Turkish Journal of Pathology - 2019; 35(3)

Intraoperative Consultations of Central Nervous System Tumors: A Review for Practicing Pathologists and Testing of an Algorithmic Approach

2019-09-01

Intraoperative consultations or frozen sections for central nervous system (CNS) tumors present a significant challenge for surgical pathologists because of their relative rarity and diversity. Yet, such lesions are encountered by every surgical pathologist, and a basic understanding of clinical, radiological and genetic information is critical to successfully evaluate CNS frozen sections. It is often beneficial to have a systematic approach or an algorithm, and to be aware of the common pitfalls and mimickers when dealing with these lesions. We propose such an algorithm in an effort to construct a sensible approach to CNS frozen sections that considers recent developments in the WHO CNS tumor classification. The algorithm was developed for surgical pathologists who are occasionally faced with making diagnosis of CNS tumors on frozen sections. To test the algorithm and its practicability, we selected a group of tumors among a total of 3288 consecutive intraoperative consultations performed at UCSF between 2013 and 2017. The selected cases represented lesions that may be encountered in everyday surgical pathology and constituted a fair reflection of the main group. The algorithm was used by three of the authors who did not have formal neuropathology training and had been in surgical pathology practice for at least 3 years. There was a very high level of concordance among the authors� diagnosis (interobserver concordance: 0.83-0.97-kappa value) using the algorithm with high intraobserver reliability (concordance 93%, p<0.001). We suggest that an algorithmic approach is an effective means for the surgical pathologists, and may help reach diagnosis during frozen sections.

Gleason Score Correlation Between Prostate Needle Biopsy and Radical Prostatectomy Materials

Ne�e YELDIR, Esin YILDIZ, G�k�e D�NDAR — 2019-09-01

Objective: Prostate cancer is the second most common cancer in men. Digital rectal examination, transrectal ultrasonography and serum prostate specific antigen represents a diagnostic triad for the detection of prostatic carcinoma. About 50 years ago, Dr. Donald Gleason created a grading system for prostate cancer based on its histologic patterns. Currently, this system maintains its validity with various changes. New updates were made in 2005 and 2014 by the International Society of Urological Pathology. The goal of biopsies is to determine the Gleason score and prognosis in prostatectomy material. The aim of this study was to determine the concordance of the Gleason score, tumor volume and tumor laterality between prostate needle biopsy and prostatectomy materials. Material and Method: The study was performed with 112 patients who had biopsy and prostatectomy materials. The Gleason grades of the tumors have been evaluated with the new grading system. Tumor volumes were calculated by the number of positive blocks while tumor laterality was evaluated as unilateral or bilateral. Statistical analysis was performed on the obtained data. Results: Gleason score, tumor volume and tumor laterality discordance between needle biopsy and prostatectomy materials was found to be statistically significant. However, the concordance increased as the Gleason score and tumor volume increased. Conclusion: Digital examination, serum prostate specific antigen value and needle biopsy together are very sensitive for a prostate adenocarcinoma diagnosis. The Gleason score, localization and volume of the tumors are important for patient follow-up, treatment and prognosis.

Direct Immunofluorescence Studies in Lichen Planus

Supriya JAIN, Vijaya BASAVARAJ — 2019-09-01

Objective: Lichen planus is a common, usually intensely pruritic, symmetrical, papulosquamous dermatosis. Direct immunofluorescence studies in patients with lichen planus shows deposition of multiple immunoglobulins and fibrin at the dermoepidermal junction and in the colloid bodies. Material and Method: Histopathological features were analysed in 100 cases of lichen planus which were sent for routine histology. Direct immunofluorescence studies were done in 22 out of the 100 cases and the features were analysed. Clinical data was recorded from patient files. Results: Positive direct immunofluorescence was seen in 78.5% of the cases. Deposits at the dermoepidermal junction and colloid bodies were detected in 88% and 40% of the cases respectively. IgG, IgM and C3 deposition was seen in 88%, 70% and 24% respectively. IgA was negative in all the cases. Conclusion: The linear and shaggy deposition of immunoreactants in a discontinuous form along the dermoepidermal junction and in the colloid bodies were indicators in support of lichen planus along with the characteristic histopathological findings. In lupus erythematosus, linear and granular deposition of immunoglobulins in a continuous form is found along the dermoepidermal junction. Direct immunofluorescence studies are of immense help in disease differentiation in cases of interface dermatitis with no specific histological or clinical characteristics and in cases with ambiguous features.

