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jhc-2019-jul-v-3-n-2-information-contributors

Journal of Histopathology and Cytopathology

 Information for Contributors

 General Information

The Journal of Histopathology and Cytopathology (JHC) aims in our understanding of the pathophysiological and pathogenetic mechanisms of human disease by publishing  original papers, review articles, case reports and short communications related to basic and translational fields in pathology. It serves as  bridges between basic biomedical science and clinical medicine with particular emphasis on, but is not restricted to, tissue based studies only. It is published twice a year as the Journal Committee of the Bangladesh Academy of Pathology.

Manuscript Preparation.

Manuscripts should be prepared in MS Word format in accordance with The Uniform Requirements for Manuscripts Submitted to Biomedical Journals

(see http://www.icmje.org). All pages of the manuscript should be double-spaced and numbered consecutively beginning with the Title page.  Each of the following sections should begin on separate pages: Title,  Name and affiliation of authors, Abstract and Keywords, Text, Acknowledgements, References, individual Tables and legends.  Reformatting of the accepted papers may be needed according to the Journal specifications.

Title Page

The title page should include (i) type of publication (original, review, case report etc.) (ii) the complete title of the article (iii) authors’ name in abbreviation  (iv) list of authors including full name, highest degree, signature, designation and institutional affiliation and (v) name, mailing address, email and telephone/mobile number of author responsible for correspondence.

Abstracts

It should begin with full title of the article. Do not write authors name in the abstract page. The abstracts should not be more than 200 words. The abstract should state the purpose of the study or investigations, basic procedures, main findings and principal conclusion. Three to ten keywords may be provided below the abstract using terms from the Medical Subject Headings (Index Medicus, NLM, USA). Abbreviations and citations should be avoided.

 Text

The text of the original articles should be divided into following sections: Introduction,

Methods, Result and Discussion.

 References

References to literature should be numbered in Arabic numerical in superscripts

consecutively in the order in which they are mentioned in the text. At the end of article the full list of references should give the name of all authors followed by the title of the article, the title of the journal abbreviated according to Index Medicus, the year of publication, volume number and first and last pages of the article. Title of the books should be followed by the edition, place of publication, the publisher, the year and the relevant pages. Examples of correct form of reference are given below: References should begin on a new page, be double-spaced and numbered in order of citation in the text, including citations in tables and figure legends. Citations that first appear in tables, figures, or supplemental data should be numbered according to the item’s first call out in the text; a separate reference list should not be prepared for supplemental data. Complete author citation is required (use of “et al” is only acceptable for sources with more than 35 authors).

References should conform to the style of the Journal.

 Examples follow:

Journals: van Riel D, Leijten LM, Kochs G, Osterhaus AD, Kuiken T: Decrease of Virus Receptors during Highly Pathogenic H5N1 Virus Infection in Humans and Other Mammals. Am J Pathol 2013, 183:1382-1389

 Electronic Journals: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 2009, 6:e1000097. http://dx.doi.org/10.1371/journal.pmed.1000097

 Books: Frosch MP: Central Nervous System. Robbins Basic Pathology, 9th Edition. Edited by Kumar V, Abbas AK, Aster JC. Philadelphia, PA, Saunders, 2012, pp. 811-850

 Product Inserts: Cite in text only: (Affymetrix technical note: Globin Reduction Protocol: A Method for Processing Whole Blood RNA Samples for Improved Array Results. Santa Clara, CA).

 

Web sites: Cite in text only. See Data Supplements and Non-Traditional Media section below for proper use of web site references. Use the doi when available. Include the name of the institution sponsoring the web site, URL address with direct linkage to the referenced information, and date of last access.

Tables

Tables should be typed written on separate numbered pages submitted after the main text on separate pages, as part of the manuscript. The preferred file format for Tables is MS Word. and should follow the reference list. All tables should be numbered consecutively using Roman numerical. Each must carry a brief descriptive heading. Tables should be planned to fit within print area. Table footnotes should use the sequential symbols: *, †, ‡, §, ¶, ∥; and abbreviations.

Illustrations

Figure file formats (including those embedded in the text) are unacceptable.

Photographs and photomicrographs should be of high resolution (minimum 5 mega pixels), in original unedited form and jpg format. These should contain a legend with magnification and stain used. Figure number and name of the first author should be mentioned in each file. Legend should be given in separate page.  Patients’ identification should be hidden.

Abbreviation

Standard abbreviation should be used whenever possible. The full term for which

the abbreviation stands followed by abbreviation in parenthesis should be proceed

the first use of the abbreviation in the text except for standard units of measurements

like 27OC and 25 mmol/L etc.

Letters to the editor

Communications with reference to an article published in the journal and current health

problems in the community will be accepted as letter to the editor.

 Electronic Copy

An electronic copy (soft copy) in the form of CD must be submitted with the printed copy of the article. Electronic copy may be send by email attachment at sadequel@yahoo.com.

Text should be processed with MS Word and pictures should be saved in JPG format.

Manuscript Submission

Electronic version of the manuscripts should be submitted through email to the Executive Editor.  Alternatively send DVD/CD to: The Executive Editor of the Journal of Histopathology and Cytopathology.  A cover letter to the editor must accompany the manuscript stating any,  (a) conflicts of interest (both financial and personal), (b) that the manuscript has not been published previously and is not being considered concurrently by another publication, and (c) all authors and acknowledged contributors have read and approved the manuscript. Submissions are not considered for review if previously published in any form (print or online) other than as an abstract. The editor reserves the customary right to style and if necessary shorten the material accepted for publication and to determine the priority and time of publication. Editor assumes that work based on honest observations. It is not the task of the editor to investigate scientific fraud paper.

Proofs

The corresponding author will be contacted by email once proofs are ready, and will be directed to download electronic proofs from a secure website. The author should check the proofs carefully, mark any printer’s errors, and answer queries as requested. Author changes should be kept to a minimum. Proof corrections and replacement figures (if any) must be returned within 48 hours to avoid any delay in publication.

The Review Strategy

On receipt, manuscripts are assessed by the Editor-in-Chief, to one Associate Editor. The Reviewers’ and Associate Editor’s views are used by the Editor-in-Chief (or a Senior Editor) in reaching a decision, usually within three weeks of submission.

 Summary of Submission, General points

Format the word processing document as double spaced A4 pages with an additional space between paragraphs and margins of at least 2 cm all round. Use a 12-pt standard font such as Times, Helvetica or Arial (with Symbol for special characters). Do not use line numbering, but include page numbers in the header or footer, aligned right. Use consistent, preferably UK English spelling.

 Manuscript title

This should be clear, simple and concise; long titles lack impact. Please remember that many readers will only scan titles, so they should reflect the message of the paper and catch the readers’ attention.

 A short running title

This must be 75 characters or less, including spaces, and reflect the main title and content of the manuscript.

 List of authors

Authorship credit should be based only on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; 3) final approval of the version to be published.

 A statement outlining the specific contribution of each author to the manuscript and the work reported in it must appear after the acknowledgements section (see below).

 Full affiliations of all authors:

Include the name of the department(s) and institution(s) to which the work should be attributed. Append the corresponding author(s) full postal address, phone number and email address.

 Conflict of interest statements

Authors must disclose all financial and personal relationships that might bias their work; to prevent ambiguity, a conflict of interest statement must appear on the manuscript title page, detailing any conflicts (or the absence thereof) for each author.

 Word count (from beginning of Introduction to end of Discussion)

Concise articles make a greater impact than long ones and are less likely to be delayed by editing to a suitable length. Full articles should be no more than 4000 words from the beginning of the Introduction to the end of the Discussion. Review articles and special features may occasionally exceed this limit by arrangement with the Editor-in-Chief.

 Abstract (not structured and no more than 300 words)

Following the title page(s), the next page should carry an unstructured prose abstract of 300 words or less. It should clearly convey the purposes of the study, and the main procedures, findings and conclusions. It should be understandable without reference to the rest of the paper, and contain no citation to references in the reference list. Only standard abbreviations as listed below are permitted.

 Keywords (3 to 10)

Below the abstract, authors should provide and identify as such 3 to 10 keywords or short phrases to assist indexing the article and that may be published with the abstract. MESH headings are a useful guide for authors in considering keywords.

 Manuscript structure

Research articles are divided into sections with the headings: Abstract, Introduction, Methods, Results and Discussion. Long articles may need subheadings (especially within the Results and Discussion) to clarify their content. The sections should not be numbered. Other types of articles, such as reviews and commentaries, still need a title and abstract and should adhere as closely as possible to these guidelines.

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jhc-2019-jul-v-3-n-2-mesenteric-ms

Mesenteric Cystic Lymphangioma – Case Report

 

*Nazrin MS,1 Rahman DS2

 

  1. *Dr. Mosammet Suchana Nazrin, Professor & Head, Department of Pathology, North East Medical College, Sylhet, Bangladesh. nazrinsuchana@gmail.com
  2. Dil Shakira Rahman, Lecturer, Department of Pathology, North East Medical College, Sylhet, Bangladesh.

 

*For correspondence

 

Abstract

Cystic lymphangioma is a rare tumor of lymphatic origin. Incidence of intra-abdominal lymphangioma  accounts <5%. A 4 years old boy, admitted in the North East Medical College and Hospital, Sylhet, Bangladesh with the complaints of abdominal distension,  severe pain in whole abdomen, nausea, anorexia and vomiting. CT findings were suggestive of mesenteric cyst. At laparotomy, a cystic tumor was found in the mesentery, that  was attached to bowel loops. Histopathological examination confirmed the diagnosis of cystic lymphangioma.

 

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):172-174]

 

Key words: Lymphangioma, Cyst, Mesentery.

 

Introduction

Lymphangioma is a rare cystic tumors of lymphatic system, characterized by proliferating lymphatic vessels, occurs most commonly in the head, neck and axilla.1 Other sites include mouth, arm, mediastinum, lung, abdomen and viscera. Intra-abdominal cystic lymphangiomas are rare and comprises less than 5% of all cystic lymphangiomas.2 Differentiating cystic lymphangioma from other cystic growths by imaging techniques alone is often inconclusive and surgery followed by histopathological examination is required for final diagnosis. We are here reporting  a rare case of mesenteric cystic lymphangioma in a 4 years old male children.

 

Case report

A 4 years old boy, admitted in the North East Medical College and Hospital with the complaints of abdominal distension and severe pain in whole abdomen for 15 days, nausea and anorexia for 15 days and vomiting for 1 day. On physical examination, abdomen was hugely distended. Tenderness was present in whole abdomen. There was no organomegaly. Umbilicus was everted and transverse slit was present. The laboratory data presented no anaemia,  CRP was 10 mg/dl, serum creatinine 0.5 mg/dl, serum electrolytes showed Na+ 141 mmol/L, K+ 4.4 mmol/L, Cl– 105 mmol/L, HCO3–18 mmol/L. However, computed tomography revealed a large cystic mass of about 16x13x10.5 cm, which extended from right side of upper abdomen to pelvic cavity and displaced adjacent gut loops towards left. No soft tissue component or calcification was seen within the cyst. There was also right sided hydronephrosis, probably due to pressure effect of the cystic mass. Patient was diagnosed clinically as a case of mesenteric cyst.  Laparotomy was done under general anaesthaesia. On laparotomy, there was a mesenteric cyst in the abdomen. Aspiration was done. The fluid color was haemorrhagic, probably due to pressure effect and congestion of the blood vessels. The cyst was clinically designated as mesenteric cyst and sent for histopathological examination.

 

 

On gross examination, there was a cystic mass measuring 7x 6 x4 cm size. The surface was smooth. On cut section, it was multiseptate and multiloculated with various sized cystic spaces. Microscopic examination showed multiple cystic spaces separated by fibrocollageous stroma. The cysts were lined by single layer of endothelium. The lumens were filled with homogenous eosinophilic material with a few clusters of macrophages. The stroma was infiltrated with lymphocytes, forming lymphoid aggregates. Histopathological examination confirmed the diagnosis of mesenteric cystic lymphangioma. The post-operative period was uncomplicated and the patient was discharged on 6th postoperative day.

Discussion

Lymphangioma, a rare cystic tumors of lymphatic system. It is  a benign, slow-growing lesions, characterized by proliferating lymphatic vessels, preferentially located in the head & neck (75%), axilla (20%). Incidence of intra-abdominal lymphangioma (accounts <5%), have been reported in the mesentery, genitourinary tract, spleen, liver & pancreas.3 Abdominal cystic lymphangiomas arises from mesentery (59% – 68%), omentum (20-27%), and retroperitonium (12-14%).4 Abdominal cystic lymphangioma is  more frequent in boyes (5:2) with mean age at 2 years.5 Intra-abdominal cystic lymphangiomas is most commonly presented with abdominal mass and distension, loss of appetite, nausea and vomiting.1,2,6 Ultrasound findings are not specific, the computed tomographic scan allows the initial diagnosis.1 The diagnosis of cystic lymphangioma can only be confirmed by histological examination.

 

Conclusion

Cystic lymphangioma is a rare benign tumor that may be arises in various sites. Confirmatory diagnosis of this lesion includes laparotomy followed by histopathology.

 

Reference

  1. Chaker K, Sellami A, Ouanes Y, et al. Retroperitoneal cystic lymphangioma in an adult: A case report. Urol Case Rep. 2018;18:33-34.
  2. Karkera PJ, Sandlas GR, Ranjan RR et al. Intra-abdominal cystic lymphangioma in children: A case series. Arch IntSurg 2012;2:91-95.
  3. Bhavsar T, Saeed-Vafa D, Harbison S etal., Retroperitoneal cystic lymphangioma in an adult: A case report and review of literature. World Journal of Gastrointestinal Pathophysiology. 2010; 1(5):171-176.
  4. Muramori K, Zaizen Y and Nogushi S. Abdominal lymphangioma in children: report of three case. Surgery today. 2009; 39: 414-417.
  5. Kati O, Gunor S, Kandur Y. Mesenteric cystic lymphangioma: Case report. Journal of Paediatric Surgery 2018;35:26-28
  6. Rami A, Mahmoudi A, EiMadi A, et al., Giant cystic lymphangioma of mesentery: varied clinical presentation of 3 cases. Pan Afr Med J. 2012; 12:7
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jhc-2019-jul-v-3-n-2-multilocular-islam-f

Case Report

Multilocular Cystic Nephroma in an Adult Patient: A Case Report

*Islam F,1 Begum A,2 Kamal M3

 

  1. *Dr. Farhana Islam, Assistant Professor, Department of Pathology, Popular Medical College, Dhaka. ifarhana2006@gmail.com
  2. Afroza Begum, Associate Professor, Department of Pathology, Anwer Khan Modern Medical College, Dhaka.
  3. Mohammed Kamal, Professor of Pathology, BSMMU, Dhaka.

 

*For correspondence

 Abstract

Multilocularcystic nephroma is relative rare, cystic neoplasm of the kidney and is usually benign. There are two peaks in the incidence of the tumor, with a bimodal distribution presenting in the first 2 to 4 years of life, and again in 40 to 60 years.They are usually incidentally found as an asymptomatic abdominal mass. Radiologically, it is difficult to differentiate between cystic nephroma and cystic RCC in adults. The exact diagnosis primarily depends on the histopathologic examination. We present a 35-year-old male patient with a palpable mass over the right upper quadrant of the abdomen, which was gradually increasing in size. A Right sided  nephrectomywas performed on thispatient. Microscopically, the tumor composed of variable-sized cysts lined by a layer of flattened or cuboidal cells thatconfirmed a diagnosis of Multilocular cystic nephroma.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):167-171]

 Key words: Multilocular cystic nephroma, Kidney, Benign renal tumor

Introduction

Multilocular cystic nephroma (MLCN) is a rare, benign cystic neoplasm of the kidney. It was first described in 1892 as cystic adenoma of the kidney and over 200 cases have been reported in the literature so far.1 MLCN is an uncommon, benign cystic lesion of the kidney with bimodal age distribution, occurring in both infants and adult population. Although it has been described in neonates, MLCN is more commonly seen in the age group of 2–4 years (of which 73% are in males). Below 4 years of age, male to female ratio is 3:1 and boys are affected more than girls. In adults, it is seen in the 4th–6th decade with its male to female ratio being 1:8.2 The main complaint in children is abdominal mass, while in symptomatic adults predominant complaints are abdominal distension, and pain, recurrent urinary system infection, and hematuria.3 However, most of the patients with cystic nephroma are asymptomatic and usually found incidentally. Herein, we present a case of a 35-year-old male whodeveloped a multilocular cystic nephroma in the upperpole of the right kidney. The clinicalpresentation, radiological findings, and histopathologic results werereported and the literature was reviewed.

Case Report

Our case a 35 years old male was suffering from lower back pain for 4 years. He did not pay attention to it until he discovered a palpable mass over the right upper quadrant of the abdomen, which was gradually increasing in size. Routine laboratory examinations were all within normal limits. Abdominal ultrasonography showed right renal cystic mass including a cluster of variable-sized cysts separated by hyperechoic tissue at the upper pole of the right kidney (Fig-1). I.V.U was done and the report suggested of mass in right kidney possibly cyst. Both the kidneys were normal functioning (Fig-2) MRI report suggested a right cystic renal mass (stage-II, Fig-3). Right sided  nephrectomy was done. Specimen of kidney with part of right ureter and peri-nephric fat was sent for histopathological examination on March 2010.

 Nephrectomy specimen with part of perinephric fat measured (14x9x6) cm. Cut surface showed multilocular cystic growth measured 9 cm in maximum  diameter involving  whole upper pole and mid portion of the kidney. The largest locule of the cyst measured 3 cm in maximum diameter. The wall of these cysts were thin and the locules contained straw colored watery fluid. Adjacent parenchyma was normal(Fig-4).

Microscopically, the tumor was composed of variable-sized cysts separated by fibrous septa. The cyst wall was partly lined by flattened epithelium and partly by cuboidal epithelium. The stromal septae was made of dense fibrous connective tissue with scattered smooth muscles. No nephron elements were found in the stromal septa. No communication among locules was noted. Kidney tissue surrounding the growth showed no significant change (Fig-5,6,7). A multilocular cystic nephromawas diagnosed on the basis of this  histopathological findings.

