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   Table of Contents - Current issue
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October-December 2018
Volume 61 | Issue 4
Page Nos. 475-646

Online since Wednesday, October 10, 2018

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EDITORIAL  

From Editor's desk Highly accessed article p. 475
Ranjan Agrawal
DOI:10.4103/0377-4929.243011  PMID:30303131
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GUEST EDITORIAL Top

Evaluation of CD4+ T-cells and CD8+ T-cells in triple-negative invasive breast cancer Highly accessed article p. 477
Sunil Vitthalrao Jagtap
DOI:10.4103/IJPM.IJPM_201_18  PMID:30303132
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ORIGINAL ARTICLES Top

Expression of α-smooth muscle actin in benign and malignant salivary gland tumors: An immunohistochemical study Highly accessed article p. 479
Mahalakshmi Ravi, Karen Boaz, Srikant Natarajan, Amitha Lewis, Mukul Prasad, Swetha Yellapurkar
DOI:10.4103/IJPM.IJPM_482_17  PMID:30303133
Background and Objectives: Myoepithelial cells (ME) are known to contribute in the patterning of salivary gland neoplasms (SGN) and possess cytoplasmic smooth muscle actin (SMA) revealed by alpha SMA (α-SMA). The present study aimed to assess the expression of α-SMA in selected benign and malignant SGN (pleomorphic adenoma javascript:window.print();, mucoepidermoid carcinoma (MEC), adenoid cystic carcinoma (ACC), and polymorphous low-grade adenocarcinoma (PLGA). Materials and Methods: The intensity and pattern of expression of α-SMA were studied in 25 cases of SGN's ACC (n = 7), MEC (n = 8), PA (n = 8), and PLGA (n = 2), and correlated with the histological patterns. Results: Maximum expression of α-SMA in the epithelial compartment was seen in ACC, followed by PA, whereas MEC and PLGA showed completely negative staining. The connective tissue expression was mild in ACC and MEC. The myxoid stroma of PA with “melting” pattern was weakly positive for α-SMA. The stroma in PLGA showed complete negativity. In ACC, α-SMA-positive cells were lining the cribriform spaces, small islands, and dispersed within large islands. Small nests showed complete positivity for α-SMA. Interpretation and Conclusion: In ACC, α-SMA expression supports the involvement of ME in epithelial organization explaining the histological patterns seen. In PA, the expression correlates with the predominantly secretory nature of ME. The absence of epithelial positivity in MEC and PLGA suggest that ME has less role to play in their histogenesis. The weak stromal positivity observed in MEC and ACC may be attributed to the positive immunoreactivity of myofibroblasts playing a role in modulating the course of SGN's.
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C-cell hyperplasia in sporadic and familial medullary thyroid carcinoma Highly accessed article p. 485
Mahima Yadav, Vinita Agrawal, Krushna Chandra Pani, Ritu Verma, Sushila Jaiswal, Anjali Mishra, Rakesh Pandey
DOI:10.4103/IJPM.IJPM_478_17  PMID:30303134
Context: C-cell hyperplasia (CCH) is characterized by increased mass of C-cells and has been identified as a precursor condition for medullary thyroid carcinoma (MTC). Varying proportion of MTCs is associated with CCH in different studies. This could be due to the lack of uniformity of the definitions and techniques used to identify CCH in these studies. Aims: This study aims to study the occurrence, clinicopathological, and immunohistochemical features of CCH in MTC diagnosed during a 22-year period at a tertiary care center in North India and to review the available literature on CCH. Materials and Methods: Eighty-seven consecutive cases of MTC were included in the study. Histological evaluation for the presence of CCH and neoplastic CCH was performed. Confirmation of CCH was done by immunohistochemistry for calcitonin and chromogranin. The presence of neoplastic CCH was correlated with clinical factors and prognostic factors. Results: Of 87 cases of MTC included in the study, 71 (82%) patients were sporadic and 16 (18%) had familial MTC. Neoplastic CCH was seen in 12 (75%) familial and in 9 (13%) sporadic MTC. Patients with familial MTC were more frequently associated with neoplastic CCH than sporadic MTC (P < 0.001), were younger (P < 0.001), and had more often bilateral and multifocal tumors (P < 0.001). However, there was no significant difference in mean survival time and progression-free survival in patients with and without CCH. Conclusion: CCH, though more common in familial MTC, can also be seen in sporadic tumors. CCH is not associated with patient survival and disease progression.
