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প্যাথলজি কারিকুলাম বিষয়ক কমিটির সভার কার্যবিবরণীঃ

প্যাথলজি কারিকুলাম বিষয়ক কমিটির সভার কার্যবিবরণীঃ

বাংলাদেশ একাডেমী অব প্যাথলজি আয়োজিত এমবিবিএস কোর্সের প্যাথলজি কারিকুলাম বিষয়ক সভা স্যার সলিমুল্লাহ মেডিকেল কলেজের প্যাথলজি বিভাগে গত ২৭/০৪/২০১৯ তারিখে পূর্বনির্ধারিত সময়ে অনুষ্ঠিত হয়। সভায় সভাপতিত্ব করেন কারিকুলাম বিষয়ক কমিটির সভাপতি অধ্যাপক মোঃ নাসিমুল ইসলাম।

সম্মানিত সদস্যমন্ডলীর মধ্যে সভায় উপস্থিত ছিলেন সর্বজনাব অধ্যাপক মোঃ ফজলুর রহমান, অধ্যাপক এনামুল কবির, অধ্যাপক শামীম ফারুক, ডাঃ কাজী নিশাত আরা বেগম, ডাঃ সায়েকা হাবিব, ডাঃ শাহনাজ বেগম প্রমুখ। এছাড়া ছিলেন প্যাথলজি বিভাগের অধ্যাপক হারুন অর রশিদ।

সকল সম্মানিত সদস্যকে শুভেচ্ছা ও স্বাগত জানিয়ে অধ্যাপক নাসিমুল ইসলাম বিএমডিসি এবং উপমহাদেশীয় অন্যান্য দেশের মেডিকেল কারিকুলামের তুলনামূলক একটি সংক্ষিপ্ত মাল্টিমিডিয়া প্রদর্শনী উপস্থাপন করে বিষয়ের উপর আলোচনার সূত্রপাত করেন।

সভায় আলোচনার মাধ্যমে নিম্নলিখিত সিদ্ধাম্ত গৃহীত হয়ঃ

১। বর্তমান এমবিবিএস কারিকুলামে যেহেতু দ্বিতীয় ফেজে ক্লিনিক্যাল ক্লাসসমুহ শুরু হয়ে যায়, প্যাথলজির বেসিক ধারণা না থাকায় ক্লিনিক্যাল বিষয় শিক্ষার্থীদের বুঝতে অসুবিধা হয়। কলেজের ক্লিনিক্যাল ফ্যাকাল্টিও শিক্ষাদানে জটিলতার সম্মুখীন হন। এ ব্যাপারে বিশেষতঃ ক্লিনিক্যাল শিক্ষকদের দাবী প্যাথলজি বিষয়টি দ্বিতীয় ফেজ থেকে শুরু করা হোক।

এর সমাধানে সভার প্রস্তাব হল,

– বর্তমান কারিকুলাম কিছুটা পরিবর্তন করে দ্বিতীয় ফেজে ফরেনসিক মেডিসিনের সঙ্গে কমিউনিটি মেডিসিন এর পরিবর্তে ফার্মাকোলজি থাকবে, সাথে প্যাথলজির ক্লাসের অফিসিয়াল অনুমতি থাকবে- যেখানে জেনারেল প্যাথলজি পড়ানো হবে এবং আইটেম ও টার্ম পরীক্ষা নেয়ার সুযোগ থাকবে।

– তৃতীয় ফেজে প্যাথলজির বাকি অংশের লেকচার, টিউটোরিয়াল ও প্র্যাকটিক্যাল ক্লাসশেষে ২য় টার্ম পরীক্ষা থাকবে।

– ২য় টার্ম পরীক্ষার পর তৃতীয় ফেজে মার্চের শেষ সপ্তাহ থেকে ৩ সপ্তাহ প্যাথলজি, মাইক্রোবায়লজি, এবং কমুনিটি মেডিসিন বিষয়ে ব্লক পোস্টিং এর ব্যবস্থা করা যেতে পারে, যাতে ছোট গ্রুপে রিভিশন ক্লাসসহ হাতে-কলমে প্র্যাকটিক্যাল শিক্ষাদান করা সম্ভব হবে।

২। সভায় একটি বিকল্প প্রস্তাব আসে, যা হল দ্বিতীয় ফেজ এ প্যাথলজির সাথে ২য় একটিমাত্র বিষয় যেমন- মাইক্রোবায়লজি বা ফার্মাকোলজি রাখা। এতে প্যাথলজির ক্লাসের জন্য পর্যাপ্ত সময় পাওয়া যাবে। এ ক্ষেত্রে প্যাথলজি সহ ২টি বিষয়ের উপর ২য় বৃত্তিমূলক পরীক্ষা অনুষ্ঠিত হবে। তবে কমিটি এটিকে মন্দের ভাল (2nd best option) আখ্যা দিয়ে ১ম প্রস্তাবের উপর গুরুত্ব আরোপ করে।

৩। কমিটির উপরোক্ত সিদ্ধান্ত সম্পর্কে Questionnaire এর মাধ্যমে প্যাথলজি আন্ডারগ্রাজুয়েট কোর্সের সকল শিক্ষকের মতামত অচিরেই সংগ্রহ করা হবে।

৪। একটি সুবিধাজনক সময়ে বিএসএমএমইউ বা ঢাকা মেডিকেল কলেজে প্যাথলজি কারিকুলাম আপডেট সংক্রান্ত অংশীজনের (Stakeholder) ওয়ার্কশপের আয়োজন করা হবে।

আলোচনা শেষে সভায় অংশগ্রহণকারী সম্মানিত সদস্যমন্ডলীকে ধন্যবাদ জানিয়ে চা-চক্রে আপ্যায়নের মাধ্যমে সভাপতি সভার সমাপ্তি ঘোষণা করেন।

অবগতির জন্য প্রেরণঃ বাংলাদেশ একাডেমী অব প্যাথলজির সকল সম্মানিত সদস্য।

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Participant list 17

4th National Convention

Bangladesh Academy of Pathology

Participants List No 17(Dyanamic)

1. TASNIM ISRAT
MD
ASSTT PROF
CUMILLA MEDICAL COLLEGE

2. Dr. Md. Ashraful Alam

Associate Professor

Department of Pathology

Rangpur Medical College

 

Added by

Dr. Nurul Kabir

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Hyperplastic Gastric Polyposis – Report of a Case and Review of Literature

Hyperplastic Gastric Polyposis – Report of a Case and Review of Literature

*Rahman F,1 Kamal M2

 Abstract

Gastric hyperplastic polyps (GHP) represent one of the common polypoid lesions of the stomach. These are usually asymptomatic and discovered incidentally.  Dyspepsia, anaemia due to bleeding, abdominal pain and rarely gastric outlet obstruction may sometimes warrant evaluation of the patient by upper gastrointestinal (GI) endoscopy.  When found, the main aim is the histological evaluation to rule out malignancy and management of the patient. Hyperplastic polyps of stomach arise in inflamed mucosa and almost never occur in normal gastric mucosa. Helicobacter pylori associated chronic gastritis is thought to be the commonest association.  These polyps are single in majority of cases, located in the antrum, sessile or pedunculated and are usually less than 20 mm in diameter.  Rarely more than fifty polyps are found when the term ‘polyosis’ is used. Here we present a case of hyperplastic gastric polyposis in a symptomatic 50 year-old female revealed by endoscopy.  Distal gastrectomy was performed which confirmed the diagnosis.

[Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):124-130]

 Key words:  Stomach, Gastric polyp, Hyperplastic polyp

 

  1. *Dr. Farzana Rahman, Department of Pathology, National Institute of Ophthalmology and Hospital, Sher-e-Bangla Nagar, Dhaka, Bangladesh. frkaroby6@gmail.com
  2. Professor Mohammed Kamal, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

 *For correspondence

Introduction

Endoscopic examination has now become a common practice for evaluation of  many gastrointestinal tract ailments.  Widespread use of endoscope can now detect subtle to marked mucosal abnormality of stomach.  Endoscopically gastric polyps appear from slightly raised plaques to soft lobulated lesions. Although vast majority are of mucosal origin, a mass lesion arising within any layer of the stomach wall can present as a polyp.  They are usually found incidentally during endoscopy or routine imaging with barium contrast radiography, magnetic resonance imaging, or computed tomography.  Because of different etiology, varying histology, neoplastic potential, and management, their correct diagnosis is important.  Endoscopy alone cannot accurately distinguish different types of polyps.  A representative biopsy, histopathological examination and in suspicious cases immunohistochemical studies are required.

 Case Report

A 50 year-old female was referred from a private clinic in Jessore, Bangladesh to the Gastroenterology department of Bangabandhu Sheikh Mujib Medical University (BSMMU)  hospital in 2013 upon initial endoscopic discovery of mucosal swelling and narrow gastric pyloric canal.  Endoscopically non-Hodgkin lymphoma was suspected.  She gave history of weakness, occasional early nausea, vomiting after meals and loss of appetite for four months. Physical examination revealed no pathological findings other than mild epigastric tenderness. Laboratory examinations of the patient showed normal blood values except mild anaemia.

A repeat gastrointestinal endoscopic evaluation was done at BSMMU.  The mucosal folds in cardia, fundus and body of the stomach were found normal.  Infiltrating lesions were seen at the antrum with narrowed pylorus.  The mucosa of the bulb revealed nodular swellings. Nodules were erythematous which was more marked at the tip (Fig. 1).  Ultrasonographic study revealed multiple mildly enlarged lymph nodes at the bulbar and postbulbar regions. No ascites was noted.  The clinical impression was non-Hodgkin lymphoma.  The biopsy taken during endoscopy was inconclusive.

 

 

 

 

 

Fig. 1.  Endoscopic appearance of stomach of the patient.  Multiple large and small erythematous nodules are seen in the mucosa.

 

 

 

 

 

 

Fig. 2.  Gross appearance of the resected antral part of the stomach.  Polyps of various sizes are present, the largest measures about 1.2 cm.

 

 

 

 

 

 

 

Fig. 3 Microscopic appearance of a polyp showing  irregular, elongated tortuous pits lined by foveolar epithelium. Serrated  appearance is seen in the cross-section (H&E, x120)

 

 

 

 

 

 

 

Fig. 4.  Higher magnification of the polyp showing oedematous lamina propria and many chronic inflammatory cells. A few goblet sells are present in the lining epithelium (H&E, x440)

 Considering the endoscopic features and the patients’ complaints, distal gastrectomy was done. The submitted sample measured 18 cm along the greater curvature and 9 cm along the lesser curvature.  Multiple polyps (>50) of various sizes were found in the pyloric mucosa and the body.  The largest polyp measured 1.2 cm in maximum dimension (Fig. 2). A small 0.6 cm gastric lymph node was also received.  Five of the larger polyps, the resection margins of the stomach and the lymph node were submitted for routine processing, sectioning and staining.  Histopathological examination of the polyps revealed irregular, elongated tortuous foveolar glands. The lamina propria was mildly oedematous and infiltrated with chronic inflammatory cells. Incomplete intestinal metaplasia was present. No adenomatous change, dysplasia or malignancy was detected (Fig. 3 and 4).  The lymph node revealed reactive changes.  The case was diagnosed as hyperplastic polypyposis of stomach.  The patient had uneventful recovery and was discharged from the hospital after seven days with and advise for follow-up.

Discussion

The present  case is a rare presentation of GHP because more than 50 polyps were found in the distal part of the stomach and suspicious look in endoscopeic examinatiom.  Distal gastric resection was performed.  Histological examination proved benign nature of the case and the patient fared an uneventful recovery.

With the increasing use of endoscopy, visually discernible abnormalities, such as polyps in the gastrointestinal tract, are encountered more often. Gastric polyps most frequently originate in the mucosa but encompass a broad spectrum of pathologic conditions. Gastric polyps are a heterogeneous group of epithelial and subepithelial lesions that can vary in histology, neoplastic potential, and management.  Even though most are asymptomatic, larger polyps may present with bleeding, anaemia, obstruction, or abdominal pain. Most have no risk of cancer, but there are certain subsets of polyps with malignant potential, necessitating further endoscopic treatment and/or periodic surveillance.

Epidemiology of gastric polyps

Gastric polyps are relatively common endoscopic finding ranging from 2 to 6%.  In Western countries where the prevalence of H. pylori infection is lower and use of proton pump inhibitor is common, fundic gland polyp is the most commonly encountered type.1 However, lower prevalence has been reported in other countries. In contrast, hyperplastic polyps and adenomas are relatively more prevalent in regions where H. pylori infection is common.2  During 2016, total 245 gastric tissue were examined at the Department of Pathology, BSMMU.  Of these 12 (4.9%) were diagnosed as hyperplastic polyp, 77 as carcinoma and the rest other lesions.  Fundic gland polyps were <1% of the total cases (Unpublished personal data).

The incidence of GHPs increases with age and although they can also be found in children, GHPs usually affects the population in 7th and 8th decades. Most studies proved higher incidence of all types of gastric polyps in women than in men.3

Types of gastric polyps

According to the macroscopic classification of Yamada and Ichikawaof 1974, gastric polyps can be divided into four categories: (a) flat polyps, i.e., slightly elevated and with indistinct margins, less than 2.5 mm in height (b) sessile polyps, i.e., elevated with a distinct border at the base, yet without a notch, height exceeds 2.5 mm and (c) semi-pedunculated polyps, i.e., elevated with distinct margins and clear notch at the base, but without peduncle and (d) pedunculated polyps.4

 A good description and detailed classification of gastric polyps has been given by D Youn Park and Gregory Y. Lauwers in their review (2008). Epithelial polyps e.g. hyperplastic polyps, fundic gland polyps and adenomatous polyps are the common varieties.5

.Classification of Gastric Polyps

(Adapted from D Youn Park and Gregory Y. Lauwers, 2008) 5

 

  1. Nonneoplastic Polyps
  1. Hyperplastic Polyps
    1. Usual (sporadic) type
    2. Gastroenterostomy stoma GE junction (reflux) polyps
  2. Inflammatory fibroid polyp

Hamartomatous and developmental

    1. Peutz-Jegher Juvenile
    2. Cowden disease
    3. Miscellaneous lesions
  1. Myoepithelial hamartomas and
  2. ectopic pancreas
    1. Heterotopic gastric gland polyp
  2. Cronkhite-Canada syndrome
  1. Neoplastic Polyps
  1. Adenoma
  2. Carcinoma (primary or secondary)
  3. Neuroendocrine tumors (Carcinoids )
  4. Fundic gland polyp
  5. Miscellaneous Lesions With Polypoid Growth Pattern
  6. Xanthelasma
  7. Lymphoid hyperplasia/lymphoma
  8. Mesenchymal stromal tumors
  9. Gastrointestinal stromal tumors (benign/malignant)
  10. Smooth muscle tumors (benign/malignant)
  • Glomus tumor
  1. Schwannoma/neuroma
  2. Ganglioneuromas
  3. Granular cell tumor
  4. Other rare tumors
    1. Lipoma/liposarcoma
    2. Rhabdomyosarcoma and fibrous histiocytoma
  5. Vascular tumors
    1. Hemangioma/lymphangioma
    2. Hemangiosarcoma-Kaposi sarcoma

Polyposis conditions of stomach

Multiple polyps found in the stomach can be sporadic or associated with inherited polyposis syndromes such as juvenile polyposis, Gardner, Peutz-Jeghers, and Cronkhite-Canada syndromes which run in families.