No postoperative complication was encountered and the patient was discharged uneventfully 7 days after the surgical procedure. No recurrence was found during 3 years of follow-up.

Discussion

MLCN has at least 20–25 synonyms, which include multilocular cystic renal tumor, benign multilocular cystic nephroma, polycystic nephroblastoma, and so on. Its etiology and histogenesis is debatable, and in the past they were considered to be developmental lesions with malignant potential. According to the World Health Organization (WHO) classification of renal neoplasms, MCN is grouped with the mixed epithelial and stromal tumors (MEST). The term renal epithelial and stromal tumor (REST) can be used to encompass both MCN and MEST.2

Cystic nephroma has a special bimodal age distribution, one in childhood of 2 to 4 years of life, predominantly in boys, and the other in the 40 to 60 years of life. The disease is predominantly found in adult female with an 8-time prevalence compared to male. Similar to other renal tumors, classical signs can include palpable abdominal mass, abdominal pain, and gross hematuria. However, most of cystic nephroma were found incidentally and asymptomatically.4

Usual ultrasonographic findings are multiple hypoechoic spaces separated by thin septa. CT scan, on the other hand, usuallyreveals a multilocular cystic tumor with curvilinear calcifications. Herniation into the renal collecting system with septal enhancement is commonly seen.3 Although in our case the patient done Magnetic Resonance Imaging (MRI) but it is rarely indicated. Imaging features include usually hypointense signal on T1-weighted sequences (although this may vary) and hyperintense signal on T2-weighted sequences. Septa are usually hypointense on all sequences due to fibrous content.2

Unfortunately, it is pretty difficult to differentiate between cystic nephroma, cystic RCC in adults and Wilms tumor in children radiologically even on CT scan.5 Since definitive discrimination is not possible via radiologi­cal means, histopathological diagnosis is required for dif­ferential diagnosis.

Grossly, cystic nephroma is a well-circumscribed tumor with a smooth surface. The cut surface reveals variable-sized cysts separated by thin septa. The cysts contain mostly clear to yellowish fluid but occasionally dark-colored fluid because of blood clots retention. They may be herniated into the renal collecting system but do not communicate with renal pelvis. That is why only parts of patients have hematuria microscopically or macroscopically. Bilateral cystic nephroma and recurrence after excision was rarely reported. Only several case reports in childhood co-existing with nephroblastoma.6

The criteria for pathologic diagnosis were established by Powell et al. in 19517 and later modified by Boggs and Kimmelstiel in 1959,8 and include the following (1) The lesion must be multilocular (2) The cysts must, for the most part, be lined by epithelium (3) The cysts must not communicate with the pelvis (4) The residual renal tissue should be essentially normal, except for pressure atrophy (5) No fully developed nephrons are present within the septa. Our patient fulfills all 5 criteria.

Development of cystic renal cell carcinoma originating from CN has been also reported, and postoper­ative follow-up is recommended. Local recurrence or me­tastasis is limited to a few cases, and it has been reported that local recurrence especially in patients who underwent partial nephrectomy is a possibility which might be re­lated with incomplete resection.3 Contrarily, Castillo et al.9 presented a series of 29 cases, and couldn’t encounter any postoperative local recurrence or metastasis. Also in our case we didn’t observe any local recurrence or metas­tasis,after 3years of  postoper­ative follow-up.

Traditionally, treatment for any solid renal mass or multilocular cystic lesion was nephrectomy. Nowadays, partial nephrectomy has become the initial standard option for small renal mass.10 If the lesion is localized enough, excision of the lesion or partial nephrectomy can be considered, even for large tumor in children.11

Conclusion

Cystic nephroma is a rare, benign renal tumor, which progresses with a silent course, and demonstrates a bimodal age distribution, and it is difficult to differentiate from cystic RCC. Neither clinical signs nor radiological findings can obtain a pre-operative diagnosis of MLCN. Surgical intervention and histopathologicexamination are necessary for the final diagnosis. Noninvasively radiological follow-up is recommended after complete resection.

 References

  1. Edmunds W. Cystic adenoma of the kidney. Trans PatholSocLond. 1892;43:89–90.
  2. Wilkinson C, Palit V,Bardapure M et al., Adult multilocular cystic nephroma: Report of six cases with clinical, radio-pathologic correlation and review of literature. Urol Ann. 2013; 5(1): 13–17.
  3. Cavıldak İD, Çakıcı MÇ, Karakoyunlu N, Ersoy H. Cystic nephroma: A case report in adult patients. Turk J Urol 2018; 44: 373-6.
  4. Chih-Yin Y, Yi-Chia L, Te-Fu T and Thomas ISH, Cystic nephroma: A case report in adult patients. Turk J Urol 2018; 44(4): 373-6.
  5. Kurian JJ, Ninan PJ. A rare case of bilateral cystic partially differentiated nephroblastoma recurring as bilateral cystic Wilmstumour. BMJ Case Rep,2015; 2:1.
  6. Joshi VV, Beckwith JB. Multilocular cyst of the kidney (cystic nephroma) and cystic, partially differentiated nephroblastoma.Terminology and criteria for diagnosis. Cancer,1989; 64: 466-479.
  7. Powell T, Shackman R, Johnson HD. Multilocular cysts of the kidney. Brit J Urol 1951;23:142-52.
  8. Boggs LK, Kimmelstiel P. Benign multilocular cystic nephroma: report of two cases of so-called multilocular cysts of the kidney. J Urol 1956;76:530-41.
  9. Castillo OA, Boyle ET Jr, Kramer SA. Multilocular cysts of kidney.A study of 29 patients and review of literature. Urology 1991;37:156-62.
  10. Dong B. Multilocular cystic nephroma treated with laparoscopic nephronsparing surgery: A case report. Can UrolAssoc J, 2014; 8: 545-547.
  11. Tanaka Y. Laparoscopic partial nephrectomy for the treatment of large cystic nephroma in children. J Laparoendosc Adv Surg Tech A, 2014; 24: 901-906.
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jhc-2019-jul-v-3-n-2-coexistence-hossain-mi

Case Report

Coexistence of Primary Tuberculosis and Metastatic Ductal Carcinoma in Axillary Lymphnode: Report of a Rare Case

* Hossain MI,1 Sadaf A,2 Sultana N,3 Khan AS4

 

  1. * Mohammad Ismail Hossain. Lecturer, Department of Pathology, Chattogram Medical College, Chattogram, Bangladesh.ismail. tushar@gmail.com
  2. Anika Sadaf, MD (Pathology) Phase B Student. Department of Pathology, Chattogram Medical College, Chattogram, Bangladesh.
  3. Nahid Sultana, Senior Consultant, Obstetrics & Gynaecology, Chandpur 250 bed General Hospital, Chandpur, Bangladesh.
  4. Professor Dr. AKM Shahabuddin Khan, Ex Professor, Department of Pathology, Cumilla Medical College, Cumilla, Bangladesh. Chief Consultant, Cytosite (Histopathology Laboratory), Chandanpura, Chattogram.

 *For correspondence

 Abstract

Concomitant breast cancer metastasis and tubercular lymphadenitis in axillary lymph node is an extremely rare occurrence. Co-existence of two pathologies in one organ always poses a diagnostic and therapeutic challenge. Here, we report a case of 47-years old female presented with lump in the right breast. Fine-needle aspiration cytology (FNAC) from breast and axillary lymph node revealed ductal carcinoma with axillary metastasis. The patient underwent total mastectomy with axillary lymph node dissection and microscopy showed concomitant presence of metastatic tumor and tubercular lymphadenitis in axillary nodes. Majority of previously reported cases were breast cancer with axillary lymphadenopathy having tubercular foci, while our patient had a metastatic carcinoma and tubercular granulomatous foci in the same lymph node with the absence of tubercular foci elsewhere. The case is being reported for its rarity. It also indicates that FNAC can fail to detect mixed lesions unless multiple punctures from many sites are performed.

 [Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):162-166]

 Key Words: Ductal carcinoma, Tuberculosis, Metastasis, Axillary lymph node, Coexistence

 Introduction

The synchronous occurrence of tuberculosis and carcinoma is unusual. Coexistence of tuberculosis and metastatic carcinoma in axillary lymph nodes, without pulmonary or mammary tuberculosis is even rarer.1 It is always adiagnostic and therapeutic challenge that simultaneous presence of two diseases in one organ. Though carcinoma of the breast and tuberculosis (TB) both are common in developing countries, their coexistence is uncommon.2 Warthinfirst described two cases of coexistence of TB and carcinoma of mammary glands in axillary node in 1899.3 Kaplan et al. examined the frequency of the coexistence between different cancer types and TB in a retrospective study and reported that the prevalence of TB was 19 per 10,000 cases of breast cancers.4 Here we report a rare case of metastatic duct cell carcinoma of breast in axillary lymph nodes harboring tubercular lymphadenitis that was incidentally discovered during the histological examination, wherein no evidence of tuberculosis was found elsewhere.

 Case Report

A 46-years old multiparous woman presented at out-patient department of Chattogram Medical College Hospital with the history of painlesslump in her right breast for about last one and halfmonths. On examination, a fixed and hard nodule measuring 3 cm in diameter was palpable in the lower outer quadrant of right breast.The overlying skin, areola and nipple were apparently normal. Multiple right axillary nodes, ranging from 0.5 to 2 cm in diameter were also palpable with mild tenderness. No palpable lump was detected in contralateral breast & axillaand no cervicalor inguinal lymphadenopathy. There was no past history/family history of tuberculosis, malignancy or any other chronicmedical illness.She was taking combined oral pills for contraception for about 20 years.

The ultrasonographyrevealed a nodule of 46x39x32 mm in the lower outer quadrant of the right breast, associated with a group of axillary lymph nodes the largest one measuring 22×15 mm.

Routine hematological & biochemical tests were within normal limit except a hemoglobin level of 9.2 g/dl with raised ESR and chest X-ray showed unremarkable change. Fine needleaspiration cytology (FNAC) from right breast lump revealed highly cellular smears showing atypical ductal cells in clusters and dispersed singly. The cells had moderately pleomorphic nuclei, coarsely granular chromatin and 1–2 prominent nucleoli. FNAC from the largest axillary node revealed tumor metastasis. A diagnosis of ductal carcinoma with axillary metastasis was given on cytology. A right modified radical mastectomy performedandthe specimens were sent to Cytosite (A private cyto-histopathological laboratory) for histopathological diagnosis. Specimen showed a firm to hard, whitish about 40×35 mm nodular lump in the breast. On axillary dissection, eight lymph nodes were isolated larger one measured 20 mm in diameter. Cut surface ofmost of the nodes were adherent and gray-white in colour (Figure 1).

The histological examination revealed a tumor composed of neoplastic ductal cells arranged in cords, nests and tubules invading into the stroma. These cells had moderate amount of cytoplasm with moderate nuclear pleomorphism and 1-2 prominent nucleoli. Mitotic count was less than ten/10 high power fields. Surgical resection margins were free of tumor, where the base was tumor-free. Lymphovascular tumor emboli were also evident with no perineural involvement.

Out of eight nodes three showed tumor metastases and two of the lymph nodes showed epithelioid cell granulomas with Langhans type giant cells and central caseaous necrosis (Figure 3, 4, 5).

Immunohistochemical (IHC) examination revealed overexpression of estrogen & progesterone receptor and negativity for Her-2/neu in the breast lesion. With these findings, diagnosis of “invasive ductal carcinoma, grade II (Nottingham modification of Bloom Richardson grade) with concomitant regional nodal metastasis done and caseating granuloma” found, so “AJCC staging II”was made. Since preoperatively tuberculosis was not suspected and no other clinical feature of TB was found, mantoux test, culture, serology or polymerase chain reaction were not performed. Due to unavailability modified Ziehl–Nielsen staining on axillary tissue and CD68 immunostain for epithelioidhistiocytes not done.

 Discussion

TB remains a major public health problem worldwide. According to the Global Tuberculosis Report 2018, it affected 10 million people in 2017 and is responsible for 1.2–1.4 million deaths globally in HIV-negative patients. It is caused by Mycobacterium tuberculosis and most often affects the lungs. About 23% of the world’s population (1.7 billion people) has latent tuberculosis, with a risk of reactivation of 5–15%.5 Tubercular lymphadenitis is the most common form of extra pulmonary tuberculosis. But isolated axillary tubercular lymphadenitis without any evidence of clinical disease in any other organ is extremely uncommon in adults. Axillary tubercular lymphadenitis can be accounted for by either retrograde spread from the mediastinal nodes or hematogenous spread from a subclinical focus.

An alternative explanation for the co-occurrence of TB and metastasis could be activation of a silent Mycobacterium tuberculosis infection due to immunocompromised state in cancer patients.6 Tubercle bacillus can exist in a state of microbial latency within the macrophage of the granulomas for the lifetime. Factors that disturb host immunity can allow the tubercle bacillus to cause endogenous reinfection.7

In general, TB is diagnosed by clinical history, erythrocyte sedimentation rate, chest X-ray, Ziehl–Nielsen staining, polymerase chain reaction (PCR)based detection of acid fast bacilli (AFB) and others. But a significant proportion of cases of extra-pulmonary TB may be negative for chest X-rays or regular stains for AFB.8

The clinical features of breast carcinoma may reveal nodules and ulcerations,appearance of lymphadenopathies lead us to suspect a metastatic tumor. It is the histological examination that enabled making the differential diagnosis.9 Ina few cases diagnosis have been made through preoperative investigations like cytology or core biopsy. PET-CT as we know is the imaging of choice in certain cancers like lung cancer, its role in breast cancer is limited.8

Breast cancer patientsalso may suffer reactivation of TB during their treatment. It not only disturb the treatment protocol but also the clinical and radiologic findings confuse the follow up process since a malignant and a tubercular lesion may be indistinguishable.7 Axillary lymph node metastasis is the most important factor in the staging of ductal carcinoma and the number of metastatic axillary nodes alter the stage. As tuberculosis also produces nodal enlargement, this can mimic or complicate the staging of malignant disease.6 Therefore, pathologists and lab technicians should also be aware and vigilant in ruling out possible differentials such as metastasis, tuberculosis, fat necrosis, actinomycosis, suture granuloma accordingly.10

 Conclusion

Simultaneous presence of axillary tubercular lymphadenitis and metastatic carcinoma is a significant but rare event that can confuse and complicate the diagnosis, grading, staging and most importantly, the treatment of the disease. It is important for the physician in endemic countries like ours to consider the possibility of a granulomatous disease masquerading as axillary metastasis in order to correctly address both diseases.

 

 References

  1. Pandey M, Abraham EK, Chandramohan K and Rajan B. Tuberculosis and metastatic carcinoma coexistence in axillary lymph node: A case report. World Journal of Surgical Oncology; 2003;1(3):1-3.
  2. Tulasia NR, Rajub PC, Damodaranb V and Radhikab TS. A spectrum of co-existent tuberculosis and carcinoma in the breast and axillary lymph nodes: Report of five cases.The Breast; 2006;15:437–439.
  3. Caroppo D, Russo D, Merollam F, Ilardi G, Caro MD, Lorenzo PD, Varricchio S, Mascolo M and Staibano S. A rare case of coexistence of metastasis from head and neck squamous cell carcinoma and tuberculosis within a neck lymph node. Diagnostic Pathology; 2015;10(197):1-3.
  4. Kaplan MH, Armstrong D, Rosen P. Tuberculosis complicating neoplastic disease:A review of 201 Cases. Cancer 1974;;33:850-858
  5. Almeida S, Valentim M, Neto C, Cerol M, Boticário M, Santos MI, Gameiro A. Extrapulmonary Tuberculosis Presenting as a Suspected Case of Metastatic Breast Cancer. European Journal of Case Reports in Internal Medicine 2019. DOI:10.12890/2019_001062
  6. Pujani M, Khan S, Hassan MJ, Jetley S and Raina PK. Coexistence of metastatic breast carcinoma and primary tuberculosis in axillary lymph nodes: A report of a rare case; Breast Disease. 2015;35:195–198.
  7. Baslaim MM, Al-Ghamdi MA, Al-Numani TS, Ashour AS and Al-Amoudi SA. Tuberculosis in 7 breast cancer cases: Diagnostic and therapeutic challenges. J Mycobac Dis; 2013;3(3):1-4.
  8. Mukhopadhyay T, Nandi M, Bhattacharya S, and Khan EM. Contralateral contiguous tuberculous lymphadenitis in a case of right breast carcinoma – Diagnostic dilemma. J Can Res Ther.2015;11:102-6.
  9. Ouedraogo AS, Bambara HA, Ademayali FAH, Ramde WN, Sawadogo RJ, Savadogo I, Ouattara S, Barry1 H, Lamien AS, Lompo OM. Anatomo-clinical case: coexistence of tuberculosis with axillary lymph node metastasis in breast carcinoma. Open Journal of Pathology; 2018;8:132-138.
  10. Lee CH. and Sharif SJ. Primary breast tuberculosis (TB) in a patient with known invasive breast carcinoma: A case report. Med J Malaysia.2016;71(3):149-151.
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jhc-2019-v-3-n-2-Is-histopathological-kabir-an

Review Article

Is Histopathological  Examination Essential  for the Diagnosis of Psoriasiform Dermatitis?

*Kabir AN,1 Rahman MM 2

  1. *Dr. AKM Nurul Kabir, Associate Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. kabir56@gmail.com
  2. Mohammad Mosiur Rahman,  Assistant Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

 *For correspondence

Abstract

Psoriasiform dermatitis encompasses a wide range of diseases, some of which show both clinical and histological overlap. Psoriasis is generally thought to be a genetic disease that is triggered by environmental factors. Psoriasis is characterized by an abnormally excessive and rapid growth of the epidermal layer of the skin.  Abnormal production and an over abundance of skin cells result from the sequence of pathological events in psoriasis, can be shown as a higher Ki-67 index compared with normal appearing, non-lesional skin. Morphometric analysis  of  histological features can also give a quantitative dimension  to histopathology  in diagnosis of psoriasis and in differentiating from other psoriasiform dermatitis. Psoriasis is also regarded as a T-cell mediated disorder, mainly CD4+ (helper/inducer) lymphocytes along with CD8+ subsets are known to occur.  The patient often prove to be a diagnostic dilemma for both dermatologists and pathologists alike. However, clinical features when considered alone may not be reliable, as they vary with both disease duration and treatment.  Though to give a precise diagnosis one relies on clinical correlation, histopathology is essential as it is possible to assign specific diagnosis in most cases with a logical and systematic histopathological approach. Morphometry along with the help of Ki-67 & Cyclin D1 and other immunostains of keratinocytes, and immunophenotyping of T-cell infiltrate, a definitive diagnosis can be made.