Effect of Preparation Technique on Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration Sample Adequacy: 3 Years of Experience from a Single Center

Dilek ECE, Gonca GE�MEN, �ermin K�KTEN, Sevda �ENER C�MERT — 2019-09-01

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is increasingly used to sample mediastinal lymph nodes and lesions. However, the methodological details of an optimal preparation technique for aspirated material have not yet been clearly determined. This study was an evaluation of the effect of 2 preparation techniques on the adequacy of aspirated specimens. Material and Method: A retrospective analysis was performed of EBUS-TBNA samples obtained at the institution over a total of 36 months. Two periods were examined. Almost all of the aspirated material was smeared onto slides and fixed with 95% alcohol in the first period of the study. Subsequently, to improve diagnostic ability, a pair of slides was prepared from each needle pass: the first was air-dried, and the second was fixed in 95% alcohol. The remainder of the aspirate was kept for cell block analysis. Results: In total, 462 samples were obtained from 260 patients. The overall sampling adequacy was 74% in the first and 81.1% in the second period (p<0.05). Approximately 14% of the specimens included a sufficient number of cells for immunohistochemical cell block evaluation in the first period and 42% in the second period (p<0.001). Histological subtyping of non-small cell lung carcinoma was determined in 18 (56.3%) and the primary origin of a tumor was determined based on morphological and immunohistochemical properties in 32 (84.2%) of the patients in the first and second periods, respectively. Conclusion: The access to a sufficient EBUS-TBNA sample and the ability to perform the appropriate preparation can impact the specific diagnosis and treatment of patient with a single procedure.

Case Series of Hemophagocytic Lymphohistiocytosis from a Tertiary Care Centre: An Underdiagnosed Entity

Vijay KUMAR, Bhavna SHARMA, Abhay S. NIGAM — 2019-09-01

Objective: Hemophagocytic Lymphohistiocytosis (HLH) is an uncommon, life-threatening hyperinflammatory syndrome, caused by severe hypercytokinemia, due to an overstimulated but ineffective immune process. The presenting features of HLH are non-specific, mimicking many other diseases, and hence its early recognition still remains a challenge. It requires a high index of suspicion and detailed analysis of clinical and laboratory findings to arrive at a conclusive diagnosis. The objective of this study is to present detailed clinical and laboratory features of a series of HLH cases. Material and Method: A retrospective study was conducted wherein all the bone marrow aspirate smears diagnosed as HLH between January 2015 to June 2018 were reviewed. Detailed correlation of clinical and laboratory criteria was done with the bone marrow findings. Results: A total of twelve cases were diagnosed as HLH from January 2015 to June 2018. Ten patients fulfilled 5 out of 8 clinical and lab diagnostic criteria of HLH (2004). After correlating clinical and laboratory criteria along with bone marrow findings the diagnosis of HLH was suggested. Conclusion: We present a series of twelve cases of Hemophagocytic Lymphohistiocytosis from a tertiary care hospital in New Delhi which will add not only to the understanding of this rare life threatening disease but also to the early diagnosis and intervention.

Changes in Conjunctiva Morphology Using Impression Cytology in Patients with Hashimoto�s Thyroiditis without Thyroid-Associated Ophthalmopathy

2019-09-01

Objective: To compare the conjunctival morphological changes in patients with Hashimoto�s thyroiditis (HT) without thyroid-associated ophthalmopathy (TAO) and controls using impression cytology technique. Material and Method: We included 25 HT patients and 33 healthy controls who did not have TAO findings or dry eye. For both groups, thyroid stimulating hormone (TSH), free T4(FT4), and anti-thyroid peroxidase (anti-TPO) were measured. Thyroid ultrasonography was performed, together with all routine eye check-ups and the Schirmer�s test. Also, conjunctival impression cytology (CIC) test was performed to analyze the conjunctival morphology. Results: When the CIC of HT patients was observed; 12% had grade 0, 40% had grade 1, 28% had grade 2 and 20% had grade 3. While patients with squamous metaplasia made up 48% of the HT group, this was observed at 6.1% in the control group (p < 0,001). In the regression model formulated, it was observed that obesity (OR=7.500; p=0.017) and anti TPO levels (OR=1.370, p=0,007) were independent stipulations for the squamous metaplasia. Conclusion: Conjunctival squamous metaplasia was more frequently seen in HT than controls and serum Anti-TPO level and obesity were detected as independent predictors of the worsening at the conjunctival impression cytology.