Fundic gland polyps (FGP)

Sporadic FGPs account for 50–77% of all gastric polyps and are found in up to 1.9% of the general population are typically asymptomatic and discovered incidentally.  These are usually found in middle-aged adults of both genders. FGPs occur singly or in groups in the acid-secreting mucosa of the gastric body and fundus. These are usually 1–5 mm in size, sessile, shiny, translucent, pale to pinkish in color.  Histologically, FGPs are characterized by cystically dilated and irregularly budded fundic glands lined by normal parietal cells, chief cells, or mucous neck cells.  The surrounding mucosa is typically normal, without any inflammatory changes.6

Cronkhite-Canada Syndrome

This rare noninherited condition of unknown pathogenesis was first described in 1955 by Leonard Wolsey Cronkhite Jr, and Wilma Jeanne Canada. It is characterized by gastrointestinal polyposis, onychotrophia, alopecia, and diarrhoea and skin hyperpigmentation. The gastric polyps show cystically dilated and distorted glands without dysplasia. The lamina propria is oedematous and contain inflammatory cells. The malignant potential of the polyps is controversial.7

Cowden’s syndrome

This rare autosomal dominant condition is due to germline mutation in PTEN on chromosome 10q23.3.  It is characterized by multiple hamartomatous neoplasms of the skin, oral mucosa, gastrointestinal (GI) tract, bones, central nervous system, eyes, and genitourinary tract. Cowden syndrome does not have increased risk of GI malignancy; however, it has an increased risk of breast, thyroid, and endometrial and renal cancer development.  Morphologically the gastric polyp present as small (1 – 2 mm), sessile nodules with excess lamina propria splayed and dissected into lobules by disorganized fascicles of muscularis mucosa running upward from base of mucosa.8

Familial adenomatous polyposis (FAP)

Familial adenomatous polyposis (FAP) is an inherited autosomal-dominant disease primarily characterized by the development of colorectal adenomas and carcinomas. Patients with FAP may also secondarily develop duodenal, gastric, and thyroid neoplasia, as well as desmoid tumors.  The prevalence of gastric adenomas in FAP was about 10% in a series from the United States and ranged from 36-50% in three studies from Asia.

The adenomas present as villous, tubular or tubulo-villous architecture lined by epithelium with dysplasia, pseudostratification, nuclear abnormalities, mitotic figures and cystically dilated glands without dysplastic changes.  Cytologically majority are intestinal type with focal goblet cells or Paneth cells.  This type is more likely to show high grade dysplasia or adenocarcinoma. The other cellular types are Gastric type and  indeterminate type.9  No significant increased risk was found for gastric or nonduodenal small intestinal cancer.10

Hyperplastic polyp (GHP)

These are also called inflammatory polyp or regenerative polyp.  GHPs are incidental finding during upper gastrointestinal tract endoscopy. Symptoms due to GHPs are nonspecific: dyspepsia, heartburn, bleeding, anaemia and sometimes gastric outlet obstruction. Endoscopy is the investigation of choice for detection and diagnosis of gastric polyps as it allows histopathological confirmation through biopsy. Imaging has only limited role in diagnosis due to high false-negative rates.11

Hyperplastic gastric polyposis

In vast majority of GHPs are single (68%-75%) and occur sporadically. Multiple GHPs (50 or more polyps) are seen as a component of a rare hyperplastic polyposis syndrome. Diffused gastric polyposis is a rare entity with only a few cases being reported.12

Sporadic GHPs are macroscopically and histologically indistinguishable from the syndromic GHPs and the latter are associated with a higher risk of malignant transformation and higher 5-year mortality rate.12

Etiopathogenesis hyperplastic gastric polyp

Excessive proliferation of foveolar cells (mucin-producing epithelial cells lining the gastric surface and the gastric pits) is believed to be responsible for GHP production. The gastric glands are usually not involved in the formation of polyps. The two main etiologic factors related to their development are: Chronic H. pylori-associated gastritis and autoimmune metaplastic atrophic gastritis.  Various other inflammatory lesions less commonly implicated are inflamed mucosa in the vicinity of ulcers, erosions and surgical gastroenterostomy, secondary to prior endoscopic coagulation therapy, in gastric mucosa with slight atrophy or metaplasia, and in cardia in patients with gastrointestinal reflux. GHPs almost never occur in normal gastric mucosa.3

Macroscopic and histopathological features

GHPs are usually small, flat or sessile dome-shaped lesions or protuberant lobular structure with smooth surface, distinct margin and red color.

Sometimes they may have surface erosions and they are often difficult to distinguish endoscopically from polypoid foveolar hyperplasia or gastric adenomatous polyps and well-differentiated adenocarcinoma.  About half are less than 0.5 cm and 90% are 2.0 cm or less in diameter.  The rest are more than 2 cm, sometimes may reach higher size and in these cases malignant transformation may be suspected.3

Contrary to hyperplastic polyps of the colon, GHPs show pronounced foveolar hyperplasia and infiltration of the lamina propria by inflammatory cells. A few smooth muscle fibers may be present derived from the muscle coat. Mucin-secreting cells from the foveolar layer of GHPs are enlarged and elongated.  They form irregular tubules and cysts extending into the stroma. PAS/Alcian blue or mucicarmine stains highlight acidic mucin in goblet cells and can demonstrate the neutral mucin in foveolar epithelium.3

GHPs have typical microscopic features relating to the epithelial component and the stroma. The former consists of elongated, dilated, distorted and branched pits with increased mucus secretion. On horizontal section these have spiral appearance and serrated or star-like appearance on the cross-section. The foveolar cells have large amounts of cytoplasm, small nuclei and exhibit low mitotic activity. The stroma is oedematous and shows randomly arranged fine bundles of smooth muscles. The second typical microscopic feature is vascularized oedematous stroma and inflammatory reaction of varied intensity, either acute or chronic or both.  The surface of GHPs can be ulcerated and inflamed, with regenerative atypia of epithelial and interstitial cells. Abnormal regenerative changes may be difficult to differentiate accurately from dysplastic atypia.3

Polypoid foveolar hyperplasia is regarded as a precursor of gastric hyperplastic polyps and differs slightly from those in the microscopic structure. Elongated pits of the mucosa without features of dilatation can  also seen in PFH and at the same time the lamina propria is either normal or only slightly swollen. Differentiation between these two lesions is of crucial clinical significance since malignant transformation affects gastric hyperplastic polyps but not foveolar polypoid hyperplasia.13

Complications and the risk of malignant transformation

GHPs may remain stable, increase in size, or rarely regress.  Some may cause bleeding and sometimes gastric outlet obstruction.  Only a small percentage (0.6 to 4.5 % ) of GHPs may show malignant transformation.  In a large series, Daibo et. al. (1987) found focal carcinomas in 10 hyperplastic polyps, which corresponded to 2.1% of the total of 477 hyperplastic polyps. The location of cancer was at the head or at the surface of the polyp, or intramucosal. Dysplastic foci were also found in 19 hyperplastic polyps without cancerous foci, which corresponded to 4.0% of the total hyperplastic polyps.  Regarding the histological type of malignancy, most reported cases were (well/ moderately) differentiated adenocarcinomas, while a few were poorly-differentiated adenocarcinomas or signet ring cell carcinomas.14

Management of GHP

The main concern after discovering GHP is to rule out malignancy.  Larger polyps (> 1 cm) may show focal intraepithelial neoplasia or cancer. Therefore, these should be removed as a whole and subjected to histopathological evaluation. Smaller polyps can be biopsied and monitored annually.  After confirmation of the diagnosis, biopsy of gastric mucosa outside the polyp and examination for H. pylori infection and its eradication are additionally recommended, Polyps causing bleeding or gastric outlet obstruction are treated by endoscopic excision.15

Conclusion

Multiple hyperplastic polyp of stomach is rare. Their endoscopic appearance may be alarming.  As many gastric polyps have similar endoscopic appearances, and because GHPs have no reliable distinguishing endoscopic features, their classification and diagnosis depends on the histologic examination.  Histopathology plays a vital role in ruling out malignancy and is integral part in their management.

