Turkish Journal of Pathology - 2016; 32(2)

The Importance of Minor Salivary Gland Biopsy in Sj�gren Syndrome Diagnosis and the Clinicopathological Correlation

2016-05-01

Objective: Minor salivary gland biopsy is one of the objective tests used in the diagnosis of Sj�gren syndrome. The aim of our study was to compare the clinical and laboratory data of primary and secondary Sj�gren syndrome cases with a lymphocyte score 3 and 4 in the minor salivary gland biopsy. Material and Method: Data from a total of 2346 consecutive minor salivary gland biopsies were retrospectively evaluated in this study. Clinical and autoantibody characteristics of 367 cases with lymphocyte score 3 or 4 and diagnosed with primary or secondary Sj�gren syndrome were compared. Results: There was no difference between lymphocyte score 3 and 4 primary Sj�gren syndrome patients in terms of dry mouth, dry eye symptoms and Schirmer test results but Anti-Ro and Antinuclear Antibody positivity was statistically significantly higher in cases with lymphocyte score 4 (p= 0.025, p= 0.001). Anti-Ro test results were also found to be statistically significantly higher in secondary Sj�gren syndrome patients with lymphocyte score 4 (p= 0.048). Conclusion: In this study, the high proportion of cases with negative autoantibody but positive lymphocyte score is significant in terms of showing the contribution of minor salivary gland biopsy to Sj�gren syndrome diagnosis. Lymphocyte score 3 and 4 cases were found to have similar clinical findings but a difference regarding antibody positivity in primary Sj�gren syndrome. We believe that cases with lymphocyte score 4 may be Sj�gren syndrome cases whose clinical manifestations are relatively established and higher autoantibody levels are therefore found.

Prognostic Value of ALDH1, EZH2 and Ki-67 in Astrocytic Gliomas

2016-05-01

Objective: Tumor stem cells have been found in a variety of neoplasms and stated to have a role in tumor progression. This study aimed to evaluate the prognostic significance of biomarkers which are said to be related to these cells, i.e., EZH2, ALDH1 and Ki-67, and their correlation with each other in astrocytic gliomas. Material and Method: Formalin-fixed, paraffin-embedded tissue specimens of 40 patients with astrocytic glioma who underwent initial surgery during the period from December 2011 to May 2014 at Zagazig University Hospitals were enrolled in the study. Consecutive 4-μm thick sections from formalin-fixed, paraffin-embedded tissue blocks were prepared and stained with hematoxylin and eosin for histopathological evaluation. Immunohistochemical analysis using ALDH1, EZH2 and Ki-67 antibodies were performed to examine the cases. Results: A total of forty patients; 22 males and 18 females were studied. The lesions were classified as follows: 14 cases of low-grade astrocytoma (WHO grade I or II), 11 cases of anaplastic astrocytoma (WHO grade III), and 15 glioblastomas (WHO grade IV). There was a significant increase in ALDH1 immunoreactivity with increasing the grade of astrocytoma (mean �SD = 0.2 �0.4, 0.5 �0.6, 1.1 �1.3 and 2.95 �2.97 in grade I to IV astrocytic gliomas, respectively). This expression was significantly correlated with overall survival (OS) and progression-free survival (PFS) (P=0.004). EZH2 expression was also significantly associated with advanced grades (mean �SD =1.35 �0.4, 3.1 �2.6, 7.2 �3.5 and 9.9 �4.1, in grade I to IV astrocytic gliomas, respectively). EZH2 and Ki-67 expressions were found to be correlated with OS and PFS (P < 0.001). Conclusion: Increased expression of ALDH1, EZH2 and KI67 are found to be associated with unfavourable prognosis in patients with astrocytic gliomas and may predict therapeutic modalities.

Gastrointestinal Parasitosis: Histopathological Insights to Rare but Intriguing Lesions of the Gastrointestinal Tract

