Indian Journal of Pathology and Oncology

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Authors: Ranjan Agrawal*

Indian Journal of Pathology and Oncology for the Year 2019. The submission rate as well as the quality of research publications has increased tremendously over the past few years. The present issue contains article of good work-up by the author and I am sure that the readers would definitely gain from them.

9-15

Authors: A. Sathish Selvakumar, Sudheer Arava, Ruma Ray, S.K. Choudhary

Objectives: Bicuspid Aortic Valve Disease (BAVD) is a rare entity associated with ascending aortic aneurysm. We present the histopathological and morphometric data of BAVD cases who had thoracic aortic aneurysms requiring surgical intervention. Materials and Methods: Thirteen cases of BAVD from 298 cases of ascending thoracic aortic aneurysms requiring surgical intervention between 1995 to 2009 were included. Controls were obtained from autopsy cases with normal aortic valve. Tunica intima was examined for fibrosis (FIB-1), and inflammation (INFL1). Tunica media was examined for lamellar count (LC) and inflammation (INFL 2) whereas elastic fragmentation (EF), cystic medial degeneration (CMD), medionecrosis (MN), smooth muscle disarray (SMD) and fibrosis (FIB-2) were graded by semi-quantitative grading system. CMD was subjected to morphometric area measurement. Tunica adventitia was examined for fibrosis (FIB 3) and inflammation (INFL 3). Results: In media EF (P<.001), SMD (P=.002), FIB-2 (P=.002) and MN (P=.02) were significantly greater in cases than controls. More BAVD cases had CMD (low grade =76.92%, moderate grade = 7.69% and high grade = 15.38%), when compared to only 6 controls (46.15%) having low grade CMD, although statistically not significant. Mean LC was greater in controls than cases (P= <0 P=0.041)> Conclusion: Patients with BAVD have significant degenerative medial changes of ascending thoracic aorta causing aneurysmal dilatation. They require surveillance, risk factor assessment and clinical disease management of aneurysmal complication.

25-27

Authors: Noora Saeed, Sayeedul Hasan Arif, A.R. Piyush, Aeman Khalid, Saima Khan

Introduction: ‘Macrocytosis’ is the term used to describe large erythrocytes with increased mean corpuscular volume (MCV) seen in peripheral blood smears. Various pathological disorders with differentiating clinical, biochemical, hematological and bone marrow findings can attribute to macrocytosis. Aims and Objectives: We conducted a one year study, from Sep 2016 to Sep 2017 with the aim to identify the number and causes of macrocytosis and also to assess the haematological features associated with macrocytosis in peripheral blood smear and routine haemogram. We also evaluated the clinical, biochemical (Vitamin B12 and folate assay) and bone marrow studies to differentiate megaloblastic from nonmegaloblastic causes of macrocytosis. Results: Among 56 cases of macrocytosis received in a year, Megaloblastic anemia was the commonest etiological factor, followed by alcoholism and drug intake. Isolated macrocytosis without anaemia was noted in 4 cases. Presence of hypersegmented neutrophils and macro- ovalocytes was the most frequent observation in peripheral smear examination in all megaloblastic conditions. Conclusions: A meticulous interpretation of routine haemogram along with peripheral blood smear and biochemical analysis helps in identifying the underlying cause and treatment for macrocytosis.

35-38

Authors: G. Anushuya, Aja Chandramohan, Ponnusamy Karkuzhali, Manickam Saraswathi

Introduction: There is a lack of proper landmark studies from South India on fungal rhinosinusitis. The varying clinical and histological presentations of fungal rhinosinusitis and lack of clinicopathological studies, prompted us to undertake this study. Materials and Methods: This study conducted over a period of 7 years at Goshen Institute of pathology (Madras medical college) one of the renowned premier institutes of Pathology in India. A total of 738 cases of sinusitis have been reported over the 7 years study period. The patients were of the age group from 12 to 92 years. All clinical data was retrieved from the patients' record file to study the emerging trend of fungal rhinosinusitis in this population of India. Result: A total of 738 cases were diagnosed as rhinosinusitis, of which 84 were of fungal etiology. It was observed in our study that the prevalence of fungal sinusitis is ~11.4%. Fungal rhinosinusitis was found to be little more common in male (55.3%). The age of patients ranged from 13yrs to 91yrs. The peak incidence was seen in 3rd to 5th decade of life. Conclusion: The study conducted in a tertiary care institute in Tamil Nadu has shown that that there is an increase in the incidence of fungal sinusitis. It is inferred from our study that the most common causative agent is mucormycosis followed by aspergillus. The prompt diagnosis of fungal rhinosinusitis is important due to the angio-invasive nature of the fungi requiring aggressive anti-fungal therapy.