References

  1. Sonnenberg A and Genta R. Prevalence of benign gastric polyps in a large pathology database. Dig Liver Dis. 2015; 47(2):164-169.
  2. Morais DJ, Yamanaka A, Zeitune JM, Andreollo NA. Gastric polyps: a retrospective analysis of 26,000 digestive endoscopies. Arq Gastroenterol. 2007; 44(1):14-17.
  3. Markowski AR, Markowska A, Guzinska-Ustymowicz K. Pathophysiological and clinical aspects of gastric hyperplastic polyps. World Journal of Gastroenterology. 2016; 22(40):8883-8891.
  4. Yamada T, Ichikawa H. X-ray diagnosis of elevated lesions of the stomach. Radiology. 1974; 110:79-83.
  5. Park DY and Lauwers GY. Gastric Polyps: Classification and Management. (Arch Pathol Lab Med. 2008; 132:633–640.
  6. Spiegel A, Stein P, Patel M, Patel R, Lebovics E. A Report of Gastric Fundic Gland Polyps. Gastroenterol Hepatol (NY). 2010; 6(1): 45–48.
  7. Sellal C, Lemarié V, Jausset F, Babouri A, Laurent V, Régent D. A rare gastric polyposis: Cronkhite-Canada syndromeDiagnostic and Interventional Imaging. 2012; 93 (10):799-803.
  8. Ha M, Chung JW, Hahm KB, Kim YJ, Lee W, An J, Kim DK, Kim MG. A case of Cowden syndrome diagnosed from multiple gastric polyposis. World J Gastroenterol. 2012; 18(8):861-864.
  9. Ngamruengphong S, Boardman LA, Heigh RI, Krishna M, Roberts ME and Riegert-Johnson DL. Gastric adenomas in familial adenomatous polyposis are common, but subtle, and have a benign course. Hereditary Cancer in Clinical Practice. 2014; 12(1):4 DOI: 10.1186/1897-4287-12-4).
  10. Johan G, Offerhaus A, Giardiello FM, Krush AJ, Booker SV, Tersmette AC. Christopher Kelley N and Hamilton SR. The risk of upper gastrointestinal cancer in familial adenomatous polyposis.  1992;102 (6):1980-1982.
  11. Islam RS, Neal C. Patel NC, Lam-Himlin D and Nguyen CC. Gastric Polyps: A Review of Clinical, Endoscopic, and Histopathologic Features and Management Decisions. Gastroenterol Hepatol (NY). 2013; 9(10): 640–651.
  12. Jayawardena S, Anandacoomaraswamy D, Burzyantseva O, Abdullah M. Isolated diffuse hyperplastic gastric polyposis presenting with severe anemia. Cases Journal. 2008;1:130. doi:10.1186/1757-1626-1-130.
  13. Gonzalez-Obeso E, Fujita H, Deshpande V, Ogawa F, Lisovsky M, Genevay M, Grzyb K, Brugge W, Lennerz JK, Shimizu M, et al. Gastric hyperplastic polyps: a heterogeneous clinicopathologic group including a distinct subset best categorized as mucosal prolapse polyp. Am J Surg Pathol. 2011; 35:670–677.
  14. Daibo M, Itabashi M, Hirota T. Malignant transformation of gastric hyperplastic polyps. Am J Gastroenterol. 1987; 82:1016–25.
  15. Goddard AF, Badreldin R, Pritchard DM, Walker MM, Warren B. The management of gastric polyps. Guidelines by The British Society of Gastroenterology 2010. http://www.bsg.org.uk/clinical-guidelines/endoscopy/the-management-of-gastric-polyps.html assessed on 20 July 2017.
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Suprasellar Ganglioglioma: Report of a Rare Case

Suprasellar Ganglioglioma: Report of a Rare Case

*Huq N,1   Jahan MI,2  Islam MN,3  Hossain SS,4  Kamal M5

Abstract

Gangliogliomas are rare central nervous system tumors composed of intimately admixed neuronal and glial components. Gangliogliomas are intra-axial masses located predominantly in the temporal lobe, but they can also arise from frontal, parietal and occipital region, and rarer sites include the cerebellum, brainstem and spinal cord. We report a case of a 22 years old female who presented with severe headache, bilateral blurring of vision, generalized weakness and history of convulsion. The lesion was radiologically indistinguishable from meningioma. Histologically the tumor was diagnosed as ganglioglioma by the presence of dual population of neoplastic ganglionic and glial components

 [Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):120-123]

 Key words: Ganlioglioma, Sellar-suprasellar tumor.

 

  1. *Dr. Naila Huq, Assistant Professor, Department of Neuropathology, National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka. nailahuqpopy@gmail.com
  2. Most. Israt Jahan, Medical Officer,  Department of Neuropathology,  National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka.
  3. Proessor Dr. Md. Nowfel Islam, Professor & Head,  Department of Neuropathology, National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka.
  4. Professor Dr. SK. Sader Hossain, Professor & Head, Department of Neurosurgery, National Institute of Neurosciences & Hospital, Sher-E-Bangla Nagar, Agargaon, Dhaka.
  5. Professor Dr. Mohammed Kamal, Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.

 

*For correspondence

Introduction

Gangliogliomas are rare central nervous system tumors composed of intimately admixed neuronal and glial components. Their incidences range from 5-8% of all brain tumors, but they are more common in the pediatric age group.1,2 Seizures are the commonest presentation reflecting involvement of temporal lobes commonly, but they can involve any part of the neuraxis including spinal cord.2 Sellar or suprasellar gangliogliomas are very rare. We report a case of suprasellar Ganglioglioma with histopathological and MRI features. This case suggests that though Ganglioglioma is rare but can occur in this location.

 Case Report

A twenty two years old female was admitted in the department of Neurosurgery of National Institute of Neurosciences and Hospital (NINS & H) with the complains of severe headache and vomiting for 25 days. She had history of loss of consciousness and convulsion and difficulty in walking associated with generalized weakness. She also complained of blurring of vision. On examination her Glasgo Comma Scale was 15/15. Higher psychic function and speech were normal. There was no sign of meningeal irritation. Bilateral blurring of vision was present.

Her Magnetic Resonance Imaging (MRI) revealed a fairly large, lobulated extra axial lesion of (3.22 x 2.34) cm with signal intensity change, in the suprasellar and right parasellar region. It was iso to hypo-intense on T1 and mildly hyperintese on T2. Post contrast scan revealed intense enhancememt of the lesion. It extends upwards through the floor of the third ventricle causing ventricular obstruction (Fig.1 and 2). Radiology suggested the lesion as a suprasellar meningioma. All the pituitary hormone levels were within the normal limit. A clinical diagnosis of craniopharyngioma was made.

