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
  1. 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.

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.

 

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

 

 

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.

 References

  1. Marrero JA, Ahn J, Reddy KR. ACG clinical guideline: The Diagnosis and Management of Focal Liver Lesions. Am J Gastroenterol, 2014; 109(9): 1328-47.
  2. Conrad R, Prabhu SC, Cobb C, Raza A. Cytopathologic diagnosis of liver mass lesions. J Gastrointest Oncol, 2013; 4(1): 53-61.
  3. Nathan NA, Narayan E, Smith MM, Horn MJ. Cell block cytology: Improved Preparation and its Efficacy in Diagnostic Cytology. Am J Clin Pathol, 2000; 114: 599-606.
  4. Ali SR, Jayabackthan L, Rahim S, Sharel MB, Prasad K, Hegdekatte N. Role of fine needle aspiration cytology in the diagnosis of hepatic lesions. Muller J Med Sci Res, 2015; 6(2): 125-128.
  5. Ahuja A, Gupta N, Srinivasan R, Kalra N, Chawla Y, Rajwanshi A. Differentiation of Hepatocellular Carcinoma from Metastatic Carcinoma of the liver – Clinical and Cytological features. J Cytol, 2007; 24(3): 125-129.
  6. Khurana U, Handa U, Mohan H, Sachdev A. Evaluation of Aspiration Cytology of the Liver Space Occupying Lesions by Simultaneous Examination of Smears and Cell Blocks. Diagn Cytopathol, 2009; 37(8): 557-563.
  7. Nazir RT, Sharif MA, Iqbal M, Amin MS.Diagnostic Accuracy of Fine Needle Aspiration Cytology in Hepatic Tumours. J Coll Physicians Surg Pak, 2010; 20(6): 373-376.
  8. Kuo FY, Chen WJ, Lu SN, Wang JH, Eng HL. Fine Needle Aspiration Cytodiagnosis of Liver Tumors. Acta Cytologica, 2004; 48(2): 142-148.
  9. Swamy MCM, Arathi CA, Kodandaswamy CR. Value of ultrasonography-guided fine needle aspiration cytology in the investigative sequence of hepatic lesions with an emphasis on hepatocellular carcinoma. J Cytol, 2011; 28(4): 178-184.
  10. Mohmmed AA, Elsiddig S, Abdullhamid M, Gasim GI, Adam I. Ultrasound- guided fine needle aspiration cytology and cell block in the diagnosis of focal liver lesions at Khartoum Hospital, Sudan. Sudan JMS, 2012; 7(3): 183-187.
  11. Ceyhan K, Kupana SA, Bektas M et al. The diagnostic value of on-site cytopathological evaluation and cell block preparation in fine-needle aspiration cytology of liver masses. Cytopathol, 2006; 17: 267–274.
  12. Ӧzkara SK, Tuneli IӦ. Fine Needle Aspiration Cytopathology of Liver Masses: 101 cases with Cyto-/Histopathological Analysis. Acta Cytologica, 2013; 57:332-336

 

Comparing PAP Smear Cytology with High Risk Human Papilloma Virus DNA Test in Patients of Cervical Lesions

Comparing PAP Smear Cytology with High Risk Human Papilloma Virus DNA Test in Patients of Cervical Lesions

*Ansari NP,1  Rahman AN,2  Saleh AM,3 Shahida SM4

 Abstract

Cervical cancer is the second most frequent type of cancer worldwide. More than eighty eight percent deaths from cervical cancer occur in developing countries. In developed countries, the cases and deaths have declined markedly due to their extensive screening programs. The present study was undertaken to assess precancerous and cancerous cervical lesions by cytology as well as Human Papilloma virus (HPV) DNA identification and their comparison with histopathology in Visual Inspection of Cervix with Acetic Acid (VIA) positive cases. This observational study was carried out at the Department of Pathology in collaboration with the Department of Gynaecology and Obstetrics of Mymensingh Medical College Hospital and Department of Microbiology and Hygiene of Bangladesh Agriculture University for HPV DNA detection during the period of July 2012 to June 2013. Study was carried out among 160 VIA positive patients and selected by non-random judgment sampling from the colposcopy clinic. Out of 160 cases, only 40(25.00%) were found HPV DNA positive, while the rest 120(75.00%) cases were negative. Among positive cases 77.50% were cancerous cases and 22.50% were precancerous cases. It was further revealed that in cancerous cases, 86.11% were HPV DNA positive. PCR showed low sensitivity, probably due to sampling error and inclusion of all cases (chronic cervicitis, precancerous and cancerous lesion). The statistical value of accuracy, sensitivity and specificity of Pap smear cytology, HPV DNA test and histopathology yielded some important directives. The sensitivity values of Pap smear cytology and HPV DNA were found 87.50% and 88.89% respectively.  Thus Pap smear test showed almost equal sensitivity to DNA test. The accuracy of the Pap smears and HPV DNA in this study was 88.13% and 96.88% respectively. The accuracy of Pap smears is lower than HPV DNA tests. The present study showed the significant relationship between cytological with HPV DNA test and histopathological diagnosis. But cytology and HPV DNA testing are not suitable as a single test. In conclusion, it can be stated that combination cytology (Pap smear), histopathology and new technologies such as HPV DNA typing would ultimately be more useful.

[Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):102-109]

 Key words: Pap smear cytology, Human Papilloma virus, Cervical lesions

  1. *Dr. Nazma Parvin Ansari, Assistant Professor of Pathology, Community Based Medical College, Mymensingh. palashansaripath@gmail.com
  2. AJE Nahar Rahman, Honorary Professor, Department of Pathology, BIRDEM, Dhaka.
  3. AFM Saleh, Professor of Pathology, Mymensingh Medical College, Mymensingh.
  4. S M Shahida, Assistant Professor of Gynae & Obs, Dhaka Medical College, Dhaka

 *For correspondence

Introduction

Cervical cancer is the second most frequent type of cancer and the leading cause of mortality among women worldwide.1 According to WHO/ICO Report2 the   incidence rates of cervical cancer in Bangladesh are highest compared to other countries of South Asia and the annual mortality is 11.6 per 1,00,000 women. The report further stated that 50.19 million women are at risk of developing cancer. Each year 17,686 women are diagnosed with cervical cancer and 10,364 die from the disease. It is observed that the cases and deaths have declined markedly in developed countries from approximately 1.4 to 1.7 per 1,00,000 women and this reduction was mainly as a result of extensive screening programs.3,4

 There is worldwide agreement that screening test for cervical cancer is a necessity because it separates healthy persons from those with a high probability of having the disease. The lower incidence in developed countries is due to the access of women to screening test, which allows precancerous lesions to be detected and treated before they develop into full blown cancer.5 Popular screening tests are Papanicolaou (PAP) smear, visual inspection of cervix with acetic acid (VIA) and HPV DNA test. The uptake of screening test in many developing countries is still poor.6,7,8,9  VIA has been introduced by the Government of Bangladesh to screen mass population because it is easy procedure and cost effective. All the government medical college hospitals, district hospitals, maternal and child welfare centers and some of the urban primary health care centers have facilities for VIA test free of cost by the support of UNFPA Bangladesh. Bangabandhu Sheikh Mujib Medical University (BSMMU) is collaborating with Government of Bangladesh in expansion of these facilities.10

At the present time a good deal of attention is being paid to screening for early confirmatory detection of cancer. The present study was undertaken to assess precancerous and cancerous cervical lesion by cytology in VIA positive cases and the relationship between the high risk Human Papilloma viruses.

 Methods

This was a descriptive, cross-sectional type of observational study. The study was carried out in the Department of Pathology, Mymensingh Medical College. Patients of different age groups were selected from colposcopy clinic of Mymensingh Medical College Hospital. Duration of study was one year ranging from July 2012 to June 2013. A total of 160  patients were selected in the mentioned study period with follwing criteria which were (1) VIA positive married married females aged 30-60 years and (ii) who were married for at least 10 years but below 30 years of age. The study excluded patients who were pregnant, below twenty years of age and patient at menstruating period.  PAP smears were collected with Ayer’s spetula and cytobrash by gynaecologists in the colposcopy clinic in the department of Mymensingh Medical College Hospital. Colposcopy guided punch biopsy were taken by same gynecologists from the suspected lesions of the VIA positive cases. Histopathological examination of the biopsy samples were done in the department of Pathology, Mymensingh Medical College. HPV DNA detection by Polymerase Chain Reaction was done from paraffin embedded tissue blocks. HPV type 16, 18, 31 and 52 primers were used.

Results

The study was undertaken to assess the precancerous and cancerous cervical lesion by cytology in VIA positive cases and compare their results with histopathology and high risk Human Papilloma Virus (hr-HPV) DNA test. Table I shows that 36 (22.50%) patients were in 20 to 29 years age group, 72 (45.00%) patients belonged to the age group 30 to 39 years, 37 (23.10%) cases in 40 to 49 years age group and 15 (9.40%)  cases in 50-59 years group.

Table I: Age distribution of the subjects

Age Groups in Year Frequency %
20-29 36 22.5
30-39 72 45
40-49 37 23
50-59 15 9.4
Total 160 100

*Mean () = 38.00 Years; Standard Deviation (SD) = 8.15 Years.

Table II shows the results of Pap smears diagnosis. On cytological examination, 63 (39.40%) cases were diagnosed as Negative for Intraepithelial Lesion or Malignancy (NILM), followed by 5 (3.10%)  cases diagnosed as lesions with  Atypical Squamous Cells of Undetermined Significance (ASCUS) and  other 5 (3.10%) cases were found Atypical Squamous Cell  that cannot exclude HSIL (ASC- H), 40 (25.00%)  patients with Low Grade Squamous Intraepithelial Lesions (LSIL); 17 (10.60%) patients with high grade squamous intraepithelial lesion (HSIL)and 30 (18.75%)  patients  were diagnosed as Squamous Cell carcinoma (SCC).

Table II: Cytological (Pap smear) diagnosis of cervical lesions

Serial no. Pap smear test

result

Frequency %
1 NILM 63 39.40
2 ASCUS 05 3.10
3 ASC-H 05 3.10
4 LSIL 40 25.00
5 HSIL 17 10.60
6 Squamous Cell Carcinoma 30 18.75
Total 160        100.00

NILM = Negative for Intraepithelial Lesion or Malignancy, ASCUS = Atypical Squamous cells with Undetermined Significance, LSIL = Lowgrade Squamous Intraepithelial Lesion, HSIL = High grade Squamous Intraepithelial Lesion, ASC-H = Atypical Squamous Cell  that cannot exclude HSIL

The histopathological result of 160 cases is presented in Table III. It was revealed that 56 (35.0%) cases had chronic cervicitis, 51 (31.9%) cases  mild dysplasia (CIN-I), 14 (8.8%)  cases diagnosed as  moderate dysplasia (CIN II), 3 (1.9%) patients were severe dysplasia / CIN III and the remaining 36 (22.5%)  cases show invasive squamous cell carcinoma (SCC).

 Table III: Histological diagnosis of patients with cervical lesions

SL. no. Histological

Diagnosis

 Frequency %

 

1 Chronic Cervicitis 56 35.00
2 CIN – I 51 31.90
3 CIN II 14 8.80
4 CIN III  3 1.90
5 Squamous cell carcinoma 36 22.50
Total 160 100

 

CIN = Cervical Intraepithelial Neoplasia

Table IV shows that on histological examination of 160 cases, a total of 56 (35.00%) cases were found with chronic cervicitis, among them 50 (79.37%) cases were correctly diagnosed previously cytologically as negative for intraepithelial lesion. Out of 51 (31.9%) diagnosed CIN I cases, 34 (85.0%) cases were diagnosed  cytologically as LSIL. Out of 14  (8.8%) cases diagnosed as CIN II, 10 (58.82%) cases were diagnosed cytologically HSIL. Out of 3 (1.90%) cases of histologically diagnosed  CIN III, 2 (11.76%) cases were diagnosed cytologically as HSIL. The 30 cases were diagnosed cytologically as carcinoma and those cases were histologically confirmed as squamous cell carcinoma. There is highly significant relationship in respect to cytological (PAP smear) and histological diagnoses of cervical lesions in the study group (P<0.005).

Table IV: Comparison of Cytological (PAP smear) and histological diagnoses of cervical lesions

 

Frequency in PAP  smear diagnosis Frequency in histological diagnosis
Pap smear

Test

Frequency Chronic Cervicitis CIN I CIN II CIN III Squamous cell carcinoma
NILM 63 50(79.37) 13(20.63) 00 00 00
ASCUS 05 00 3(60.00) 2(40.00) 00 00
ASCH 05 00 00 2 (40.00) 1(20.00) 2 (40.00)
LSIL 40 6 (15.00) 34 (85.00) 00 00 00
HSIL 17 00 1 (5.89) 10 (58.82) 2 (11.76) 4 (23.52)
Squamous cell carcinoma 30 00 00 00 00 30 (100.00)
Total 160 56 51 14 03 36

NILM = Negative for Intraepithelial Lesion or Malignancy, ASCUS = Atypical Squamous cells with Undetermined Significance, LSIL = Lowgrade Squamous Intraepithelial Lesion, HSIL = High grade Squamous Intraepithelial Lesion, ASC-H = Atypical Squamous Cell  that cannot exclude HSIL

*Figures within parentheses indicate percentage

 The HPV DNA test of cervical lesions was conducted on all 160 cases. The result is shown table V. Out of 160 cases, only 40 (25%) cases were positive and the rest 120 (75%) cases were negative for HPV DNA.

Table V: Diagnosis of cervical Lesions by HPV DNA test (PCR)

HPV DNA test Frequency %
Positive 40 25
Negative 120 75
Total 160 100

Table VI gives a correspondence result of Histological Diagnosis with Pap smear and HPV DNA test. It was remarkable that out of 36 squamous cell carcinoma cases 31 patients were detected by HPV DNA test. The result further indicates that the cytological diagnosis nearer to the histological findings in almost all cases under this study and in case of high grade lesion and carcinoma it was almost close to positive reaction to HPV DNA test.