47-51

Authors: Bindhu Joseph, Rekha V Kumar, Champaka G, Ashok Shenoy, Sabitha K. S

Introduction: The eukaryotic translation initiation factor 4E (eIF4E) is a protein that plays a key role in the tumourigenesis and metastasis. eIF4E overexpression usually precede morphological changes. The amplification of this biomarker in the surgically negative margins of resected Head and Neck cancer patients is associated with early recurrence and failure in several earlier studies. This subset may benefit from adjuvant radiotherapy even in the absence of morphological risk factors. We evaluated the pattern of expression of eIF4E protein in the surgically negative margins of Head and Neck cancer patients and its role in the treatment and outcome. Material and Methods: Twenty-nine patients with Oral and 14 patients with Head and Neck cancers having surgically negative margins were analyzed for the expression of eIF4E with relation to local failure and treatment outcome. Results: There were 11 local failures with 9 deaths, all within 6 months documented. The overall median survival was 12 months. Notably patients who had received adjuvant radiotherapy had a 45% better chance of survival 29.5 months vs 13.5 months (p=0.79). The clinical features of size, grade and co-expression of p53 did not correlate significantly with eIF4E overexpression. The Oral cancer subset when individually analyzed; showed a similar pattern of outcome with 17% (5/29) failing locally. Patients who had received adjuvant radiotherapy fared better with a 30% higher chance of survival 30.8 months vs 15.7 months. In Head and Neck cancer patients the failure rate was 57.8% (8/14). Patients who received radiotherapy had a median survival of 15.43 months vs 10.85 months (p=0.28). Conclusion: The overexpression of eIF4E in surgically negative margins of resected Head & Neck and oral cancers may predict a more unfavorable microenvironment at risk for early recurrence and mortality within 6 months. The addition of adjuvant radiotherapy or targeting the eIF4E pathway may benefit these patients.

57-62

Authors: Adil S. A. K, Sharath Kumar H. K, Chaithra M. S, Bharathi M

Introduction: Colorectal cancer is the most common cancer of gastrointestinal tract. It is ranked fourth in causing cancer related deaths. Compared to western world, the incidence rates are low in India. The pathogenesis involved here is tumor induced angiogenesis which is the most important factor for tumor growth, invasion and metastasis. Vascular endothelial growth factor (VEGF) is known to play a major role in angiogenesis. Aim: Is to study the expression of VEGF in colorectal malignancies and correlate the expression with histomorphological findings. Materials and Methods: Tissue samples from 30 patients with colorectal cancer of various stages, who had undergone resection during May 2016- February 2018, were taken for the study. Out of 30 cases, 27 were of Adenocarcinoma, 2 were Neuroendocrine tumors and 1 was Rectal Gastrointestinal stromal tumor. Scoring system was applied to assess the VEGF expression. Results: Patients with stage 1, well differentiated and grade 1 tumors had predominantly score 2 of VEGF expression; patients with stage 2, grade 2 and moderately differentiated tumors with mucinous component had predominantly score 3 of VEGF expression and patients with stage 3, grade 3 and poorly differentiated tumors had predominantly score 4 of VEGF expression. Thus VEGF expression was positively correlated with tumor grade, and TNM stage (p<0> Conclusion: Quantification of VEGF expression in colorectal cancers may give a reliable prognostic information, which could further help in selecting patients of high risk of disease progression for adjuvant therapy.