 [Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):151-161]

Key words: Psoriasis, Psoriasiform dermatitis, Morphometry, Ki-67, CD4+, CD8+

 Introduction

Psoriasiform  dermatitis  encompasses a wide range of inflammatory dermatoses, some of which show both clinical and histological overlap.  The term psoriasiform means  that  the lesion either clinically or histopathologically mimic  psoriasis and this group includes: psoriasis- the prototype of psoriasiform dermatitis,1 and others as  seborrheic dermatitis,  pityriasis rubra pilaris (PRP), allergic dermatitis, atopic dermatitis , nummular dermatitis,  lichen simplex chronicus (LSC), prurigo nodularis,  pityriasis rosea (PR), inflammatory linear verrucous  epidermal nevus (ILVEN) and mycosis fungoides (MF). Besides, clinical features in one patient may differ at different times and the diagnosis get obscured.3 As there is varied clinical presentation, a definitive histopathological  diagnosis is essential in the treatment of such inflammatory dermatoses.1 It is a challenging  task even to experienced pathologists to give a precise diagnosis every time and one relies also on clinical correlation. However, a stepwise systematic histopathological approach enables one to reach at a specific diagnosis in most cases.2

The morphometry parameters such as length of rete ridges, the length of dermal papillae and the ratio of length/average width of rete redges are statistically significant in the differentiating  psoriasis from psoriasiform dermatitis and can be used in addition to routine histopathology.3 As the prototype of psoriasiform dermatitis, psoriasis is a hyperproliferative skin disorder with increased epidermal turnover rate and mitotic index, proliferation markers Ki-67 & Cyclin D1 immunostain of keratinocytes can be added as diagnostic tools  to differentiate from other non- psoriasiform dermatitis.4  Expression levels of pRb and p53 were found to be higher in the psoriasis group in a study,  compared with the normal epidermis.5  Psoriasis is an autoimmune skin disease and regarded to be T- cell mediated disorder. CD4+ T-cells are important in initiating and maintaining the pathogenic process of psoriasis but cross-primed CD8+ T-cells are the main effector cells. Mixtures of CD4+ T cells and CD8+ T-cells are found in papillary dermis and epidermis of psoriatic lesion.  Psoriasiform lesions on the other hand show a high proportion of CD4+ T-cells in dermis.  Immunophenotyping of T-cell infiltrate in the lesion can be done in differentiating the cases.6

 

History of Psoriasis

History of psoriasis begins in Ancient Greece, when psoriasis, leprosy, and other inflammatory skin disorders were believed to be the same condition and the Greeks termed the skin diseases as  psora, lepra and lichen. Psora referred to itch, and lepra from lopos & lepo (the epidermis & to scale respectively). Hippocrates (460-377 BC) used the word lopoi to describe the dry, scaly, disfiguring disorders.  The Old Testament also lumped together many cutaneous   disorders, including leprosy and psoriasis, by the biblical term tsaraat or zaraath. Lepers were considered divinely punished, and cruelty was imposed upon those who were suffered from psoriasis and leprosy alike. Roman medical writer Celsus (25BC-45AD) first described papulosquamous diseases, suggesting as psoriasis one of these. Galen (133-200) first used the term psoriasis, but his description was likely represented seborrheic dermatitis. Gilbert (1797-1866) and Hebra finally distinguished the clinical picture of psoriasis from that of leprosy.7

 Epidemiology

Although psoriasis occurs worldwide, it is a common chronic inflammatory skin disorders affecting 1.5-2% population in the western countries and 1.3% in general population.6 The prevalence of psoriasis is low in certain ethnic groups such as the Japanese.8

Psoriasis can present at any age and has been reported at birth and in older people of advanced age. A bimodal age of onset has been recognized in several large studies. The mean age of onset for the first presentation of psoriasis can range from 15 to 20 years of age, with a second peak occurring at 55–60 years. Henseler and Christophers studied a series of 2147 patients and also reported as two clinical presentations of psoriasis, type I and II. Type 1 begins on or before age 40 years; Type II begins after the age of 40 years. Type I disease accounts for more than 75% of cases. Patients with early onset, tended to have more relatives affected and more severe disease than patients who have type II psoriasis. In addition, strong associations have been reported with human leukocyte antigen (HLA)-Cw6 in patients with early onset of psoriasis. The course and progress of psoriasis is unpredictable. In one study, 39% of patients reported complete remission of disease at the age between one and 54 years. Higher figures have been reported in Japan.8 A family history of the disease is common. Approximately 30% of patients have a first-degree relative with psoriasis, and the risk of psoriasis increases with the number of affected relatives a patient has.9

 Lifestyle and Morbidity

There is a link between cigarette smoking and psoriasis severity. There is sufficient evidence that aggravation of psoriasis is associated with alcohol consumption. Various recent studies report association of diabetes and other cardiovascular diseases to the severe form of psoriasis.10 Recent research suggests that patients with psoriasis have a systemic inflamma­tory state, putting them at increased risk of cardiovascular complications, including metabolic syndrome, peripheral vascular disease, stroke, myocardial infarction, and cardiac death.11  Psoriasis is increasingly being recognized as a disease that not only affects the skin but also has multi-systemic implications. Increasing epidemiological evidence suggests that patients with psoriasis may be more obese compared with the general population. Although the exact mechanism underlying the epidemiological association between psoriasis and obesity is uncertain, researchers have theorized that adipocyte elaboration of pro-inflammatory cytokines may exacerbate psoriasis.12 Many, but not all, studies have shown a positive association between metabolic syndrome and cardiovascular disease (CVD) and psoriasis, especially for (young) patients with moderate to severe disease. A recent study showed that Glyc A, which is a novel biomarker for systemic inflammation  was associated with psoriasis.13  Nearly 60% of psoriasis patients and 40% of psoriatic arthritis patients report their disease as a large problem in their everyday life. Psychosocial limitations of both diseases include enduring low self-esteem, feeling physically unattractive or sexually undesirable and avoiding social activities.14

Etiology

Etiology of psoriasis remains unknown,  even though, it is believed to be multifactorial with numerous key components including genetic susceptibility, environmental triggers in combination with skin barrier disruption and immune dysfunction.15 Various data suggest that infection is an important trigger for psoriasis. Streptococcal throat infection can initiate and exacerbate chronic psoriasis.15 Another research has shown that the composition of the cutaneous microbiota is related to many dermatological diseases including  psoriasis, atopic dermatitis, and acne vulgaris.16

Genetic Factors

Epidemiological studies have demonstrated that psoriasis has an important genetic component, where the role of environmental triggers (e.g., stress, mechanical trauma and streptococcal infections) is well documented.  Familial recurrence is also documented and disease concordance is higher in monozygotic than dizygotic twins. So, psoriasis is widely regarded as a multifactorial disorder caused by the interaction between inherited susceptibility alleles and environmental risk factors.17 The molecular genetic basis of psoriasis is complex, however, there are evidence that multiple genes are involved. Seven major psoriasis susceptibility loci have been reported and   a major susceptibility locus for psoriasis is at 6p21, referred to as PSORS1 and is overrepresented in all populations tested.  An association between psoriasis and other loci has also been reported on chromosomes 1p (PSORS7), 1q (PSORS4), 3q (PSORS5), 4q (PSORS3), 17q (PSORS2), and 19p (PSORS6). The strength of associations between such genes and susceptibility to psoriasis, apart from PSORS1, is variable, may relate, in part, to heterogeneity among different populations.8

 Mechanism

Psoriasis is characterized by an abnormally excessive and rapid growth of the epidermal layer of the skin. Abnormal production of skin cells and an overabundance of skin cells result from the sequence of pathological events in psoriasis.  Skin cells are replaced every 7 days in psoriasis rather than the usual about 53 days.18 Exclusive cellular “responsibility” for the induc­tion and maintenance of psoriatic plaques has not been clearly defined. Increased proliferation of keratinocytes and endothelial cells in conjunction with APC/T cell/monocyte/macrophage inflammation leads to the distinct epidermal and vascular hyperplasia that is characteristic of lesional psoriatic skin.15  CD8+ T cells seem to be dominant in the epidermis whereas the CD4 + T cells predominant subset in the dermis.  Activated CD4+ T cells produce a variety of  cytokines  including interleukin-2 (IL-2), TNFα and γINF.  TNFα stimulating keratinocytes may produce  IL -8, a potent T- lymphocyte and neutrophil chemoattractant  and may involved in the formation of Munro microabscess. γINF is believed to play in important role in the initiation of psoriatic lesion.18 In individuals with a genetic predisposition, external stimuli such as trauma (known as Koebner phenomenon), infections, stress, drugs, and alcohol can all trigger an initial episode of psoriasis. This initial trigger activates the innate immune system (Figure 1). Complexes of the antimicrobial peptide LL-37 and host DNA/RNA, both released by keratinocytes after common epidermal damage, activate plasmacytoid dendritic cells (pDCs) to produce large amounts of type I IFNs (α/β).  Subsequently, type I IFNs trigger maturation and differentiation of dermal dendritic cells (dDCs), and these dDCs then stimulate autoreactive T cells. Thereby, psoriatic autoimmune T cells are biased to produce Th1 and Th17/Th22 cells and which induce TNFα,/INFγ and IL-17/IL-22 production respectively. These mediators act on keratinocytes, leading to the activation and proliferation. In addition, type I IFNs directly upregulate IL-22 receptor (IL-22R) on keratinocytes, increasing their responsiveness to IL-22, and inhibits terminal differentiation and induces hyperproliferation of keratinocytes leading to epidermal hyperplasia, resulting psoriasis.19  In psoriasis , along with epidermal changes there is markedly increased dermal vascularity. The dermal vascular changes have been evaluated and shown to be due to change from arterial-type vessels to venules. The vascular changes may also precede the epidermal alterations, as shown in some studies.20

Clinical Features

Psoriasis is a papulosquamous disease with variable morphology, distribution, severity and course. Papulosquamous diseases are characterized by scaling papules and plaques.8  There are five clinical subtypes of psoriasis: vulgaris (plaque), guttate, pustular, inverse, and erythrodermic. The most common variant of psoriasis is plaque psoriasis, which includes approximately 85%–90% of psoriatic patients.15 The lesions are typically distributed symmetrically on the extensor surfaces of elbows, knees, and lumbosacral area and scalp. Psoriasis may also develop at the site of trauma, known as Koebner’s phenomenon.  Guttate psoriasis has drop-shaped lesions.  Inverse psoriasis forms red patches in skin folds. Pustular psoriasis presents as small non-infectious pus-filled blisters. Erythrodermic psoriasis involves widespread inflammation and exfoliation of the skin over most of the body surface. Psoriatic nail disease affects fingernails more commonly than toenails with small pits in the nail plate.8

Clinical Diagnosis

Psoriasis is a clinical diagnosis, and a skin biopsy is usually not necessary for a classic presentation of the disease.9 Diagnosis of psoriasis is usually based on the appearance of the skin. The characteristic lesions are sharply demarcated, scaly, erythematous plaques, papules, or patches on skin that may be pruritic and/or painful. They may be ovoid, round or irregular and often distributed symmetrically.9 Auspitz sign, named after Heinrich Auspitz, where there is pinpoint bleeding on removal of scales from the lesions of psoriasis. The test by which Auspitz sign is elicited by light tangential scratching with the edge of glass slide is called as Grattage test can be used  as clinical tool.21

Microscopic Diagnosis

Histopathology is considered as a “gold standard” for the diagnosis of most dermatological conditions including psoriasis.21 Common histological features in  psoriasis vulgaris are  hyperkeratosis, parakeratosis,  psoriasiform hyperplasia (Figure 2),  Munro microabscess / spongioform pustule of Kogoj,   thin suprapapillary plate, hypogranulosis, dilated capillaries in papillary dermis and dermal inflammation.1  However, other than  Munro microabscess, spongioform pustule of Kogoj and dilated tortuous capillaries in papillary dermis,  the remaining features , such as  parakeratosis,  psoriasiform hyperplasia can be seen  also in chronic eczematous dermatitis, such as atopic dermatitis, nummular dermatitis or allergic contact dermatitis and appear to be “psoriasiform”.18  However, following a systematic approach one can reach at conclusive diagnosis.

 

Tirumalae described a detail  microscopic description for definitive diagnosis as follows.2

 Scanning magnification

Examination of microscopic sections under scanning magnification forms the first step. The presence of evenly elongated, thin rete ridges with equally long dermal papillae can seen in one condition i.e., psoriasis. All other diseases exhibit an uneven psoriasiform pattern, where rete ridges are of uneven of lengths and thickness with thick supra-papillary plates as in PRP (Figure 3).

 Stratum corneum

The normal basket-weave pattern is lost in most cases and it is common to find parakeratosis. Parakeratosis can be present in small mounds or may be broad and confluent.  Mounds of parakeratosis can be present throughout the epidermis in conditions like psoriasis and dermatophytosis, in seborrheic dermatitis confined to the infundibular ostia or seen in both locations in PRP.  The classic “checkerboard” pattern i.e., parakeratosis staggered in both vertical and horizontal fronts is seen in PRP. Confluent parakeratosis is seen in dermatophytosis, syphilis, pityriasis lichenoides chronica (PLC) and most importantly, in MF. A sharply defined thick zone of parakeratosis alternating with orthokeratosis and mild papillomatosis are features of ILVEN.

Epidermis

Diminished or absent granular layer is seen in classic psoriasis, but is not a constant feature. Significant amounts of plasma in the scale crust goes against a diagnosis of psoriasis, and  large amounts of plasma and a rapidly proliferating epidermis are hostile to fungi. The finding of spongiotic vesicles in a psoriasiform dermatitis are seen in allergic contact/nummular dermatitis and seborrheic dermatitis. Spongiotic psoriasiform pattern is also encountered in patch-stage of MF.

 Changes in Papillary Dermis

Psoriasis is characterized by thin supra-papillary plates and elongated dermal papillae with dilated, tortuous capillaries. The presence of extravasated erythrocytes is a sign of acuteness and is seen in eruptive psoriasis and PR. Vertical streaks of collagen with uneven psoriasiform acanthosis and compact orthokeratosis is diagnostic of LSC. However, changes of LSC can be superimposed on any chronic, itchy dermatitis including psoriasis. In contrast, thin haphazard, wiry bundles of collagen are seen in the papillary dermis in PLC and MF.

 Nature of Infiltrate

Most of the psoriasiform dermatoses are dominated by lymphocytes in the dermis. When eosinophils are present among them, it indicates allergic/contact dermatitis or a drug eruption.  However, eosinophils are not a pre-requisite for diagnosis of either of these conditions. Histiocytes and plasma cells in a psoriasiform dermatitis with scale crusts give hints for secondary syphilis. Superficial and deep infiltrates are seen in syphilis and lichen striatus (LS).  In LS, there is a psoriasiform lichenoid pattern with deep infiltrates of lymphocytes along the adnexae, especially around the eccrine glands.

 Morphometry

Morphometric analysis of histological features can give a quantitative dimension to histopathology. The results of morphometry parameters such as length of rete pegs, the length of dermal papillae and the ratio of length/average width of rete pegs  can help in achieving the accurate diagnoses of psoriasis and psoriasiform dermatitis. In one study using eye-piece micrometer with the light microscope without special software and found statistically significant results in differentiating psoriasis from psoriasiform dermatitis. The mean length of rete pegs was 1.74 times greater in psoriasis when compared to psoriasiform dermatitis. The ratio of average length and width of rete pegs was considered representative of shape of rete pegs. The higher ratio of length over average width of rete pegs confirms the histopathological finding of slender long rete pegs, which favors the diagnosis of psoriasis.

The dermal vascular changes have been evaluated in different studies by electron microscopy and shown to be due to change from arterial-type vessels to venules. The vascular changes may also precede the epidermal alterations, as shown in some studies. Morphometric parameters of papillary dermal vessels in psoriasis and to compare these with psoriasiform lesions can also be used. Morphometric evaluation of dermal vasculature in psoriasis has shown increased endothelial and luminal volume of vessels compared to control subjects. On light microscopic evaluation of CD34 immunostained sections, biopsies from psoriasis showed much greater microvascular staining in the papillary dermis in comparison to psoriasiform dermatitis.20

 Role of Immunohistochemistry

  Ki-67 and Cyclin D1 Immunostaining

As Psoriasis is a hyperproliferative skin disorder with increased epidermal turnover rate and mitotic index,  proliferation markers Ki-67 (Figure 4) and Cyclin D1 immunostaining  can be used to differentiate psoriasis from non-psoraisis psoriasiform dermatitis( NPPD ) (Figure 5). In a study Ki-67 and Cyclin D1 positive cells were counted per mm2 of suprabasal and total epidermal area by Sezer. et al. 4

Psoriatic lesions have been shown to reveal a higher Ki-67 index compared with normal appearing, non-lesional skin.  In psoriasis group, suprabasal Ki-67 positive cells were more than 75% of the total epidermal Ki-67 positive cells in the epidermis (including basal and suprabasal cell population) in psoriasis group, whereas this ratio was lower than 75% (cut-off value) in NPPD group. The suprabasal/total epidermal count ratio for Cyclin D1 immunostaining was higher in the psoriasis group compared with the NPPD group, but a cut-off value to distinguish between these two was not detected, suggesting that Ki-67 is a more sensitive marker than Cyclin D1 in terms of the presence of a cut-off value and could be a useful tool for dermatopathologists to differentiate psoriasis from other psoriasiform dermatitis.4

 pRb and p53 Immunostaining

Expression levels of pRb and p53 were found to be higher in the psoriasis group  in a study,  compared with the normal epidermis.  The phosphorylation of pRb is associated with cyclin D1, cyclin E and P16.  pRb phosphorylation in psoriasis is incresed by the activity of cyclin D1 and Cyclin E and showed a higher expression of pRb than that of normal epidermal expressions.  Total basal layer cell counts for p53 expression were found to be significantly higher in psorisis group compared with the normal group.5 It is postulated that increased expression of p53 in psoriatic skin is a physiological reaction indicating the attempt  to counteract the proliferation and to repair DNA errors, and is most often expressed as an increased number of mitoses.22

 CD4+ and CD8+ cell distribution

Psoriasis also known as a skin disorder with immunological factors playing an important role in its pathogenesis, and lymphocytic infiltrates, mainly CD4+ and CD8+ cells provide a major contribution in the initiation and maintenance of the lesion. Psoriasis is an autoimmune skin disease characterized by T-cell mediated hyperproliferation of keratinocytes. It is regarded as a T-cell mediated disorder, mainly CD4+ (helper/inducer) lymphocytes along with CD8+ (suppressor/cytotoxic) subsets are known to be associated. T-lymphocytes in psoriatic lesion are in an activated state with expression of HLA-DR and IL-2 receptor. Mixtures of CD4+ T-cells and CD 8+ T-cells are present in papillary dermis and epidermis of psoriatic lesion. T-cell also plays a role in the pathogenesis of psoriasiform lesions, and reported a high proportion of CD4+ T-cells in the dermis on immunohistochemical analysis.6

A comparative study was done by Rana. et al to see the infiltration of CD4+ and CD8+  cells in psoriasis and psoriasiform lesions. The inflammation in the epidermis was present in about half of psoriasis cases and predominant cells were polymorphs. In the upper dermis, inflammation was evident in all cases with predominant cells were lymphocytes. Inflammation in the lower (reticular) dermis was present with mostly lymphocytes.