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A prospective study of association of cancer stem cell marker aldehyde dehydrogenase 1 with clinicopathological profile in lung carcinoma patients p. 489
Neema Tiwari, Anand N Srivastava, Nishi Tandon, Nirupma Lal, Shailendra Yadav, Surya Kant, Manoj Jain
DOI:10.4103/IJPM.IJPM_318_17  PMID:30303135
Context: In India, lung carcinoma is the fifth-most common tumor and second-most common tumor in the males as per the Indian Council of Medical Research registry of 2002. It has been seen that ALDH1 expression in non-small cell lung cancer (NSCLC) and the presence of marker was linked to a more tumorigenic potential in the in vivo assessment and shorter disease-free survival in NSCLC patients with platinum treatment. Aims: Hence, our objective was to detect association of cancer stem cell (CSC) marker aldehyde dehydrogenase 1 (ALDH1) with clinicopathological profile in lung carcinoma patients. Settings and Design: This is a Pilot study. Subjects and Methods: It was a Pilot study where biopsies from 55 fresh previously untreated lung cancer patients visiting the Pulmonary Medicine Department of Era's Lucknow Medical College and Hospital Lucknow and King George's Medical University were taken for 18 months November 2014–April 2016, after taking proper informed consent from them. Paraffin blocks were taken and stained by hematoxylin and eosin (Sigma) to make the histopathological diagnosis and immunohistochemistry was done for detection of CSC marker ALDH1 (Daco). Statistical Analysis Used: The statistical analysis was done using Statistical Package for Social Sciences Version 15.0 Statistical Analysis Software. The values were represented in number (%) and mean ± standard deviation. Results: Expression of stem cell marker ALDH1 with the staging of the tumor was observed in 62.5% of Stage I, 80% of Stage II, 94.1% of Stage III, and 100% of Stage IV cases. Statistically, there was a significant association between ALDH1expression and stage of disease (P < 0.001). Diagnostic efficacy of ALDH1 expression in the detection of any positive clinical stage, it was found to be 88.6% sensitive and 90.9% specific. Conclusions: Strong ALDH1 expression correlates with higher stage of lung carcinoma making it a prognostic marker needing in-depth study.
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An autopsy based descriptive study of the spectrum of pulmonary lesions encountered in fetal deaths at a tertiary care center p. 495
Saara Neeha, Santosh Rao Kattimani, Anita A Mahanta, Anuradha G Patil
DOI:10.4103/IJPM.IJPM_461_17  PMID:30303136
Background: Fetal autopsy has been an indispensable tool in evaluating the cause of death. The most common cause for fetal deaths is associated with respiratory disorders accounting for around 60%. This study was undertaken to evaluate the gross and microscopic features of lungs in fetal autopsies and estimate the incidence of deaths attributable to pulmonary causes. Materials and Methods: All fetuses received for autopsy at our institute were included in the study with prior consent. Gross and microscopic findings along with relevant clinical data were recorded. Results: A total of 426 autopsies were conducted from January 2011 to August 2016. Of those, 184 had abnormal pulmonary findings constituting 43.19%. Aspiration pneumonia was the most common finding with 67 cases (36.4%), followed by atelectasis 54 cases (29.3%), congenital cystic adenomatoid malformation in 13 cases (7.1%), lung hypoplasia 12 cases (6.5%), pulmonary hemorrhage 21 (11.4%), 15 cases (8.15%) of hyaline membrane disease, one case (0.5%) of heterotaxy, and one case of extralobar pulmonary sequestration (0.5%). Congenital malformations of lungs were seen in 27 (14.67%) cases and 38 cases (20.65%) had other associated anomalies. Conclusion: Pulmonary pathology is the most common finding in fetal deaths with aspiration pneumonitis being the most common avoidable cause. Accurate fetal autopsy along with clinical data are important in evaluating fetal deaths and can help in reduction of unexplained stillbirths.