67-74

Authors: Nitin Rohira, Farah Jalaly Meenai

Introduction: Pancytopenia is an important clinico-haematological entity observed in our day to day clinical practice. It is a disorder in which all the three major formed elements of blood (red blood cells, white blood cells and platelets) are decreased in number. The causes of pancytopenia can be due to decrease in hematopoietic cell production in the marrow resulting from infections, toxins, malignant cell infiltration, post- chemotherapy or post-radiation. Materials and Methods: 150 patients having pancytopenia were included in the present study. The study was conducted in the Department of Pathology of Chirayu Medical College & Hospitals, Bhopal. The study period was 1 July 2016 to 31 December 2017. Study was performed in patients attending outdoor and indoor departments of Chirayu medical college and hospitals, Bhopal. Informed consent was obtained from each of the patient fulfilling the inclusion criteria prior to their enrolment in the study. Those how had age<10> Results: This is a clinico-haematological study on Pancytopenia and its correlation with bone marrow aspiration carried out in the Department of Pathology over a period of one and half year from 1 June 2016 to 31 December 2017. A total number of 150 patients in all the age group presenting with pancytopenia were evaluated. Out of 150 cases 95 were males and 55 were females. The age of the patients ranged from 0 years to >70 years. 64% cases were observed in the age group of 11-30 years. Most of the patients were in the age group of 11-30 years. Megaloblastic anaemia was the commonest underlying etiology of pancytopenia in 50% patients. Next common cause was hypersplenism in 18% and aplastic anaemia in 11% cases. Acute leukaemia was the cause in 9%. MDS was seen in 10%. Nutritional anaemia was seen in 2% patients. Conclusion: The present study concludes that detailed primary hematological investigations along with bone marrow aspiration in pancytopenic patients are helpful for understanding disease process and to diagnose or to the rule out causes of pancytopenia. These are also helpful in planning for further investigations and management.

80-83

Authors: Sumangala. G, Premalatha T.S, Kiran Abhijit Kulkarni, Geeta Acharya, Vishakha C Bidkar

Aims: To evaluate the clinicopathological features and relationship of tumor grade, myometrial invasion and lymph node metastasis. Settings and Design: Retrospective analysis. Materials and Methods: The medical records of patients with endometrioid adenocarcinoma of the endometrium treated between January 2013 and January 2016 were reviewed retrospectively. Statistical Analysis Used: The continuous variables were reported using mean +/- SD and the categorical variables were reported using number and percentages. The pre and post operative grades were compared using Wilcoxon Sign Rank Test. All the analyses were done using SPSS version 18.0. Results: A total number of 40 patients were included in the analysis. The mean age was 58.65 years (range- 39 to71). While 29 (72.5%) were post menopausal, 28 (70%) patients presented with PMB. metastases was detected in 12.5% patients. Conclusions: Complete surgical staging is the precise way of determining stage and requirement of adjuvant treatment as it defines prognosis and survival. Studies including large number of patients with complete surgical staging done is required to define the surgical management of patients with endometrial carcinoma.

90-97

Authors: Sridevi C, Pavitra K, Jijiyabai

Introduction: Carcinoma of stomach is a common malignancy and globally stands at fourth position frequency- wise. E-cadherin, is a major cell adhesion molecule, the loss of which gives rise to invasive and metastatic properties to the cancer cells. Aim of the Study: To study the E-cadherin expression in gastric carcinomas by immuno-histochemistry and to correlate its pattern of staining with tumor differentiation, invasion, histological variants, and lymph node status. Materials and Methods: A two year prospective study was done from September 2011 to August 2013 at Kakatiya Medical College and MGM Hospital, Warangal. The resected specimens of stomach and endoscopic biopsy specimens taken from carcinoma stomach in this study period were considered. Routine histopathology and immunohistochemistry for E-cadherin were done on the sections. Results: 60 cases were studied of which 26 were gastric biopsies and 34 were gastrectomy specimens. The patient age ranged from 41-72 years and the male to female ratio was 1.6:1. There were 70% and 30% cases that showed intestinal type and diffuse type morphology respectively. Preserved E-cadherin was mainly seen in intestinal type tumors 14/42 (33.33%) with grade 3 staining, while majority of diffuse adenocarcinomas 8/18 (44.44%) were negative for E-cadherin staining. Higher stage tumors and poorly differentiated adenocarcinomas showed reduced E-cadherin staining. Cases with positive lymph nodes 22/29(75.86%) had diminished / absent E-cadherin staining. Conclusion: Normal gastric mucosa on IHC shows strong membranous E-cadherin positivity. There is a gradual decrease in intensity and percentage, and the pattern changes towards cytoplasmic staining in gastric carcinomas