In psoriasiform lesions the inflammation was present in the epidermis in only few cases showing mixtures of polymorphs and lymphocytes. Within the upper dermis, all cases showed inflammation with predominant of lymphocytes. Few cases showed inflammation in the lower dermis with lymphocytes as majority of the cells. Immunohistochemical staining was done to see the distribution of CD4+ and CD8+ cells.  the distribution of CD4 positive cells was seen in psoriasis patients.  In the epidermis of psoriasis cases only one fifth were positive for CD4+ cells. In the upper dermis, CD4+ cells were present in 92% cases.  In the lower dermis about half of cases were positive for CD4+ cells.

D 8+ positive cells on the other hand were seen in the epidermis in 40% cases.  In the upper dermis, all the cases showed CD8+ positive cells.  In the lower dermis, CD8+ positive cells were found in large number of cases.

An immunophenotyping of the inflammation of psoriasiform lesions showing, CD4+ cells as predominant cells in the upper dermis. In lower dermis area showed 16% cases having CD4+ cells.

Various studies have shown that CD4+ cells are less frequent in psoriatic epidermis. In epidermis CD8+ cells were seen in 40% cases, and 8% in psoriasiform lesions. The difference was statistically significant.  In the upper dermis, one study has shown the mixtures of CD4+ and CD8+ T-cells in psoriasis, whereas psoriasiform group showed that CD4+ cells in abundance.

The difference in amount and pattern of CD4+ and CD8+ T-cells in the various compartments is helpful in differentiating between psoriasis and psoriasiform lesions especially in cases with borderline morphology.6

 Conclusion

Psoriasis, the prototype of psoriasiform dermatitis, is a genetically determined, inflammatory, and proliferative disease of the skin characterized by dull red, sharply demarcated scaly plaques. The two clinical signs, Auspitzs sign and the Grattage test have been described as pathognomonic of psoriasis when biopsy is not done.  However, these signs are present only in untreated patients. Psoriasis has many different clinical differentials as other psoriasiform lesions. Besides, the same patient can present at different times with a different clinical presentation.  Since satisfactory management of the condition requires both symptomatic and specific therapy, it is essential to reach a definitive diagnosis. The recurrent nature and prognosis of psoriasis differs from that of psoriasiform dermatitis, thus, further highlighting the importance of reaching the correct diagnosis. Clinical features, considered alone, may not be reliable. Histopathology is regarded as a gold standard for the diagnosis of most dermatological conditions including psoriasis and constitutes definite hard evidence, which can be preserved for future review.  Though to give a precise diagnosis one relies on clinical correlation, histopathology is essential as it is possible to assign specific diagnosis in most cases with a logical and systematic histopathological approach.  In selected cases morphometry, Ki-67 & Cyklin D1, pRb and p53 immunostaining of keratinocytes can be added when needed. The pattern of T-cell infiltrate by immunophenotyping can give an additional diagnostic clue.

Acknowledgement

The authors are grateful to Faisal Kabir Taj for his help in preparing the figure 1.

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  14. Busse K, Liao W.Which Psoriasis Patients Develop Psoriatic Arthritis? Psoriasis Forum. 2010; 16(4): 17–25.
  15. Ayala-Fontánez N,  Soler D C, McCormick TS.   Current Knowledge on Psoriasis and Autoimmune Diseases.    Psoriasis: Targets and Therapy 2016;6: 7–32;.org/10.2147/PTT.S64950.
  16. Benhadou F, Mintoff D, Schnebert B, Thio H B. Psoriasis and Microbiota: A Systematic Review. Diseases 2018, 6, 47; doi:10.3390/diseases6020047.
  17. Capon F. The Genetic Basis of Psoriasis. Int J Mol Sci. 2017;18(12):2526. Published 2017 Nov 25. doi:10.3390/ijms18122526.
  18. Mobini N, Toussaint S, Kamino H: Noninfectious Erythematous, Papular, and Squamous diseases. In Lever’s Histopathology of the Skin, 10 th Edition. Edited by Elder DE, Elenitsas R, Johnson BL, Murphy GF, Xu X.  India, Woltrs Kluwer, 2009, pp 169-203.
  19. Flatz L, Conrad C. T-cell-mediated inflammation in psoriasis: pathogenesis and targeted therapy.Psoriasis: Targets and Therapy 2013; 3:1-10. org/10.2147/PTT.S26339.
  20. GuptaS,  KaurM,  Gupta R, SinghS, PantL, SinghP P.Dermal Vasculture in Psoriasis and Psoriasiform dermatitis: a  Morphometric study. Indian J Dermatol. 2011 Nov-Dec; 56(6): 647–649. doi: 10.4103/0019-5154.91820: 10.4103/0019-5154.91820
  21. Mehta S, Singal A, Bhattacharya SN. A  study of clinicohistopathological correlation in patients of  psoriasis and psoriasiform dermatitis. Indian J Dermatol Venereol Leprol 2009;75:100.
  22. Baran W, Szepietowski J. C, Szybejko-Machaj G. Expression of p53 protein in psoriasis. Acta Dermatoven APA 2005;14(3):79-83.
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Histopathological Pattern of Central Nervous System Infection: Experience of 61 cases at Referral Neuroscience Hospital in Bangladesh

 Huq N,1 Haque ME,2 Jahan N,3 Yusuf MA,4 Baqui MN,5 Rozhana S,6 Shirin S,7 Islam MN8

Abstract

Background: Central nervous system (CNS) infections presenting as space occupying lesions are not uncommon in a developing country like Bangladesh.
Objective: The purpose of the present study was to see the histomorphological pattern of CNS infections.
Methodology: This retrospective study was carried out in the Department of Neuropathology at National Institute of Neurosciences & Hospital (NINS&H), Dhaka, Bangladesh during the time period of June 2013 to March 2018 for a period of around five (05) years. All the patients biopsied in neurosurgical department and was reported as infectious lesions from the Department of Neuropathology of NINS&H were selected as study population.
Result: A total number of 2504 cases of surgical specimens were reported during the study period of which 61(2.4%) cases were infectious lesions. Among 61 infectious cases tubercular lesion, suppurative and fungal causes of infection were found in 33(54.1%) cases, 21(34.4%) cases and 7(11.5%) cases respectively. Majority of the study population was in less than 40 years of age group which was 48(80.0%) cases. Male was predominant than female which was 38(62.3%) cases and 23(37.7%) cases respectively.
Conclusion: In conclusion tubercular infection is the most common CNS infection followed by suppurative and fungal infection.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):143-150]

Key words: CNS infection, Tuberculosis, Fungal infection

  1. *Dr. Naila Huq, Associate Professor, Department of Neuropathology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh. nailahuqpopy@gmail.com
  2. Mohammad Enamul Haque, Senior Consultant, Victoria Hospital, Narayanganj, Bangladesh. doctorenamk43@gmail.com
  3. Nasreen Jahan, Research assistant, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh.dr.nasreen2014@gmail.com
  4. Md. Abdullah Yusuf, Assistant Professor, Department of Microbiology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh. ayusuf75@yahoo.com
  5. Nazmul Baqui, Senior Lecturer, Unit of Pathology, Faculty of Medicine, AIMST University, Kedah, Malaysia. doctornazmul@yahoo.com
  6. Sharmin Rozhana, Lecturer, Unit of Microbiology, Faculty of Medicine, AIMST University, Kedah, Malaysia. srozhana@gmail.com
  7. Sadia Shirin, Medical Officer, Department of Neuropathology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh. sadiashirin77@gmail.com
  8. Md. Nowfel Islam, Professor & Head, Department of Pathology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh. nowfel2008@gmail.com

 *For correspondence

 Introduction

Top of FormBottom of FormDiseases causing multiple ring enhancing lesions of the brain are infectious, neoplastic, inflammatory or vascular origin.1-3 Central nervous system (CNS) infections are important because of many emerging and reemerging pathogens. Now a day’s persons are at increased risk of CNS infection due to acquired immunodeficiency syndrome (AIDS). CNS becomes a watershed for Human Immunodeficiency Virus (HIV) infection.4 Infections are also common among the recipients of organ transplantation.2-5 Infections are caused by a wide variety of organisms including bacteria, fungi, parasite and virus. Environmental factors in tropical countries play a significant role in the pathogenesis of CNS fungal infections. Immunocompromised patients are commonly susceptible to fungal infection.5 But exposure to drug or contaminated devices can also cause CNS fungal infection in immunocompetent person. Even People of endemic region can get CNS infection following heavy exposure to fungi.4, 6

Radiology is not always helpful for the diagnosis of CNS infection. Some treatable infectious diseases can even mimic the MRI features of demyelinating disease like multiple sclerosis.3,7,5 Although neoplasms are the common considerations in the presence of enhancing lesions with perilesional edema and mass effect on neuroimaging; non-neoplastic conditions particularly, infectious lesions can have similar imaging characteristics.1

Histopathological diagnosis is essential in case of neoplasm for diagnosis, grading as well as treatment. But infectious lesions that could not be diagnosed by noninvasive procedure also need biopsy. Distinguishing non-neoplastic from neoplastic lesion is extremely important to relieve the patient from the potential side effect of chemotherapy and radiotherapy.3 On the other hand, though brain infections are rare but due to limited space and involvement of vital areas they are associated with high morbidity and mortality.2,8

As Bangladesh has conservative society; HIV infection is not so common. However, like other part of the world, Bangladesh deals with a considerable number of patients having organ transplantation. Moreover, it is one of the densely populated countries of the world. Communicable diseases impose heavy burden on health care system. Tuberculosis is an emerging global health problem. In a country with huge population burden, poor hygiene, malnutrition, less health awareness of people, tuberculosis as well as other infections with involvement of CNS is not rare. There are a very few study regarding the frequency or prevalence of CNS infection in Bangladesh. This study was focused on the frequency and distribution pattern of CNS infections in Bangladesh.

 Methods

The present retrospective study was based on the data collected from the Department of Neuropathology NINS&H, Dhaka, Bangladesh during the time period of June 2013 to March 2018 for a period of around five (05) years. In this study the data of the patients who were underwent CNS surgery and histopathologically diagnosed as infectious lesions were collected. Cases of meningitis were not included in this study as diagnosis of meningitis based only on CSF examination. All extra-cranial skin, soft tissue and bony infectious lesions were excluded from this study. Specimens were stained by routine Hematoxyline & Eosin (H&E) stain. Furthermore, Zeihl-Neelsen stain was performed in all cases of tuberculosis. Periodic Acid Schiff (PAS) stain was done in all cases of fungal infection. Statistical analyses were performed by Statistical Package for Social Science (SPSS) software, versions 22.0 (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). Continuous data that were normally distributed were summarized in terms of the mean, standard deviation and minimum, maximum. Categorical or discrete data were summarized in terms of frequency and percentages.

 Result

A total number of 2504 cases of surgical CNS specimens were reported during the study period of which 61(2.4%) cases were infectious lesions. Only cases of infectious lesions were further analyzed. The age range of patients was 9 months to 85 years. The patients were stratified into 4 groups which were less than 20 years, 20 to 40 years, 40 to 60 years and more than 60 years. Most of the patients belong to 20 to 40 years age group which was 26(42.6%) cases followed by less than 20 years which was 23(37.7%) cases. CNS infection was very rare in more than 60 years of age; only two cases were found in this age group. However, male predominance with a male to female ratio of 1.7:1 was seen. Male was 38(62.3%) cases and female 23(37.7%) cases respectively (Table I).

In 61.0% cases of histologically diagnosed CNS infections radiological diagnosis were tumors. However in 39.0% cases radiological diagnosis was infection which correlates with the histological diagnosis. In 19 cases radiological diagnosis correlates with the histopathological diagnosis and all of them were tubercular lesion. Radiological diagnosis did not correlate with histopathological diagnosis in 32 cases. And radiology was not available in 10 cases.

 

Of the total 61 cases 33(54.1%) cases were tubercular, 21(34.4%) cases were suppurative and 7(11.5%) cases were fungal infection. AFB stain done in 30 cases of tuberculosis and result was negative. All cases of fungal infection were further stained by PAS stain and found positive.

 Discussion

CNS includes a wide variety of diseases ranging from suppurative, tubercular, fungal, parasitic and viral infection. For the diagnosis of these cases combined approach of clinical, radiological, CSF and histopathological examination are necessary. There is a scarcity of research works related to the pattern of CNS infections in Bangladesh. As National Institute of Neurosciences & Hospital (NINS&H) is a tertiary level referral hospital in Bangladesh, it deals with different neurological diseases having a well-developed neurosurgery department. Therefore, a great number of patients attend in this hospital.

CNS infection producing space occupying lesions are not uncommon in Bangladesh. About 2.4% of surgical specimens of this study belong to infectious lesions. The age range of the study population was 9 months to 85 years with highest percentage 42.6% cases between 2nd to 4th decades, followed by 37.7% cases in less than 20 years. CNS infection was very rare in more than 60 years of age; only two cases found in this group. The age distribution is consistent with most of the previous studies conducted in different parts of India.9,10,11 In our study 62.3% cases were male and the male to female ratio was 1.7:1. A male predominance seen in most of the reported studies indicating that male are more prone to these infections.9,10,11 This may be due to more exposure of the male of this age group to the environmental agents, vectors due to their outward activities.9 Some zoonotic infections like Neurobrucellosis occur due to occupational exposure.12 Moreover, in the developing countries male got priority over the female in getting treatment facilities.9 This observation matches with Bangladesh having the similar socioeconomic pattern.

We analyzed the anatomical location of the total 61 cases. It has been observed that most of the cases 49(80.0%) were cranial and 12(20.0%) cases were in spinal location. The percentage could be different if lesion like Pott’s disease would include in the study. Rosenblum5 has reported that 20.0% of brain abscess are not associated with predisposing bacterial infection; however, remaining results are from established pyogenic infection in extraneural site. Contiguous spread of infection can result from sinusitis, otitis, dental sepsis and pyogenic infection of face and scalp which causes intracerebral abscess or subdural empyema.5 Contamination of the CNS can occur in three routes. Arterial route is the main route of contamination and the disposition of intracerebral arterial division causes development of diseases in this way at the junction of white matter and gray matter or in the territory of perforating artery. Therefore, frontal or temporal region lesion is most common. Spinal anomalies predispose to intramedullary abscess but such infections are extremely rare5. Herpes simplex, Rabies, Varicella Zoster or a few viruses disseminated through neural route. Direct contamination can result from cranial or vertebral wound or following intracranial surgery. All these explanations suggest that cranial location is more common site of CNS infection particularly in case of acute bacterial infection which is similar to our study.5,8 Another study has been mentioned that infectious lesions in the brain stem are very rare.13

Among 61 cases radiology is not available in 10 cases which are histologically diagnosed as CNS infection. In the remaining, radiological diagnosis correlates with the histopathological diagnosis in 39.0% cases. However, in 61.0% cases radiological diagnosis are tumors. From biostatistical point of view it is not the indicator of sensitivity of radiology. As cases of CNS tumors were not included in the study, it would be a biased statement.

In radiology, neoplasm is the common consideration in enhancing lesions with perilesional edema and mass effect. But infectious lesion, occasionally demyelinating disease can share the similar imaging characteristic1,5. There are some limitations of early imaging and overlapping imaging appearance of many of the infections. Pyogenic abscess often show amino acid at spectroscopy.  Neurotuberculosis, neurosyphilis shows nodular meningeal enhancement with or without vasculitis which can also be seen in fungal infection. Some diseases like, neuro-cysticercosis, echinococcosis may have highly characteristic imaging pattern. But many other infections share common imaging findings. So, a high degree of suspicion is required to assume the diagnosis of CNS infection in radiology.1,14

Of the total 61 cases 54.1% cases are tubercular; 34.4% cases are suppurative and 11.5% fungal. As primary tuberculosis has high prevalence in Bangladesh, CNS tuberculosis might be the commonest presentation in this study. Garg RK3 et al also mentioned intracranial tuberculoma as frequently encountered brain lesion in tropical country. Bacteria are responsible for majority of suppurative infections of CNS and its covering.5 According to working criteria, cases of meningitis are not included in this study. Pyogenic abscess is the second common presentation (34.4% ). Our study is limited by non-availability of relevant microbiological analysis. So type of organism producing pyogenic abscess could not be determined from this study.

We found 7 cases of fungal infection. One of them was suffering from rheumatoid arthritis and receiving treatment with methotrexate. And another was a baby of 9 monthsage. Rest of the patients has no known history of immunodeficiency. Incase of fungal infection we found highest incidence of aspergillosis(4) followed by zygomycosis(2). Only one case of phaeohyphomycosis was found. A hospital based study of India also shows increased incidence of hyphal form like aspergillosis and Zygomycosis in non immunocompromised host.15The cryptococcus usually causes meningitis and rarely presentas cryptococcoma.16,17 Therefore, the cryptococcus is not found in this study.