Pathology of Resin-Induced Gastrointestinal Damage: Report of 15 Cases and Review of Literature

Smiley Annie GEORGE, Issam FRANCIS — 2019-09-01

Objective: Medication resins such as Kayexalate and Sevelamer used in the setting of chronic kidney disease for the correction of hyperkalemia and hyperphosphatemia are associated with gastrointestinal mucosal injury. In this study we describe the clinico-pathological features of Resin-induced gastrointestinal mucosal injury highlighting the histo-morphological appearances and differential diagnoses. The aim of this study is to increase the awareness of pathologists and clinicians alike to an under-reported etiology and pattern of intestinal mucosal injury�related to medical resin therapy which may at times pose a clinical emergency. Material and Method: The archives of the Department of Histopathology, Mubarak Al Kabir hospital were analyzed for cases of resin-induced gastrointestinal mucosal injury between 2013 and 2018.� Results: Of the 15 cases, Kayexalate crystals were identified in 7 cases, Sevelamer in 5 cases and both together were seen in 3 cases. Resin crystals were identified in the gastric antrum&duodenum (3 cases), colon (9 cases in the left colon, 2 cases in the right colon) and anal canal (1 case). The histological tissue reactions included mucosal necrosis (1 case), inflammatory polyps (2 cases), mucosal ulcerations with granulation tissue formation (10 cases), perforation (1 case) , and luminal crystals (1 case). Conclusion: Accurate and timely recognition of the resin crystals in biopsy samples with clinical correlation is mandatory to avoid serious complications.

Lean Methodology for Pathology Laboratories: A Case Study from a Public Hospital

Fatih DURUR, Yasemin AKBULUT — 2019-09-01

Objective: The increase in the financial imposition of laboratories together with developing technology and evidence-based medicine applications increased the importance of quality and efficiency studies in laboratories. The aim of the study is to examine the processes of pathology laboratory, determine the causes of waste and select lean management techniques to eliminate the causes of waste. Material and Method: A five-phase plan was used for the application of lean management in the pathology laboratory. After a comprehensive literature review, these phases were determined as follows; the support of the senior management, observation, training of employees, drawing of value stream maps and creation of value stream plan. Gastric biopsy process was selected as product/service family when value stream maps were generated. In addition, fishbone diagram and Pareto analysis were used to determine the causes of waste. Results: In the current state, 73.6% of the time spent on a gastric biopsy sample in the pathology laboratory was wasted. The most common causes of waste were identified as problems with cleaning, equipment supply problems, lack of clinical information, equipment malfunction and errors. A value stream plan was developed with lean techniques to eliminate the causes of these wastes. In the pathology laboratory, a 4.6% improvement will be achieved with the achievement of the future stated target. Conclusion: A model for lean management techniques in a developing country that will enable the pathology laboratories to work more efficiently and with improved quality has been developed in this study

Collision of Malignant Melanoma and Squamous Cell Carcinoma in Rectum: First Report of a Rare Tumor

Fouzia SIRAJ, Sharma SHRUTI, Sonam JAIN, Amar BHATNAGAR, Usha AGRAWAL — 2019-09-01

The term collision tumor is used to describe two neoplasms occurring in the same anatomic location with juxtaposition of different tumor elements. Such a coexistence of tumors anywhere in the body is relatively rare. We report a case of 32-year-old female with collision tumor of rectum. The tumor showed two distinct histological patterns with predominant component consisting of malignant melanoma and a minor component of squamous cell carcinoma. The morphological picture of collision was further confirmed by specific immunohistochemical profile of the two tumors. Collision tumors of rectum are uncommon with most of the reported cases comprising adenocarcinoma and neuroendocrine tumors. To the best of our knowledge this is the first case of collision tumor of malignant melanoma and squamous cell carcinoma in the rectum.

Primary Splenic Pregnancy- A Rare but Imperative Cause of Hemoperitoneum - Case Report and Review of Literature

Ruchi RATHORE, .Shilpi, Ratna CHOPRA, Namrata NARGOTRA — 2019-09-01

Primary splenic pregnancy is an extremely rare form of extratubal ectopic pregnancy. These cases often cause splenic rupture in very early course of their gestation thereby presenting with hemoperitoneum in emergencies. Owing to the higher risk of exsanguination and death caused by hemoperitoneum, it is essential to diagnose these cases for proper management and better prognosis of the patients. We present the case of a 23-year-old female, gravida 2, para 1, live issue 1 presenting to the emergency outpatient department with acute abdomen and hemoperitoneum. There was no history of trauma. The patient had a positive urine pregnancy test and raised beta HCG levels. Emergency laparotomy revealed an otherwise unremarkable fallopian tube and ovary with a hemoperitoneum of 2.5 liters. A tiny splenic laceration was considered to be the source of bleeding and splenectomy was performed. Microscopy was suggestive of a primary ectopic pregnancy, spleen. Since hemoperitoneum in pregnancy is a rare but potentially fatal condition with a high risk of mortality, an accurate preoperative diagnosis is crucial in the management of such patients. The possibility of a ruptured extratubal ectopic pregnancy must be considered as one of the differential diagnoses of acute abdomen with hemoperitoneum in women of childbearing age.