102-106

Authors: Archana Shetty, Vijaya C

Introduction: Thyroid imbalances and anaemia due to their high prevalence and close interrelationship constitute a good proportion of problems encountered by practitioners, especially in the female reproductive age group. In a developing country it becomes all the more important to study the relationship between the same as correction of the hormonal imbalance may restore the deranged haematological parameters to normal. |Aims and Objectives: To compare the haematological parameters among the various thyroid hormonal statuses (euthyroid hypothyroid and hyperthyroid) in non-pregnant females. Materials and Methods: 50 non pregnant females between ages of 18–45 years newly diagnosed with hypothyroidism and hyperthyroidism were taken up for the study. 50 normal age matched females with normal thyroid hormonal levels were taken as controls. The haematological parameters of the three categories were further compared with a p value of <0> Results: There was significant variation in the haematological parameters like Haemoglobin, RBC count, total count highest between the hyper and hypothyroid groups. RDW and AEC was significantly more in hypothyroid groups though within normal limits. No significant variation was seen for MCV indicating the type of anaemia in the hypothyroid group to be of the normocytic type. Conclusion: Thyroid dysfunction has effect on haematological parameters. Evaluation of anaemia in females must include screening for thyroid dysfunction

112-117

Authors: R. Thiripurasundari

Introduction: To study the prevalence of various cancer in a rural setting and to study the distribution of various cancers among diverse age and sex groups. Materials and Methods: The study was conducted on 200 subjects who were diagnosed to have malignancy by histopathology in Vinayaka Missions Research Foundation Karaikal Pondicherry District. The prevalence of various cancers was evaluated and further correlated with age and sex of the patient. Results: The study enrolled 200 malignant cases with age ranging from 13yrs to 85 years. 54% were female and 46% were male. Out of 200 cases 40 cases that is 20% of malignant cases were there in oral cavity buccal mucosa. Next comes breast accounting for 17%, followed by colon and rectum – 9.5%. Regarding type of malignancy, squamous cell carcinoma is the most common malignancy 35% followed by adenocarcinoma 17.5% and infiltrating duct carcinoma- 15%. Below 18 years malignancy is reported only in thyroid and soft tissues. Maximum number of malignant cases were reported in age group 40-60years (87 cases). Conclusion: Our study shows increase in incidence of cancer in Karaikal which was only 26 in year 2001-2002. Now in 2016-2017 it was 200. Also the organs affected shows slight variation from Indian scenario where lung is the most common malignancy. But in our study oral cancers are maximum. This study highlights the need for cancer screening programs to be individualised for regions and the importance of maintaining cancer registries.

123-127

Authors: Priyadarshini Dehuri, Srikant Kanungo

Introduction: Even with the advent of effective treatment strategies for breast cancer, the prognostication and treatment of each case varies owing to the varied expression of different prognostic markers. Aims and Objectives: In this study, there has been an attempt to study the immunohistochemical expression of p53 and BRCA1 proteins in invasive breast cancers and to find the correlation if any, between the expressions of p53 and BRCA1 with various prognostic factors like histological grading, the hormone receptors and Her-2/neu status. Materials and Methods: The study was conducted in the Department of Pathology at S.C.B. Medical College, Cuttack. Fifty histologically proven cases of invasive carcinoma of were included in the study. Results: P53 positivity was seen in 40% of cases in our study while BRCA1 expression was observed in 48% of the total cases. P53 positivity was found to be associated with higher histologic grades (p value =0.05), Her-2/neu [removed]p value = 0.0005) and negative hormone receptors (p value = 0.0046). BRCA1 positivity was well associated with positive hormone receptors (p value = 0.03).The absence of BRCA1 staining was mostly seen in tumours of large sizes (p value = 0.01) and higher histologic grades (p value = 0.04). No significant association was seen between the expressions of BRCA1 and HER-2/neu. Conclusion: Immunohistochemical staining of P53 can be used as a prognostic indicator in cases of invasive breast carcinoma. The immunohistochemical detection of BRCA1 may be used to generate a larger pathologic picture of breast cancers in conjunction with the traditional prognostic parameters.