The patient had a left sided V-P shunt (Fig.3) inserted two months back to releif hydrocephalus at an outside hospital. Her previous ultrasonogram (USG) report of whole abdomen was normal. Recent USG showed a large thin walled cystic lesion in left lobe of liver suggesting CSFoma. Lower end of VP shunt tube was within the lesion. She was anaemic and had high ESR. Her serum amylase level was within normal limit and gastric biopsy revealed features of chronic gastritis.

The patient underwent right frontal craniotomy with subtotal removal of the tumor. The tumor was encapsulated, lobulated, firm, gritty and haemorrhagic. Peroperative findings suggested it to be a suprasellar meningioma. Part of the specimen was sent for routine histopathological examination.

Microscopic examination of the tumor showed collections of large ganglion cells with prominent nucleoli, abundant cytoplasm admixed with glial component. The glial component was mostly pilocytic in nature with some astrocytes in a fibrillary background. No evidence of meningioma or craniopharyngioma  was seen. Finally it was diagnosed as Ganglioglioma, WHO grade I/IV.

After 18 days of surgery, the patient became quite healthy and symptom free. Her vision improved. She got discharged from hospital with almost full recovery.

 

 

 

 

 

 

 

 

Fig.1. MRI of brain showing sellar tumor

 

 

 

 

 

 

 

Fig.2. MRI of brain showing sellar contrast enhancing tumor and dilated lateral ventricles.

 

 

 

 

 

 

 

Fig.3. X-ray showing V-P shunt in situ

 

 

 

 

 

 

Fig.4. Photomicrograph of sellar tumor showing neoplastic glia (A) and  ganglionic cells (B)     (H & E, x120)

 

 

 

 

 

 

Fig.5. Photomicrograph of sellar tumor showing large neoplastic ganglionic cells (H & E, x400)

 

Discussion

Temporal lobes are the commonest location for supratentorial gangliogliomas, but they can also arise from frontal, parietal and occipital region, and rarer sites include the cerebellum and brainstem. Sellar and suprasellar gangliogliomas are very rare and a few cases have been reported.2,3,4,5

The differential diagnoses of suprasellar lesions in children include neoplastic conditions like hypothalamic glioma, craniopharyngioma, germ cell tumors and pituitary adenomas; or non-neoplastic conditions such as granulomatous diseases and benign cyst. The most common lesions in adults are meningioma and pituitary adenoma3,4 . Our case was also diagnosed radiologically as meningioma due to suprasellar location. All the pituitary hormone levels were done to exclude the possibility of pituitary adenoma. The hormone levels were within the normal limit and finally preoperative diagnosis was Craniopharyngioma, which is a common tumor in this location.

The radiographic appearance of gangliogliomas is variable, but certain characteristics prevail. It may be solid or cystic. The cystic appearance varies from a single large cyst with a mural nodule to a multicystic mass. Imaging studies reveal a well-circumscribed lesion situated in the peripheral cortex. On MRI, it is iso-to-hypointense on T1 weighted images, hyperintense on T2 weighted and FLAIR images and shows variable contrast enhancement either a nodular rim or a solid pattern. Calcification is common. The cyst margins can enhance, mimicking the ring enhancement of malignant glioma.3,4,6 The present case has similar radiological findings, but calcification and cyst formation are absent.

The pathologic criteria of ganglioglioma includes irregular groups of large, dysplastic, multipolar neurons admixed with glial component surrounded by a reticulin network. The glial component is generally pilocytic or fibrillary, but ependymal and even oligodendroglial components have been described. Eosinophilic granular bodies, hyaline bodies, microcystic changes, calcification, desmoplasia and perivascular lymphocyte infiltration may be present variably.2,8

The case under discussion presented with a suprasellar lesion having complains of headache, bilateral blurring of vision and history of convulsion. 15-25% patient of ganglioglioma undergoing surgery usually presents with a history of seizure7. Histopathology of our case showed  combination of both neuronal and glial cell elements. The ganglion cells were large having vesicular nuclei, prominent nucleoli and abundant cytoplasm arranged in sheets and groups. The glial elements showed mostly pilocytes, scattered astrocytes and occasional foci of reticulin formation in a fibrillary background. Immunohistochemistry for CD34 antigen expressed in neuronal cells in 70-80% of gangliogliomas7. But as this case showed very typical and prominent ganglion cell component in a large area of the tumor, immunohistochemical analysis was not necessary. Jalali R et al., Siddique K et al., Shuangshoti S et al. also found ganglioglioma in sellar-suprasellar location which were radiologically diagnosed  as other common entities of this site.3,4,5

Conclusion

Gangliogliomas are mostly benign tumors with good prognosis. A complete surgical resection is necessary for recurrence free survival of the patient. But in most of the cases the sellar gangliogliomas are misdiagnosed both clinically and radiologically. A well-demarcated lesion with signal intensity changes in the sellar-suprasellar region should alert the clinician in considering gangliglioma as a possible differential diagnosis, which will help in proper surgical management of the patient.

 References

  1. Courville CB. Ganglioglioma: Tumour of the central nervous system: review of the literature and report of two cases. Arch Neurol Psychiatr, 1990; 24:439-91.
  2. Zentner J, Wolf HK, Ostertun B, Hufnagel A, Campos MG, Solymosi L, et al. Gangliogliomas: clinical, radiological, and histopathological findings in 51 patients. J Neurol Neurosurg Psychiatry, 1994; 57:1497-502.
  3. Jalali R, Deopujari CE, Bhutani R, Suhas U, Rajasekharan P, Kane SV, Gupta T. Suprasellar ganglioglioma with unusual diffuse involvement of the entire optico-chiasmal hypothalamic pathway. J Cancer Res Ther,2008 Jul-Sep; 4(3):140-3.
  4. Shuangshoti S, Kirsch E, Bannan P, Fabian VA. American J of Neuroradiology, 2000 Sep; 21(8):1486-1489.
  5. Siddique K, Zagardo M, Gujrati M, Olivero W. Ganglioglioma presenting as a meningioma: case report and review of the literature. Neurosurgery, 2002 May;50(5):1133-5.
  6. Burger PC and Scheithauer BW, Tumours of the central nervous system. In: Rosai J, ed. Atlas of Tumor Pathology, 3rd series, Fascicle 10. Armed Forces Institute of Pathology, Washington DC. 1994: pp.163-172.
  7. Louis DN, Ohgaki H, Wiestler OD, Cavenee WK, Neuronal and mixed neuronal-glial tumours. In: WHO Classification of Tumors of the Central Nervous System. 4th Ed, International Agency for Research on Cancer, Lyon, 2007 pp.103-105.
  8. Rosenblum MK. Central nervous system. In: Rosai J. Ed. Rosai and Ackerman`s Surgical Pathology 10th. St Louis, Mo. Elsevier. 2010. vol-2, pp 2366-2369.