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Evaluation of CD30/CD4/CD8 in triple-negative invasive ductal carcinoma of breast in association with clinicopathological prognostic factors p. 500
Amir Hossein Jafarian, Aida Tasbandi, Hamed Gilan, Maryam Sheikhi, Nema Mohamadian Roshan
DOI:10.4103/IJPM.IJPM_67_18  PMID:30303137
Background: Triple-negative breast cancer (TNBC) lacks the benefits of receptor-targeted therapeutic strategies. The limitations in treatment options along with poor patients' outcome heighten the need for novel approaches. Due to recent concentration on the role of biomarkers in prognosis, treatment, and survival of various cancer subtypes, this study involves an investigation of CD4, CD8, and CD30 markers detected by immunohistochemistry in TNBCs and their association with clinicopathological and prognostic factors. Materials and Methods: Tissue samples of 85 hormone receptor- and human epidermal growth factor receptor-2-negative ductal breast carcinomas extracted from the archive of pathology department. Regarding CD4/CD8 ratio, the infiltrated T-lymphocytes were investigated. The tumoral tissue regions were also identified to be immunohistochemically assessed for the CD30 expression levels. Results: With an elevated CD4/CD8 ratio, a significant increase in lymph node involvement was observed (P < 0.05); in contrast, increased expression levels of CD8 were related to significant reduction of lymph node involvement. CD30 overexpression was found to be significantly associated with shortened overall survival (OS) and highly involvement of lymph nodes. Conclusion: Following the progression in stage and grade of tumor, CD4/CD8 ratio and CD30 expression levels are increased and are accompanied by adverse prognosis and poor OS, while CD8-enhanced expression carries a favorable prognostic impact as it improves OS status. Therefore, all these findings could be of interest in the field of target therapy.
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Prognostic indices predictive of short-term disease-free survival of breast carcinoma patients receiving primary surgical treatment in Sri Lanka p. 505
Harshima Disvini Wijesinghe, Poobalasingham Thuvarakan, Anandi Samarasekera, Menaka Dilani S. Lokuhetty
DOI:10.4103/IJPM.IJPM_321_17  PMID:30303138
Background: Breast carcinoma (BCa) is the commonest malignancy among women worldwide and in Sri Lanka. Several prognostic indices are described for BCa. Aims: To assess clinicopathological features and prognostic indices derived from routine clinical, histopathological and immunohistochemical (IHC) data, in a cohort of patients undergoing primary surgery for BCa and to determine their prognostic impact on short-term disease free survival. Setting and Design: This is a bidirectional cohort study of 208 women undergoing primary surgery for BCa at the National Hospital of Sri Lanka, from 2012-2014, excluding post-neoadjuvant chemotherapy cases. Material and Methods: Clinical details, tumor size and nodal status were obtained from histopathology reports. Histopathology and estrogen/progesterone receptor and HER2 status were reviewed. Molecular subtype based on IHC was determined. Nodal ratio (number of positive nodes/total number retrieved) and Nottingham prognostic index were calculated. Follow up information was obtained by patient interviews and record review. Statistical Analysis: Data was analyzed by univariate and multivariate Cox regression using SPSS19.0. Results: Mean follow-up duration was 27.16 months (0.5-52 months, s = 9.35 months). 174 (82.9%) remained disease free with 19 (9%) deaths. Thirteen (6.2%) survived with metastasis and 4 (1.9%) with recurrences. On univariate Cox regression, tumor, nodal and TNM stages, nodal ratio and lymphovascular invasion (LVI) were predictive of disease free survival (DFS) (P = 0.001, P = 0.021, P = 0.022, P = 0.002, P = 0.018). On multivariate analysis TNM stage and LVI were predictive of DFS. Conclusion: TNM stage and LVI were the most important predictors of short-term disease free survival in this study population, confirming that early detection of BCa at a lower stage has a significant impact on short-term outcomes.
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Diagnostic utility of CD10 immunohistochemical staining on cellblock in differentiating hepatocellular carcinoma from secondary malignancies of liver p. 510
Joydeb Singha, Kalyan Khan, Souvik Chatterjee
DOI:10.4103/IJPM.IJPM_788_16  PMID:30303139
Background: Differentiation of hepatocellular carcinoma (HCC) from metastatic malignancy in liver may be difficult at times on fine-needle aspiration cytology, especially in case of moderate-to-poorly differentiated tumors. The benefit of cell-block technique is the recognition of histologic pattern of diseases along with application of a wide variety of immunohistochemical (IHC) stains to differentiate hepatic malignancies. In this study, CD10 IHC staining was done on cellblocks prepared from aspirates of clinicoradiologically/cytologically suspected malignant liver neoplasms to differentiate HCC from malignancies metastasizing to liver. Objective: The objective of the study was to assess the diagnostic utility of CD10 IHC stain on cell-block preparation for differentiating primary from Secondary malignancies of liver. Materials and Methods: Formalin-fixed, paraffin-embedded cellblocks of 61 cases (25 cases of HCC and 36 cases of metastatic carcinoma) were prepared from a fine-needle aspirate of the suspected malignant liver neoplasm and immunostained using monoclonal antibody against CD10. Results: Twenty-two (88%) of 25 cases of HCC were positive for CD10 with a canalicular staining pattern. Two (8%) were positive for CD10 with membranous and one (4%) with cytoplasmic staining pattern. Conclusion: CD10 immunostaining on cellblock is useful in discriminating HCC and metastatic carcinoma of the liver with a diagnostic accuracy of 88.52%.