CNS parasitoses include a great variety of protozoa and helminth.5,17 We did not find any case of neurocysticercosis, toxoplasmosis, echinococcosis, malaria, schistosomiasis and also rare amoebic infection of CNS. A study in India by Bhalla et al9 showed that these infections produce intracranial mass lesion in HIV positive patients. An HIV infected patient having CD4 cell count less than 200 cells/µL is at high risk for opportunistic brain infection. HIV infection is not so common in Bangladesh in comparison with other South Asian country like India or Thailand. As patients of HIV get treatment only in Infectious Disease Hospital (IDH) of Bangladesh, the data of those patients could not be included in this study. These infections may be less frequent in our environment or poor access of our people to the tertiary level hospital like NINS&H may result such outcome. As most of the affected people belong to lower socioeconomic condition the people may die before reaching the health care system. Another study in India showed that some of these infections of nervous system diagnosed mostly in autopsy specimen.5,18 A study in Hill tracts of Bangladesh; endemic for malaria showed significant cases of cerebral malaria in autopsy specimens.19 As facilities of autopsy are not available in our institute the study might be missing these infections.


Conclusion

Tubercular infection is the most common CNS infection followed by suppurative and fungal infection in biopsied specimen. Less than 40 years age group is the most vulnerable age group. High clinical suspicion, awareness of imaging pattern and microbiological approach can minimize the need for brain biopsy. Further large scale multi-institutional study including autopsy should be carried out.

 References

  1. Santosh V, Mahadevan A, Chickabasaviah YT, Bharath RD, Krishna SS. Infectious lesions mimicking central nervous system neoplasm. Semin diagn pathol, 2010;27(2):122-35
  2. Sundaram C, Shankar SK, Thong WK, and Villamizar CAP. Pathology and diagnosis of Central nervous system infections. Pathology Research International, 2011, Article ID878263:1-4
  3. Garg R K, Singha M K, Multiple ring-enhancing lesion of the brain. Journal of Postgraduate Medicine 2010;56(4):307-316
  4. Wig N, Wali JP. Central nervous system and HIV/AIDS. Journal of Indian Academy of Clinical Medicine Vol. 2008;5(2):164-168
  5. Rosenblum MK. Central nervous system in Rosai and Ackermans Surgical Pathology.10th vol.2,2327-2338
  6. Rodriguez T. Fungal infection of the CNS: Diagnostic and Treatment Approaches. Neurology adviser, 2018 May, 1-8; Website: https://www.neurologyadvisor.com/topics/general-neurology/fungal-infections-of-the-cns-diagnostic-and-treatment-approaches/
  7. Rocha AJD, Littig IA, Nunes RH, Tilbery CP. Central nervous system infectious diseases mimicking multiple sclerosis: recognizing distinguishable features using MRI. Arq Neuropsiquiatr 2013;71(9-B):738-746
  8. Sarrazin J-L, Bonneville F, Blondel GM. Brain infections in Diagnostic and Interventional Imaging 2012;93:473-490
  9. Bhalla A, Kharbanda PS. Tropical CNS infections: one must not forget. Update on Tropical Fever 2011;75-86
  10. Joshi R, Clinical presentation, etiology and survival in adult acute encephalitis syndrome in rural Central India in Clin Neurol Neurosurg.2013;115(9):1753-1761
  11. Modi A, Atam V, Jain N, Guth M, Verma R. The etiological diagnosis and outcome in patients of acute febrile encephalopathy: a prospective observational study at tertiary care center. Neurol India 2012;60(2):168-173.
  12. Algahtani H, Shirah B, Abdulghani D, Farhan R, and Algahtani R,Occapational Neurobrucellosis Mimicking a Brain Tumor: A Case Report and Review of the Literature in Case Report in infectious Diseases ;Volume 2017, Article ID 1434051:1-5
  13. Hall WA, Infectious lesions of the brain stem in Neurosurg clin N Am. 1993;4(3): 543-51
  14. Robert Y. Shih LTC, Kelly K. Koellar, MD Bacterial, Fungal and Parasitic Infections of the Central Nervous System: Radiologic-Pathologic correlation and Historical perspectives. Radiographics 2015;35(4)4:1141-1169
  15. Shankar SK, Mahadevan A, Sundaram C, Sarkar C, Chako G, Lanjewar D N, Santosh V, Yasha TC, Radhakrishnan V. Pathobiology of fungal infections of the central nervous system with special reference to the Indian scenario. Neurology India 2007;55(3):198-215
  16. Gupta K, Radotra B. Non-neoplastic Lesions Mimicking CNS Tumors. Essentials of Diagnostic Surgical Neuropathology: 230-239
  17. Matthew P. Frosch, Douglas C. Anthony, Girolami UD, The central nervous system in Robbins and Cotran, Pathologic basis of disease, eighth ed. 1299-1309
  18. Shankar SK, Mahadevan A, Parmar S, Histological Atlas of Common Infections of the Nervous System With Teaching Slides:1-64
  19. Islam SMJ, Uddin MJ, Haque WS, autopsy findings in cerebral malaria, Journal of Armed Forces Medical College  Bangladesh, December 2006; vol 2(2).
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jhc-2019-jul-v-3-n-2-The-Role-yasmin-i

The Role of Special Stains in Trephine Biopsy of Lymphoma

 *Yesmin I,1 Begum F,2 Yunus A,3 Kabir AL,4 Baqui MN5

 *Dr. Israt Yesmin, Specialist Pathology, Pathology and Laboratory Medicine, Square Hospital, Dhaka. badhanydr29@gmail.com

  1. Ferdousy Begum, Associate Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka. ferdousy_begum2000@yahoo.com
  2. ABM Yunus, Professor & Chairman, Department of Haematology, Bangabandhu Sheikh Mujib Medical University, Dhaka. abmyunus.bsmmu@gmail.com
  3. Amin Lutful Kabir, Associate Professor, DEPT of Haematology, BSMMU Email aminlutful@gmail.com
  4. Muhammad Nazmul Baqui, Senior Lecturer, Faculty of Medicine, AIMST University, Kedah, Malaysia. doctornazmul@yahoo.com

*For correspondence

 Abstract

Background: Accurate diagnosis of lymphoma is always challenging to histopathologists. Aside from routine H& E stain special stains play an important role inreaching the final diagnosing of  lymphomacases. Here we have studied the use of these special stains in trephine biopsy material of lymphoma cases.
Methods: This descriptive cross sectional study was carried out at the Department of Pathology Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from July 2012 to June 2014. Total 17 cases, which underwent trephine biopsy were included in this study. Different special stains and immunostains were done to reach the final diagnosis. Statistical analyses were performed to find out the usefulness of these special stains.
Results: Fourteenpatients were male and rests were female. Mean age of the patients was 41.8±12.5 years. IHC of trephine biopsy material aids in diagnosis of lymphomatous infiltration with further sub classification. While conventional H&E and giemsa stain revealed only 6(35.3%) cases with lymphomatous infiltration of bone marrow. Among these 14 cases, 10 (58.8%) cases were B-NHL, 3 (17.6%) cases were T-NHL and rest 1(5.9%) was lymphocyte-rich classical Hodgkin lymphoma.
Conclusion: It was found that, use of special stains and IHC of trephine biopsy material of lymphoma cases improved the diagnostic accuracy of lymphoma.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):134-142]

Key words: Trephine biopsy

Introduction

Trephine biopsy of the bone marrow has wide application in clinical medicine. Its important use is in the evaluation of patients with various haematological disorders like malignant lymphoma, acute leukaemias, myeloproliferative disorders, myelodysplastic syndromes, metastatic tumor, granulomatous disorder, myelofibrosis, aplastic anaemia and plasma cell dyscrasias. Examination of the bone marrow aspirate and trephine biopsy is essential for the diagnosis of bone marrow disorders. The aspirate and trephine biopsy provide complimentary and useful information. It is recommended that both bone marrow aspirate and biopsy be routinely performed for correlation of representative findings.

The bone marrow trephines are particularly useful in identifying focal lesion that may be less apparent on aspirate smear alone. The bone marrow biopsy is also a common and important staging procedure that is performed routinely on patients with hematologic and non-hematologic malignancy. Pathomorphological examination of trephine biopsies of the bone marrow represents a standard method for the diagnosis and staging of hematological neoplasms and other disorders involving the bone marrow.  The use of special stains in bone marrow pathology should be determined following examination of the routinely stained biopsy and the patient’s clinical history.1 Although conventional morphology remains the gold standard for paraffin embedded BM trephines, IHC staining has become an integral part of the diagnostic and prognostic workup.2 Distinction of the most common type of B-NHL in the trephine biopsy can be difficult on morphological ground alone due to overlapping cytological features and distribution pattern and therefore require IHC and occasionally molecular data for primary diagnosis.2

Non Hodgkin lymphoma (NHL) composed of small B lymphocytes comprises the majority of lymphoma infiltrates in the bone marrow. Bone marrow involvement is seen in virtually 100% of B cell chronic lymphocytic leukemia (B-CLL) / small lymphocytic lymphoma (SLL), in almost all cases of lymphoplasmacytic lymphoma (LPL) and hairy cell leukemia (HCL), in 55-93% of mantle cell lymphoma (MCL), in 50-60% of follicular lymphoma (FL) and invariably in splenic marginal zone B cell lymphoma (SMZL). In nodal and extra nodal marginal zone B cell lymphoma the marrow involvement is found in 10-30% cases.2

The pattern of bone marrow involvement is one of the most important hints for diagnosis. Different patterns of bone marrow infiltration by NHLs are recognized, namely paratrabecular, randomly focal / intertrabecular / non paratrabecular, interstitial, diffuse and sinusoidal / intravascular. In some cases, multiple or mixed pattern are present in the same specimen. Although most infiltrates are easily recognizable in standard stains, sparse interstitial and sinusoidal involvement can be practically undetectable by conventional morphology and requires IHC to highlight the neoplastic population.2

Lymphoma demonstrate significant increased incidence rates throughout the world and causes mortality.3 Though uses of special histochemical stain in trephine biopsy is an established practice in histopathology, the application of immunohistochemistry (IHC) to diagnostic bone marrow trephine biopsy specimen is a relatively new practice.4 IHC is a powerful auxiliary technique for the diagnosis of hematologic disorder in bone marrow trephine biopsies.2 IHC reveals clear architectural features and estimates tumor cellularity in paraffin sections. By using IHC an accurate characterization and primary classification of lymphoid neoplasm is possible in the majority of cases and expands the diagnostic scope of bone marrow histology.2 The ability to define such subgroups is increasingly important as treatment is tailored not only to specific types of lymphoma but also on the basis of their prognostic group.5 Therefore the aim of this study was undertaken to see the role of special stains in bone marrow trephine biopsy in the diagnosis of lymphoma and to detect lymphoma of bone marrow and their typing.

Methods

This descriptive cross sectional study was carried out at the Department of Pathology Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from July 2012 to June 2014. A total of 17 patients of different age and sex were selected from the department of Hematology BSMMU, Dhaka and other different institutes of Dhaka by using non probability sampling method. Patients who underwent trephine biopsy and histologically and clinically suspected as cases of lymphoma and cases accompanied by clinical information were included in this study. Exclusion criteria include patients who were not suspected as cases of lymphoma in histological diagnosis, specimen having severe crush artifact and specimen less than 1 cm in length. According to standard protocol the biopsy samples were taken from the posterior superior iliac spines under local anesthesia. Formalin fixed trephine biopsy sample were allowed to fix over night at room temperature in 10% buffered formalin fixative. Trephine biopsy samples collected from haematology department of BSMMU and other different institutes of Dhaka were decalcified in 10% formic acid for four hours followed by wash in running tap water for an hour.  Routine processing and paraffin embedding were done according to BSMMU standard tissue processing protocol in automated machines.  Paraffin blocks were made.  Subsequent tissue sections were analyzed by using routine H&E stain, periodic acid Schiff (PAS) stain, Giemsa stain and a primary histological diagnosis were made.

Sections with at least five well preserved marrow spaces were studied for cellularity, normal hematological elements, presence of infiltration if any, the extent, histologic pattern and morphology of infiltration and other secondary changes. The morphology and histologic pattern of infiltration were categorized as diffuse, interstitial, focal (non-paratrabecular), paratrabecular and mixed patterns. Diffuse pattern was defined when there was extensive replacement of the marrow elements, both hematopoietic tissue and fat, obscuring the marrow architecture.  Interstitial pattern was indicated when individual neoplastic cells were interspersed between hematopoietic cells and fat, focal, where nodular aggregates were seen separated by normal hematopoietic marrow, paratrabecular, when infiltrate aggregates were seen immediately adjacent to bony trabeculae.

2–3 μm thick sections were cut from the paraffin blocks for IHC. EnVision method was followed. The immunohistochemical staining procedure of all antibodies except TdT was performed in the IHC lab of BSMMU by following its staining protocol. Table I shows the IHC panel done for diagnosis.

Results of immunostains were assessed by light microscopy using a 10× objective lens with subsequent use of 20 and 40 lenses for confirmation. Immunostains results were expressed as positive, weakly positive or negative. Cases where quantification of specific type of immunohistochemical markers positive cells are needed counted at x40 magnification, excluding cortical and trabecular bone, periosteal connective tissue, adipose tissue or areas of haemorrhage. The specific immunohistochemical marker positive cells were counted in five or more randomly selected fields and the number of positive cells was expressed as a percentage of total number of bone marrow nucleated cells.  Slides were reviewed by two senior histopathologists. Subsequently special histochemical stains and immunohistochemical finding was analyzed and final reports were issued. This was performed in the department of pathology of BSMMU, Dhaka.

 Results

Age, sex and clinical findings

It was observed that maximum case (35.3%) patients belonged to age grouped 31-40 years. The mean age was found 41.8±12.5 years with range from 20 to 70 years. Majority14 (82.4%) patients were male and 3(17.6%) were female indicating male predominance. Male and female ratio was 4.7:1. Out of 17 patients of the present study 13 patients had fever, 6 complained of weakness and 6 presented with hemorrhagic manifestation e.g. gum bleeding, cyanosis, bleeding spot etc. The other complains included weight loss, bone and joint pain, swelling of whole body, night sweat, pruritus, yellow discoloration of skin and sclera, neck swelling, oral ulcer etc. Anaemia was the most prevalent (88.2%) feature. Other signs included jaundice, oedema, cyanosis etc. Five (29.4%) patients had generalized lymphadenopathy, two (11.8%) had grouped palpable lymph node, one (5.9%) had bony tenderness and all had normal tonsil.

 Ultrasonographic findings

Among 17 cases USG reposts were not available in 5 cases. Two (11.8%) patients had splenomegaly, 2(11.8%) had hepatomegaly, 6(35.3%) had hepatosplenomegaly, 1(5.9%) had abdominal lymphadenopathy and USG findings were normal in 1(5.9%) cases.

Bone marrow examination

Comparison of Primary histological diagnosis with final diagnosis after IHC

Out of these 17 cases 14 cases as various types of lymphoma. In the present study, primary histological diagnosis on trephine biopsy was made as haematolymphoid malignancy unclassified in 11(57.1%) cases and NHL in 6(42.9%) cases. Fibrosis was not seen in any of the 17 cases.


Trephine biopsy samples of 17 cases were histologically analyzed with the help of H&E stain along with PAS and Giemsa stain. Five patients were finally diagnosed as NHL by primary histological diagnosis was made on the basis of different pattern of abnormal cellular infiltration in the bone marrow trephine biopsy.

Discussion

In this series it was observed that most of the patients with haematological disorder were in 4th decade and their mean age was 36.1±15.01 years. Male to female ratio was almost 3:1. Similarly study conducted by Chen et al. (2000) observed male to female ratio was 2.9:1.6 Similar observations regarding the male predominant were also made by Matsuo et al. (2003) and Lone & Naeem (2011).7 On the other hand Kumar et al. (2009) observed female predominant, where they found female to male ratio was almost 5:1.8

 The pattern of marrow involvement also differs to some extent in various NHL subtypes, for example paratrabecular infiltration is strongly associated with follicular lymphoma. A bone marrow biopsy performed in patients with low grade lymphoma sometime shows unexpected high grade transformation, which necessitates a different therapeutic approach.9

 Among initial 11 cases of haematolymphoid malignancy unclassified in trephine biopsy were finally seven of them were diagnosed as B-NHL and one case as Hodgkin lymphoma. The remaining three cases were finally excluded from haematolymphoid malignancy. This result indicates the importance of IHC in the diagnosis of haematolymphoid malignancy. The remaining six cases of NHL were further sub classified as B-NHL and T-NHL (Table IV).

It is very much clear that trephine biopsy reports are superior as it could specify the diagnosis in most of the cases with the exception of cases of B-NHL and T-NHL. The latter cases were diagnosed only on the basis of CD3, CD20 and CD79a immunomarker. The incidence of bone marrow involvement in extra nodal MZL is lower (~20%) than in other low grade B-NHL, albeit recent studies described BM infiltration in up to 44% of cases.10

West et al. (2002) studied 61 cases (26 follicular lymphoma and 35 benign or atypical aggregates). They found that no single stain is sufficient for identification of neoplastic lymphoid aggregates. However, this distinction was made possible by using a panel of antibodies. The most useful antibodies were CD10, bcl-2, CD5, and CD20. Most benign or atypical aggregates do not express CD10 and CD23.11

Bone marrow specimens from 317 patients with non-Hodgkin’s lymphoma (NHL) obtained at initial staging was evaluated for the presence of lymphoma or benign lymphoid aggregates were studied by Conlan et al. (1990). They have found thirty-two percent (102 patients) had lymphoma in their bone marrow, and 9% had benign lymphoid aggregates. Bone marrow lymphoma was present in 39% of low-grade, 36% of intermediate-grade, and 18% of high-grade lymphomas. The bone marrow was involved in 25% of patients with diffuse large-cell or immunoblastic NHL. Bone marrow involvement did not affect survival of patients with low-grade NHL, but survival was significantly shorter (P<0.05) for patients with intermediate- and high-grade NHL with bone marrow involvement. Bone marrow involvement was equally common in B-cell and T-cell NHL (31% v 32%).12

Bone marrow involvement by lymphoma is considered a systemic dissemination of the disease arising elsewhere, although some tumors may arise primarily in the bone marrow microenvironment 13. IHC is important for lymphoma in particular those with heterogeneous histology to establish accurate diagnosis and adequate therapy14.