 

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Laboratory Findings of Histopathologically Confirmed Tuberculous Lymphadenitis

Laboratory Findings of Histopathologically Confirmed Tuberculous Lymphadenitis

*Huda MM,1 Kamal M,2 Sultana AT,3 Yusuf MA,4 Taufiq M,5 Begum F6

Abstract

Laboratory findings are important for the tuberculous lymphadenitis patients for diagnosis and treatment. The purpose of the present study was to see the laboratory findings of tuberculous lymphadenitis patients. This cross-sectional study was done at the Department of Pathology, Banghabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from January 2009 to March 2011 for a period of nearly two (2) years. All the patients irrespective of age and sex with the clinical features of tuberculous lymphadenitis and later confirmed by histopathological examination were selected for the study purposively. Relevant information was recorded in a prescribed data sheet and histomorphological findings were recorded accordingly. In cases where fresh specimen was available, caseous portion of lymph node was sent for culture. Fite Faraco staining was done on lymph node sections in all cases. A total of 50 cases tuberculous lymphadenitis patients were recruited for this study. Raised ESR was found in 42 (84.0%) cases. Mantoux (MT) test was positive in 37 (74.0%) patients. Out of 50 patients 34 (68.0%) cases had well-formed granuloma and 8 (16.0%) cases had both well-formed and ill-defined granuloma. Growth of Mycobacterium culture in Lowenstein-Jensen media was seen in 12 (60%) cases. In conclusion, majority of the tubercular lymphadenitis patients presented with raised ESR with positivity of Mantoux test (MT) and well defined granuloma.

[Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):116-119]

 Keywords: Tuberculous lymphadenitis; tuberculosis; lymph nodes; laboratory findings

  1. *Dr. Mohammad Mahmudul Huda, Assistant Professor, Department of Pathology, Dhaka National Medical College, Dhaka, Bangladesh. mmhuda.himel@gmail.com
  2. Mohammed Kamal, Professor, Department of Pathology, Banghabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
  3. Akhand Tanzih Sultana, Assistant Professor, Department of Respiratory Medicine, Bangladesh Institute of Child Health & Dhaka Shishu Hospital, Dhaka, Bangladesh.
  4. Md. Abdullah Yusuf, Assistant Professor, Department of Microbiology, National Institute of Neurosciences & Hospital, Dhaka, Bangladesh.
  5. Mohammad Taufiq, Associate Consultant (Pathology), Square Hospital, Dhaka, Bangladesh.
  6. Ferdousy Begum, Associate Professor, Department of Pathology, Banghabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.

*For correspondence

Introduction

Lymph nodes are usually involved in the early stages of the pulmonary disease or as secondary tuberculosis by hematogenous spread.1 However, tuberculous lymphadenitis may arise without a detectable preceding pulmonary involvement.2 Tuberculous lymphadenitis affects mainly the cervical lymph node group and is an important cause of lymphadenopathy worldwide.3 The clinical as well as the demographic characteristics are varied. To confirm the diagnosis histopathological examination or FNAC is needed. These investigations help to arrive at an early diagnosis of tubercular lymphadenitis and institution of treatment before a final diagnosis is made by culture.4

Histopathological examination is suggestive of tuberculous lymphadenitis where Langhans’ giant cells, caseation necrosis, coalescing granuloma are present.5 The physicians treat these cases with anti-tubercular chemotherapy. In cases which are reported as suggestive of tuberculosis, the physician needs additional laboratory findings such as positive Mantoux test and other laboratory tests to start anti-tubercular chemotherapy.6 Therefore this present study was to see the laboratory findings of tuberculous lymphadenitis patients.

 Methods

This cross-sectional study was done at the Department of Pathology, Banghabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from January 2009 to March 2011 for a period of nearly two (2) years. All the patients irrespective of age and sex with the clinical features of tuberculous lymphadenitis and later on proved to be the same histologically were selected for the study purposively. The patients without having history of anti-tubercular drugs, malignancy and symptoms other than TB were excluded from this study. Relevant information was recorded in a prescribed data sheet and histomorphological findings were recorded accordingly. In cases where fresh specimen was available, caseous portion of lymph node was sent to ICDDRB for culture in conventional egg based Lowenstein- Jensen medium7. This part was done maintaining high level of sterility. Ziehl-Neelsen stain was done in smear prepared from 20 fresh cases. Fite Faraco staining was also done on lymph node sections in all cases. Computer based statistical analysis was carried out with appropriate techniques and systems. All data were recorded systematically in preformed data collection form (questionnaire) and quantitative data were expressed as mean and standard deviation and qualitative data were expressed as frequency distribution and percentage. Statistical analysis was performed by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-22.0) (SPSS Inc, Chicago, IL, USA).

 Results

A total of 50 patients were recruited for this study. Raised ESR was found in 42 (84.0%) cases. Mantoux (MT) test was positive in 37 (74.0%) patients. Two (4.0%) patients had chest X-ray (CXR) suggestive of pulmonary TB; however, no case was positive for AFB on sputum (Table I).

 Table I: Laboratory and radiological findings

 

Investigations Frequency Percentage
Raised ESR 42 84.0
Mantoux test 37 74.0
X-ray chest 2 4.0
Sputum for AFB 0 0.0

 

In this study, out of 50 patients 34 (68.0%) cases had well-formed granuloma and 8 (16.0%) cases had both well-formed and ill-defined granuloma, and the remaining 8 (16.0%) cases had ill-defined granuloma (Table II).

Table II: Distribution of study sopulation according to types of granuloma

 

Types of granuloma Frequency Percentage
Well formed 34 68.0
  Coalescing 06 17.6
Discrete 06 17.6
Both coalescing & discrete 22 64.7
Ill defined 8 16
Both well formed and ill defined 8 16

Culture was done in 20 fresh cases in Lowenstein-Jensen media. Caseous portion of the lymph node was taken for culture. Growth of Mycobacterium was seen in 12 (60%) cases (Table III).

Table II: Culture of lymph node material in Lowenstein-Jensen media (n=20)

 

Culture Frequency Percentage
Growth present 12 60.0
Growth absent 8 40.0
Total 20 100.0

Discussion

Tuberculosis is a major cause of unpleasant health and mortality worldwide.1 The risk of infection however is a lot larger in midst of communities of inferior socioeconomic groups.2 Yearly 2.2 million individuals acquire TB in India of which approximately 0.87 million are infectious cases and responsible for about more than 330,000 per annum.3 TB is considered as the most usual opportunistic infection in belts where HIV infection is rampant. Someone in the world is newly infected with TB bacilli every second. Overall, one-third of the world’s population is currently infected with the TB bacillus.5 Among the various diagnostic tools of tubercular lymphadenitis, histological diagnosis is an important one.  As the morphological features are variable, this descriptive study was performed in 50 cases of tubercular lymphadenitis to find out histomorphological features and correlate with clinical profile and treatment outcome.

In this present study histomorphological examination shows a well formed granuloma in majority of the study population (68.0%). Among the well formed granuloma 64.7% had both coalescing and discrete granuloma, 17.6% had only coalescing granuloma and 17.6% had only discrete granuloma. Pahwa et al6 found well formed granuloma in 89.0% cases, which is higher than the percentage found in this present study. Extent of caseous necrosis was also observed in present study. Of 50 patients, 18% patient had focal area of caseous necrosis, 54.0% had moderate caseous necrosis and 28.0% had extensive caseous necrosis. This present study showed variation in percentage of caseous necrosis in individual cases.

Out of 50 cases caseous material of 20 fresh cases were cultured on Lowenstein-Jensen medium for Mycobacterium tuberculosis. In this study culture positivity was 60.0%. Similar to the present study result Iqbal et al7 found 62.0% culture positive cases in their study. However, Sathekge et al8 found 45.0% culture positive cases in their study. Fite Faraco stain was performed on lymph node sections in all 50 cases. No case was positive for AFB.  Jayalakshmi et al9 found 49.2% AFB positive cases in tissue section. They have performed Fite Faraco stain in several sections. Further analysis of the cases through several sections might have revealed positive cases. Five culture positive cases (41.7%) out of 12 needed treatment for nine months. Bacterial load in culture positive cases might play a role in requiring long duration of treatment.