Table VI. Correspondence of histological diagnosis with PAP smear and HPV DNA test

 

Histological

diagnosis

Frequency Frequency of Pap Smear diagnosis N0. of patients

positive to HPV DNA test

NILM ASCUS ASCH LSIL HSIL Squamous cell carcinoma Positive Negative
Chronic

cervicitis

56 50 06 00  56
CIN – I 51 33 03 00 34 01 00 02  49
CIN – II 14 02 02 10 05  09
CIN – III 03 00 01 00 02 02  01
Squamous cell carcinoma

 

36 02 04 30 31  05
Total 160 63 05 05 40 17 30 40 120

 

NILM = Negative for Intraepithelial Lesion or Malignancy, ASCUS = Atypical Squamous cells with Undetermined Significance, LSIL = Lowgrade Squamous Intraepithelial Lesion, HSIL = High grade Squamous Intraepithelial Lesion, ASC-H = Atypical Squamous Cell  that cannot exclude HSIL

The result illustrates that the sensitivity value of this test is almost equal to both Pap test and HPV DNA test, those were found 87.50% and 88.89% respectively. In case of specificity value the Pap test yielded 89.29% and HPV DNA tests yielded higher value, 100%.

Table   VII: Comparison of statistical analysis of PAP smear and HPV DNA test

 

Statistical value Pap smear

Cytology in %

HPV DNA test in %
Sensitivity 87.50   88.89
Specificity 89.29 100.00
Accuracy 88.13   96.88
Predictive value of a

positive test

93.81 100.00

 

Predictive value of a

negative test

79.37  95.83

 HPV DNA revealed that, HPV – 16 were present in the highest percent (75%), HPV-18 were in 15% and the lowest number of occurrences were HPV – 31 type in 5% and HPV – 52 type in 5 %.

 Discussion

The present study focused on traditional Pap smear method and HPV DNA type identification for cervical screening and their comparison with colposcopic biopsy. In this study, 160 VIA positive women were selected. Pap smear cytology, histopathological examination and HPV DNA test were done in every cases. On cytological (Pap Smears) examination it was revealed  that 63 (39.4%) cases were diagnosed as Negative for Intraepithelial Lesion or malignancy (NILM), 5 (3.10%) cases were diagnosed as Atypical Squamous Cell of Undetermined Significance (ASCUS) and 5 (3.10%)  cases were Atypical Squamous Cell  cannot exclude HSIL (ASC- H), 40 (25%)  patients with Low Grade Squamous Intraepithelial Lesions (LSIL); 17 (10.6%) patients with high grade squamous intraepithelial lesion (HSIL) and 30 (18.75%) cases were diagnosed as Squamous Cell carcinoma (SCC). A study on patients attending the OPD of BSMMU showed much lower incidence in Pap smear. The percentages of SCC, LSIL and NILM were 0.2%, 4.20% and 91.70% respectively. The lower incidence may be due to incorporation of normal cases in BSMMU study.11

The result of histopathological examinations of 160 cases revealed 56 (35%)  cases of chronic cervicitis, 51 (31.9%) cases of mild dysplasia (CIN-I), 14 (8.8%)  cases of moderate dysplasia (CIN II), 3 (1.9%) patients of severe dysplasia (CIN III) and the remaining 36(22.5%)  cases as invasive squamous cell carcinoma (SCC). Among cytologically diagnosed 30 (18.75%) squamous cell carcinoma cases all were confirmed histologically as squamous cell carcinoma. Highly significant relationship was found with cytological (Pap smear) and histological diagnoses of cervical lesions in this study group (p<0.005).

A study was performed in BSMMU on 70 histologically diagnosed cases of CIN. Out of 70 cases, 34 (48.6%) cases were CIN-I and 36 (50.4%) cases were CIN-II/III.12  Another study  from Brazil reported the percentage of CIN-I, CIN-II and squamous cell carcinoma to be 12.0%, 4.3% and 1.0% respectively13. The higher percentage of the present study reflects the inclusion of VIA positive cases only. In Bangladesh a cross sectional study was found and the above occurrences as 21.4%, 10.0% and 29.0% respectively.14

Therefore, out of 160 cases 91(56.88%) cases were correctly diagnosed by cytology, 13 (8.13%) cases were false negative, 6 (3.75%) cases were false positive and 50 (31.25) cases were negative for precancerous and cancerous lesions. There is a significant correlation between Pap smear and Histological findings. Others studies similarly found a significant concordance between Pap smear and histological tests for the diagnosis of precancerous cervical lesions.15,14,16

The result of the HPV DNA detection conducted on all 160 cases. Out of 160 cases, only 40 (25.00 %) were found positive and the rest 120 (75.00%) cases were negative. Present study shows that 86.11% positive in cancerous lesions. The technology can find the HPV DNA in almost 100.0% of the invasive cervical cancer cases, 75.00-100.00% of precancerous lesions and 50.00% of borderline lesions’ samples.17,18

.Comparison between HPV DNA test and Pap smear diagnosis represents none of the NILM and ASCUS positive cases exhibited positive reaction to PCR. Among 5(3.10%) ASCH cases 02(40.0%) were PCR positive. Out of 40(25.0%) LSIL cases only 2(5.00%) cases were detected positive. The detection of HSIL cases were found to 11(64.7%) cases out of 17(10.6%) cases. The Squamous cell carcinoma patient’s show out of 30(18.75%) cases 25 (83.33%) cases were positively detected by PCR. The present study indicated that Pap smear cytology is still better than only HPV DNA test for the diagnosis of chronic cervicitis, LSIL, HSIL.

However, a study, comparing the histological diagnosis and it was revealed that none of the chronic cervicitis cases exhibit positive for PCR test.19 Present study also revealed that none of the chronic cervicitis cases show positivity to PCR detection.

 The present study has shown that the occurrence of different types of HPV virus be responsible for the causation of cervical cancer. These are detected in samples of patients of cervical lesions. HPV DNA revealed that, HPV – 16 were present in the highest percent (75.00%), HPV-18 were 15.00% and the lowest number of occurrences were HPV – 31 type 5.00 % and HPV – 52 type 5.00 %.

The accuracy of the Pap smears and HPV DNA in this study show to 88.13% and 96.88% respectively. This demonstrates that the accuracy of Pap smears is lower in respect to HPV DNA tests. The accuracy thus determines that the probability of correct diagnosis could be detected by the later tests singly or combined.  Specificity  in case of Pap smear test is 89.29 and in case case of HPV DNA 100.0%. This means that specificity is higher in DNA test. The sensitivity values of Pap smear cytology and HPV DNA were found 87.5% and 88.89%   respectively. The sensitivity value focuses on the ability of a test to correctly diagnose the disease. In this case the cytological diagnostic test is almost equal to DNA test.

 Conclusion

It can be concluded that HPV DNA test is not suitable as a single test for detecting precancerous and cancerous lesion than routine Pap smear test. All the cytologically diagnosed NILM (negative for intraepithelial lesion or malignancy) cases and all histologically diagnosed chronic cervicitis cases were HPV DNA test negative. So, mass screening programme does not need HPV DNA test. This will reduce the cost of the screening programme. Combination of cytology (Pap smear) and new technologies such as HPV DNA test would ultimately be more useful. Based on findings, the study recommended that, PAP test should be routinely used in every patient attending the colposcopy clinic, biopsy should be taken in all VIA positive patient and combined pap test and histopathological examination is enough to detect cervical precancerous and cancerous lesion. In our country HPV DNA test is not mandatory as a routine test.

 References

  1. Parkin DM. The global burden of infection-associated cancers in the year 2002. Int. J. Cancer, 2006; 118:3030-44.
  2. WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre), 2010. Human Papilloma virus and related cancers in Bangladesh. Summary Report [accessed: 10-03-2013]; available at www.who.int/hpvcentre.
  3. Carter JR, Ding Z and Rose BR. 2011 HPV infection and cervical disease: A review. Australian and New Zealand Journal of Obstetrics and Gynaecology, 51: 103- 108.
  4. Tomljenovic L, Shaw CA, Spinosa JP. Human Papillomavirus (HPV), Vaccines as an option for Preventing cervical malignancies; How effective and safe? Current Pharmacological Design, 2013; 19:1-2.
  5. Crum PC. The Female Genital Tract’ in Robbins and Cotran Pathologic Basis of Diseases. 7th edition Kumar V, Abbas AK and Fausto N (eds) Elsevier Saunders, Philadelphia, 2004; Pp1049-1053.
  6. Goldie SJ, Kuhn L Denny L, Pollack A, Wright TC. Policy Analysis of Cervical Cancer Screening Strategies in Low-Resource Settings: Clinical Benefits and Cost-effectiveness. JAMA 2001; 285:3107-15.
  7. ACCP (Alliance for Cervical Cancer Prevention) 2004. Planning and implementing cervical cancer prevention and control programs. A manual for managers. ACCP, Seattle.
  8. Ngoma T, 2006. World Health Organization cancer priorities in developing countries. Ann. Oncol. 17, Suppl 8, viii9-viii14.
  9. Sangwa-Lugoma G, Mahmud S, Nasr SH, Liars J, Kayembe PK, Tozin RR, Drouin P, Lorincz A, Ferenczy A, Franco EL. Visual inspection as a cervical cancer screening method in a primary health care setting in Africa. Int. J. Cancer, 2006; 119:1389-95.
  10. Tahera A, Ashrafunnessa, Jebunnessa R. Development of a visual inspection programme for cervical cancer prevention in Bangladesh. Reproductive Health Matters. 2008; 16(32):78-85.
  11. Ashrafunnesa, Khatun S, Shamsuddin L, Rahman AJ, Kamal, Kabir S etal. Cervical dysplasia among the women attending gynaecological outpatient department of a teaching hospital. Bangladesh Journal of Medical Science, 2002; 8(1):39-41.
  12. Ashrafunnesa, Khatun S, Haq F, Islam MN, Hossain MS, Aziz MM et al. 2006.Human Papilloma virus in cervical cancer in Bangladesh. Bangladesh J Obster Gynecol, 2006; 21(2):51-57.
  13. Syrjänen K, Naud P, Derchain S, Roteli-Martins C, Longatto-Filho A, Tatti S et al. Comparing Pap smear Cytology. Aided Visual Inspection, Screening colposcopy, cervicography and HPV testing as optional screening tools in Latin America. Study design and Baseline Data of the LAMS study. Anticancer research, 2005; 25: 3469-3480.
  14. Israt T. Study on HPV DNA test and conventional PAP test for identification of cervical intraepithelial lesions and cancer. MD thesis, Dept. of Pathology,2006; Bangabandhu Sheikh Mujib Medical University, Dhaka.
  15. Islam, Shamina. Relation of Human Papilloma Virus (HPV) load with cervical precancerous and cancerous lesions. MD thesis Department of Pathology,2013; Bangabandhu Sheikh Mujib Medical University, Dhaka.
  16. Xu Y, Dotto J, Hui Y, Lawton K, Schofield K, and Hui P, 2009. Grade cervical Intraepithelial Neoplasia and Viral load High risk Human Papilloma virus. Significant correlations in patients of 22 years old or younger Int. J. Clin. Exp.Path, 2009; 12:169-175.
  17. Zhao FH, Lewkowitz AK, Chen F, Lin MJ, HU, SY. Pooled analysis of a Self-sampling HPV DNA test as a Cervical Cancer Primary Screening Method. J. Natl Cancer Inst. 104:1-11 gynecol, 2012; 21(2):51-57.
  18. Castle PE, Solomon D, Wheeler CM, Gravitt PE, Watchholder S and Schiffman M. 2008. Human pailloma genotype Specificity of Hybrid capture-2 J Clin Microbiol, 2008;46 (8):2595.
  19. Schiffman M, Wentzensen N. From human papillomavirus to cervical cancer. Obstetrics & Gynecology, 2010; 116(1):177–185.

 

 

Correlation of Proliferation Index and Microvessel Density in Glial Tumors with WHO Tumor Grades

Correlation of Proliferation Index and Microvessel Density in Glial Tumors with WHO Tumor Grades

 *Begum A,¹ Kamal M²

Abstract

This study was carried out to find the association of proliferative index (PI) and microvessel density (MVD) in different histo-morphological grades of glial tumor according to WHO criteria. Paraffin embedded tissue blocks of 42 patients with glial tumors were included in this study. Ki-67 and CD 34 immunostaining were done in all cases and was compared with the WHO grade. Proliferation indix was detected by Ki-67 immunostaining and micro vessel densitywas detected by CD 34 immunostaining in glial tumors. Glial tumor was common in 3rd decade with male predominance. Most common location of glial tumor was frontal lobe 19.0%. Anaplastic astrocytoma (WHO grade III) in 21.4% cases and glioblastoma multiforme (WHO grade IV) in 21.4% cases was diagnosed commonly. Glioblastoma multiforme (WHO grade IV) had mean proliferative index 24.3±8.7%, anaplastic astrocytoma (WHO grade III) had 25.1±12.4%, diffuse fibrillary astrocytoma, (WHO grade II) 4.5±3.7% and pilocytic astrocytoma (WHO grade I) had 2±0.8%. The mean proliferative index difference was statistically significant (p<0.05) in different WHO grades. Glioblastoma multiforme (WHO grade IV) had mean MVD 100.11±46.62, anaplastic astrocytoma (WHO grade III) had 57.13±20.14, diffuse fibrillary astrocytoma (grade II) had 32.0±12.01 and pilocytic astrocytoma (WHO grade I) had 47.75±19.91. The microvessel density difference was statistically significant (p<0.05) in different WHO grades. A weak positive correlation was found between proliferative index and microvessel density in the 42 patients of glial tumors. Patients of low grade glial tumor with increased proliferative index and microvascular proliferation are at risk of progressing to higher grade tumor.

[Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):91-101]

Key words: Glial tumors, Tumor grades, Proliferation index, Ki-67 Labeling index, CD34, Microvessel density (MVD)

 

  1. *Dr. Afroza Begum, Assistant Professor of Pathology, Anwer Khan Modern Medical College and Hospital, Dhaka. afroza.mithila@gmail.com
  2. Mohammed Kamal, Professor, Department of Pathology, Bangabondhu Sheikh Mujib Medical University, Dhaka.

