extensive research is needed along this line to conclusively establish its effectiveness.

Adenomatoid tumor of tunica albuginea mimicking seminoma on fine needle aspiration cytology: a case report.

BACKGROUND: Adenomatoid tumor is one of the most common primary neoplasms of the paratesticular area. The epididymis is the most common site of involvement; however, it can also arise from the tunica albuginea, spermatic cord, tunica vaginalis and testis. Fine needle aspiration cytology (FNAC) is being increasingly used for lesions in the paratesticular area. Review of the literature showed very few reports on the cytologic features of adenomatoid tumor. We report the cytologic features of a case of adenomatoid tumor arising from testicular tunica albuginea. CASE: A 40-year-old man presented with right-sided scrotal swelling of 1 years' duration. FNAC of the lesion showed highly cellular smears composed of clusters of monomorphic plump cells with oval eccentric nucleus, fine granular chromatin, small single nucleolus and abundant pale to vacuolated cytoplasm. The background showed "tigroid substance," classically described in seminoma. Histopathologic examination confirmed the diagnosis as adenomatoid tumor of tunica albuginea. CONCLUSION: FNAC of an adenomatoid tumor poses a diagnostic challenge when the tumor arises from sites other than the epididymis because they can be mistaken for intratesticular tumors. It is thus important to consider this tumor in the differential diagnosis of scrotal swellings.

Polymorphic fibro-osseous lesion of the bone: a case report with review of literature.

A polymorphic fibro-osseous lesion of the bone is a benign fibro-osseous lesion of the bone with a marked predilection for the proximal femur and characterized by a complex mixture of histological elements. We present one such case of a 35-year-old female with spontaneous onset of pain in the left hip for 3 months and trauma sustained a year ago. An examination revealed tenderness with painful movements over the anterior aspect of the left hip joint and trochanter. A clinico-radiological differential diagnosis of simple bone cyst or fibrous dysplasia was entertained. A microscopic examination of the lesion with clinico-radiologic correlation led to the diagnosis of a polymorphic fibro-osseous lesion. This is a genuine clinico-pathologic entity that is usually asymptomatic with a rare history of trauma or hip pain. It has a distinctive histopathological picture with a better prognosis than its mimics.

Periductal stromal sarcoma of breast with lipoblast-like cells: a case report with review of literature.

The specialized mesenchyme of the breast is the seat of neoplasms with distinct morphology, though with considerable overlap due to the ever increasing number of variants. This article seeks to describe the morphologic features of one such rare neoplasm. A 35-year-old female patient presented with a breast lump that was subsequently excised. Morphological assessment and immunohistochemistry were performed and a diagnosis of periductal stromal sarcoma with lipoblast-like cells (pseudolipoblasts), was made. Being an unusual finding in a rare entity of intermediate grade, it has to be considered, before rendering a diagnosis of a malignant, higher-grade neoplasm.

Adrenal oncocytoma masquerading as a functional tumor.

Adrenal oncocytoma is a rare entity, with 20 cases reported in literature. A functional oncocytoma is extremely rare. We present a case of adrenal oncocytoma in a hypertensive male who had elevated catecholamine levels, which improved after adrenalectomy with decrease in daily antihypertensive requirement.

Pap smear quality parameters of 3 sampling devices used by auxiliary nurse midwives on symptomatic rural Indian women.

OBJECTIVE: To determine whether auxiliary nurse midwives (ANMs) could make good-quality Pap smears after focused training and to determine which sampling device is most effective in their hands in field practice areas. STUDY DESIGN: In a downstaging cervical cancer screening program, 394 symptomatic rural Indian women between the ages of 35 and 60 were identified by the ANMs in 2 villages, with a total population of 14,747, and were invited to have a smear taken. Two hundred of these symptomatic women responded. The ANMs were educated to render information on screening for cervical cancer and to take smears with 3 sampling devices--Ayre spatula, modified spatula (with extended tip) and Cytobrush (Medscand AB, Malmö, Sweden). The smears were evaluated for 6 adequacy parameters. Smears made by gynecologists were used as controls. To establish the superiority of a method, chi2 tests were used. RESULTS: All smears made by the ANMs could be used to render a cytologic diagnosis. The adequacy parameters of all the smears made by ANMs at least matched those of the gynecologists. The best results were obtained with modified spatula (with extended tip) and combination of Cytobrush with modified spatula. CONCLUSION: Since only 50% of symptomatic rural women came for Pap testing, we conclude it is not easy to motivate women for such testing, even if a large-scale educational effort is made. ANMs can be taught to take reasonably good qualisuperior sampling device for ANMs is ty Pap smears. The superior sampling device for ANMs is the modified spatula (with extended tip).

Multiple myeloma with amyloidosis presenting with recurrent gastrointestinal bleeding.

We report a 45-year-old woman who presented with hematemesis. Endoscopy showed nodular lesions and ulcers in the gastric antrum; histology of the lesions showed amyloidosis. The patient had received melphalan and prednisolone for multiple myeloma 5 years earlier.