Synchronous Cervical Minimal Deviation Adenocarcinoma, Gastric Type Adenocarcinoma and Lobular Endocervical Glandular Hyperplasia Along with STIL in Peutz-Jeghers Syndrome: Eliciting Oncogenesis Pathways

2019-09-01

We describe an unusual case of a Peutz-Jeghers syndrome associated with a composite synchronous cervical neoplasia comprising precursor �lobular endocervical glandular hyperplasia (LEGH)�, �minimal deviation adenocarcinoma (MDA)� and �gastric-type adenocarcinoma (GTA)� along with a serous tubal intraepithelial lesion (STIL) in the right fallopian tube. A 24-year-old woman presented with a white mucoid discharge and bleeding per vaginum for one year. Histopathological evaluation showed MDA & GTA in FIGO grade III with pelvic lymph node metastasis despite a deceptively bland tumour morphology and low Ki-67 index, indicating an aggressive tumour course and poor prognosis. Diagnostic marker profile in the cervix showed gastric type mucin and positive expression of CK-7, CK-20 (patchy), CEA, and negative CDX-2, p16, ER and PR. Further an attempt at eliciting the oncogenesis pathway in view of the p16 and HPV negative nature of the gastric type cervical adenocarcinoma showed negativity for p53 but activation of cyclin D1. Growth factors including Her2 and EGFR were negative while VEGFR was over-expressed. She was treated by radical hysterectomy and pelvic radiation. She was free from recurrence at the 12-month follow-up. This is a first-time report of a STIL in the fallopian tube which was validated by a unilateral mutant type p53 expression and increased Ki67 index, associated with synchronous gastric type adenocarcinoma of the cervix in all stages of evolution.

Follicular Dendritic Cell Sarcoma of the Larynx: Apropos a Rare Case with Review of the Literature

Ayushi SAHAY, Munita BAL , Asawari PATIL, Shubhada KANE, Prathamesh PAI — 2019-09-01

Extranodal follicular dendritic cell sarcomas are extremely rare neoplasms included under the hematolymphoid and dendritic group of neoplasms. Histologically, fascicular, whorled spindle cells with sprinkled lymphocytes are typical; however higher grade epithelioid morphology seen in a subset makes diagnosis of follicular dendritic cell sarcoma challenging. Rarity of occurrence, a wide histologic spectrum and a long list of differential diagnostic entities render follicular dendritic cell sarcoma an under-recognized entity susceptible to diagnostic pitfalls. Application of a judicious panel of immunohistochemical markers is imperative to avoid errors in diagnosis and patient management. We report here an extremely rare case of follicular dendritic cell sarcoma of the larynx- a hitherto unreported site.

Concomitant Intraocular Retinoblastoma and Choroidal Hemangioma in a 1-Year-Old Boy

2019-09-01

We report a case of concomitant choroidal hemangioma in an eye that harbored intraocular retinoblastoma (RB) in a 1-year-old child. A 12-month-old boy presented with right white pupil (Leukocoria). The initial clinical diagnosis was unilateral intraocular RB Group C. The eye was treated initially by systemic chemotherapy combined with focal consolidation therapy followed by I-125 plaque radiotherapy. Massive sub-retinal recurrence was seen 4 months later, and Magnetic Resonance Imaging (MRI) showed extra-scleral invasion of the tumor, and therefore enucleation was performed. Microscopic examination revealed a differentiated retinoblastoma associated at the site of the base of the tumor with choroidal hemangioma with trans-scleral invasion. Orbit MRI was repeated 3 months after the surgery, and there was no orbital tumor recurrence. We are reporting a rare case of pathologically concomitant choroidal hemangioma with trans-scleral invasion in an eye that harbored active recurrent intraocular RB. This trans-scleral extension of hemangioma was misinterpreted by MRI as extraocular retinoblastoma and resulted in enucleation.

High-Resolution Image Sharing (HIS) on WhatsApp: A Method to Facilitate Instant and High-Quality Case Consultations in Cytopathology

Fikret DIRILENO�LU — 2019-09-01