 

*For correspondence

 

Introduction

Glial tissue neoplasm is the most common intracranial tumors. Worldwide incidence of primary brain tumors is approximately seven per 100,000 individuals per year, accounting for 2% of all primary tumors1 40% of all primary Central Nervous System (CNS) tumors are Gliomas. 75% of which are Astrocytomas. Ependymomas, oligodendrogliomas and other subtypes includes the rest 25 %.2  Pathologic diagnosis of gliomas depends on established histopathologic criteria after examination of hematoxylin and eosin (H&E) stained slides of sampled tissue and grading on the basis of cellularity, nuclear atypia, mitotic activity, pseudopalisading necrosis and/or microvascular proliferation according to WHO classification of CNS neoplasms.3

Prognosis depends on several factors like age, preoperative status, extent of resection, and histopathological WHO grades along with mitotic count and necrosis in glial tumor. Prediction of clinical outcome in individual patient on the basis of grade alone is impossible as same tumor grade may behave differently. A continuous search for auxillary diagnostic and prognostic markers resulted for this limitation. Increased proliferative activity of tumor cells and micro vascular proliferation in tumor are associated with more aggressive tumor behavior and immunohistochemical techniques have been employed to quantitatively assess proliferative activity and micro vessel density in tumor tissue. The most reliable method to assess cell proliferation in gliomas is the antibody against Ki-67 antigen. The MIB-1 antibody identify a non-histone nuclear matrix protein associated antigen Ki-67 present in the nuclei of cells in the G1, S, G2 and M phases of the cell cycle, but is not expressed in the resting  G0 phase.4

Proliferation indices less than 1.5% were associated with longer survival and higher then 1.5% had shorter survivals. Proliferation index was particularly useful in WHO grade II and III tumors, as it identifies aggressiveness.5   However, a significant positive correlation between Ki-67 indices and histologic grade have demonstrated in many investigations and observed higher Ki-67 proliferation indices associated with shorter survivals. So, both the WHO grade and proliferation index have prognostic predictive value.4

CD 34 is used as an endothelial cell marker in order to study vascular proliferation in glial tumor; specially astrocytomas.6 Microvascular density is a measure of microvascular proliferation, which is also an independent prognostic factor for adult glioma.7  Angiogenesis is rate limiting for tumor growth, and therefore a rational therapeutic target.1.

The association of PI and MVD with different WHO grade of glial tumors has not been studied till now in Bangladesh. Results of studies by various authors in different countries show proliferation index and MVD correlate with different WHO grades of glial tumors and also in some cases, can predict progression of tumor from lower grade to higher grades. The aim of this study was to investigate the association of proliferative index measured with Ki-67 and microvessel density measured by CD34 with different histo-morphological grades of glial tumor according to WHO.

 Methods

Paraffin embedded tissue blocks of primary brain tumor diagnosed at the department of Pathology, BSMMU and other private pathology of Dhaka city were collected from the archive from the year 2012 to 2013. Forty two cases were selected for the study. Clinically suspected glial tumor but subsequently proved to be non-neoplastic conditions like demyelinating disease or reactive gliosis on histological examination, any CNS tumor other than glial tumor or metastatic tumor to CNS and samples without clinical data were excluded.

 Collection of clinical information

Detailed clinical information was obtained by taking history recorded in clinical proforma of departmental archives. Filling up of the clinical proforma was performed in all cases.

 Sectioning and staining of paraffin embedded tissue blocks for routine histopathological examination: The sections  were  cut and  stained  with  haematoxylin  and  eosin (H&E) staining method by using auto-stainer (Varistain 24-4 Automatic Slide Stainer, Thermo  Scientific,  USA) following  standard  protocol.  PAS staining of the slides were done according to the standard protocol followed at BSMMU and was used for the detection of three hot spots (area showing maximum vascularity) in the tissue sections. Slides of all cases were examined in light microscope after mounting in DPX.

 Methods used for immunohistochemistry (IHC)

For  IHC  stain,  2-3  µm  thick  tissue  sections  were  taken  from  the  paraffin  blocks  on coated  slide  (DAKO,  codeK8020). DAKO EnVision™+/HRP (Horseradish peroxidase) system which is based on advance Labeled Streptavidin-biotin (LSAB) method was used for visualizing the section. These methods were carried out manually.

 Scoring of Ki-67

It is done by the percentage of tumor cell nuclei allowing Ki-67 staining per total of 1000 neoplastic cells. One thousand tumor cells were counted in several areas of tissue where positively stained nuclei were evenly distributed. But in those cases with uneven distribution of positive nuclei, the tumor cells were counted in the areas with highest density of positive nuclei by visual analysis.8  In this study, 500 neoplastic cells were calculated and percentages of Ki-67 stained neoplastic cells were determined. Usually proliferative index of glial tumor with WHO grade-I has 0 to 3.9%, WHO grade-II has up to 4%, WHO grade-III has 5 to 10% and WHO grade-IV has 15 to 20% (WHO classification of tumors of the CNS, IARC, Lyon, 2007).

 MVD calculation

Brown staining of cytoplasm of endothelial cells with CD 34 was considered positive reaction. MVD were calculated according to Weidner’s method. At first the sections were scanned at low power (X10) looking for hot spots. Hot spot is an area with the most dense vessels growth. Only hot spots close to the tumor cell clusters in viable areas (non-necrotic and non-sclerotic areas) were included. When the hot spots were defined, microvessel count (MVC) was performed by counting the individual stained microvessels (at power X20) representing a field size of 0.74mm² (20X objective, 10X ocular; equivalent to 0.7386 mm² per 200X field.9 First three hot spots were chosen. In each hot spot, MVC was performed at power X20. Finally MVD was calculated as the mean of the total number of microvessels in these three hot spots.

 Statistical analysis

Statistical analyses of the results were obtained by windows based computer software devised with Statistical Packages for Social sciences (SPSS-17). The qualitative data were presented as numbers and percentages while the quantitative data were presented as mean, standard deviations and ranges. The results were calculated by using statistical formulae Chi-square test and and Fisher exact test was used only when the expected count in any cell found less than 5. Also the comparison between two groups with quantitative data was done by using Independent t-test and the comparison between three groups with quantitative data was done by using One Way ANOVA. Pearson correlation coefficient was used to assess the relations between the studied parameters.

 Results

The mean age was found 35.38±17.55 years with range from 4 to 82 years, highest occurrences observed in 3rd decade (31.0%) and almost three fourths 31 (73.8%) patients were male. Male female ratio was 2.8:1. Frequent site of involvement were frontal lobe 8 (19.0%) cases, parietal lobe 6 (14.3%) cases and temporal lobe 6 (14.3%) cases. (Table I)

 

Table I: Age, sex and tumor location in study cases

 

Clinical Variables Results
Age in years  
Mean±SD 35.38±17.55
Range (min-max) 4-82
Gender N (%)
Male 31(73.8 %)
Female 11(26.2 %)
Location of tumors  
Frontal lobe 8(19.0 %)
Parietal lobe 6(14.3 %)
Temporal lobe 6(14.3 %)
Temporoparietal lobe 4(9.5 %)
Frontoparietal lobe 2(4.8 %)
Frontotemporal lobe 2(4.8 %)
Parieto-occipital lobe 2(4.8 %)
Cerebral 4(9.5 %)
Spinal 2(4.8 %)
Ventricle 2(4.8 %)
Corpus callosum 1(2.4 %)
Cerebellum 1(2.4 %)
Posterior fossa 2(4.8 %)

 

9 (21.4%) patient had anaplastic astrocytoma, WHO grade III and glioblastoma multiforme WHO grade IV respectively and 6 (14.3%) cases had diffuse fibrillary astrocytoma WHO grade II. According to WHO grading majority 17 (40.7%) patients had grade II lesion followed by 12 (28.6%) had grade III lesion, 9 (21.4%) had grade IV lesion and 4 (9.5%) had grade I lesion. Anaplastic astrocytoma, WHO grade III had mean mitotic count 6.56±2.3 /10HPF ranging from 4 to 11 /10HPF. The glioblastoma multiforme WHO grade IV had mean mitotic count 8.11±2.76 /10HPF ranging from 5 to 12 /10HPF. Other results are depicted in this table. The mean difference was statistically significant (p<0.05). The findings are shown in table II.

 

All (100.0%) patients with glioblastoma multiforme WHO grade IV had necrosis and necrosis was not found in the remaining cases. Four patients had pilocytic astrocytoma WHO grade I among them 3(17.6%) had mild and 1(10.0%) had moderate nuclear pleomorphism. Nine patients had anaplastic astrocytoma, WHO grade III among them 1(5.9%) had mild, 5(50.0%) had moderate and 3(21.4%) had marked nuclear pleomorphism. Nine patients had glioblastoma multiforme WHO grade IV among them 2(20.0%) had moderate and 7(50.0%) had marked nuclear pleomorphism. Other results are depicted in this table VI. The difference was statistically significant (p<0.05) between three groups (Table: II).

Table II: Histopathological findings in different glial tumors of different grades

Histopathological Diagnosis WHO grades N (%) Nuclear pleomorphism Cellularity
(No. of cells/ HPF)
Mitoses/

10HPF

Mild
(n=18)
Moderate
(n=10)
Marked
(n=14)
N (%) N (%) N (%) Mean±SD Mean±SD
Pilocytic astrocytoma I 4(9.5) 3(17.6) 1(10.0) 0(%) 159.5±75.2 1.67±0.58
Diffuse fibrillary astrocytoma II 6(14.3) 5(29.4) 0(0.0) 1(7.1) 325.2±102.14 2.17±0.75
Ependymoma 5(11.9) 5(29.4) 0(0.0) 0(0.0) 249.0±97.58 2.80±1.10
Gemistocytic astrocytoma 2(4.8) 1(5.9) 0(0.0) 1(7.1) 234.5±31.82 6.0±1.41
Oligoastrocytoma 2(4.8) 2(11.8) 0(0.0) 0(0.0) 188.3±104.07 2.50±0.71
Oligodendroglioma 2(4.8) 1(5.9) 1(10.0) 0(0.0) 182.0±25.46 2.00±1.41
Anaplastic astrocytoma III 9(21.4) 1(5.9) 5(50.0) 3(21.4) 602.67±44.06 6.56±2.30
Anaplastic ependymoma 3(7.1) 0(0.0) 1(10.0) 2(14.3) 385.11±167.27 6.00±2.00
Glioblastoma multiforme IV 9(21.4) 0(0.0) 2(20.0) 7(50.0) 503.89±130.92 8.11±2.76
P     0.003s 0.001s 0.001s

Anaplastic astrocytoma WHO grade III had mean proliferative index 25.1±12.4% ranging from 8.8% to 40% (fig 1 and 2). The glioblastoma multiforme WHO grade IV had mean proliferative index 24.3±8.7% ranging from 15% to 40%. The gemistocytic astrocytoma WHO grade II had mean proliferative index 10.8±10.3% ranging from 3.5% to 18%. The anaplastic ependymoma WHO grade III had mean proliferative index 18.0±7.6% ranging from 10% to 25%. The mean difference was statistically significant (p<0.05).

Anaplastic astrocytoma WHO grade III had mean MVD 57.13±20.14 ranging from 35 to 87. The glioblastoma multiforme WHO grade IV had mean MVD 100.11±46.62 ranging from 38 to 197 (fig 3 and 4). The oligoastrocytoma WHO grade II had mean MVD 110.5±68.59 ranging from 62 to 159. The mean difference was statistically significant (p<0.05) (Table III).

A positive correlation was found between proliferative index and microvessel density. The value of Spearmen’s correlation coefficient was 0.244 and it is not significant (p=0.119). Therefore, there was a weak association between proliferative index and microvessel density in the study population but not statistically significant (fig 5).

Table III: Proliferative index with histological diagnosis and WHO grades of different glial tumors

 

Histopathological Diagnosis WHO grades N (%) Proliferative index, Ki67 (%) Microvessel density,CD34
Mean±SD Mean±SD
Pilocytic astrocytoma I 4(9.5) 2.0±0.8 47.75±19.91
Diffuse fibrillary astrocytoma II 6(14.3) 4.5±3.7 32.0±12.01
Ependymoma 5(11.9) 3.0±3.1 41.0±19.58
Gemistocytic astrocytoma 2(4.8) 10.8±10.3 32.0±18.38
Oligoastrocytoma 2(4.8) 1.6±0.6 110.5±68.59
Oligodendroglioma 2(4.8) 1.0±0.0 52.0±5.66
Anaplastic astrocytoma III 9(21.4) 25.1±12.4 57.13±20.14
Anaplastic ependymoma 3(7.1) 18.0±7.6 51.0±25.94
Glioblastoma multiforme IV 9(21.4) 24.3±8.7 100.11±46.62
P-value     0.001s 0.002s

 

 

 

 

 

 

 

 

Fig 1. Photomicrograph of a diffuse fibrillary astrocytoma, WHO grade II (Ki67 immunosatin, x220)

 

 

 

 

 

 

 

 

 

Fig 2. Photomicrograph of  anaplastic astrocytoma WHO grade-III.  Many Ki67 positive cells are present (Ki-67 immunostain, x220)

 

 

 

 

 

 

 

 

Fig 3.  Photomicrograph of a diffuse fibrillary astrocytoma WHO grade-II (CD34  immunostain x210)

 

 

 

 

 

 

 

 

Fig 4. Photomicrograph shows glioblastoma multiformi WHO grade-IV (CD34 immuno stain, x210)

 

 

 

 

 

Fig 5. Scatter diagram showing Spearmen’s positive correlation (r=0.244; p=0.119) between proliferative index and microvessel density

Discussion

In this series it was observed that most of the patients (31.0%) having glial tumors were in the 3rd decade and their mean age was 35.38±17.55 years with age range from 4 to 82 years. Similarly, Chaloob et al.6 and Arshad et al.10 showed the mean age of the glial tumor patients was 35.98 years (age range 2-68 years) and 35 years (age range 5 – 67 years) respectively. Regarding the sex distribution of glial tumors, a number of investigators reported predominance of male. Gender distribution of astrocytoma cases showed slight male preponderance with 53.0% cases compared to female with 47.0% cases obtained by Chaloob et al.6  In another study Arshad et al.10 observed 70.0% and 30.0% were male and female respectively. Similarly, in this study almost three fourths (73.8%) of the patients were male and 26.2% were female. Male female ratio was 2.8:1, which is consistent with the study by Giannini et al.11 study, where they found male 61.6% and female 38.4% with a male to female ratio was 1.6:1.