2016-05-01

Objective: Gastrointestinal parasitosis is a significant cause of morbidity and mortality. Definitive diagnosis is usually made by stool tests and/or serology but may require tissue evaluation. Although pathologists are usually familiar with common parasites, it is not well established whether the diagnosis could be suspected without seeing the �parasite� itself. Material and Method: Resection or biopsy specimens of 32 cases with Giardia intestinalis (n=20), Enterobius vermicularis (n=5), Entamoeba histolytica (n=4), Fasciola hepatica (n=1), Strongyloides spp. (n=1) and Taenia saginata (n=1) infections were retrospectively re-evaluated for accompanying mucosal changes, and compared with nonparametric tests. Results: The most common changes were congestion (65.6%) and eosinophilic infiltration (50%). Chronic active mucosal inflammation accompanied 37.5% of the cases. More than 10 eosinophils/HPF were present in 43.8%. Only one case of G. intestinalis, E. vermicularis, E. histolytica, and F. hepatica showed more than 50 eosinophils/HPF. Mucosal architectural abnormalities were present in 34.4%. Granulomas, giant cells and Charcot-Leyden crystals were only seen accompanying F. hepatica. No statistically significant difference was found between parasite subspecies regarding presence of inflammation, lymphoid aggregates, architectural distortion, congestion, ulceration and increase of eosinophils. Conclusion: Parasites induce nonspecific inflammation, slight mucosal architectural changes, mild eosinophilic infiltrate or granuloma formation. They may cause ulceration, bowel obstruction or perforation. Parasitosis should also be considered when evaluating cases mimicking inflammatory bowel disease, celiac disease or those that do not fulfill diagnostic criteria.

Utility of Direct Immunofluorescence Studies in Subclassification of Autoimmune Sub-Epidermal Bullous Diseases: A 2-Year Study in a Tertiary Care Hospital

Supriya JAIN, Vijaya BASAVARAJ, Manjunath GUBBANNA VIMALA — 2016-05-01

Objective: Sub-epidermal bullous disorders belong to immunobullous diseases which develop as a result of autoantibody action against epidermal basement membrane proteins. Clinically, they are tense bullae and do not rupture easily. They are classified into various forms based on histopathology and direct immunofluorescence patterns. This study was undertaken to assess the incidence of various sub-epidermal bullous disorders and the utility of direct immunofluorescence in accurately classifying them, and to study the intensity and pattern of immunofluorescence in various sub-epidermal bullous disorders Material and Method: A 2-year study of 38 cases of sub-epidermal bullous disorders sent for direct immunofluorescence studies formed the study group. The specimens were processed as per standard protocols. The clinical details were obtained from case files and requisition sent for histopathological and direct immunofluorescence studies. Results: Thirty-eight patients were diagnosed to have sub-epidermal bullous disorders over the period of 2 years. Twenty five cases of Bullous Pemphigoid, 5 cases of Dermatitis Herpetiformis, 3 cases of Linear IgA Bullous disorder, 2 cases of Bullous Systemic Lupus Erythematoses and 1 case each of Epidermolysis Bullosa Acquisita, Cicatricial Pemphigoid and Pemphigus Gestationis was diagnosed. Positive direct immunofluorescence was seen in 91.3% of the cases. Conclusion: Histopathology alone cannot classify sub-epidermal bullous disorders and direct immunofluorescence studies are mandatory in all of them. Bullous Pemphigoid needs to be distinguished from Epidermolysis Bullosa Acquisita which requires Salt split direct immunofluorescence studies. Dermatitis Herpetiformis, Bullous Systemic Lupus Erythematosus and Linear IgA Bullous disorder show more or less similar histological picture with neutrophilic microabscess. Direct immunofluorescence studies help in the majority of cases but further testing such as immunoblotting, immunoelectron microscopy or indirect immunofluorescence becomes essential in cases with overlapping features.

The Relationship Between Apoptotic Activity and Prognostic Factors in Neuroblastomas

S�meyye EKMEKC�, Nur OLGUN, Erdener �ZER — 2016-05-01

Objective: Prognostic parameters in determining risk groups for treatment in neuroblastoma are cellular differentiation, mitosis karyorrhexis index (MKI), N-myc amplification and age. However, additional prognosticators are still needed because patients can show unpredictable biological behavior. We aimed to study the prognostic significance of apoptotic activity in neuroblastomas. Material and Method: Thirty-five primary neuroblastoma were evaluated. The data including stage, treatment protocol, metastatic disease, survival, N-myc status, age and prognostic categorization were obtained from the clinical records. The differentiation and MKI were evaluated in hematoxylin and eosin stained slides. Apoptotic activity was assessed by both bcl-2 immunohistochemical staining and the transferase-mediated d-UTP-biotin nick end labeling (TUNEL) method. Data were correlated with established prognostic factors and clinical outcome. Results: Twenty-five (71.4%) cases were located in the adrenal. Sixteen cases showed low and 19 high MKI. Thirty-three (%94) were immunopositive for bcl-2. TUNEL staining was negative in 2 cases. Of the remaining positive 33 cases, 14 had an apoptotic index of ≤2%, 11 of 2-4% and 8 of ≥4%. Cases located in the adrenal showed higher scores of bcl-2 positivity than extra-adrenal tumors. There was no statistical significance for both bcl-2 staining and apoptotic index in correlation with cellular differentiation, MKI, N-myc amplification, age and other clinical parameters. Statistical significance was observed between bcl-2 scoring and tumor localization. Conclusion: According to our results, apoptotic activity is unlikely to be a prognostic parameter in neuroblastomas. Some studies showing significant correlations between clinical outcome and both bcl-2 immunoscoring and apoptotic index, as assessed by the TUNEL method, differences in case numbers and methodology can explain these conflicting results. Larger series and different methodologies are needed to evaluate the prognostic value of apoptotic activity in neuroblastomas.