 Conclusion

In conclusion majority of the histologically confirmed tubercular lymphadenitis patients presents with raised ESR. Furthermore, maximum shows positivity of Mantoux test (MT). Such laboratory findings with lymphadenitis should lead to histological confirmation of tubercular lymphadenitis.

 References

  1. Swaminathan S, Rekha B. Pediatric tuberculosis: global overview and challenges. Clin Infect Dis 2010;50(Supplement 3):S184-94
  2. Kumar V, Abbas AK, Fausto N, Aster JC. In: Robbins and Cotran Pathologic Basis of Disease. Elsevier Health Sciences; 2014 Aug 27
  3. Seth V, Kabra SK, Jain Y, Semwal OP, Mukhopadhyaya S, Jensen RL. Tubercular lymphadenitis: clinical manifestations. Indian J Pediatr 1995;62(5):565-70
  4. Chao SS, Loh KS, Tan KK, Chong SM. Tuberculous and nontuberculous cervical lymphadenitis: a clinical review. Otolaryngology–Head and Neck Surg 2002;126(2):176-9
  5. Raviglione MC, Narain JP, Kochi A. HIV-associated tuberculosis in developing countries: clinical features, diagnosis, and treatment. Bull WHO 1992;70(4):515
  6. Pahwa R, Hedau S, Jain S, Jain N, Arora VM, Kumar N, Das BC. Assessment of possible tuberculous lymphadenopathy by PCR compared to non-molecular methods. J Med Microbiol 2005;54(9):873-8
  7. Iqbal MA, Subhan AN, Aslam AS. Frequency of tuberculosis in cervical lymphadenopathy. J Surg Pakistan 2010;15(2):107-09
  8. Sathekge M, Maes A, D’Asseler Y, Vorster M, Gongxeka H, Van de Wiele C. Tuberculous lymphadenitis: FDG PET and CT findings in responsive and nonresponsive disease. Europ J Nuclear Med Molecul Imag 2012;39(7):1184-90
  9. Fontanilla JM, Barnes A, Von Reyn CF. Current diagnosis and management of peripheral tuberculous lymphadenitis. Clin Infect Dis 2011;53(6):555-62

 

 

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Fine Needle Aspiration Cytology in the Diagnosis of Focal Liver Lesions

Fine Needle Aspiration Cytology in the Diagnosis of Focal Liver Lesions

*Saem AM,1 Saha NK,2 Begum F,3 Hye AA,4 Islam N,5 Anam T6

 Abstract

Fine needle aspiration cytology (FNAC) assisted by cell block examination might be more accurate method for the definitive diagnosis of focal liver lesions (FLL). This study was designed to find out the role of FNAC in the diagnosis of FLLs in comparison to cell block preparations. This cross sectional observational study was carried out in the department of Pathology in collaboration with the department of Radiology & Imaging at Sylhet MAG Osmani Medical College. Study period was from 1 July, 2015 to 30 June, 2016. Clinically & radiologically diagnosed patients of focal liver lesions were study populations. The age of the study patients ranged from 15 to 80 years with a mean of 53.58 years. On FNAC, 10% cases were unsatisfactory, 8% cases were cystic lesion, 4% cases were benign tumor and 78% cases were malignant tumor. Among 39 malignant cases, 30.77% cases were hepatocellular carcinoma (HCC) and 69.23% cases were metastatic adenocarcinoma. Unsatisfactory samples were 18.18%, 6.82% were benign tumors and 75% were malignant tumors. Among the malignant lesions, 18.18% were HCC and 81.82% were metastatic adenocarcinoma. The sensitivity, specificity, positive predictive value (PPV), negative predictive value(NPV) and accuracy of FNAC in the evaluation of FLLs were 100%, 66.67%, 97.06%, 100% and 97.22%, respectively. The sensitivity, specificity, PPV, NPV and accuracy of FNAC in the detection of HCC were 66.67%, 85.18%, 50%, 92% and 81.82% respectively. FNAC of focal liver lesions has high sensitivity and accuracy in the detection of malignancy but it has low sensitivity in the detection of HCC. Cell block preparations were found superior to cytomorphology as immunostaining can be done on cell block preparations.

[Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):110-115]

 Key words: Focal liver lesions, FNAC, Cell block, Immunohistochemistry, HCC, and Metastatic carcinoma.

  1. *Dr. Abu Mohammad Saem, Lecturer, Department of Pathology, Comilla Medical College, Comilla. saemshampa@yahoo.com
  2. Naba Kumar Saha, Professor & Head, Department of Pathology, MAG Osmani Medical College, Sylhet.
  3. Ferdousy Begum, Associate Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.
  4. Azizul Qadar Md. Abdul Hye, Associate Professor Department of Pathology, MAG Osmani Medical College, Sylhet.
  5. Nazmul Islam, Assistant Professor, Department of Pathology, Army Medical College, Comilla.
  6. Tasmina Anam, Scientific Officer, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.

 * For correspondence

 Introduction

A focal liver lesion (FLL) is a solid or cystic mass or area of tissue that is identified by radiological or imaging techniques as an abnormal part of the liver. It may be either a benign lesion such as focal nodular hyperplasia, hepatocellular adenoma and hepatic cyst or a malignant lesion such as hepatocellular carcinoma, cholangiocarcinoma, hepatoblastoma and metastatic carcinoma.1

Pathological examination is an important aspect in the evaluation of an FLL. FNAC is the preferred method for diagnosis of focal liver lesions and needle core biopsy (NCB) for evaluating diffuse liver diseases where architectural details are important.2 In recent years FNAC has emerged as an effective tool for diagnosis of a hepatic mass.

 

Cell blocks prepared from residual materials of fine needle aspirations can be useful adjuncts to smears for establishing a more definitive cytopathological diagnosis.3 Use of cell blocks improves diagnostic accuracy as it facilitates study of architecture details of multiple sections, use of special stains and immunohistochemistry.4

The distinction of moderately to poorly differentiated hepatocellular carcinoma from metastatic carcinoma may be a major problem for cytologists and this distinction is clinically important. Immunohistochemistry is required in this situation to differentiate hepatocellular carcinoma from metastatic carcinoma.5

With this background the study was designed to find out the role of FNAC in the diagnosis of focal liver lesions and to correlate its efficacy with cell block preparations using H&E and immunohistochemistry.

Methods

This cross sectional observational study was carried out in the department of Pathology in collaboration with the department of Radiology & Imaging at Sylhet MAG Osmani Medical College from 1 July, 2015 to 30 June, 2016. Clinically and radiologically diagnosed patients of focal liver lesions attending the department of Radiology & Imaging from different departments during the study period were the target population and those who fulfilled the inclusion and exclusion criteria were considered as study population. Patients of all ages and both sexes were included. Patients with bleeding diathesis, suspected liver abscess, hydatid cyst and hemangioma were excluded from the study. 22 gauge needle was placed in the lesion under ultrasound guidance and the material was aspirated with a 10 ml disposable syringe. After placing aspirates on the slides, thin smears were prepared by gentle friction of two slides. Then smears were fixed in 95% ethyl alcohol for at least 30 minutes and stained with Papanicolaou stain. After preparation of smears, the residual material was secured for clot preparation. It was then transferred into 10% formalin and processed as a cell block.6 Then, the cell blocks were cut at 5 micrometer thickness and were stained with Harri’s Haematoxylin and Eosin stain. From the paraffin block 3 micrometer sections were cut and stained for immunohistochemistry with Glypican-3 antibody. The immunohistochemistry was performed in the Immunohistochemistry Laboratory of Bangabandhu Sheikh Mujib Medical University (BSMMU) following their staining protocol. All the data were organized by using scientific calculator and Statistical Package for Social Science (SPSS) version 23.