Bone marrow aspiration and bone marrow biopsy are important diagnostic procedures for diagnosis of hematological, non-hematological malignancies and other diseases. These procedures are also valuable for follow up of patients undergoing chemotherapy, bone marrow transplantation and other forms of medical treatment. In the study conducted by Toi et al. (2010),  comparative evaluation of all such bone marrow aspiration (BMA) and bone marrow biopst (BMB), to see the complementary role of both the procedures, to study the advantages and disadvantages of both the procedures done simultaneously. There was 61.25% positive correlation between BMA and BMB in the study15.

Conclusion

It can be concluded that correct diagnosis can be made in majority of cases with the application of PAS, Giemsa and limited number of immunomarker. Correct and relevant clinical information along with appropriate special stain of bone marrow trephine biopsy improves the diagnostic accuracy of lymphoma cases.

 References

  1. Brunning RD, Arber DA, 2011. Bone marrow. In J, Rosai Rosai and Ackerman’s Surgical Pathology, Tenth edition, Mosby Elsevier Inc, pp. 1927-2012.
  2. Kremer M, Quintanilla-Martínez L, Nährig J, von Schilling C, Fend F. Immunohistochemistry in bone marrow pathology: a useful adjunct for morphologic diagnosis. Virchows Arch Int J Pathol. 2005 Dec;447(6):920–37.
  3. Tahmasby B, Marnani AB, Maleki M, Barouni M, Mousavi SH, Naseriyan B, et al. Blood malignancies in Mazandaran province of Iran. Asian Pac J Cancer Prev APJCP. 2013;14(2):1053–6.
  4. Olsen RJ, Chang C-C, Herrick JL, Zu Y, Ehsan A. Acute leukemia immunohistochemistry: a systematic diagnostic approach. Arch Pathol Lab Med. 2008 Mar;132(3):462–75.
  5. Guidelines on the management of acute myeloid leukaemia in adults – – 2006 – British Journal of Haematology – Wiley Online Library [Internet]. [cited 2019 Sep 30]. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2141.2006.06314.x
  6. Clinicopathological studies on bone marrow involvement of non-Hodgkin’s lymphoma [Internet]. ResearchGate. [cited 2019 Sep 30]. Available from: https://www.researchgate.net/publication/12095478_Clinicopathological_studies_on_bone_marrow_involvement_of_non-Hodgkin’s_lymphoma
  7. Matsuo T, Kuriyama K, Miyazaki Y, Yoshida S, Tomonaga M, Emi N, et al. The percentage of myeloperoxidase-positive blast cells is a strong independent prognostic factor in acute myeloid leukemia, even in the patients with normal karyotype. Leukemia. 2003 Aug;17(8):1538–43.
  8. Kumar S, Rau AR, Naik R, Kini H, Mathai AM, Pai MR, et al. Bone marrow biopsy in non-Hodgkin lymphoma: a morphological study. Indian J Pathol Microbiol. 2009 Sep;52(3):332–8.
  9. Juneja SK, Wolf MM, Cooper IA. Value of bilateral bone marrow biopsy specimens in non-Hodgkin’s lymphoma. J Clin Pathol. 1990 Aug;43(8):630–2.
  10. Feugier P, De March AK, Lesesve JF, Monhoven N, Dorvaux V, Braun F, et al. Intravascular bone marrow accumulation in persistent polyclonal lymphocytosis: a misleading feature for B-cell neoplasm. Mod Pathol Off J U S Can Acad Pathol Inc. 2004 Sep;17(9):1087–96.
  11. West RB, Warnke RA, Natkunam Y. The usefulness of immunohistochemistry in the diagnosis of follicular lymphoma in bone marrow biopsy specimens. Am J Clin Pathol. 2002 Apr;117(4):636–43.
  12. Conlan MG, Bast M, Armitage JO, Weisenburger DD. Bone marrow involvement by non-Hodgkin’s lymphoma: the clinical significance of morphologic discordance between the lymph node and bone marrow. Nebraska Lymphoma Study Group. J Clin Oncol Off J Am Soc Clin Oncol. 1990 Jul;8(7):1163–72.
  13. Primary bone marrow lymphoma: an uncommon extranodal presentation of aggressive non-hodgkin lymphomas. – PubMed – NCBI [Internet]. [cited 2019 Sep 30]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22251943
  14. Bone marrow aspiration before bone marrow core biopsy using the same bone marrow biopsy needle: a good or bad practice? [Internet]. [cited 2019 Sep 30]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860622/
  15. Toi PC, Varghese RG, Rai R. Comparative evaluation of simultaneous bone marrow aspiration and bone marrow biopsy: an institutional experience. Indian J Hematol Blood Transfus Off J Indian Soc Hematol Blood Transfus. 2010 Jun;26(2):41–4.
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Study of Ovarian Tumours: Histomorphological Types

 *Ansari M,1  Khan AH,2 Hossain S,3 Khanom F4

  1. *Dr. MAS Ansari, Associate Professor of Pathology, Sylhet Women’s Medical College, Sylhet. drmasansari@gmail.com
  2. Professor Dr. Amjad Hossain Khan, Professor of Pathology, Sylhet Women’s Medical College, Sylhet.
  3. Sabbir Hossain, Associate Professor of Pathology, North East Medical College, North East Medical College, Sylhet.
  4. Farida Khanom, Medical Officer of Gynae & Obs, Jalalabad Ragib-Rabeya Medical Colleg, Sylhet.

 *For correspondence

 Abstract

Background: Ovarian tumour accounts for 3% of total cancer in females and is the 5th most common form of cancer related death in females with a varied clinical, morphological and histological features.

Objectives: The present  study was carreid out with an aim to find out  the frequency, age distribution and the histopathological  patterns of ovarian tumours.
Methods: Retrospective  study was done during the period  of 3 years comprised of 125 ovarian tumours diagnosed in the Department of Pathology, Sylhet Women’s Medical College, Sylhet. After thorough gross examination, representative bits were routinely processed and stained with H & E. Tumours were classified as per WHO classification.
Results: Out of 125 cases studied, majority were benign tumours (88%), followed by malignant (10.4%) and borderline tumour (1.6%). Age ranged from 11-70 years. Epithelial tumours were most common (76%), followed by germ cell tumours (16%), sex cord stromal tumours (7.2%) and metastatic ovarian tumours (0.8%). Serous cystadenoma was the commonest benign tumour and serous cyst adenocarcinoma was the commonest malignant ovarian tumour.
Conclusion: The prognosis and varying therapeutic strategies of ovarian tumours necessitate an accurate pathological evaluation. Although newer techniques like IHC and molecular analysis have made the diagnosis easier and more precise, in the institutes with provision of limited resources, histopathological study is still the gold standard in diagnosing most of these tumours.

 [Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):125-133]

Key words: Ovarian tumour, Histopathology

 Introduction

Ovarian tumours include complex, wide spectrum of neoplasms involving a variety of histological patterns ranging from epithelial tissues, connective tissues, specialized hormone secreting germinal and embryonal cells.1

The poor survival is due to the fact that they do not clinically manifest early and approximately 60-70% of the neoplasms present as either stage III or stage IV.1,3,4 Benign ovarian cysts are the commonest constituting about 80% of ovarian tumours and mostly occur in young women between the ages of 20-40 years. Borderline tumours occur at slightly older ages whereas the malignant tumours are common in older women between the ages of 40-65 years.1,4 Metastatic tumours subsequently involve the ovaries and mimic primary ovarian neoplasia. Approximately, 7% of lesions presenting clinically as primary ovarian tumours are of metastatic origin.5, 6 It is important to determine the histological pattern of ovarian tumour to achieve the optimum treatment response as prognosis depends on the degree of differentiation.2,3,7

Thus present study was undertaken to analyse the frequency of various histological subtypes, age distribution pattern and the  histopathological pattern of ovarian tumours.

 Methods

This retrospective  study was conducted for a period of 3 years (January2015 – December 2018) at Sylhet women’s Medical College, Sylhet.

Specimens sent in 10% formalin were routinely processed with paraffin embedding after adequate fixation. Paraffin sections and slides from fresh blocks and the retrieved blocks were stained with H & E. The slides were then reviewed microscopically in detail and tumours were classified according to the WHO classification of ovarian tumours.

Inclusion criteria

All histologically proven both primary and secondary ovarian tumours.

Exclusion criteria

Non- neoplastic ovarian lesions of study period.

Results

A total number of 125 cases were studied. Among these, majority were primary ovarian tumours (124; 99.2%), while one was metastatic ovarian tumours (1; 0.8 %). Of them 69 cases were benign (88%), 15 cases were malignant (10.4%) and rest 2 cases (1.6%) were borderline. Epithelial tumours (ET) were the most common histological type (95;76%), followed by Germ cell tumours (GCT) (20;16%) and sex cord stromal tumour (SST 9;7.2%; Table I).

Age Distribution

Majority of the tumours occurred in the reproductive age group (57; 45.6%) followed by 41-50 years of age group (26; 20.8%).Youngest patient was 13 years of age and older patient was about 68 years. Epithelial tumours and Sex cord stromal tumours had its peak between 31 to 40 years, whereas Germ cell tumours showed a peak in 21 to 30 years. Metastatic tumoursshowed  distribution between 61-70 years of age group.

 Gross Features

Most of the cases in this study were unilateral (117; 93.6%) and few were bilateral (8; 6.4%). Out of the total 95 Epithelial tumours, 76 were cystic in nature (80%), followed by those with cystic to solid in consistency (18; 18.9%) and solid (1; 1.05%), whereas most of Germ cell tumours were cystic in nature (16; 72.7%), followed by solid in consistency (5; 22.7%). Majority of sex cord stromal tumours (5; 71.4%) and all of the metastatic tumours were partly solid to cystic in consistency.

 Microscopy

The most common benign tumour was Serous cystadenoma (54; 43.2%), followed by Mucinous cystadenoma (14; 11.2%) and Mature cystic teratoma (16; 12.8%). Serous cyst adenocarcinoma was the most common malignant tumour (6; 4.8%), followed by Adult granulosa cell tumour (3; 2.4%). Borderline serous tumour were two in numbers. There was one case of metastatic ovarian tumours, was Krukenbergtumour. (Table II).

Discussion

Ovarian tumours are one of the major health problems and their diagnosis can be difficult due to variety of pathologic conditions affecting the ovaries. Thus knowledge of morphology and age-specific characteristics can help refine the diagnosis.8, 9

In the present study of 125 ovarian tumours, Primary ovarian neoplasms (99.2%) were the most common tumours of all ovarian tumours. Similar observations were made by Bhagyalakshmi A et al.10 (98.5%) and Vaddatti T et al.3 (98.9%). Most of the tumours belonged to Epithelial tumour category (76%) which was comparable to the results seen by Singh S et al.11 (69.17%), Krishna M & Maurya G12 (77.7%) and Badge S et al.13 (77%). GCT and SST accounted for 16% and 7.2%, respectively in our study compared to 42.2% and 3.1% reported in the others.14

In the present study, majority of the tumours were benign (88%) followed by malignant tumours (10.4%) and rest was borderline (1.6%). Findings of the present study correlated well with the studies of various authors.However, in this study the frequency of malignant tumours (10.4%) was little less than the study of Couto F et al.15 (40%).

In the present study, the patient’s age ranged from 11 years to 70 years and this was supported by the study done by Swamy GGEt al.16 where the youngest patient was 13 years old and the oldest was 68 years old. The majority of ovarian tumours (60.7%) were seen in the age group of 21-40 years, which was consistent with the study done by Kuladeepa A VK et al.17 (58.9%) and Pilli GS et al.18 (58.3%) .

In our study, majority of the tumours were unilateral (97.1%) and least were bilateral (2.9%) which were consistent with the findings of  VaddattiT et al.3, Jindal U8 and Prabhakar BR and Maingi K.19

In the present study, majority of the tumours were cystic (72%), followed by partly cystic & solid (18.4%) and few were solid (9.6%). These findings were comparable with the findings of Misra RK et al.20 where most of the tumours were cystic (78.2%) and few were solid (4.1%), whereas Couto F et al.15 have found 10.2% solid tumours which was close to our findings. Benign epithelial tumors were the commonest type (88.4%), followed by malignant epithelial tumors (9.47%) and the rest was borderline (2.10%). These findings were almost similar as observed in the study conducted by Kuladeepa A VK et al.17) Sharma I et al.21

In this study, maximum number of epithelial tumors (78%) were noted in 31-50 years age group. All malignant tumours were seen in the cases above 50 years of age. The results corroborated with the various studies done by Tushar K et al. (2005),22 Jha R & Karki S14 and Jindal U.8 Among the histomorphological types of epithelial tumors, Seroustumours (73.6%) were the most common, followed by Mucinous tumours (16.8%), Seromucinoustumours (8.42%) and least common were endometrioid tumours (1.05%). Similar results were seen by Krishna M & Maurya G12 andSarkar R.23 Serous cystadenoma was the commonest ET (53.3%) followed by Mucinous cystadenoma (21.7%) and serous cyst adenocarcinoma (8.4%). Similar results were reported by various authors in their studies.

In the present study, majority of the  germ cell tumours were benign (81.8%) and include mature cystic teratoma and Struma ovarii. These results were closer to the findings of Agrawal P et al.24 and Verma K & Bhatia A25 with 77.7% and 83.5% respectively. Malignant tumours include Dysgerminoma and Embryonal carcinoma. Germ cell tumours showed maximum cases below 35 years of age, with a gradual decline in 31-40 years age group and they were found to be uncommon after the age of 60 years. These findings were consistent with the studies of Jha R & Karki S14 and Agrawal P et al.24

In this study, majority of the sex cord stromal tumours were benign (57.1%) and the results were not similar to the findings of Rao KN et al.26 (55.6%) and were lower when compared to the findings of Jindal U8 (75%). On the contrary study of Badge SAEt al.13 (66.7%) showed mostly benign sex cord stromal tumours against malignant. The age range of sex cord stromal  tumours in our study was 41-70 years whereas Bhagyalakshmi A Et al.10 recorded age range of 21-70 years in their study. Adult granulosa cell tumour which is potentially malignant tumour occurred in 2.4% of all ovarian tumours. The frequency was consistent with the findings of Gupta SC et al.27 and Pilli GS et al.18 who recorded it as 4.4% and 3.54% respectively.

Our study showed one case of secondary tumours and constituted 0.8% of all ovarian tumours. This was lower when compared to the findings of Badge SA Et al.13  (10.9%) but was almost similar to the studies of Gupta N et al.28 (2%), Jha R & Karki S14 (2.4%) and Bhagyalakshmi A Et al.10 (1.5%). The former when compared with the studies of Misra RK et al.20 (1.07%), Prabhakar BR and Maingi K19 (1.57%) and Couto F et al.15 (1.46%) showed a good correlation.

 Conclusion

Ovarian tumour is a silent menace that presents as a tremendous clinical challenge to gynaecologist, medical oncologist and radiotherapists. Emergence of borderline tumours with prognostic difference from the benign and malignant counterparts, has added a wing to research in the field of ovarian tumours. Accurate diagnosis of ovarian tumours can be rendered in almost all of cases by correlating the clinical presentation, radiographic appearance and histomorphological features, which remains the gold standard. Even then, in the modern era by the application of specialised methods like special stains, IHC markers, ultrastructural studies and cytogenetics, there is a vast scope for reaching specific & reliable diagnosis of difficult dilemmatic cases of ovarian tumours, by which the therapeutic and prognostic implications could be modified.