Adrenal Histoplasmosis in Immunocompetent Patients Presenting as Adrenal Insufficiency

2016-05-01

Objective: Histoplasmosis is an infectious disease caused by the dimorphic fungus Histoplasma capsulatum, endemic in central and eastern states of United States, South America and Africa. India is considered to be non-endemic area for histoplasmosis. Disseminated histoplasmosis may affect almost all systems. Disseminated histoplasmosis with asymptomatic adrenal involvement has been described in immunocompromised patients; whereas isolated adrenal involvement with adrenal insufficiency as the presenting manifestation of the disease is rare. Material and Method: Twelve patients from a non-endemic area with adrenal histoplasmosis, who were immunocompetent and diagnosed as adrenal histoplasmosis by cytology/histopathology between January 2012 to December 2014 were studied. 18F-FDG PET/CT (fluorodeoxyglucose positron emission tomography/computed tomography) was used to assess the extent of involvement. Results: There were a total of 12 immunocompetent males (mean age: 56.9 years). Ten patients had bilateral adrenal involvement and two had a unilateral left adrenal mass. All the patients had histopathologically/cytologically proven adrenal histoplasmosis. Two patients had simultaneous histoplasmosis of other sites, one in the epiglottis and the other in the alveolus. 18F-FDG PET/CT was performed in 10 patients showing high FDG uptake in the adrenals. All these patients received Amphotericin B and/or Itraconazole treatment that led to symptomatic improvement. Conclusion: A diagnosis of invasive fungal infection requires a high index of suspicion, especially in immunocompetent patients who present with nonspecific symptoms, clinical signs, laboratory and radiological features that can resemble adrenal neoplasms. Clinical specimens must be sent for cytopathology/histopathology together with fungal culture for a definite diagnosis and appropriate management.

Inking in Surgical Pathology: Does the Method Matter? A Procedural Analysis of a Spectrum of Colours

2016-05-01

Objective: Proper identification of surgical margins along with margin status holds utmost importance in histopathology. Inking margins is one way. India ink has long been used but it can ink only one margin. On other hand acrylic colours, available in variety of colours can be used for inking multiple margins along with many more advantages. The present study was undertaken to analyse acrylic colours and Indian ink for inking surgical margins via three different methods for optimum results. Material and Method: Thirteen acrylic colours along with India ink were evaluated via three different methods on radical specimens of breast and colon after preliminary requisites of grossing were completed. In Method 1, coloured inks were applied to an overnight formalin fixed specimen and representative sections were taken. In Method 2, the specimen was inked and kept for overnight fixation. The specimen was sampled following day. In Method 3, the specimen was inked and kept for overnight fixation. The following day, it was re-coloured with the same colours as of the previous day and subsequently sections were taken. Coloured inks were assessed on different parameters for their performance as surgical ink and given scores. Results: Acrylic shades #04, #22, #06, #01, #02 and India ink had very good to excellent score on microscopy in all three methods. Shades #64, #18, #09, #23 had poor microscopic visibility in all three methods. Shade #09 showed loss of colour and the shade #23 showed penetration into deeper tissues on microscopy. Results were best with Method 3 followed by Method 1 and 2, respectively. Conclusion: Acrylic colours have more advantages compared to India ink. Method 3 is recommended for inking. Few acrylic shades meet the criteria of surgical inks in all three methods.