137-140

Authors: Swathi Chilukuri, Ramesh Teegala, Sai Bandarupalli, Asha Thota, Anjana Priyanka Aluri

Introduction: Information on epidemiological profile of supratentorial tumors pathology is scant in developing countries like India hence; more institutional data are needed to know the tumor burden in pediatric population, to undertake necessary research and to improve the therapeutic modalities in any given locality. Aim: To study the distribution of various supratentorial tumors in pediatric age group according to age, sex, anatomical location and histological type and correlate findings from our institute with other institutional studies. Materials and Methods: We conducted a retrospective study to analyze the data on archived surgical samples of 45 pediatric patients (0-18 years) with supratentorial brain tumors, operated over a period of 10 years (January 2008 to December 2017). Data regarding age, gender, site of the tumor and histopathology were considered for the analysis. The results obtained were compared with the available published literature data matching to our study on Indian population. Results: The most common pediatric primary brain tumors occupying supratentorial region were astrocytic tumors (33.3%) followed by craniopharyngiomas (20%) and meningiomas (13.4%). The most common astrocytic tumor was pilocytic astrocytoma. Pediatric brain tumors were more common in males (60%) as compared to females (40%) with male to female ratio of 1.5: 1. Conclusion: Astrocytomas and craniopharyngiomas were observed to be the common supratentorial tumors among pediatric age group at our institute consistent with other multicentric studies conducted in India.

146-147

Authors: Amit Pandey, Arun Kumar Yadav, Mansi Barthwal, Disha Tiwari, Rajeev Gupta

Case Presentation: A 45-year-old female presented to out patient clinic of Radiotherapy with a chief complaints of bleeding per vaginum for last 6 month and foul smelling discharge per vaginum for last 5 months. The cervical biopsy was reported as squamous cell carcinoma (moderately differentiated). Her general physical examination revealed pallor only. Per speculum examination examination showed 3.5x 3 cm cervical lesion with involvement of upper 1/3rd of anterior vaginal wall. Patient was staged as FIGO IIA. Peripheral smear and bone marrow biopsy was suggestive of CML in chronic phase. The patient received a radical course of external beam radiotherapy (EBRT) with concurrent weekly cisplatin 40mg/m?2; followed by HDR brachytherapy. We report here a rare case of CML with carcinoma cervix.

151-154

Authors: Kanica Chaudhary, Veena Ramaswamy, Kinjal Majumdar, Rachana Prasad, Vishal Rao

The authors here present a rare case of angiomyolipoma arising in the oropharynx. The tumor was found in a 55-year-old man, not associated with tuberous sclerosis. Histopathologic examination of the tumor revealed an admixture of numerous smooth muscle cells, mature adipose tissue and numerous thin –walled capillaries and thick-walled vessels. Both histological and immunohistochemical findings were typical for tumors of the mucocutaneous angiomyolipoma group.

158-160

Authors: Varun Bajaj, KC Singh, Rony Chakravarty

Introduction: Pure lipomas of the uterus are exceedingly rare, and their origin is of deep interest in terms of histogenesis. The tumours often pose a diagnostic challenge and a host of differentials are made on clinical and radiological assessment. The authors present a case of a pure uterine lipoma detected at a peripheral Airforce hospital. Materials and Methods: Case report with clinical, ultrasound and histopathological findings. Conclusion: A rare case with a controversial histogenesis and recently described chromosomal anomalies adds to our knowledge of this uncharacteristic lesion in the uterine corpus.

164-166

Authors: H.R. Chandrasekhar, Sunita Nyamagoudar, Seema Bijjaragi

Inflammatory myofibroblastic tumour (IMT) is a rare tumour with an unknown malignant potential. IMTs are known to occur in many sites. These tumours very rarely noted in bladder. It is important to distinguish this tumor from other malignant spindle cell tumors, such as the sarcomatoid variant of urothelial carcinoma and leiomyosarcoma. This distinction has clinical consequences because IMT is generally considered benign and treated with conservative management. Here we report a case of IMT in bladder in a 23 years old female who presented with a lower abdominal mass and abdominal pain. Histopathology revealed that muscularis propria of the bladder, was widely infiltrated by loosely arranged plump spindle shaped cells and immunohistochemistry was positive for both SMA (smooth muscle actin) and ALK1 (Anaplastic lymphoma kinase 1). So we present this case for its rarity and diagnostic uncertainty.