 

The most common location of tumor of the patients in the present study was frontal lobe (19.0%) followed by parietal lobe (14.3%), temporal lobe (14.3%) and the temporoparietal and cerebral lobe (9.5%). Chaloob et al found that 33.3% cases were frontal, 31.4% cerebellar, 25.5% parietal and 9.8% temporal lobe.6

In case of WHO grades of glial tumors it was observed in this present series, most 9 (21.4%) patients had anaplastic astrocytoma, (WHO grade III) and glioblastoma multiforme (WHO grade IV) respectively and 6 (14.3%) patient had diffuse fibrillary astrocytoma (WHO grade II) and 4 (9.5%) patient had pilocytic astrocytoma (WHO grade I). Chaloob et al.6 found that 13.2% cases were pilocytic astrocytomas (WHO grade I), 43.1% cases were diffuse fibrillary astrocytomas (WHO grade II), 11.8% cases were anaplastic astrocytomas (WHO grade III) and 31.4% cases were glioblastomas (WHO grade IV), unlike the current study.

 The association between cellularity and WHO grades of glial tumor were also assessed in the present study. The mean cellularity was 503.89±130.92 cells/HPF ranging from 208 to 618 cells/HPF in glioblastoma multiforme (WHO grade IV). In anaplastic astrocytoma (WHO grade III), mean cellularity was 385.11±167.27 cells/HPF ranging from 189 to 600 cells/HPF. In ependymoma (WHO grade II), mean cellularity 325.2±102.14 cells/HPF ranging from 200 to 478 cells/HPF and in pilocytic astrocytoma (WHO grade I) 159.5±75.2 cells/HPF ranging from 100 to 268 cells/HPF. In this study there is a trend of little increasing of cellularity with WHO grades and the mean difference of cellularity significantly (p<0.05) differ with different WHO grades. Schiffer et al.12 stated that after multivariate analysis on the histologic parameters, cell density was more significant than number of mitoses. Cell density is categorized as follows: low (<400 cells X high-power field (HPF); medium (400 to 800 cells X HPF); or high (>800 cells nuclei in the most cellular regions of the section. In this study maximum value of cellularity is 648/HPF found in anaplastic ependymoma which is greater than GBM WHO grade-IV. Size of the specimen, representative biopsy and presence or absence of necrosis may affect the cellular density in various grades of glial tumors.

Nuclear pleomorphism alone is considered as an important factor for the recognition of malignancy.13  However, Schiffer et al.12 suggested caution because pleomorphic nuclei can be found in well-differentiated astrocytoma. It was observed in the present study that the association was significant. The current study found four patients had pilocytic astrocytoma, WHO grade I. Among them three (17.6%) had mild and one (10.0%) had moderate nuclear pleomorphism. Nine patients had anaplastic astrocytoma, WHO grade III. Among them one (5.9%) had mild, five (50.0%) had moderate and three (21.4%) had marked nuclear pleomorphism. Nine patients had glioblastoma multiforme WHO grade IV. Among them, two (20.0%) had moderate and seven (50.0%) had marked nuclear pleomorphism (WHO grade I and grade II) are consistent with mild nuclear pleomorphism, (WHO grade III) is regular with moderate and WHO grade IV, with marked nuclear pleomorphism. The association of WHO grades differ significantly (p<0.05) with nuclear pleomorphism.

Regarding the association between mitoses and WHO grades in glial tumors, it was observed in this current study that the mean mitotic count was 8.11±2.76 /10HPF ranging from 5 to 12 /10HPF in glioblastoma multiforme (WHO grade IV), 6.56±2.3 /10HPF with range 4 to 11 /10HPF in anaplastic astrocytoma (WHO grade III), 6.00±2.0 /10HPF ranging from 4 to 8 /10HPF in anaplastic ependymoma (WHO grade III), 6.00±1.41 /10HPF with range 5 to 7 /10HPF in gemistocytic astrocytoma, (WHO grade II), 2.80±1.1 /10HPF ranging from 2 to 4 /10HPF in ependymoma (WHO grade II), 2.50±0.71 /10HPF ranging from 2 to 3 /10HPF in oligoastrocytoma, (WHO grade II), 2.17±0.75 /10HPF ranging from 1 to 3 /10HPF in diffuse fibrillary astrocytoma, (WHO grade II), 2.00±1.41 /10HPF ranging from 1 to 3 /10HPF in oligodendroglioma, (WHO grade II) and 1.67±0.58 /10HPF ranging from 1 to 2 /10HPF in pilocytic astrocytoma (WHO grade I). The above result indicates that there is a linear increase of mitotic count with increasing WHO Grades.

In the present study it was observed that all (100.0%) patients with glioblastoma multiforme (WHO grade IV) had necrosis but no necrosis was found in other WHO grades. The mean difference was statistically significant (p<0.05). According to WHO classification of tumors of the central nervous system, IARC: Lyon 2007, necrosis may be of any type is one of the major histologic features of WHO grade IV glial tumors. Peri necrotic pallisading of tumor cells need not be present. Giannini et al.11 stated that proliferation index was not an independent marker of prognosis when grade IV tumors were considered. The presence of necrosis was a very statistically powerful predictive marker for grade IV tumors. Limited blood supply and hypoxia due to sluggish blood flow and interstitial oedema has been identified as important causes of necrosis.1

Many investigations have demonstrated a significant positive correlation between Ki-67/MIB-1 indices and WHO grades. It was observed in this study that the mean proliferative index was 24.3±8.7% ranging from 15 – 40% in glioblastoma multiforme (WHO grade IV), 25.1±12.4% ranging from 8.8 – 40% in anaplastic astrocytoma (WHO grade III), 18.0±7.6% ranging from 10–25% in anaplastic ependymoma (WHO grade III), 10.8±10.3% ranging from 3.5-18.0 in gemistocytic astrocytoma, (WHO grade II). 4.5±3.7% ranging from 1.0 -10.0% in diffuse fibrillary astrocytoma, (WHO grade II), 3.0 ± 3.1% ranging from 1.0- 8.0 in ependymoma (WHO grade II), 1.6±0.6% ranging from 1.1 -2.0% in oligoastrocytoma, (WHO grade II), 1.0±0.0% in oligodendroglioma, (WHO grade II) and 2.0±0.8% ranging from 1.1 -3.0% in pilocytic astrocytoma (WHO grade-I). There is a linear increase of proliferative index with increasing WHO grades. The mean Proliferative index significantly (p<0.05) differed with different WHO grades. Proliferation marker is helpful in cases where clinical or histopathologic factors are ambiguous. As part of a larger study of proliferation and prognosis, Giannini et al.11 studied the MIB-1 index as an independent prognostic factor in 140 diffuse astrocytomas, including 45 grade II, 50 grade III and 45 grade IV. MIB-1 indices were higher in grade III than in grade II (P = 0.001) and were higher in grade IV than in grade III (P = 0.014). Giannini et al.11 also mentioned that the MIB-1 proliferation index was particularly useful in grade II and III because it identifies aggressive tumors in the grade II category.

The study revealed that MVD by CD34 is significantly different between astrocytomas. MVD is increased with the progression of the pathological grade of astrocytoma. Significant differences of MVD were found among astrocytomas of different grades. Regarding the association between diagnosis and WHO grades with microvessel density it was observed that oligoastrocytoma (WHO grade II) had mean microvessel density 110.5±68.59 ranging from 62 -159, oligodendroglioma, (WHO grade II) 52.0±5.66 ranging from 48 – 56, ependymoma (WHO grade II) 41.0±19.58 ranging from 21 – 72, diffuse fibrillary astrocytoma, (WHO grade II) 32.0±12.01 ranging from 17 – 50, gemistocytic astrocytoma, ( WHO grade II) 32.0±18.38 ranging from 19 – 45, glioblastoma multiforme (WHO grade IV) 100.11±46.62 ranging from 38 – 197, anaplastic astrocytoma, (WHO grade III) 57.13±20.14 ranging from 35 – 87, anaplastic ependymoma (WHO grade III) 51.0±25.94 ranging from 30 – 80, pilocytic astrocytoma (WHO grade I) had mean microvessel density 47.75±19.91 ranging from 26 – 70. The mean microvessel density was higher in WHO grade II and WHO grade IV. The mean microvessel density difference was significantly (p<0.05) differ with different WHO grades.

Spearmen’s positive correlation (r=0.244; p=0.119) was found between proliferative index and microvessel density but not significant (p>0.05). Cavalcante et al.14 stated that association between SPECT-MIB1 and the MVD of low grade astrocytoma, anaplastic astrocytoma and glioblastoma multiforme cases were not significant. But Safy et al.15 showed significant correlation between Ki67 (PI) and CD34 (MVD) which is consistent with my study.

 Conclusion

The prognostic utility of proliferative indices among the gliomas (WHO grades I to IV) has been debated and evaluated that the proliferative index is an independent prognostic marker for survival. The determination of a proliferation index is not a routine part of the evaluation of all gliomas, due to limitations associated with tumor heterogeneity and sampling, as well as differences in staining methodology, index determination, and the degree of inter-observer variability. It may be prognostically helpful in histologically borderline cases, such as those that are at the grade II–III and III–IV border. Raised proliferation index indicates a more aggressive neoplasm or tumor progressing to higher grade. Like in this study, six patients out of nine with anaplastic astrocytmas WHO grade-III, had proliferation index >10% indicating progression toward GBM. Among WHO grade II glial tumors in the study, one case of gemistocytic astrocytoma, one case of ependymoma and one case of diffuse fibrillary astroytoma  had proliferation index >4% suggesting progress to a higher grade gliomas. Moreover it correlates with the WHO grades. The transition from low-grade to anaplastic astrocytomas or anaplastic astrocytomas to secondary GBM is a dramatic increase in microvascular proliferation. An equivalently robust microvasculature proliferation phenotype is observed also in primary GBM. Vredenburgh et al.16 stated that the combination of anti angiogenesis therapy (bevacizumab) and cytotoxic therapy (irinotecan) is an active regimen for recurrent grade III-IV glioma with acceptable toxicity. Thirty-two patients were assessed (23 with grade IV glioma and 9 with grade III glioma). The median progression-free survival was 23 weeks for all patients. So it can be said that addition of anti-angiogenesis drugs would be beneficial for patients with increased microvessel density in glial tumors. This study may also help the oncologist to select anti angiogenesis therapy along with conventional treatment of glial tumor which show increased MVD. More over, patients of low grade glial tumor with increased proliferative index and microvascular proliferation are at risk of progressing to higher grade tumor. This cases can be detected and predicted as risk group for close monitoring and follow up.

Acknowledgements

The authors acknowledge contribution of

  1. Shabnam Akhter, Associate Professor, Department of Pathology, in preparing the manuscript
  2. Tasmina Anam, Medical Officer, Department of Pathology for immunohistochemical staining

 References

  1. Furnari FB, Fenton T, Bachoo RM, Mukasa A, Stommel JM, Stegh A, et al. Malignant astrocytic glioma: genetics, biology, and paths to treatment. Genes & development 2007; 21(21):2683-710.
  2. Grier JT, Batchelor T. Low-grade gliomas in adults. The Oncologist, 2006; 11(6):681-93.
  3. Kleihues P, Cavenee WK. Pathology and genetics of tumours of the nervous system. InPathology and genetics of tumours of the nervous system 2000 Lorger M. Tumor microenvironment in the brain. Cancers, 2012; 4(1):218-43.
  4. Brat DJ, Prayson RA, Ryken TC, Olson JJ. Diagnosis of malignant glioma: role of neuropathology. Journal of neuro-oncology, 2008;89(3):287-311.
  5. Hsu DW, Louis DN, Efird JT, Hedley-Whyte ET. Use of MIB-1 (Ki-67) immunoreactivity in differentiating grade II and grade III gliomas. Journal of Neuropathology & Experimental Neurology. 1997;56(8):857-65.
  6. Chaloob MK, Ali HH, Qasim BJ, Mohammed AS. Immunohistochemical expression of Ki-67, PCNA and CD34 in astrocytomas: a clinicopathological study. Oman Medical Journal, 2012;27(5):368-74.
  7. Leon SP, Folkerth RD, Black PM. Microvessel density is a prognostic indicator for patients with astroglial brain tumors. Cancer, 1996;77(2):362-72.
  8. Ralte AM, Sharma MC, Karak AK, Mehta VS, Sarkar C. Clinicopathological features, MIB-1 labeling index and apoptotic index in recurrent astrocytic tumors. Pathology & Oncology Research, 2001;7(4):267-78.
  9. Weidner N, Folkman J, Pozza F, Bevilacqua P, Allred EN, Moore DH, et al. Tumor angiogenesis: a new significant and independent prognostic indicator in early-stage breast carcinoma. CancerSpectrum Knowledge Environment, 1992;84(24):1875-87.
  10. Arshad H, Ahmad Z, Hasan SH. Gliomas: correlation of histologic grade, Ki67 and p53 expression with patient survival. Asian Pac J Cancer Prev, 2010;11(6):1637-40.
  11. Giannini C, Scheithauer BW, Burger PC, Christensen MR, Wollan PC, Sebo TJ, et al. Cellular proliferation in pilocytic and diffuse astrocytomas. Journal of Neuropathology & Experimental Neurology, 1999;58(1):46-53.
  12. Schiffer D, Chiò A, Giordana MT, Leone M, Soffietti R. Prognostic value of histologic factors in adult cerebral astrocytoma. Cancer, 1988;61(7):1386-93.
  13. Nelson DF, Nelson JS, Davis DR, Chang CH, Pajak TF. Survival and prognosis of patients with astrocytoma with atypical or anaplastic features. Journal of neuro-oncology. 1985;3(2):99-103.
  14. Pantoja Cavalcante S, De Almeida JR, Clara CA, Scapulatempo Neto C, Verzinhase Peres S, Moriguchi SM, et al. Evaluation of the microvascular density in astrocytomas in adults correlated using SPECT-MIBI. Experimental and Therapeutic Medicine. 2010;1(2):293-9.
  15. Safy HME, Hamied HEA, Hassan RA, Rezk HM, Ahmed EM, Farag The role of immunohistochemical markers in diagnosis and prognosis of diffuse astrocytoma. Life Science Journal, 2013:12(10): 365-371.
  16. Vredenburgh JJ, Desjardins A, Herndon JE, Dowell JM, Reardon DA, Quinn JA, et al. Phase II trial of bevacizumab and irinotecan in recurrent malignant glioma. Clinical cancer research. 2007;13(4):1253-9.