Lymphangiomatous Polyp of Tonsil: A Case Report

Hamide SAYAR, �a�da� SAYAR, Fulya ADAMHASAN, Aysun U�UZ — 2016-05-01

Lymphangiomatous polyps of the palatine tonsils are uncommon hamartomatous proliferations that could be clinically misdiagnosed as malignant neoplasms. These polyps consist of dilated lymphatic vessels located inside fibrous and/or adipose tissue. In this paper, a 27-year-old man who presented to the outpatient clinic with a complaint of dysphagia is presented. On physical examination, the patient had a smooth, polypoid mass extending from the posterior section of the right palatine tonsil into the oropharynx. The patient underwent right tonsillectomy. Histopathological examination of the specimen showed typical features of a lymphangiomatous polyp of the tonsil. The case is reported with the accompanying literature to avoid the possibility of misdiagnosing it as a malignant lesion clinically.

Mucoepidermoid Carcinoma in Carcinosarcoma of the Lung - A Rare Combination

Meetu AGRAWAL, Tara Roshni PAUL, Shantveer G. UPPIN, Sundaram CHALLA — 2016-05-01

Carcinosarcomas of the lung are uncommon neoplasms and are presently categorized along with sarcomatoid carcinomas in the WHO 2004 classification. Morphological recognition of individual components in a surgical specimen is usually straightforward. The respiratory epithelium is also a rare site for salivary gland type tumors. A 72-year-old lady who was investigated for an episode of hemoptysis was found to have a well circumscribed intraluminal tumor. The histo-morphological features were unique and composed of mucoepidermoid carcinoma and undifferentiated sarcoma. To the best of our knowledge, this unusual morphological combination has never been reported in literature.

Ovarian Yolk Sac Tumor with Granulomatous Reaction Resembling Tuberculosis � A Unique Presentation

2016-05-01

Yolk sac tumors (endodermal sinus tumors) are an important subgroup of germ cell tumors of the ovary. They are seen in young females and are highly aggressive, but respond well to treatment. Although different morphological patterns can be seen on light microscopy, granulomatous reaction and giant cells are a very rare occurrence. We report the case of a young female with ovarian yolk-sac tumor in which a widespread granulomatous reaction was seen, causing a diagnostic dilemma.

Chordoid Meningioma - A Case Report: Clinicopathological Features and Differential Diagnosis of an Uncommon Tumor

2016-05-01

Meningiomas are tumors that originate from the arachnoid cell and the majority are benign and grade I tumors according to World Health Organization. Chordoid meningioma is an uncommon variant of meningioma and corresponds to grade II tumor in the World Health Organization Classification of Tumors of the Nervous System 2007 because of its more aggressive behavior and increased likelihood of recurrence. A 75-year-old female was referred to the neurosurgery department complaining of headache, syncope, and seizure. Radiological examination revealed a mass lesion in the neighbourhood of the frontal lobe that destructed bone and was associated with peritumoral edema. The patient underwent surgery. The tumor was totally excised with the dura beneath. Histopathological examination showed that the tumor was composed of clusters and cords of small polygonal cells with fine chromatin and eosinophilic vacuolated cytoplasm embedded in a myxoid matrix, and also focal whorls of spindle-shaped cells. Two mitoses were seen in 10 high power fields. Vascular proliferation was observed in some tumoral areas. Bone invasion was present. Immunohistochemical analysis of the tumor cells revealed widespread strong membranous and cytoplasmic expression of epithelial membrane antigen. The Ki67 labeling index was 6-8%. All of these findings were consistent with a diagnosis of chordoid meningioma, the neoplasm was identified as grade II based on the World Health Organization Classification, 2007. In this report we present a case of chordoid meningioma without classical radiological findings of meningioma with areas of vascular proliferation that mimicked glial tumors at histopathologic examination.

Sublingual Dermoid Cyst: A Case Report

Merva Soluk TEKKE��N, Nedim �ZER, Vakur OLGA� — 2016-05-01

Dermoid cysts are uncommon, benign congenital lesions of ectodermal origin that can occur in any region of the body. They arise from epithelial rests during embryogenesis. Nearly 7% occur in the head-neck region, and they represent less than 0.01 % of all cavity cysts. They are usually diagnosed during the 2nd and 3rd decade of life, and rarely present in children. A case of dermoid cyst in the sublingual region in a 4-year-old female child was presented. The floor of the mouth is the most common location in the oral cavity and should be considered in the differential diagnosis of any midline lesion. Treatment is surgical excision.

Relationship of c-Kit Gene and Microsatellit Instability in the Pathogenesis of Wilms Tumors

G�lden DINIZ, Yasemin BASKIN, Gizem �ALIBA�I, Safiye AKTA� — 2016-05-01