References

  1. Pradhan A, Sinha AK, Upreti D. Histopathological patterns of ovarian tumors at BPKIHS. Health Renaissance. 2012; 10(2):87-97.
  2. Malli M, Vyash B, Gupta S, Desai H. A Histological study of ovarian tumors in different age groups.Int J Med Sci Public Health. 2014; 3(3):338-341.
  3. Vaddatti T, Reddy ES, Vahini G. Study of morphological patterns of ovarian neoplasms. IOSR Journal of Dental and Medical Sciences. 2013; 10(6):11-16.
  4. Ellenson LH, Piorg EC. The Female Genital Tract.Kumar V, Abbas AK, Aster JC. In: Robbins and Cotran Pathological Basis of Diseases. 9th edn: Elseiver, 2014; 2:1022-1034.
  5. Prat J, Morice P. Secondary tumours of ovary. Tavassoli FA, Devilee P. In: WHO classifications of tumours: Pathology of the breast and female genital organs. 3th edn. IARC Press: Lycon, 2003, 193.
  6. Rosai J. Female reproductive system- Ovary. In: Rosai and Ackerman’s Surgical Pathology. 10th edn. Missouri: Elsevier, 2012; 2:1553-1609.
  7. Sohail I, Hayat Z, Saeed S. A comparative analysis of frequency and patterns of ovarian tumours at a tertiary care hospital between two different study periods 2002-2009. J Postgrad Med Inst. 2012; 26(2):196-200.
  8. Jindal U. Pattern of ovarian neoplasm in rural population: A five year study from tertiary care hospital. Journal of evolution of medical and dental sciences. 2014; 3(8):2033-2039.
  9. Mondal SK, Banyopadhya R, Nag DR, Roychowdhury S, Mondal PK, Sinha SK. Et al. Histologic pattern, bilaterality and clinical evaluation of 957 ovarian neoplasms: A 10-year study in a tertiary hospital of eastern India. J Can Res Ther. 2011; 7(4):433-437.
  10. Bhagyalakshmi A, Sreelekha A, Sridevi S, Chandralekha J, Parvathi G, Vekatalakshmi A. Et al. Prospective study of histopathological patterns of ovarian tumours in a tertiary care centre. Int J Res Med Sci. 2014; 2(2):448-456.
  11. Singh S, Saxena V, Khatri SL, Gupta S, Garewal J, Dubey K. Et al. Histopathological evaluation of ovarian tumors. Imperial Journal of Interdisciplinary Research. 2016; 2(4):435-439.
  12. Krsihna M, Maurya G. Pattern of ovarian tumors and their age distribution in Kangra Valley Himachal Pradesh. Journal of Evolution of Medical and Dental Sciences. 2015; 4(61):10602-10608.
  13. Badge SA, Gosavi AV, Sulhyan KR. Histopathological study of ovarian tumors. Indian Medical Gazette, 2013; 345-351.
  14. Jha R, Karki S. Histological pattern of ovarian tumors and their age distribution. Nepal Med Coll J. 2008; 10(2):81-85.
  15. Couto F, Naolkarni NS, Rebello MJ. Ovarian tumours in Goa: A clinic pathological study of ovarian tumours. J ObstetGynaecol of India. 1993; 43(3):408-12.
  16. Swamy GG, Saryanarayan N. Clinico pathological analysis of ovarian tumors – A study on five years samples. Nepal Med Coll J. 2010; 12(4):221-223.
  17. Kuladeepa AVK, Muddegowda PH, Lingegowda JB, Doddikoppad MM, Basavaraja PK, Hiremath SS Et al. Histomorphological study of 134 primary ovarian tumors.Adv Lab Med Int. 2011; 1(4):69- 82.
  18. Pilli GS, Suneeta KP, Dhaded AV, Yenni VV. Ovarian tumours: A study of 282 cases. J Indian Med Assoc, 2002; 100:423-424.
  19. Prabhakar BR, Maingi K. Ovarian tumors – prevalence in Punjab. Indian J PatholMicrobiol, 1989; 32:276-81.
  20. Misra RK, Sharma SP, Gupta V, Gaur R, Mishra SD. International Journal of Medical and Health Research ,Pattern of ovarian neoplasm in eastern UP. J ObstetGnecol. 1991; 41(2):242-6.
  21. Sharma I, Sarma U, Dutta UC. Pathology of ovarian tumour- A hospital based study. International Journal of Medical science and Clinical Invention. 2014; 1(6):284-286.
  22. Tushar K, Asaranti K, C MP. Intra-operative cytology of ovarian tumours.J ObstetGynecol India. 2005; 55(4):345-349.
  23. Sarkar R. Ovarian neoplasms – A 14 years study. J ObstetGynecol India, 1996; 46:156-160.
  24. Agrawal P, Kulkarni DG, Chakrabati PR, Chourasia S, Dixit M, Gupta K Et al. Clinico pathological spectrum of ovarian tumors: a 5 year experience in a tertiary health care center. Journal of Basic and Clinical Reproductive Sciences. 2015; 4(2):90-96.
  25. Verma K, Bhatia A. Ovarian neoplasms: A study of 403 tumors. J ObstGynecol India.1981; 31:406-411.
  26. Rao KN, Koteswari M, Devi CP, Sailabala G, Katta R. Morphological study of ovarian tumors with special reference to germ cell tumors. IOSR Journal of Dental and Medical Sciences. 2015; 14(1):55-60.
  27. Gupta SC, Singh PA, Mehrotra TN, Agarwal R, A clinic pathological study of ovarian tumours: Indian J PatholMicrobiol. 1986; 29(4):354-62.

28. Gupta N, Bisht D, Agarwal AK, Sharma VK. Retrospective and prospective study of ovarian tumours and tumour-like lesions.Indian J PatholMicrobiol. 2007; 50(3):525-7.

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Ultrasound Guided Fine Needle Aspiration Cytology and Histopathology in the Diagnosis of Ovarian Mass

 *Ahmed NU,1 Saha NK,2 Bhowmik DK,3 Mazumder AR,4 Shariar S,5 Hira AD,6 Keya SA7

  1. *Dr. Nasir Uddin Ahmed, Assistant Professor, Department of Pathology, Faridpur Medical College. nasirdr32@yahoo.com
  2. Naba Kumar Saha, Professor, Department of Pathology, Sylhet MAG Osmani Medical College.
  3. Dilip Kumar Bhowmik, Professor, Department of Gynaecology & Obstetrics, Sylhet MAG Osmani Medical College.
  4. Ashikur Rahman Mazumder, Professor, Department of Radiology & Imaging, Sylhet MAG Osmani Medical College.
  5. Sakib Shariar, Pathologist, Railway General Hospital, Dhaka.
  6. Ananda Dyuti Hira, Pathologist, Department of Pathology, Khulna Medical College.
  7. Shamim Ara Keya, Lecturer, Department of Pathology, Shaheed Suhrawardy Medical College, Dhaka.

* For correspondence

 Abstract

Objective: The study was designed to evaluate the efficacy of ultrasound guided fine needle aspiration cytology in the diagnosis of ovarian mass and to correlate with histopathological diagnosis.
Methods: This  cross sectional study was done on 60 patients. FNA smears were prepared before surgical procedure. Histopathological examination was done by collection of surgical specimens. Cytomorphological findings were noted and correlated with histomorphological diagnoses.
Results: The age of patients ranged from 16 to 70 years with a mean of 36 years. Study showed 59 (98.33%) were unilateral and 1(1.67%) tumor was bilateral. Among 60 histopathologically diagnosed cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors, 10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion. All hemorrhagic cysts and cystic lesions were considered benign because they were cytologically negative for malignancy. Concordant diagnosis between cytology and histopathology was in 57 (95%) cases.
Conclusion: USG guided FNAC showed a relatively safe, quick, cost effective and patient compliant procedure with minimal morbidity.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):117-124]

 Key words: Ultrasound Guidance, Fine Needle Aspiration Cytology, Histopathology, Ovarian Mass.

 Introduction

Tumors of the ovary are incredibly varied. This multiplicity is due to the presence of three cell types in the normal ovary: the multipotent surface (coelomic) epithelium, the totipotent germ cells, and the sex cord–stromal cells, each of which gives rise to a number of different tumors.1 The clinicopathological evaluation of ovarian masses is a challenging field. Difficulty in gaining access to the tumor site is itself a major obstacle and the wide spectrum of lesions present an enigmatic picture to the pathologist. Although histopathology remains the gold standard, in recent times image guided aspiration is being increasingly used as a rapid, inexpensive and efficient method for the pre-surgical diagnosis of ovarian masses as well as planning and evaluation of treatment.2 Historically, gynaecologists are hesitant to aspirate ovarian masses in view of the possibility of seeding of an early stage ovarian cancer. The magnitude of risk of such a procedure is unknown and not substantiated by convincing evidence. It is rather overestimated and has not been pathologically confirmed.3

 However, a lot of studies have clearly documented that risk of tumor spreading by needle tract is negligible in comparison to the potential benefits of this simple, quick and effective modality of diagnosis.4 With sonographic support, any structure visualized radiologically can usually be reached precisely in any desired plane, thus increasing the cytological yield. Nevertheless, as with any technique, image-guided FNAC has its short comings; false-negative results are usually due to failure of the needle to enter the mass and failure to sample representative areas.5 In the preoperative diagnosis of ovarian masses, acellular fluid should not be considered non-diagnostic, because it represents benign cysts in a majority of the cases. Literature search failed to trace any study to see the effectiveness of USG guided FNAC in comparison with histopathology in the diagnosis of ovarian masses in our country. With this background, the study was designed to evaluate the efficacy of ultrasound guided fine needle aspiration cytology in the diagnosis of ovarian mass and to correlate with histopathological diagnosis.

 Methods

The cross sectional study was carried out in the Department of Pathology, Sylhet MAG Osmani Medical College, Sylhet in collaboration with the Department of Obstetrics and Gynaecology and Department of Radiology and Imaging, Sylhet MAG Osmani Medical College Hospital, Sylhet from 1st July 2014 to 30th June 2015. All patients with ovarian masses attended the inpatient department of Obstetrics & Gynaecology were considered as the target population and those who fulfilled the inclusion and exclusion criteria were considered as study population. Patient of all ages with ovarian mass were included in this study and patients with hemorrhagic diathesis, those who refused to undergo  USG guided FNAC and surgery, diagnosed cases under treatment and ovarian mass with pregnancy were excluded from this study. Aspirations were done by expert radiologist in radiology and imaging department. The tumors were located by USG and needle was inserted into the lesion without negative pressure. The content of the needle was expelled on to a glass slide and then allowed the aspirated material to spread by gently pulling apart two slides in opposite direction. The smeared slides were promptly dropped in 95% ethyl alcohol for fixation and kept for at least 30 minutes. This smears were then stained according to Papanicolaou method. The cytopathological examination of the stained slides was carried out on the same day or following day. Surgical specimens were collected from all patients in whom USG guided FNAC were done. All the specimens were preserved in 10% formalin. Routine tissue processing with paraffin impregnation was done and stained with hematoxylin and eosin. The diagnoses of ovarian tumors were done according to the cytopathological and histopathological findings and then cytopathological diagnoses were compared with the histopathological diagnoses.

After meticulous checking, all the relevant collected data were compiled first on a master table. Then the data were organized by using scientific calculator and standard computer based statistical software SPSS-21. Percentages were calculated to find out the proportion of the findings. The results were presented in tables, graphs and diagrams. The efficacy of USG guided FNA cytology for the diagnosis of ovarian mass was determined by calculating sensitivity, specificity, positive predictive values, negative predictive values and accuracy.

 Results

Total 62 cases were selected considering inclusion and exclusion criteria. Tissue for histopathological examination was available in 60 cases for comparison with cytopathological diagnosis. The age of patients ranged from 16 to 70 years with a mean of 36 years. Highest frequency 18 (29.03%) was found in 21- 30 age group (Table-I).

Categorization of neoplastic ovarian masses according to cell of origin

 Of the 60 histopathologically diagnosed cases, benign, borderline and malignant tumors were 40, 2 and 10 respectively. Among the benign tumors, surface epithelial tumors, germ cell tumors and sex cord-stromal tumor were 30, 9 and 1 respectively. All the malignant and borderline tumors were surface epithelial in origin. Table II shows categorization of neoplastic ovarian masses according to cell of origin.

All the smears obtained from USG guided FNA of ovarian masses were satisfactory for cytological evaluation and cytological diagnosis was made in most of the smears. Among 62 cases, 31(50%) were diagnosed as benign tumors, 7 (11.29%) were borderline tumors, 4 (6.45%) were malignant tumors, 1(1.61%) was inflammatory lesion and 19 (30.65%) were benign cystic lesions. Cytopathological diagnoses of ovarian masses are shown in Table III.

 Histopathological diagnoses of ovarian masses

Among 60 histopathologically diagnosed cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors,10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion.  Histopathological diagnoses of ovarian masses are shown in Table IV.  

Histopathological examination of 60 ovarian masses was performed and comparison between cytological and histopathological diagnoses of ovarian masses is shown in Table V.

Discussion

In present study, age of the patients ranged from 16 to 70 years. The maximum number of cases 18 (29.03%) were seen in third decade which is  similar to the studies done by Sengupta et al & Agarwal et al.4,6 Ellenson and Pirog found maximum number of cases in  third & fourth decades.7  Among the 40 benign tumors, 39 (97.50%) cases were found unilateral and 1 (2.50%) case was bilateral. All the malignant, borderline and non-neoplastic lesions were found unilateral in this study. Ray S  reported that 76.56% of non-neoplastic lesions and benign tumors were unilateral and 23.44% were bilateral, 35.71% malignant tumors were unilateral and 64.29% malignant tumors were bilateral.8 This discrepancy is probably due to small sample size in the current study. On gross evaluation of the 60 ovarian masses, 46 (76.67%) were cystic, 2(3.33%) were solid and 12 (20%) were partly solid and partly cystic (mixed). Ray S  reported 64 benign tumors, of which 51(79.69%) were cystic, 7(10.94%) were solid and 6(9.37%) were mixed. Of the 14 malignant tumors, 2(14.28%) were cystic, 7(50%) were solid and 5(35.72%) were mixed in consistancy.8 These findings are  almost similar to the findings of this study. In the present study, among the 52 neoplastic ovarian masses, 42 (80.77%) were surface epithelial, 9 (17.30%) were germ cell and 1(1.93%) was sex- cord stromal origin. Out of 40 benign tumors, 30(75%) were surface epithelial, 9(22.5%) were germ cell and 1(2.5%) was sex- cord stromal origin. All borderline and malignant tumors were found surface epithelial in origin. Similar findings were found in study by Tushar, Asaranti and Mohapatra.9 They showed out of67 ovarian tumors, 53(79.10%) were surface epithelial, 11(16.41%) were germ cell, 1(1.50%) was sex-cord stromal origin and 2 (2.98%) cases were metastatic tumors. In the present study, out of 62 USG guided FNA of ovarian masses, 31(50%) were benign tumors, 7(11.29%) were borderline tumors, 4(6.45%) were malignant tumors, 1(1.61%) was inflammatory lesion and 19(30.65%) were benign cystic lesions.

Agarwal et al. reported 110 USG guided FNA diagnoses of ovarian masses. Out of 110 ovarian masses, 17 (15.50%) were non-neoplastic, 50 (45.5%) were benign and 43 (39%) were malignant tumors.6 In the present study, cytologically mucinous cystadenoma was the most common benign tumor accounting for 12 (19.35%) and mucinous cystadenocarcinoma was the most common malignant tumor accounting for 2(3.23%). Most of the internationally published journal shows, cytologically most common benign tumor is serous cystadenoma and most common malignant tumor is serous cystadenocarcinoma.3,5,6,10 The findings of present study differ from the findings of internationally published journal which may be due to small sample size. If large sample size was taken, the findings of our study might coincide with the findings of international journals. In histopathological diagnosis of 60 cases, 7(11.67%) were non-neoplastic cysts, 40 (66.67%) were benign tumors, 2(3.33%) were borderline tumors, 10(16.67%) were malignant tumors and 1 (1.66 %) was inflammatory lesion. Similar findings were found in study of 77 cases by Ray et al.3  Out of 77 cases, 43 (55.84%) were benign, 22 (28.57%) were malignant and 12 (15.59%) were non-neoplastic lesions. In the present study, histopathologically most common benign tumor was serous cystadenoma accounting for 16 (26.66%) and most common malignant tumor was mucinous cystadenocarcinoma accounting for 6(10%). Agarwal et al. reported that the most common benign tumor was serous cystadenoma accounting for 17 (24.63%) and most common malignant tumor was serous cystadenocarcinoma accounting 10 (14.50%).6 These findings are partially consistent with the current study. Among the 31 cytologically diagnosed benign tumors, 29 cases were diagnosed correctly in histopathology and 2 cases were diagnosed as malignant tumor. Cytologically diagnosed 4 malignant tumors were also diagnosed as malignant in histopathology. In cytologically diagnosed 7 borderline tumors, histopathologically 04 were malignant, 2 were borderline and 1 was benign tumor. One inflammatory lesion diagnosed correctly both in cytology and histopathology. All 17 benign cystic lesions diagnosed cytologically, were also benign in histopathology. Concordant diagnosis between cytology and histopathology was in 57 (95%) cases.

 Conclusion

USG guided FNAC is a relatively safe, quick, cost effective and patient compliant procedure with minimal morbidity and fair diagnostic accuracy. In the preoperative diagnosis of ovarian masses, acellular fluid should not be considered non-diagnostic, because it represents benign cysts in a majority of the cases. False negative results are due to paucicellularity and secondary degenerative changes of epithelial cells. Most of the hospitals in our country are not equiped with frozen section facilities.  USG guided FNAC has particular value as a preoperative diagnostic procedure where frozen section facilities are not available. USG guided FNAC in the diagnosis of ovarian masses can be practised in any centre where the help of sonologist and cytopathologist is available.

 References

  1. Sattar HA. Female Genital System and Breast. In: Kumar V, Abbas AK, and Aster JC, eds. Robbins Basic Pathology, 9th ed. Philadelphia, USA: Elsevier Saunders 2013: pp.681-714.
  2. Afzal S, Ansari H, Ansari M, Maheshwari V, Mehdi G. Image- guided fine-needle aspiration cytology of ovarian tumors: An assesment of diagnostic efficacy. Journal of Cytology 2010; 27(3): 91-95.
  3. Ray S, Gangopadhyay M, Bandyopadhyay A, Majumdar K, Chaudhury N. USG guided FNAC of ovarian mass lesions: A cyto-histopathological correlation, with emphasis on its role in pre-operative management guidelines. Journal of the Turkish German Gynecological Association 2014; 15: 6-12.
  4. Sengupta S, Mondal R, Bose K, Ray R, Jana S, Deoghoria D. Evaluation of role of ultra sound guided fine needle aspiration cytology for diagnosis of ovarian lesions with particular references to diagnostic pitfalls. Bangladesh Journal of Medical Science 2014; 13(2):158-162.
  5. Goel S, Agarwal D, Goel N, Naim M, Khan T, Ekrammulah. Ultrasound guided fine-needle aspiration cytology in ovarian neoplasms: An assesment of diagnostic accuracy and efficacy and role in clinical management. The Internet Journal of Pathology 2010; 11(2): 1-10.
  6. Agarwal N, Garg S, Aggarwal N, Santwani PM. Ovarian Neoplasm: Diagnostic accuracy of ultrasound guided fine needle aspiration cytology with histopathological correlation. IOSR Journal of Dental and Medical Sciences 2014; 13(7): 24-28.
  7. Ellenson LH, Pirog EC. The Female Genital Tract, In: Kumar V, Abbas AK, Fausto N, Aster, JC, eds. Robbins and Cotran Pathologic Basis of Disease, Philadelphia, USA: Elsevier Saunders 2010: pp.1039 -1052.
  8. Ray S. The role of imprint cytology in the diagnosis of ovarian lessions [ M. Phil thesis]. Sylhet MAG Osmani Medical College 2008,
  9. Tushar K, Asaranti K, Mohapatra PC. Intra-operative cytology of ovarian tumors. The Journal of Obstetrics and Gynaecology of India 2005; 55(4): 345-349.
  10. Khan N, Afroz N, Aqil B, Khan T, Ahmad I. Neoplastic and non-neoplastic ovarian masses: Diagnosis on cytology. Journal of Cytology 2009; 26(4):129-133.
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jhc-2019-jul-v-3-n-2-concurrent-sharmin-s

Concurrent Core Needle Biopsy with Fine Needle Aspiration Biopsy in The Diagnosis of Palpable and Clinically Suspicious Breast Lesions

 *Sharmin S,1 Dewan MR,2 Jinnah SA,3 Sharmin R,4 Runa NJ,5 Ambiya AS,6 Rahman N,7 Afrin SS,8 Hussain M9

 

  1. *Dr. Shegufta Sharmin, Assistant Professor, Department of Pathology, US Bangla Medical College, Dhaka. sheguftasharmin1982@gmail.com
  2. Md. Rezaul Karim Dewan, Professor & Head, Department of Pathology, Dhaka Medical College, Dhaka.
  3. Shahed Ali Jinnah, Associate Professor, Department of Pathology, Dhaka Medical College, Dhaka.
  4. Rumana Sharmin, Lecturer, Department of Pathology, Dhaka Medical College, Dhaka.
  5. Nusrat Jahan Runa, Assistant Professor, Department of Pathology, Dhaka Central Inrernational Medical College, Dhaka.
  6. Ahmed Shahed e Ambiya, Resident Medical Officer, Department of Medicine, Holy Family Red Crescent Medical College Hospital, Dhaka.
  7. Najibur Rahman, Assistant Professor (Rtd), Department of Pathology, Dhaka Medical College Hospital, Dhaka.
  8. Syeda Sadia Afrin, Resident, Department of Pathology, Dhaka Medical College Hospital, Dhaka.
  9. Maleeha Hussain, Professor of Pathology Department, Dhaka Medical College Hospital, Dhaka.