 Results

The age of the study patients ranged from 15 to 80 years with a mean of 53.58 years (SD +15.32). Out of 50 cases, 33 (66%) were male and 17 (34%) were female with male to female ratio of 1.94:1. Among these patients, the highest number of patients 13(26%) were in the age group 51-60 years (Table I).

Table I: Age and sex distribution of study cases (n=50)

 

Age Groups (years) Male
No (%)		 Female

No (%)

 Total

No (%)
11-20 2(4) 1(2) 3(6)
21-30 1(2) 0(0) 1(2)
31-40 2(4) 4(8) 6(12)
41-50 9(18) 3(6) 12(24)
51-60 7(14) 6(12) 13(26)
61-70 10(20) 2(4) 12(24)
71-80 2(4) 1(2) 3(6)
Total 33(66) 17(34) 50(100)

 

Out of 50 focal liver lesions, 5 cases were unsatisfactory, 4 cases were cystic lesion, 2 cases were benign tumor and 39 cases were malignant tumor in cytology. Among the malignant cases, 12 were hepatocellular carcinoma (HCC) and 27 were metastatic adenocarcinoma (Figure 1).

 Figure 1. Pie diagram showing distribution of study cases according to FNA cytomorphology

Finally, 8 unsatisfactory, 3 benign and 33 malignant cases were diagnosed in cell block preparations. Among 33 malignant cases 6 were diagnosed as hepatocellular carcinoma (HCC) and 27 were diagnosed as metastatic adenocarcinoma (Figure-2).

 Figure 2. Pie diagram showing distribution of 44 cases according to combined cell block preparations.

 36 cases were conclusive on both cytomorphology and cell block preparations. On evaluation of cytomorphological diagnosis of 36 cases, 33 were true positive diagnosis, 2 were true negative diagnosis, 1 was false positive diagnosis and there was no false negative diagnosis (Table II). Sensitivity, specificity, PPV, NPV and accuracy of FNAC in the diagnosis of malignant focal liver lesions were100%, 66.67%, 97.06 %, 100 % & 97.22 %, respectively.

Table II: Statistical evaluation of cytomorphological diagnosis of 36 conclusive cases.

 

Combined cell block preparations (H&E and IHC) Cytomorphological diagnosis
Disease positive (Malignant) Disease negative(Benign)
Positive(Malignant)   33 TP               33 FP                  1
Negative(Benign)       3 FN                0 TN                  2
Total                         36                    33                        3

 

TP= True positive, TN= True negative, FP= False positive, FN= False negative

33 cases were diagnosed as malignant by both FNAC and cell block preparations. On evaluation of cytomorphological diagnosis, 4 were true positive, 23 were true negative, 4 were false positive and 2 were false negative in the detection of HCC (Table III). Sensitivity, specificity, PPV, NPV and accuracyof FNAC in the detection of HCC were 66.67%, 85.18%, 50%, 92% and 81.82%, respectively.

Table III: Statistical evaluation of cytomorphological diagnosis in the detection of HCC.

 

Combined cell block preparations (H&E and IHC) Cytomorphological diagnosis
Disease positive (HCC) Disease negative

(Non HCC)
Positive (HCC)                   6 TP               4 FP                   4
Negative (Non HCC)        27 FN               2 TN                  23
Total                                 33                     6                        27

 

TP= True positive, TN= True negative, FP= False positive, FN= False negative

Discussion

In the present study, USG guided FNAC was compared with cell block preparations (H&E and immunohistochemistry) in differentiation of focal liver lesions. FNA smears were available in all the 50 cases, but cell blocks were available in 44 cases.

Age of the study patients ranged from 15 to 80 years with a mean of 53.58 years. Nazir et al. (2010) and Kuo et al. (2004) showed 55 and 58.1 years as mean age in their studies which are close to the mean age of present study.7,8 Highest number of patients (26%) was in the age group of 51-60 years in our study. Nazir et al. (2010) reported that maximum number of cases was seen between 55-65 years of age which is nearly similar to present study.7 Out of 50 cases, 33 (66%) were male and 17 (34%) were female with male to female ratio of 1.94:1. Similar findings were reported by Swamy et al. (2011).9 Nazir et al. (2010) showed a male to female ratio of 1.7:1 which is also close to present study.7

Out of 50 cases, 5 (10%) cases were unsatisfactory, 4 (8%) cases were cystic lesion, 2 (4%) cases were benign tumor and 39 (78%) cases were malignant tumor on cytomorphology. Further categorization of benign tumors was not done as in Khurana et al. (2009).6 Among 39 malignant cases, 12 (30.77%) cases were HCC and 27 (69.23%) cases were metastatic carcinoma. All the cases of metastatic carcinoma were adenocarcinomas. Nearly similar findings were found on cytomorphology in the study of Mohmmed et al. (2012), Nazir et al. (2010), Khurana et al. (2009) and Ceyhan et al. (2006).6,7,10,11 Ozkara et al. (2012) found 9.9% of cases as unsatisfactory on cytomorphology which is similar to the unsatisfactory smear (10%) of the present study.12

In final diagnosis of 44 cases by combined cell block preparations (H&E and immunohistochemistry), 8 (18.18%) were unsatisfactory, 3 (6.82%) were benign tumors and 33 (75%) were malignant tumors. Nazir et al. (2010) reported 85% cases as malignant which is nearly close to the malignant cases found in the present study.7 But Mohmmed et al. (2012) showed 39% cases as malignant which is lower and Khurana et al. (2009) showed 93.75% cases as malignant which is higher than that of present study.6,10 Among the malignant lesions, 6 (18.18%) were HCC and 27 (81.82%) were metastatic adenocarcinoma in our study. Khurana et al. (2009) found 17.78% cases as HCC and 82.22% cases as metastatic tumor which are concordant with the present study.6

The sensitivity, specificity, and accuracy of USG guided FNAC in the evaluation of focal liver lesions were 100%, 66.67% and 97.22%, respectively. Sensitivity of the present study (100%) is similar or close to the sensitivity of studies done by Khurana et al. (2009), Nazir et al. (2010), Swamy et al. (2011) and Mohmmed et al. (2012).6,7,9,10 Specificity of the present study (66.67%) has concordance with the specificity found by Mohmmed et al. (2012).10 The specificity shown by Khurana et al. (2009), Nazir et al. (2010) and Swamy et al. (2011) has discordance with that of current study.6,7,9The present study showed an accuracy of 97.22% which is similar to that of Nazir et al. (2010) and Swamy et al. (2011).7,9

The sensitivity, specificity, and accuracy of FNAC in the detection of HCC were 66.67%, 85.18% and 81.82% respectively in our study.  Sensitivity of FNAC in the detection of HCC described by Ozkara et al. (2013) was 68.2% which is similar to the sensitivity of present study.12 Khurana et al. (2009) and Nazir et al. (2010) showed the sensitivity in the detection of HCC as 72.3% and 96% respectively which are higher than the sensitivity of present study.6,7 Specificity and accuracy showed by Nazir et al. (2010) were 100% and 97.5% respectively which are also higher than those of the present study.7

 Conclusion

FNAC of focal liver lesions has high sensitivity and accuracy in the detection of malignancy but it has low sensitivity in the detection of HCC. No significant complication was observed during aspiration. FNAC is a relatively safe, quick, cost effective and patient compliant procedure which has high accuracy in the differentiation between benign and malignant focal liver lesions. Simultaneous cell block preparations can improve the efficacy of FNAC in the subtyping of malignancy.

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