 

Histomorphological Pattern of Radiologically Detected Osteolytic Lesions of Bone – A Study of Eighty Cases

Histomorphological Pattern of Radiologically Detected Osteolytic Lesions of Bone – A Study of Eighty Cases

*Runa NJ,1 Khan JB,2 Kaizer N,3 Dewan MR,4 Sharmin S,5 Ahmed SS,6 Hasan AM,7 Haque N,8 Hussain M9

 

Abstract:

To determine the spectrum of lesions and to correlate them with age, sex of patients and also anatomical site a histomorphological study of radiologically detected osteolytic lesions of bone was done. Eighty cases of radiologically detected lytic lesions of bone were studied over a period of two years from January 2014 to December 2015. Out of 80 cases of lytic lesion of bone, 18 cases were of inflammatory, 32 cases were of benign tumors, 20 cases of primary malignant bone tumors and 10 cases of metastatic lytic lesions were found. Most of the patients belonged to the middle age group with the age incidence varying with the type of lesion. Out of the 80 cases, 46 were males and 34 were females. Most of the bone diseases occurred more commonly around the knee joint and in the males within the age group of 11-20 years. Conclusion: Benign tumors are more common amongst all lytic lesions with giant cell tumor ranking first. Tuberculous osteomyelitis is more common in this study than pyogenic osteomyelitis. Osteosarcoma and secondary metastasis were more common among malignant bone tumors.

 [Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):83-90]

Key words: Bone, Osteolytic lesions, Histopathology, Radiology

 

 

 

  1. *Dr. Nusrat Jahan Runa, Assistant Professor, Department of Pathology, Dhaka Central International Medical College, Dhaka. njruna03@gmail.com
  2. Zubaida Bahroon Khan, Lecturer, Department of Pathology, Dhaka Medical College, Dhaka.
  3. Nahid Kaizer, Assistant Professor of Pathology, MH Samorita Medical College, Dhaka.
  4. Md. Rezaul Karim Dewan, Professor of Pathology, Dhaka Medical College, Dhaka.
  5. Shegufta Sharmin, Resident of Pathology, Dhaka Medical College, Dhaka.
  6. Syed Salauddin Ahmed, Associate Professor of Pathology, National Institute of Traumatic and Orthopedic Rehabilitation, Dhaka.
  7. AZ Mahmudul Hasan, Assistant Registrar, Department of Orthopedic Surgery, Dhaka Medical College Hospital, Dhaka
  8. Nazmul Haque, Associate Professor, Department of Pathology, Dhaka Medical College, Dhaka.
  9. Maleeha Hussain, Professor and Head, Department of Pathology, Dhaka Medical College, Dhaka.

 

*For correspondence

Introduction
Lesion of bone is a frequently found radiological presentation of patients seen in orthopedic practice. Osteolytic lesions are evident radiologically where the destructive processes outstrip the laying down of new bone. The spectrum of pathological conditions causing osteolytic changes can be inflammatory to neoplastic lesions.1-3 Within benign lesions, the common differential diagnosis of lytic lesion includes simple bone cyst, aneurysmal bone cyst, osteochondroma (exostosis), enchondroma, non-ossifying fibroma and brown tumor of the bone. Among the malignant tumors the most common are Ewing sarcoma, osteosarcoma and multiple myeloma.4 Primary bone cancer is much rarer than bone metastasis.5,6 Bone is the third most common site of metastatic disease. Metastatic tumor that produces osteolytic lesions, detected in X-ray when the lesion is greater than 1.0 cm and 30% – 50% of the bone density have beendestroyed.4 As far as secondary tumors are concerned primary sites like lung, kidney, thyroid, breast, gastrointestinal and melanomas produce mainly lytic lesion while others elicit mixed lytic and sclerotic reaction.7 Carcinomas are much more likely to metastasize to bone than sarcomas.

It is difficult to determine radiologically with plain film imaging whether a lytic lesion is benign or malignant. It is important to remember, however that some benign processes such as osteomyelitis can mimic malignant tumors and some malignant lesions such as metastases or myeloma can mimic benign. The osteolytic lesions of tuberculosis may closely mimic those due to multiple myeloma or secondary malignant deposits.8 The histopathologist is the final person to guide an orthopedic surgeon for the treatment of patients with lytic lesions.

 Methods

This study was conducted at the Department of Pathology, Dhaka Medical College, Dhaka from January 2014 to December 2015. The criterion for the selection of the patient was radiologically detected osteolytic lesions of bone. Total 80 cases were selected. Detailed history was taken. Biopsy for histopathology was performed in all patients for the diagnosis of lytic lesions of bone. Biopsy was taken mainly by incision and excision method.

In laboratory soft tissue were fixed in 10 % formalin while for bone 3 to 5 mm thick sections were made and adequately fixed in 10% buffered formalin and then decalcification was achieved by placing the specimens in 5% nitric acid for 2 days. After that all tissue were processed by increasing concentrations of alcohol and paraffin blocks were prepared. Sectioned were stained with haematoxylin and eosin. After that all slides were examined under microscope, the final diagnosis was made into inflammatory, benign and malignant lesion accordingly.

 Results

In this study 18 cases of inflammatory, 32 cases of benign, 20 cases of primary malignant and 10 cases of secondary malignant lytic lesions were found out of total 80 cases. Benign neoplastic lesions of bone comprises the highest number (32 cases, Table I).

Table I: Distribution of frequency of study patients by histological diagnosis (n=80)

Lesions Number %
             Inflammatory 18 22.5
Neoplasm
Benign 32 22.5
Malignant primary 20 25.0
Malignant Secondary 10 12.5
Total 80 100%

From different age group, the most common age group was 11-20 years, in which total 32 cases of lytic lesion were found. Benign neoplastic lesions (18 cases) were most common in this group. In age group 21-40 years, total 25 cases of lytic lesion were found, of which benign lesion (12 cases) was most common. In age group of above 40 years, total 19 cases of lytic lesion were found, in which 12 malignant lesions were found. In below 10 year group only 4 cases were found, which were of malignant type (Table II).

Table II: Showing distribution of the study patients by age

 

 

Lesions

Age groups (in years)
0-10 11-20 21-40 Above 40
Inflammatory Pyogenic Osteomyelitis 0 4 2 2
Tuberculous osteomyelitis 0 1 6 3
Neoplasm Benign 0 18 12 2
Malignant primary 4 9 3 4
Malignant secondary 0 0 2 8
         Total 4 32 25 19

 

Out of 80 patients, 46 (57.50%) were male and 34 (42.50%) were female. In male patients 19 cases were of benign neoplastic lesion, 8 cases were inflammatory lesion and 19 cases were malignant lesion. Where as in female, 13 cases were benign lesion, 10 cases were inflammatory lesion and 11 cases were malignant lesion. So, benign neoplastic lesions were the most common among both the sex (Table- III).

 

Table III: Types of leions with sex distribution of the study patients

 

               Lesions                    Male                Female
        Inflammatory Pyogenic osteomyelitis                     02 (2.5%)                   06 (7.5%)
Tuberculous osteomyelitis                     06 (7.5%)                   04 (5.0%)
 

 

Benign

Giant cell tumor                     06 (7.5%)                   09 (11.25%)
Enchondroma                     04 (3.75%)                   01 (1.25%)
Simple bone cyst                     02 (2.5%)                   01 (1.25%)
Fibrous dysplasia                     02 (2.5%)                   01 (1.25%)
Aneurymal bone cyst                     03 (3.75%)                   01 (1.25%)
Hemangioma                     02 (1.25%)                   —
 

 

Malignant

     Primary
Osteosarcoma                     05 (6.25%)                  03 (3.75%)
Ewing sarcoma                     03 (3.75%)                  04 (5.0%)
Chondrosarcoma                     02 (2.5%)                  01 (1.25%)
Multiple myeloma                     01 (1.25%)                  —
          MFH                     01 (1.25%)                  —
    Secondary                     07 (8.75%)                 03 (3.75%)
                                           Total                    46 (57.50%)                 34 (42.50%)

Out of 80 cases, 24 patients had osteolytic lesion in the tibia. Among them 17 lesions were in the upper end. The second most common site of lesion was femur [Table IV].

 

Table IV: Distribution of the study patients according to anatomical site (n=80)

 

Diagnosis Femur
Upper
Femur

Lower

Tibia

Upper

Tibia

Lower

Fibula Humerus Radius Meta-carpal Phalanges Total
Tubercular osteomyelitis 2 3 3 1 1 10
Pyogenic osteomyelitis 2 2 2 1 1 8
Giant cell tumour of bone 6 3 2 1 1 1 15
Enchondroma 1 4 5
Hemangioma 1 1 2
Benign cystic lesion 1 1 1 3
Aneurysmal bone cyst 1 1 2 4
Fibrous dysplasia 2 1 3
Ewing sarcoma 1 2 1 1 1 1 7
Osteosarcoma 3 5 8
Chondrosarcoma 1 2 3
Multiple myeloma 1 1
MFH 1 1
Metastatic adenocarcinoma 1 2 3
Metastatic squamous cell carcinoma 1 1
Metastatic renal cell carcinoma 2 2
Metastatic follicular variant of papillary carcinoma 2 1 3
Metastatic Prostatic carcinoma 1 1
Total 6 15 18 10 4 14 5 2 5 80

 

MFH – Malignant fibrous histiocytoma

Out of total 18 inflammatory lytic lesions, 8 cases were of pyogenic osteomyelitis and 10 cases were of tuberculous osteomyelitis (fig 1 and 2). So, tuberculous osteomyelitis was slightly more common than pyogenic osteomyelitis in inflammatory lytic lesions (Table V). From total 32 benign neoplastic lytic lesions, 15 cases were of giant cell tumor, 5 cases were of enchondroma. Giant cell tumour shows a higher incidence than other benign lytic lesion (Table VI).

Table V: Distribution of inflammatory lesion

 

Histologically diagnosed Inflammatory lesion   Number %
Pyogenic osteomyelitis          08 10
Tuberculous osteomyelitis          10 12.5

 

Table VI: Distribution of frequency of benign lesion by histopathological diagnosis

 

Histologically diagnosed Benign lesion No of cases %
   Giant cell tumor       15 18.75
   Enchondroma       05   6.25
   Simple bone cyst       03   3.75
   Fibrous dysplasia       03   3.75
  Aneurysmal bone cyst       04   5.0
  Hemangioma       02   2.5
            Total       32 40.0

While in 30 malignant lesions, 20 cases were primary and 10 cases were secondary malignant lesions. Primary malignant lesions were more common than metastatic lytic lesions in the present series  (Table VII).

 

Table VII: Distribution of frequency malignant lytic lesion by histological diagnosis

 

          Malignant lesion No of cases Percentage (%)
Primary Osteosarcoma 08 10
Ewing sarcoma 07 8.75
Chondrosarcoma 03 3.75
Multiple myeloma 01 1.25
Malignant fibrous histiocytoma 01 1.25
Secondary Metastatic follicular variant of papillary
carcinoma of thyroid in bone
03 3.75
Metastatic adenocarcinoma of lung in bone 03 3.75
Metastatic renal cell carcinoma in bone 02 2.5
Metastatic adenocarcinoma of prostate in bone 01 1.25
Metastatic squamous cell carcinoma of lung in bone 01 1.25
                    Total 30 37.5

 

Osteosarcoma and metastatic tumours from lung were common in the primary and secondary malignant tumour groups (fig 3 and 4).

 

 

 

 

 

 

Fig 1. X-Ray photograph showing lytic area in the right upper tibia. Subsequent biopsy revealed tubercular osteomyelitis (case no 16)

 

 

 

 

 

 

 

Fig 2. Photomicrograph of the case in fig 1 showing epithelioid cells, lymphocytes, a giant cell and bone, consistent with tubercular osteomyelitis (ase No: 16, H & E stain ´200)

 

 

 

 

 

 

Fig 3. X-ray photograph showing lytic lesion with destruction of the overlying cortical bone with ‘sunburst’ appearance in lower end of femur (Case no. 42)

 

 

 

 

 

 

Fig 4. Photomicrograph showing Osteosarcoma (Case No: 42, H&E stain ´400)

 

 

 

 

 

Fig 5. X-ray photograph showing a lytic lesion in upper end of femur (Case no. 17)

 

 

 

 

 

 

Fig 6. Photomicrograph showing metastatic squamous cell carcinoma (Case No: 17, H&E stain´400)

Discussion

This study was carried out to determine various histomorphologic pattern of lytic lesions of bone. Of total 80 cases, 18 cases of inflammatory, 32 cases of benign neoplastic lesion, 20 cases of primary malignant bone tumors and  10 cases of secondary tumors were found. One of the important point to be considered is the age of the patient. Some of the lytic lesions are most probably confined to certain age groups such as: metastatic neuroblastoma in the infant and young child, metastasis and multiple myeloma in the middle-aged and elderly, lymphomas affecting only bone usually occur during adult life. Ewing sarcoma mostly affecting children and young teenagers while giant cell tumor in the young to middle aged adults.9,10 In our study, the most common age group of bone lesions was in second decade. Among 32 cases of benign osteolytic lesion, 18 cases were belonging to age group 11-20 years. In age group 21-40 years, total 25 cases of lytic lesion were found, in which benign (12 cases) were the commonest. In age group above 40
years, a total of 19 cases were found, in which malignant lesion was the most common diagnosis. In below 10 years age group only 4 cases were found to be Ewing’s sarcoma (Table II).In our study, osteomyelitis was found in all age groups above ten years. The diagnosis of chronic recurrent multifocal osteomyelitis is essentially one of exclusion. Infective osteomyelitis and malignancy are the main differential diagnoses.11 The osteolytic lesions of tuberculosis at multiple sites need to be differentiated from multiple myeloma, secondary metastasis and bacterial osteomyelitis.