 *For correspondence

Abstract

Background: Breast lump is one of the most common surgical problem in female patients. Though excision biopsy of palpable breast lump is considered to be the gold standard method for diagnosis, there should be an improved and definitive method for establishing an accurate diagnosis of breast masses prior to surgery.
Objectives: The aim of this study was to determine the diagnostic accuracy of concurrent fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) in cases of suspicious breast lesions and to study the discordance between them.
Methods: This descriptive cross sectional study included 72 female patients with breast lumps, presented to Dhaka Medical College Hospital over a period of two years and subsequently underwent concurrent FNAB and CNB in the same sitting. The results were then compared with final histopathological findings and the correlations between FNAB and CNB were determined.
Results: Out of 72 cases included in the study, histopathological diagnosis was available in 42 cases. There were four false negative cases in FNAB (14.28%) and two false negative cases (7.14%) in CNB.  The false negative rate in the combined approach was 3.57% which is lower than the rate in individual tests. The sensitivity of combined approach was 96.5%, where FNAB and CNB had 85.71% and 92.85% respectively. The specificity and positive predictive value of both FNAB and CNB were individually 100%, so the concurrent result was also the same. The diagnostic accuracy of combined FNAB and CNB was higher than individual results, which was statistically significant (p<0.05).
Conclusion: Concurrent FNAB and CNB can provide accurate preoperative diagnosis of breast lesions and provide important information for appropriate treatment. Identification of discordant results and, therefore, careful correlation can reduce false negative rate.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):107-116]

 Key Words: Breast lesions, FNAB, CNB, Histopathology

Introduction

Breast cancer is the second most common cancer in the world and the most frequent cancer among women with an estimated 1.67 million new cancer cases diagnosed in developing countries in 2012.1 Breast cancer is the leading cause of cancer death in women in the less developed regions (324,000 deaths, 14.3% of total) and the second cause of cancer death in the more developed countries  (198,000 deaths, 15.4%) after lung cancer.2 According to the Globocan estimate, more than half of the 1.67 million new breast cancer cases were diagnosed in developing countries in 2012 which is about 52.9%, whereas the corresponding figure for 1980 was only 35%.3,4 In Bangladesh, the number of new cases of breast cancer in the year 2008 was 17,781.5

Breast cancer usually presents with a palpable breast lump. Most breast lumps are benign and of no serious consequence. Fine needle aspiration biopsy (FNAB) and core needle biopsy (CNB) are both used in the evaluation of breast lesions and play an important role in the management.6 Both have their specific advantages and limitations. Recent studies have shown the high accuracy and cost effectiveness of FNAB to identify cancer in patients with palpable breast lump.7

FNAB is often used as a first priority investigation in patients with breast lump, but this technique is highly dependent on the skill and expertise of the aspirator.8 FNAB cannot confirm the presence of tumor invasion and therefore cannot be used to differentiate between invasive and in situ neoplasia. In addition, low grade breast lesions, such as atypical ductal hyperplasia, ductal carcinoma in situ and tubular carcinoma cannot be accurately diagnosed using this modality alone. Therefore, erroneous diagnosis can occur due to sampling error or due to misinterpretation.

Tru cut biopsy, also known as core needle biopsy (CNB) is now one of the most useful means of obtaining histopathological diagnosis.9 Besides, core biopsy allows the discrimination between in situ and invasive lesions and is a more accurate method to distinguish between invasive ductal and invasive lobular carcinoma.9 A well sampled CNB specimen usually has greater diagnostic efficacy and provides more tissue for ancillary studies.10 However, CNB still has some pitfalls.11 In some cases, even with image guidance, CNB can miss the lesion and yield inadequate material.12 During the procedure, blood vessels may be injured by large bore needles; in such cases the invasive biopsy procedure will only yield clotted blood on repeated puncture.13 In these instances, core biopsies cannot produce adequate samples which in turn will cause a delay in the histological interpretation.

If FNAB and CNB are used concurrently in cases of suspicious breast lesions, the sensitivity and specificity may be better than either alone.

This study was aimed to find out the diagnostic accuracy of concurrent CNB and FNAB of palpable and clinically suspicious breast lesions.

 Methods

The present cross sectional study was carried out in the Department of Pathology, Dhaka Medical College over a period of two years from January 2015 to December 2016. Female patients of any age group with clinically suspicious and palpable breast lumps who were advised for FNAB or CNB were enrolled and were subjected to concurrent FNAB and CNB in the same sitting with their informed written consent.

With proper aseptic measures, fine needle aspiration was done using a 5 cc or 10 cc disposable syringe for each puncture and for each patient and two to six smears were prepared in glass slides for each patient according to need.  The core needle biopsy was performed by an automated biopsy device equipped with a 14 gauge needle having a sample notch of 15 mm in length. Samples were obtained from different areas of the lesion, usually from the center and close to the borders at the 3, 6, 9 and 12 O’clock positions and were placed in a vial containing 10%  neutral buffered formalin. For each CNB procedure, the number of biopsies taken was recorded. The outcomes of FNAB and CNB were reported using the standard National Health Service Breast Screening Programme (NHSBSP) criteria.

In this study, histopathological examination of mastectomy or lumpectomy or excisional biopsy was considered as gold standard. Statistical analysis of the results was obtained by window based computer software devised with Statistical Packages for Social Sciences (SPSS).

 Results

A total 72 cases were included in the study in whom FNAB and CNB were performed, and subsequently lumpectomy or mastectomy specimen were available in 42 cases. Histopathological diagnosis was the gold standard of the study. Individual and combined FNAB and CNB were compared and validity test results were calculated. It was observed that the majority (44.4%) of patients belonged to the age group of 31-40 years. The mean age was found 40.94±7.9 years with range from 28 to 62 years (Table I).


More than one third (43%) of the samples were cytologically diagnosed as malignant, 07(9.72%)were diagnosed as suspicious and 09(12.5%) showed atypia. 25(34.72%) cases were cytologically diagnosed as benign(Table II). On the other hand in CNB, 34 (47.2%) cases were found to be malignant cases, 26(36.11) benign , 06 suspicious of malignancy, 05(6.94%) of uncertain malignant potential and 01 (1.38%) unsatisfactory tissue (Table III). Finally, after histopathology of the 42 cases, where surgical biopsy were available, 28(66.66%) cases were confirmed as malignant and 14(33.33%) cases were found to have benign lesions. It was observed that 25(59.52%) patients with duct cell carcinoma was the most frequent diagnosis, followed by 2(4.8%) papillary carcinoma and 1(2.3%) lobular carcinoma (Table IV)

Of the 20 malignant cases and 4 suspicious cases diagnosed by FNAB, all proved to be malignant by histopathology. Among the 05 cases presented with atypia in FNAB, 4 were diagnosed histologically as malignant and 1 was benign. None of the benign cases diagnosed by FNAB was otherwise in histology (Table V).Of the 19 patients diagnosed as malignancy by CNB, 17(79.2%) were diagnosed as duct cell carcinoma, 01(100.0%) as lobular carcinoma and 01(100.0%) as papillary carcinoma by histopathology (Table VI). All 07 suspicious cases in CNB were histologically diagnosed as malignancy and the 04 cases presented with atypia in CNB, ultimately diagnosed as benign in 03 cases and malignant in 01 case (Table VI).

ith concurrent FNAB and CNB, true positive cases were 27 in number, true negative cases were 14 and false negative cases was 1 in number. There were no false positive case (Table VII). In the present study, the sensitivity of FNAB is 85.71%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 77.77% and accuracy 90.47%. In comparison, the sensitivity of CNB is 92.85%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 87.5% and accuracy 95.23%. When both FNAB and CNB are combined, the sensitivity is 96.05%, specificity 100%, PPV (positive predictive value) 100%, NPV (negative predictive value) 93.33% and accuracy 97.61% (Table VIII). So the combined results are superior to FNAB or CNB alone (p<0.05) statistically significant


Discussion
Fine needle aspiration biopsy and core needle biopsy currently are the most widely used methods for pathological diagnosis of breast lumps. They have their specific advantages and limitations. To minimize the limitations of individual procedure, in the current study simultaneous FNAB and CNB was used for the diagnosis of clinically suspicious and palpable breast lumps. Results of the combined approach were compared with FNAB and CNB separately.

With a population of over 163 million, Bangladesh is one of the most densely populated countries in the world.14 Not much information on breast cancer in Bangladesh is available as there is no population based cancer registry in our country. However, the only hospital based cancer registry at the National Institute of Cancer Research and Hospital tracks new cancer cases systematically in this country. According to NICRH report, 5255 breast cancer cases were diagnosed during the period of 2005-2010.15,16 The data of NICRH states that breast cancer has overtaken cervical cancer as the most common female cancer in Bangladesh. (Breast cancer cases 26% and cervical cancer cases 21.1% during the period 2008-2010: NICRH, Cancer registry report).16

In the present study, a total of 72 cases of clinically suspicious and palpable breast lumps were included. FNAB and CNB were done in all of them but surgical biopsy was available in 42 cases only. Of these 42 cases, 28 were malignant and 14 were benign. The firm to hard consistency, irregularity and larger size of the lumps in these 14 benign cases made them to be clinically suspicious. Histopathology was the gold standard in this study and the validity test results of FNAB and CNB were evaluated and compared with it.

In this study, among the 48 cancer patients diagnosed either by core needle biopsy or fine needle aspiration biopsy, age ranged from 33 years to 62 years with a mean age of 42.5 years. In this present study, 26(54.16%) cancer patients out of 48 malignant cases were premenopausal and 22(45.83%) cases were postmenopausal.

Fine needle aspiration biopsy is a routine procedure in the diagnosis of breast lesions in our laboratories. It is a relatively rapid, inexpensive, maintains tactile sensitivity and allows multidirectional passes allowing a broader sampling of the lesions and immediate reporting where it is necessary. However, it has some limitations in the assessment of tumor invasion, tumor grade or receptor status. In this perspect, use of core needle biopsy has been shown to be an excellent tool while working with the tissue specimens because it permits the evaluation of both the architectural and cytological patterns and provides adequate material to perform diagnostic ancillary studies.

However, the performance of CNB has a few disadvantages. Missampling can occur, even with image guidance.12 Improper processing of small tissue fragments may lead to tissue distortion and challenge sample adequacy. These technical errors or missampling can lead to false negative results. The study showed that the sensitivity of FNAB was 85.71% in the diagnosis of breast cancer with a false negative rate of 14.28%. The specificity was 100%. This result is similar to other studies done by Mahmood H. Hasssan in Iraq (2014).17 Mohammed Bdour et al (2008) in Pakistan18 and Tiwarie M. in Nepal (2007).19

All four false negative cases in FNAB belonged to proliferative breast disease with atypia group. The false negative results of FNAB were mainly due to underestimation of cellular atypia.

In our study, CNB had a sensitivity of 92.85% and specificity of 100% in the diagnosis of breast cancer. The false negative rate was 7.14%. The results are comparable to others studies done by Mahmood H. Hasssan in Iraq(2014),17 Mohammed Bdour in Pakistan (2008),18 Karimian F. in Iran (2008),9 AD Baildum in UK (1989)19 and Stanley Minkowitz in USA (1986)20 which showed 95.0%, 90.0%, 98.07%, 95.0% and 89.0% sensitivity, respectively .

We found that, there were two false negative cases in CNB. Out of the two cases, one showed cystic change in ultrasonography. The repeated missing of the lesion in core biopsy may be due to this cystic change. . In this case as FNAB could cover much more area, it yielded adequate material from solid area.

Though accuracy of CNB is superior to FNAB,to minimize the limitation, the aim of pathologist should be to diagnose all the breast cancers confidently and not a single case should be missed. With this aim, the concurrent FNAB was done in this study and it showed sensitivity of 96.5%. In this present study, the number of cores taken from each patient was four or above. The combined approach of FNAB and CNB yielded better diagnostic accuracy than FNAB and CNB alone. The sensitivity of combined approach is 96.5%, where FNAB and CNB had 85.71% and 92.85% respectively. The specificity and positive predictive value of both FNAB and CNB are individually 100%, so the concurrent result is also the same. The 100% specificity of FNAB or CNB should not be generalized for all breast lesions in this study, because all the cases in the present study had breast lumps more than 2 cm in size and all were palpable.

The false negative rate in the combined approach was 3.57% which is lower than the rate in individual tests (14.28% in FNAB and 7.14% in CNB). A false negative diagnosis may delay the treatment of breast cancer. The concurrent examination of FNAB and CNB reduced the false negative rate by 50 %(7.14% to 3.57%), in comparison to CNB alone.

Conclusion
It is established that CNB is superior to FNAB regarding sensitivity and specificity. 9,10,11,13 In our country with poor resource setting, guided FNAB and CNB are not always possible. So to increase the sensitivity and to reduce the numbers of false negative cases of CNB, combined approach are helpful.

Reference
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2. Globocan, IARC 2012 IARC, 2012. Latest world cancer statistics Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. http://globocan.iarc.fr.
3. IARC, 2012. Latest world cancer statistics Global cancer burden rises to 14.1 million new cases in 2012: Marked increase in breast cancers must be addressed. http://globocan.iarc.fr.
4. Forouzanfar MH, Foreman KJ, Delossantos AM, Lozano R, Lopez AD, Murray CJ and Naghavi M, Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. The lancet, 2010; 378(9801):1461-84.
5. IARC, 2008. World cancer report 2008. International Agency for Research on Cancer. http://globocan.iarc.fr/
6. Cochrane RA, Singhal H, Monypenny IJ, Webster DJT, Lyons K and Mansel RE. Evaluation of general practitioner referrals to a specialist breast clinic according to the UK national guidelines. European Journal of Surgical Oncology (EJSO), 1997; 23(3):198-201.
7. Touhid Uddin Rupom, Tamanna Choudhury, Sultana Gulshana Banu. Study of Fine Needle Aspiration Cytology of Breast Lump:Correlation of Cytologically Malignant Cases with their Histological Findings. BSMMU J, 2011;4(2):60-64.
8. Yong WS, Chia KH, Poh WT and Wong CY. A comparison of trucut biopsy with fine needle aspiration cytology in the diagnosis of breast cancer. Singapore medical journal, 1999;40(9):587-89.
9. Karimian F, Aminian A, Hashemi E, Meysamie AP, Mirsharifi R and Alibakhshi A. Value of core needle biopsy as the first diagnostic procedure in the palpable breast masses. Shiraz E Medical Journal, 2008;9(4):188-192.
10. Pieter J, Westenend Ali R, Sever, Hannie JC., Beekman-de Volder et al. A comparison of Aspiration Cytology and Core Needle Biopsy in the evaluation of breast lesions. Cancer cytopathol 2001,93:146-150.
11. Liberman L, Dershaw DD, Rosen PP, Giess CS, Cohen MA, Abramson AF and Hann LE. Stereotaxic core biopsy of breast carcinoma: accuracy at predicting invasion. Radiology, 1995;194(2):379-81.
12. Yao-Lung Kuo, Tsai-Wang Chang. 2010, :Can concurrent core biopsy and fine needle aspiration biopsy improve the false negative rate of sonographically detectable breast lesions? BMC cancer, 2010;10(371):1-7.
13. Berner A, Davidson B, Sigstad E, Risberg B. Fine needle aspiration cytology vs. core biopsy in the diagnosis of breast lesions. Diagnostic cytopathology, 2003;; 29(6):344-8.
14. CIA. The world factbook; 2014.
15. NICRH. Cancer Registry Report National Institute of Cancer Research and Hospital 2005-07; 2009.
16. NIRCH. Cancer Registry Report National Institute of Cancer Research and Hospital 2008-2010; 2013.
17. Mahmood H. Hassan Ahmed R, HizamSafa, M. Al-Obaidi. The role of Tru-cut needle biopsy in the diagnosis of palpable breast masses. J Fac Med Baghdad, 2014;56: 292-295.
18. Mohammed Bdour, Saleh Hourani, WaseemMefleh, Ashraf Shabatat, Samer K.A. Radsheh, et al. Comparision between Fine needle aspiration cytology and Tru-cut biopsy in the diagnosis of breast cancer: Journal of surgery Pakistan international 2008: 13; 19-21.
19. Tiwari M. Role of fine needle aspiration cytology in diagnosis of breast lumps.Kathmundu University Medical Journal, 2007;5:215-17.
20. Baildam AD, Turnbull L, Howell A, Barnes DM and Sellwood RA, 1989. Extended role for needle biopsy in the management of carcinoma of the breast. British Journal of Surgery, 1989;76(6):553-58.
21. Stanley Minkowitz, Robert Moskowitz, Rene A., Khafif Martha N, Tru-cut needle biopsy of the breast and analysis of its specificity and sensitivity. Cancer 1986;15;320-323.