 

In this study, more than half (57.50%) of the patients were male and  42.50% were female; male to female ratio was 1.4:1, which indicates that osteolytic lesion are predominant in male subjects, which closely agrees with available literature.12,13

 

The bone around the knee joint that is, the distal end of the femur and the proximal end of the tibia, were found to be the commonest sites for osteolytic lesions comprising 38.7% in this series. The lower end of the femur was affected in 17.5% of cases and the upper end of the tibia in 21.2% of cases that has matched with other literature.14

In our study, out of 80 cases of lytic bone lesions, most common were benign neoplastic lesions making 32 cases. Among them, 15 cases were giant cell tumour of bone having female predominance (Table III).  In present study, the most common site of giant cell tumor was lower end of femur and upper end of tibia [Table IV]. Characteristic radiologic findings demonstrate the lesion is most often eccentrically placed lytic lesion with no periosteal reaction to the long axis of the bone. Total 5 cases of enchondroma has been reported with an incidence of 6.26% of total cases and an incidence of 15% of all benign tumors, mostly seen in patients younger than age 20 years (3/5 cases) in the current study.

Osteosarcoma is the most common primary bone tumor in young and adolescents. It occurs most frequently in the second decade, occurring in the metaphysis, mostly in lower end of femur followed by upper end of tibia.15,16 In the present study, we observed a similar finding. Ewing sarcoma is a highly malignant, undifferentiated, peripheral primitive neuro-ectodermal tumor occurring most commonly at the diaphysis of long bones, in the 0-20 years age group, with female predominance.15,16 Our study has matched with the available literature. Pain, pathological fractures and hypercalcemia are the major sources of morbidity with bone metastasis. Pain is the most common symptom found in 70% patients with bone metastases.17 Pain is caused by stretching of the periosteum by the tumor as well as nerve stimulation in the endosteum. Pathological fractures are most common in breast cancer due to the lytic nature of the lesions.18 In our study ten cases of metastatic lytic lesion were found, which included Follicular Variant Of Papillary Carcinoma of thyroid metastasize to upper end of the humerus, Carcinoma of kidney with metastasis to upper end of femur, Squamous Cell Carcinoma and adenocarcinoma of Lung metastasize to upper end of femur and humerus.  In case of follicular variant of papillary carcinoma of thyroid lytic lesion over humerus was the first noticeable sign and even the patient & clinician were unaware of thyroid malignancy.

Among the various diagnoses, benign tumors form the largest group (40%) of patients presenting with a lytic lesion on radiological findings. There is a male preponderance with 57.5% of the patients being males. Also, majority of the patients fall into the second decade with 40% of the patients in the age group of 11- 20 years. The common diagnoses among the benign lesions were giant cell tumors, while there were a slightly higher number of cases of tuberculous osteomyelitis as against bacterial osteomyelitis in the inflammatory conditions. Among the malignant lesions, primary tumors were a commoner diagnosis as opposed to the secondaries. The metastatic tumors tend to occur more commonly in the elderly population. The commonest primary malignant lesion that showed up was osteosarcoma. Overall, giant cell tumor is the commonest diagnosis presenting with a lytic lesion on radiological finding. Occult malignancy can be presented as lytic lesion of bone in the form of secondary. All lyticlesions may have osteoclastic giant cells and they should not be misinterpreted as Giant cell tumor.

 Conclusion

Lytic lesion of bone is a very used to radiological finding for orthopedic surgeon in many patients. Even an orthopedic surgeon and radiologist together won’t be able to reach to the precise conclusion and further treatment. Histopathology is the gold standard for the precise diagnosis from a very large number of conditions leading to lytic lesion.

 References

  1. Bommer KK, Ramzy I & Mody D. Fine needle aspiration biopsy in the diagnosis and management of bone lesions: A study of 450 cases. Cancer, 1997; 81:148-156.
  2. Kreicbergs A, Henrik C, Bauer F, Brosjo O, Lindholm J & Skoog L. Cytological Diagnosis of Bone Tumors. The Journal of Bone and Joint Surgery, 1996; 78(2):258-263.
  3. Ackerman LV & Del Regato JA 1954, Cancer: Diagnosis, Treatment, and prognosis. 2nd edition, Louis, Mosby, p. 1028.
  4. Popat V, Sata V, Vora D, Bhanvadia V, Shah M & Kanara L. Role of Histopathology In Lytic Lesions of Bone. The Internet Journal of Orothopedic surgery, 2010; 19(1):1-7.
  5. Bhattacharya P, Chowdhury AR, Bhaskar M & Biswanath P. Clinico pathological correlation of Primary Malignant Bone Tumors. Open Journal of Orthopedics, 2015; 5:100-108.
  6. Wedin R, Henrik C, Bauer F, Skoog L, Soderlund V & Tani E. Cytological diagnosis of skeletal lesions. The Journal of Bone and Joint Surgery, 2000; 82(5):673-678.
  7. Adler O & Rosenberger A. Fine Needle Aspiration Biopsy of Osteolytic Metastatic Lesions. AJR, 1979; 33:15-18.
  8. Chawla KP, Pandit, AA, Jaiswal PK & Ahuja A. 1990, ‘Ostearticular tuberculosis with involvement of multiple sites (a case report)’, J Postgrad Med,1990;36:171-72.
  9. Manaster BJ. Tumors. In: Manaster BJ, Disler DG, May DA, eds. Musculoskeletal
    Imaging: The Requisites.2nd ed. St. Louis, MO: Mosby; 2002:1-104.
  10. Resnick D. Tumors and tumor-like lesions of bone: Imaging and pathology of specific lesions. In: Resnick D, ed. Bone and Joint Imaging.2nd ed. Philadelphia, PA: W.B. Saunders; 1996:991-1063.
  11. L P Robertson, P Hickling. Chronic recurrent multifocal osteomyelitis is a differential diagnosis of juvenile idiopathic arthritis. Ann Rheum Dis 2001; 60:828-831.
  12. Chakrabarti S, Datta AS & Hira M. Critical Evaluation of Fine Needle Aspiration Cytology as a Diagnostic Tecnique in Bone Tumors and Tumor-like lesions. Asian Pac J Cancer Prev, 2012; 13: 3031-4
  13. Wahane R. Fine Needle Aspiration Cytology of Bone Tumors. ACTA, 2007; 51(%):711-720.
  14. Mahajan S, Saoji AA & Agarwal A. Utility of Fine Needle Aspiration Cytology in Diagnosis Bone Tumors. Cancer Transl Med, 2015; 1(5):166-169.
  15. Bone RJ. Ackerman’s Surgical Pathology. In: Rosai J, editor. St. Louis: Mosby; 1996. pp. 1917–2020.
  16. Rosenberg AE. Bones, joints and soft tissue tumors. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and cotran; Pathologic Basis of disease. 8th ed. Gurgaon: Elsevier Reed Elsevier India private limited; 2010. pp. 1205–56.
  17. Vinholes J et al., Effects of Bone Metastases on Bone Metabolism: Implications for Diagnosis, Imaging and Assessment of Response to Cancer Treatment, Cancer Treatment Reviews, 1996; 22:289-331.
  18. Stoll B and Parbhoo S, Bone Metastasis, Raven Press Books, Ltd.: New York NY, 1983, p. 14. 3 Vinholes, et al. 1/14/98 8:46 AM 1.

 

Pathology-Based Cancer Registry in Bangladesh: The Need of Our Time


Editorial
Pathology-Based Cancer Registry in Bangladesh:  The Need of Our Time

 Kamal M*

 *Professor Mohammed Kamal, Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh. kamalzsr@yahoo.com

Cancer is a public health concern both in the developed and developing countries and is among the leading causes of death worldwide. In 2012, there were 14 million new cases and 8.2 million cancer-related deaths worldwide. The number of new cancer cases estimated to rise to 22 million within the next two decades.  More than 60% of the world’s new cancer cases occur in developing and resource constrained countries of Asia, Africa, and Central and South America.  70% of the world’s cancer deaths also occur in these regions.1  Bangladesh is not spared from this problem. Cancer is the sixth leading cause of death in Bangladesh. The magnitude of cancer in Bangladesh is getting alarming because of abundance of environmental carcinogens, malnutrition, lack of awareness and screening facilities. Poverty, ignorance and illiteracy have compounded the problem. The magnitude of the problem from cancer is often unrecognized by health and general policy makers alike due to other overwhelming and more visible competing health problems and natural calamities. Therefore, appropriate prevention and surveillance of cancer deserves urgent attention.2

Tumour registries are systems for collection, storage, analysis and interpretation of data from cancer patients.  It involves recording of personal particulars of cancer patients and the clinical and pathological characteristics of the cancers, collected continuously and systematically from various data sources.  Ideally the key source of information on cancers in any country is through a population-based cancer registry. About 200 population-based cancer registries exist in various parts of the world.3   However, because of the costs for maintaining a population-based cancer registry and lack of necessary infrastructure, Bangladesh, like many other developing countries, has not been able to establish any such registry to date. In spite of having high morbidity and mortality from many cancers (e.g., lung, head and neck, cervix, liver, colon, stomach etc.), there are no reliable data for the incidence, prognosis, morbidity and mortality from cancers in Bangladesh. Data sources and methods used for Bangladesh statistics are estimated from national incidence estimates using modeled survival and mortality based on reports from a few tertiary care hospitals and from neighboring countries.4

To overcome this, an effective alternative is ‘Pathology Based Cancer Registry’ which is efficiently going on in many parts of the world. The basis of this approach is documentation of cancers through hospital and/or pathology laboratories where the cancer patients attend for their diagnosis and follow-up. Although not perfect, this method is proving to be an effective in some developing countries.5.6,7  Though an accurate picture of cancer situation depends on the establishment of a population based cancer registry, data derived from pathology based cancer registry would be able to measure levels of cancer burden in the community by recording all cases of cancers (and non- cancer) in given laboratories  with emphasis on pathological diagnosis and clinical Information of the patients. In the absence of population based cancer registry, pathology based cancer data can be utilized as a reflection of the patterns of cancer in the population.

To establish a pathology based cancer registry in Bangladesh, the practical approach will be to start a collaborative network of all pathologists based at academic institutions, hospitals, and private clinics and laboratories. It can be done phase wise, starting from the Dhaka city and gradually expanding throughout the country. The collected data can provide estimation of cancer incidence and prevalence, patterns, epidemiology and other valuable information. Collaborative between government and non-government institutions, pathologists, epidemiologists, practitioners and relevant national and international policy makers is needed for smooth functioning.

References

  1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11
  2. Lyon, France: International Agency for Research on Cancer; 2013.
  3. Rahman A, Zaman M, Hossain A and Karim ABMF. National Cancer Control Strategy and Plan of Action 2009-2015, Directorate General of Health Services. Ministry of Health and Family Welfare Dhaka, Bangladesh. 2008; 1-37.
  4. Wagner G. History of cancer registration. In Jensen OM, Parkin DM, MacLennan R, Muir CS, and R.G. Skeet RG, editors. Cancer Registration: Principles and Methods. IARC Scientific Publications No. 95. Lyon, France.IARC.1991. p. 3-6.
  5. Kalam MA and Ahmed T. Cancer, Cancer Control and Bangladesh, Editorial. Bangladesh Journal of Plastic Surgery. 2012; 3(1): 1-2.
  6. Jensen OM, Whelan SL. Planning a cancer registry. . In Jensen OM, Parkin DM, MacLennan R, Muir CS, and R.G. Skeet RG, editors. Cancer Registration: Principles and Methods. IARC Scientific Publications No. 95. Lyon, France.IARC.1991.p. 22-28.
  7. Bhurgri Y. The role of cancer registration in national cancer control, Pakistan. J Pak Med Assoc. 2004 Aug; 54(8). P. 402-404.
  8. Etemadi AI, Sadjadi A, Semnani S, Nouraie SM, Khademi H, Bahadori M. Cancer registry in Iran: a brief overview. Arch Iran Med. 2008 Sep;11(5):577-80.

 

Angiolipoma of Stomach: A Case Report


Angiolipoma of Stomach: A Case Report

 *Jahan JA,1 Akhter S,2  Kamal M,3 Karim SS4

 Abstract

Angiolipoma is a variant of benign lipomatous tumors and generally found in subcutaneous tissues. The tumor is rarely found in gastrointestinal tract. We present a case of a 55-year-old male who presented with melena. Endoscopy of upper gastrointestinal tract showed a polypoid mass, while abdominal CT scan suggested a submucosal lipoma. After partial gastrectomy,  histological examination of the tumor revealed an encapsulated nodule composed of mature fatty tissue, fibrous tissue and small blood vessels, and accordingly the lesion was diagnosed as angiolipoma.

  [Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):63-67]

Key words:  Angiolipoma, Stomach

 

  1. *Dr. Jasmine Akhter Jahan, Resident,  Department of  Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka. drjasmine30@gmail.com
  2. Shabnam Akhter, Associate Professor, Department of  Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.
  3. Professor Mohammed Kamal, Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.
  4. Syed Sirajul Karim, Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka.

 

* For correspondence.

 Introduction

Angiolipoma is one of the benign adipocytic tumors that usually occur in subcutaneous tissues.1  The tumor is composed of adipose tissue and proliferating blood vessels. It is commonly found in subcutaneous tissues of the trunk and extremities.2  Although endoscopic and radiologic examination may provide helpful information, the final diagnosis of angiolipoma relies on histopathological features of excised specimen.3

Case report

A 55-year-old male patient was admitted in a private hospital in  Dhaka with the complaints of gastric mass, melena and generalized weakness. His symptoms had begun 20 days back and he experienced bloody stool with foul smell, which had lasted for seven days. Initially he visited an outside hospital, where he was diagnosed as a severely anaemic patient. His laboratory test results were as follows: hemoglobin level 7.8 g/dl, red blood cell count  2.78 × 1012/L, white blood cell count 13× 109/L, neutrophil count 74% and erythrocyte sedimentation rate (ESR) 82 mm in first hour. He was admitted in that hospital for blood transfusion because of his severe anemia and 2 units of fresh whole blood were transfused. Further investigation including complete metabolic panel, liver function tests, serum ferritin,  urinalysis and stool culture were all found within normal limit. Ultrasound of whole abdomen was also performed, which showed fatty infiltration in the liver (Grade-1). Endoscopy of upper gastro-intestinal tract revealed a polypoid mass in the gastric antrum with smooth surface and evidence of recent bleeding (Fig. 1).

The esophagus and duodenum appeared normal. Biopsy of the lesion showed massive necrosis and fibrinous exudate. After the blood transfusions when the patient became hemodynamically stable, he was discharged on request. Later the patient got admitted into Bangabandhu Sheikh Mujib Medical University with melena, cough and fever for definitive treatment. On arrival his abdomen was soft and non-distended. The patient’s past medical history was occasional dyspepsia for one year which was relieved by antacids. The family history was unremarkable. Repeat laboratory tests showed haemoglobin level of 11.6 g/dl, red blood cell count of 4.15 × 1012/L, white blood cell count of 9.0× 109/L,  neutrophil count of 67% and erythrocyte sedimentation rate (ESR) of 60 mm in 1st hour. A complete biochemical panel, serum albumin, fasting blood sugar, complete urine analysis, chest X-ray, electrocardiography (ECG) and echocardiography were all normal. An abdominal CT scan with contrast showed a well defined almost rounded fat density area measuring about 4.1 cm x 3.9 cm in the lumen of pyloric and antral part of stomach appeared to be arising from posterior wall, suggestive of submucosal lipoma at pyloric and antral part of stomach (Fig. 2). Tiny calcification is seen in hepatic parenchyma. Accordingly the patient was operated. A large antral growth was found and distal partial gastrectomy with gastrojejunostomy was performed. The patient recovered from surgery without complication. The specimen was sent to the department of pathology where gross examination showed a 5 × 5 × 3 cm polypoid tumor on the lesser curvature and posterior surface in the antrum  (Fig. 3). Three lymph nodes ranging from 02 mm to 04 mm were identified. Histologic examination revealed a tumor composed of lobules of fatty tissue with intervening fibrous tissue and small thin walled blood vessels  (Fig. 4 and 5). Mucosal ulceration was present. Lymph nodes showed reactive changes with no evidence of tumor. The final pathologic diagnosis was angiolipoma of the stomach. During follow-up, this patient showed no recurrence.

 

 

 

 

 

 

 

Fig 1.  Endoscopic appearance of the gastric polypoid mass.

 

 

 

 

 

 

Fig 2.   CT scan of abdomen showing gastric mass with low intensity in the centre (arrow)

 

 

 

 

 

Fig 3. Specimen of stomach showing mass with yellow fatty core (P) and normal mucosa (M).

 

 

 

 

 

Fig 4.  Histological section of stomach showing angiolipoma (T) and normal mucosa (M) (H&E x120)

 

 

 

 

 

 

Fig 5.   Histological section  showing adepocytes (A), blood vessels (BV) and fibrous tissue (F) (Masson Trichrome x220)

Discussion

Angiolipoma is a benign adipocytic tumour, usually arising in subcutaneous tissue. It is composed of adipose tissue and proliferating blood vessels.2 Most common site of angiolipoma are the extremities. It also involves subcutaneous tissue of trunk. Angiolipomas usually appear in the late teens or early twenties and has a male predominance.1

Angiolipoma was first defined in 1912  by Bowen (cited by Howard).4 The histopathological features of angiolipomas were differentiated from those of lipomas by Howard (1960).5 Clinically angiolipomas usually present with multiple subcutaneous, tender, small nodules in arms and trunk. They are most often less than 2 cm in diameter.1,6 Cytogenetic analysis detected chromosomal aberrations, such as rearrangements of 12q14-15, rearrangements of 6p21-22, or deletions of 13q12-14 and 13q22. The gene involved in 12q14-15 is HMG A2 and in 6p21-22 is HMG A1.7 These aberrant expressions suggest that the pathogenesis of angiolipomas may be different from other lipomas. The tumor in some cases show familial incidence, which is rare (5% of all cases) and have autosomal dominant inheritance.1,8

Grossly, the tumour is well defined, encapsulated and have cut surface which is yellowish to reddish according to the prevalence of fat or vascular component. Morphologically, it is comprised of mature adipose tissue with an interspersed vascular proliferation.1,2  Occasional fibrin thrombi are seen. The tumor can be classified as lipomatous or angiomatous type. This classification is based on the ratio of presence of adipose tissue or vascular tissue (8). The tumor is typically diagnosed with hemotoxylin & eosin stain. The immunohistochemical examination is rarely needed. Angiolipoma shows focal to diffuse positivity for S100 protein in the adipocytes. Also endothelial markers e.g. CD34 and CD31 are positive in the vascular component.2

Angiolipoma in the gastrointestinal tract is very rare and  seen mostly in the colon.9, 10  Twenty two cases of angiolipoma involving the gastrointestinal tract have been reported in the literature up to 2013. Among them, four cases were in the stomach. The antrum is the common site for gastric angiolipoma. Other involved areas are oesophagus, duodenum, small intestine, colon and rectum.9, 2

Patients with angiolipoma in the gastrointestinal tract are usually asymptomatic. Some may present with indigestion, abdominal discomfort, abdominal pain, GI bleeding and anaemia, symptoms of intussusceptions or obstruction with increasing size of the tumor .2, 9, 10 Submucosal polypoid mass lesion is typically found in upper GI endoscopy. Histologically, angiolipoma in the stomach is composed of mature fatty tissue and proliferating blood vessels. Fibrin thrombus is rarely seen in gastric angiolipoma and other nonsubcutaneous angiolipomas, in contrast to cutaneous angiolipomas.2, 10

Diagnosis of angiolipomas in the gastrointestinal tract can be made by radiological examination via barium radiograph, abdominal ultrasound, abdominal computed tomography (CT) or magnetic resonance imaging (MRI) before polypectomy or resection. A filling-defect in lumen by barium enema and a hyperechoic lesion on transabdominal ultrasound. Abdominal computed tomography (CT) image may show variable findings depending on tissue components of the lesion. This has an appearance from high-density mass due to lipomatous component to heterogeneous lesion with mixed fatty and soft tissue density.2, 9 The final diagnosis is confirmed by histopathological examination.2,8,9

The pre-operative diagnostic accuracy for gastric angiolipomas is quite low. So the correct diagnosis is usually made intraoperatively and confirmed by histopathology.9 The treatment options depend on the type of the lesion. It varies from polypectomy of small pedunculated lesions to surgical excision of large mass. After complete excision, the tumor typically does not recur.2

The angiolipoma in our case presented with melena and anaemia requiring whole blood  transfusion. Endoscopy revealed polypoid mass with recent bleeding. As the lesion was submucosal, endoscopic biopsy failed to diagnose the tumour. A well circumscribed submucosal lipoma was identified on abdominal CT scan. After distal partial gastrectomy, final diagnosis  of gastric angiolipoma was made by histopathological examination by its typical morphological features.

Conclusion

Angiolipoma is a benign tumor, commonly occurring in subcutaneous tissue but rare in gastrointestinal tract. It is important to remember that submucosal polypoid lesions in GI tract with or without symptoms can be an angiolipoma, although it is quite rare.

 References

  1. Christopher DM, Fletcher C, Bridge JA, Hogendoorn PCW, Mertens F. WHO classification of Tumours of Soft Tissue and Bone. 4th ed.: IARC Press; 2013.
  2. Liu YJ, Karamchandani DM. Gastric Angiolipoma, a rare entity. Arch Pathol Lab Med. 2017; 141: 862-866.
  3. Chen YY and Soon MS. Preoperative diagnosis of colonic angiolipoma. World J Gastroenterol, 2005; 11(32): 5087-5089.
  4. Hang Y. and Zhu CQ. Angiolipoma of the colon. Journal of Digestive Diseases, 2014; 15: 154-157.
  5. Howard WR, Elson MC, Helwig B. Arch Dermatol, 1960; 82(6):924-931.
  6. Rogy MA, Mirza D, Berlakovich G, Winkelbauer F, Rauhs R. Submucous large-bowel lipomas: presentation and management. An 18-year study. Eur J Surg, 1991; 157(1): 51-55.
  7. Rosai J. Rosai and Ackerman’s Surgical Pathology. 10th ed.: Elsevier; 2011.
  8. Kacar S, Kuran S, Temucin T, Odemis B, Karadeniz N, Sasmaz N. Rectal angiolipoma: A case report and review of literature. World Journal of Gastroenterology, 2007; 13(9): 1460-1465.
  9. Wang L, Chen P, Zong L, Wang GY, Wang H. Colon angiolipoma with intussusception: a case report and literature review. World Journal of Surgical Oncology. 2013; 11: p. 69.
  10. Nam YH, Park SC, Kim HJ, Lee SW, Kim J, Choi DH, et al. Angiolipoma of the stomach presenting with anaemia. Przeglad Gastroenterologiczny. 2014; 9(6): 371-374.

 

Rising Trend of Adenocarcinoma of Cervix: A Global Perspective


Rising Trend of Adenocarcinoma of Cervix: A Global Perspective

*Akhter S,1 Khatun S2

 Abstract

Worldwide incidence of invasive cervical cancer including squamous cell carcinoma has been decreasing for the last 40 years, but incidence of adenocarcinoma of cervix shows a steady increase. This increase is mostly reported from the developed countries with organised cancer screening system and cancer registries. Human papillomavirus (HPV) has been established as the most important etiological factor for cervical cancers including adenocarcinoma. This review article discussed the epidemiological data from several articles including meta-analyses and international projects to give an overview of the increasing incidence of cervical adenocarcinoma throughout the world. The article then delved into the epidemiological studies that provided data regarding association of HPV with adenocarcinoma of cervix. It is evident from these studies that HPV types 16, 18 and 45 are responsible for more than 90% of adenocarcinoma of cervix. Differences in type specific HPV prevalence among countries might be the reason for the variation in the incidences of adenocarcinoma of cervix from region to region. The rising trend in the incidence of cervical adenocarcinoma can be explained as a cohort effect related to increased exposure to prevalent HPV infection in younger women, and also to less effective performance of cytology screening methods in detecting glandular lesions of cervix. In this context, the currently available prophylactic vaccines against HPV should come in the frontier to prevent occurrences of invasive cervical cancer including adenocarcinoma worldwide.

[Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):56-62]

 Key words: Cervical cancer, Adenocarcinoma, Incidence, Human papillomavirus

 

  1. *Dr. Shabnam Akhter, Associate Professor of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka. akhtershabnam66@gmail.com
  2. Shahana Khatun, Assistant Professor of Pathology, MH Samorita Hospital and Medical College, Dhaka

*For correspondence

 

Introduction

Worldwide incidence of invasive cervical cancer has been decreasing over the last 40 years owing to organised as well as opportunistic practices of cytology screening mostly in the developed countries.  Majority of cervical cancers are squamous cell carcinomas (SCC), while adenocarcinomas (ADC) are small in number. There is no doubt that cytology screening programs have lead to increased detection and early management of precursor lesions of cervical carcinoma. However, despite the decline in overall incidence of cervical cancer, several studies have reported increasing incidence of cervical ADC in comparison to SCC, particularly among younger women and mostly in the developed countries since the 1970’s.1-6

When German virologist Harold zur Hausen and his team, after their extensive works from 1972 to 1984, revealed their revolutionary discovery that human papillomavirus (HPV), notably HPV 16 and HPV 18, are causative agents of cervical cancer, subsequent researches related to cervical cancer were directed towards HPV. Several years later, Bosch et al. (1995)7 reported from their international survey that 93% of cervical cancers contained HPV DNA. They also found that the prevalence of HPV did not show variation between histologic subtypes of cervical cancer (SCC, ADC and adenosquamous carcinomas). By 1999, Walboomers et al.8 published their seminal studyfindings that the prevalence of HPV in cervical cancers was 99.7% worldwide, thus proclaiming that infection with high-risk HPV was central to the pathogenesis of almost all cervical cancers.

With this background this review article will give an overview of the changing trend of cervical ADC from the data provided by epidemiological studies. The studies are mostly from the developed countries of North America and Europe, while few international works have also included data from underdeveloped countries of Asia, Africa and South America.3,9 In the latter half of the article, the etiological aspect of cervical ADC will be discussed, that will include the role of HPV and other risk factors identified so far.

 Rising trend of adenocarcinoma of cervix

Peters et al.1 reported in 1986 about increase in the proportional incidence of ADC of the cervix during 1972-1982 among white women aged less than 35 years in Los Angeles County, California. The authors’ thought that this was due to use of oral contraceptives before the age of 20 years. Being intrigued by such observation, Schwartz and Weiss2 followed the rates of invasive cervical cancer by age, time period and histologic types between 1973 and 1982 among 8,647 women identified by the SEER (The Surveillance, Epidemiology, and End Results) program registries. They found that the incidence of ADC of the cervix in women under the age of 35 years had increased more than twofold between 1973 and 1982. They speculated that other potential risk factors related to sexual behaviour were also to be considered, as for example, in young women early age at first intercourse or increased number of sexual partners concurred with the early use of oral contraceptives.

Vizcaino et al. (1998)3 conducted a study with International Agency for Research on Cancer (IARC) to find out the time trends in the incidence of cervical ADC, particularly in young women. They collected incidence data on ADC and adenosquamous cell carcinoma during the period 1973-1991 from 60 population-based cancer registries of 32 defined populations in 25 countries. Their analyses focused three aspects of the incidence trend: age, calendar period of diagnosis and birth cohort. The final results reported a significant increase in incidence among women born after 1930 in the United States (white and Hispanic women), Canada, Australia, United Kingdom, Denmark, Sweden, Slovakia and Slovenia. Increasing trend was also observed in Bombay (Mumbai, India), in Japan (Osaka) and among Chinese women in Singapore. The analyses also showed that besides age, the increasing incidence was found related to year of birth, with each successive cohort showing higher risk at a given age compared with their precedent cohorts. However, a decreasing trend was also observed in Finland, France and Italy, and no significant changes in incidence were found in several other countries. The authors concluded that part of the increase might be due to an increasing prevalence of HPV infection and partly to increased detection of atypical glandular lesions by cytology screening.3

Later, Smith et al. (2000)4 used the SEER (The Surveillance, Epidemiology, and End Results) database to identify all cases of cervical cancer registered from 1973 to 1996 with the objective to find out the trends in the age-adjusted incidence of ADC of the uterine cervix relative to SCC in the United States. Their results showed that over 24 years the age-adjusted incidence rates decreased for all invasive cervical cancers by 36.9% and for SCC by 41.9%, but increased for ADC by 29.1%. The percentage of SCC relative to all cervical cancer had decreased from 76.21% (between 1973 and 1977) to 70.17% (between 1993 and 1996). On the other hand, percentage of ADC had increased from 12.4% (1973-1977) to 24.2% (1993-1996). The findings were all in favour of the fact that the absolute frequency as well as the relative frequency of ADC showing a rising trend.4

Subsequently Bray et al. (2005)5 carried out a study to examine the secular trends in the incidence of ADC of cervix in women ages <75 in 13 European countries using an age-period-cohort- model. The study reported that age-adjusted ADC incidence rates had increased throughout Europe, the rate of increase ranging from around 0.5% per year in Denmark, Sweden, and Switzerland to ≤3% in Finland, Slovakia and Slovenia. The increases were calculated first to affect generations born in the early 1930s through the mid-1940s, with risk rising in women born in the mid-1960s relative to those born 20 years earlier.5

Bulk et al. (2005)6 of Netherlands did a population-based study on the incidence of invasive cervical cancer to evaluate trends in relation to age at time of diagnosis. The cases were collected from the Netherlands Cancer Registry for all women with invasive cervical cancer between 1989 and 1998. The results depicted that in this 10-year period, the incidence of SCC had decreased substantially from 7.1/100,000 to 6.1/100,000, and the incidence of ADC overall remained static, but it had increased in women aged 15-29 and in women aged 30-44.6

 Etiological factors related to adenocarcinoma of cervix

ADC of cervix, like SCC, has been reported to be associated with high-risk HPV infection, which is considered to play the central role in cervical carcinogenesis.7-9 So, the etiological factors will be discussed in two parts, the first will be about the association of HPV in ADC of cervix, and the second part will encounter the postulated risk factors other than HPV infection.

 HPV and adenocarcinoma of cervix

With regard to increasing incidence of cervical ADC, Andersson et al. (2000)10 tried to find out the presence of HPV in diagnosed cases of ADC of cervix during 1986-1996, the cases identified through Swedish Cancer Registry. HPV was identified in 71% cases of ADC; in the HPV-positive cases, HPV18 was present in 52% and HPV16 in 33%. They also reported that the prevalence of HPV in ADC differed with age; women <40 years were HPV-positive in 89% of cases, while women ≥60 years were HPV-positive in 43% cases.

Clifford et al. (2003)11 carried out a meta-analysis and reported HPV18 to be the most frequent type (37.7%) in ADC followed by HPV 16 (31.3%) and HPV 45 (5-7%), whereas HPV 16 was the dominant type in SCC of cervix. On the other hand, the population-based study by An et al. (2005)12 in Korea revealed that HPV16 was the most frequent type followed by HPV 18, while overall HPV prevalence in the cervical ADC among Korean women was 90%.

To find out the extent to which HPV and cofactors may be responsible for the increasing trend of cervical ADC, Castellsague et al. (2006)13 examined eight case-control studies during 1985-1997 from eight different countries with differences in the incidence of cervical cancer. Countries were from North Africa, South America and Southeast Asia. They found HPV to be the main risk factor, prevalence ranging from 86% in Paraguay to 100% in Algeria. HPV16 and HPV18 were the most dominant HPV types, together being present in 82% of the cases.

International Collaboration of Epidemiological Studies of Cervical Cancer (2006)14 conducted a collaborative reanalysis from 12 epidemiological studies. Their analyses revealed that HPV16 was the commonest type in both SCC and ADC of cervix. However, HPV16 was more common in SCC (56% versus 40%) whereas HPV18 was more common in ADC (35% versus 16%). Similarly, Smith et al. (2007)15 published their meta-analysis update on HPV type distribution covering six continents where they reported that HPV positivity overall was a little more in SCC (90%) than in ADC (85%), HPV16 was less frequent in ADC (33%) and more frequent in SCC (55%), and HPV18 was the dominant type in ADC (37%) compared with SCC (13%). They also found that HPV 16/18 proportion was higher in Europe, North America and Ocenia (74-77%) than in Africa, Asia and South/Central America (65-70%).

On behalf of the Retrospective International Survey and HPV Time Trends Study Group, Silvia de Sanjose (2010)16 completed an international project with the aim to provide distribution pattern of HPV genotypes in samples of invasive cervical cancer. Samples were collected covering 38 countries from Europe (10), North America (USA), central South America (10), Africa, Australia and Asia (12 including Bangladesh). From the analyses of data, they found that HPV types 16, 18 and 45 were the three most common types in each histological type of SCC, ADC and adenosquamous cell carcinoma of cervix. Both HPV18 and HPV45 were more common in ADC than in SCC. The other intriguing finding was that cancers related to HPV18 and HPV45 occurred at a much younger age (<50 years). The early presentation of invasive cancers in these cases indicates that these virus types possibly require a short time of progression to invasive cancer with a high integration rate into the host genome.

Afterwards, Pirog et al. (2014)17 did a worldwide analysis of HPV prevalence and genotypes in different histological subtypes of cervical ADC. They found that relatively narrow spectrum of high-risk HPV types, HPVs 16, 18 and 45 were present in the vast majority of ADC, together constituting 94.1% of HPV-positive cases. In contrast to the earlier meta-analyses by Clifford et al. (2003)11 and Smith et al. (2007)15, they found HPV16 to be the most frequent type (50.9%) followed by HPV18 (31.6%) and HPV 45 (11.6%) in HPV-positive ADC cases. Though the ratio of HPV16 to HPV18 in ADC varied from study to study, the percentage of combined HPV16 and HPV18-positive cases were found much uniform among studies (75.7-94.8% of cases) with an average of 89.8%.

To find out the HPV subtypes in cervical ADC in women of Bangladesh, Akhter et al. (unpublished data, presented as poster at the Annual meeting of USCAP 2017)18 studied 71 cases of cervical ADC. The results showed that, in contrast to western countries, HPV16 was the most frequent type (63.4%) followed by HPV18 in 16.9%. HPV DNA was detected in 100% cases. These data indicate a significant epidemiological difference in the type-specific prevalence of HPV between the developed and underdeveloped countries.

 Risk factors other than HPV infection

The other risk factors for ADC are more or less similar to those for cervical cancer in general, being related to factors that promote spread of HPV infection from person to person as any other sexually transmitted disease.

Several studies12,14,19-21 have worked with risk factors associated with cervical ADC in comparison to SCC. The notable risk factors other than HPV are described in the following sections.

  1. Lifetime number of sexual partners was reported to show strong association with both SCC and ADC, risk of cancer increasing with the increasing number of partners.12,14,19-21
  2. Earlier age at first intercourse was found to be associated with increased risk of both SCC and ADC of cervix, the association being stronger for SCC.12,14,19-21
  3. Longer duration of use of oral contraceptives was reported to be strongly related to risk for both SCC and ADC.12,14,19-22
  4. Smoking was considered a risk factor for SCC compared to never smokers whereas it was found not to be a risk for adenocarcinoma. 12,14,19-21
  5. High parity showed significant association with both SCC and ADC (three or more live births or full-time pregnancies versus none), the association being stronger for SCC. 12,14,19-21
  6. Herpes simplex virus type 2 (HSV-2) seropositivity was reported to be associated with a more than twofold increase in the risk of cervical ADC.12

 Conclusions

The review discussions have highlighted infection with high-risk HPV as the most important etiological factor for cervical ADC. In terms of type specific prevalence, HPVs 16, 18 and 45 are reported to be responsible for more than 90% of ADC of cervix. Differences in type specific HPV prevalence among countries may be responsible for the variation in the incidences of ADC of cervix from region to region. The rising trend in the incidence of cervical ADC can be explained as a cohort effect related to increased exposure to prevalent HPV infection in younger women, and also to less effective performance of cytology screening methods in detecting glandular lesions of cervix. In this context, the currently available prophylactic vaccines against HPV should come in the frontier to prevent occurrences of invasive cervical cancer including adenocarcinoma of cervix worldwide.

 References

  1. Peters RK, Chao A, Mack TM, et al. Increased frequency of adenocarcinoma of the uterine cervix in young women in Los Angeles County. JNCI 1986; 76:423-8.
  2. Schwartz SM and Weiss NS. Increased incidence of adenocarcinoma of the cervix in young women in the United States. American Journal of Epidemiology 1986;124(6): 1045-47.
  3. Vizcaino AP, Moreno V, Bosch FX, Munoz N, Barros-Dios XM and Parkin DM. IARC. International trends in the incidence of cervical cancer: I. Adenocarcinoma and adenosquamous cell carcinomas. International Journal of Cancer 1998; 75: 536-545.
  4. Smith HO,Tiffany MF, Qualls CR and Key CR. The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States – A 24-year population-based study. Gynecologic Oncology 2000; 78: 97-105.
  5. Bray F, Carstensen B, Moller H, Zappa M, Zakelj MP, Lawrence G et. al. Incidence trends of adenocarcinoma of the cervix in 13 European countries. Cancer Epidemiol Biomarkers Prev 2005; 14(9): 2191-99.
  6. Bulk S, Visser O, Rozendaal L, Verheijen RH, Meijer CJ. Cervical cancer in the Netherlands 1989-1998: decrease of squamous cell carcinoma in older women, increase of adenocarcinoma in younger women. Int J Cancer 2005; 113:1005-1009
  7. Bosch FX, Manos MM, Munoz N, Sherman M, Jansen AM, Peto J et al. Prevalence of human papillomavirus in cervical cancer: a worldwide perspective. JNCI 1995;87(11):796-802
  8. Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 1999; 189(1): 12-19.
  9. Parkin DM and Bray F. Chapter 2: The burden of HPV-related cancers. Vaccine 2006. Doi: 10.1016/j.vaccine.2006.05.111
  10. Andersson S, Rylander E, Larsson B, Strand A, Silfversvard C, Wilander E. The role of human papillomavirus in cervical adenocarcinoma carcinogenesis. European Journal of Cancer 2001;37:246-250.
  11. Clifford GM, Smith JS, Plummer M, Munoz N and Franceschi S. Human papillomavirus types in invasive cervical cancer worldwide: a meta-analysis. Br J Cancer 2003; 88: 63-73.
  12. Castellsague X, Diaz M, Sanjose S, Munoz N, Herrero R, Franceschi S et al. Worldwide human papillomavirus etiology of cervical adenocarcinoma and its cofactors: Implications for screening and prevention. Journal of the National Cancer Institute 2006; 98(5): 303-315
  13. An HJ, Kim KR, Kim IS, Kim DW, Park MH, Park IA et al. Prevalence of human papillomavirus DNA in various histological subtypes of cervical adenocarcinoma: a population-based study. Modern Pathol 2005;18:528-534.
  14. International Collaboration of Epidemiological Studies of Cervical Cancer. Comparison of risk factors for invasive squamous cell carcinoma and adenocarcinoma of the cervix: Collaborative reanalysis of individual data on 8,097 women with squamous cell carcinoma and 1,374 women with adenocarcinoma from 12 epidemiological studies. Int. J. Cancer 2006;120:885-891.
  15. Smith JS, Lindsay L, Hoots B, Keys J, Franceschi S, Winer R. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: A meta-analysis update. Int. J. Cancer 2007;121:621-632.
  16. Silvia de Sanjose, Quint WGV, Alemany L, Geraets DT, Klaustermeier JE, Lloveras B et al. on behalf of the Retrospective International Survey and HPV Time Trends Study Group. Human papillomavirus genotype attribution in invasive cervical cancer: a retrospective cross-sectional worldwide study. Lancet Oncol 2010; 11:1048-56.
  17. Pirog EC, Lloveras B, Molijin A, Tous S, Guimera N, Alejo M et al. HPV prevalence and genotypes in different histological subtypes of cervical adenocarcinoma, a worldwide analysis of 760 cases. Modern Pathol 2014; 27: 1559-67.
  18. Akhter S, Kamal M, Barua AR, Sung CJ, Lawrence WD, Quddus MR. Adenocarcinoma of cervix is surging: Is high-risk HPV subtype(s) infection pattern changing in a cervical carcinoma prevalent developing country? A retrospective PCR-based study. Poster presentation at the Annual Meeting of USCAP 2017. San Antonio, Texas, USA
  19. Green J, Berrington de Gonzalez A, Sweetland S, Beral V, Chilvers C, Crossley B et al. Risk factors for adenocarcinoma and squamous cell carcinoma of the cervix in women aged 20-44 years: the UK National case-control study of cervical cancer. Br J Cancer 2003;89:2078-2086.
  20. Berrington de Gonzalez A, Seetland S and Green J. Comparison of risk factors for squamous cell and adenocarcinomas of the cervix: a meta-analysis. Br J Cancer 2004;90:1787-1791.
  21. Altekruse SF, Lacey JV, Brinton LA, Gravitt PE, Silverberg SG et al. Comparison of human papillomavirus genotypes, sexual, and reproductive risk factors of cervical adenocarcinoma and squamous cell carcinoma: Northeastern United States. Am J Obstet Gynecol 2003;188:657-63.
  22. Lacey JV Jr, Brinton LA, Abbas FM, Barnes WA, Gravitt PE, Greenberg MD et al. Oral contraceptives as risk factors for cervical adenocarcinomas and squamous cell carcinomas. Cancer Epidemiol Biomarkers Prev 1999;8:1079-85.