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Intracholecystic papillary–tubular neoplasm of gallbladder: A 5-year retrospective pathological study p. 516
Prabir Hazarika, Manoj Kumar Sharma
DOI:10.4103/IJPM.IJPM_489_17  PMID:30303140
Background: Intracholecystic papillary–tubular neoplasm (ICPN) is a relatively new entity which includes neoplastic polyps, adenomas, and papillary neoplasms that are ≥1.0 cm. This study is done to evaluate the pathological features of ICPN and to find out the factors associated with invasion. Materials and Methods: This is a 5-year retrospective study in a referral pathology center. A total of 19 cases of ICPN are found. The cases are analyzed for age and sex distribution, clinical suspicion, stages, histological architecture, differentiation, and grade of dysplasia. Descriptive statistics and test of significance by Chi-square and t-test are used in the study. Results: ICPN comprises 23.5% of all gallbladder neoplasms. Two-thirds of the cases were suspected radiologically. Age range is 26–65 years with mean age of 50 years. They are 2.8 times more common in female. Approximately one-third of the cases show invasion. The most common histological pattern is papillary, followed by papillary–tubular and finally by tubular pattern. Pyloric and biliary are the most common differentiation pattern followed by oncocytic and intestinal pattern. About three-fourths of the cases are associated with high-grade dysplasia mostly diffuse high-grade dysplasia. Conclusion: We have found the younger age of presentation, less proportion of invasive tumors, fewer tumors with biliary phenotypes, and fewer tumors with high-grade dysplasia as compared to previous studies. Factors significantly associated with invasion are grade and extent of dysplasia particularly diffuse high-grade dysplasia.
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Prevalence estimation of microsatellite instability in colorectal cancers using tissue microarray based methods – A tertiary care center experience p. 520
Sonali Susmita Nayak, Paromita Roy, Neeraj Arora, Indu Arun, Manas Kumar Roy, Sudeep Banerjee, Indranil Mallick, Mohandas K Mallath
DOI:10.4103/IJPM.IJPM_430_17  PMID:30303141
Aim: Microsatellite instability (MSI) pathway is known to be implicated in carcinogenesis of 15% colorectal carcinomas (CRC), including 2%–3% of cases of Lynch syndrome, as per western literature. MSI status has important prognostic and therapeutic implications. The prevalence of MSI in Indian CRC patients is unknown. We aimed to determine the prevalence by studying 231 consecutive unselected cases of CRC. Methods: Tissue microarrays using duplicate cores per case for 141 cases, and whole tissue sections for 90 cases, were used. Immunohistochemistry with four mismatch repair (MMR) markers – MLH1, MSH2, MSH6, and PMS2 was performed. Molecular analysis for MSI status was performed in 18 randomly selected cases. Correlation with various clinical and histopathological features was done using univariate and multivariate analysis. Results: Loss of MMR immunohistochemical (IHC) was seen in 53/231 cases, i.e. 22.94% (95% confidence interval 17.52%–28.36%). MLH1-PMS2 dual loss comprised 13.9%, MSH2-MSH6 7.4%, and isolated PMS2 loss in 1.73% of cases. Univariate analysis showed significant association with age (<60 years), right-sided tumor location, histologic type, high grade, the presence of severe intratumoral lymphocytic (ITL) and peri-tumoral lymphocytic response, and N0 nodal stage. On multivariate analysis, independent variables were age < 60 years, right-sided location, and severe ITL. Molecular testing for MSI corroborated with the IHC results. Conclusion: The study results show a slightly higher prevalence of MSI-H phenotype, compared to Western literature, stressing the need for more widespread testing for better clinical management and identification of possible hereditary colon cancer syndrome.
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Evaluation of topoisomerase II, ki-67, and P53 expression in non-muscle-invasive urothelial carcinoma and their clinical significance p. 526
Noha Elkady, Mohamed Sultan, Enas Elkhouly
DOI:10.4103/IJPM.IJPM_588_17  PMID:30303142
Background: Transurethral resection of tumor is the main treatment of non-muscle-invasive urothelial carcinoma, but it is associated with high rate of recurrence and/or progression and this arouses the need for adjuvant therapy. Topoisomerase II (Top II), KI-67, and P53 are proliferation and cell cycle regulation markers that may predict tumor response to therapy. Aim: This study aimed to assess Top II, KI-67, and P53 expression and their effect on clinical outcome and response to therapy of non-muscle-invasive urothelial carcinoma. Materials and Methods: Fifty cases of non-muscle invasive urothelial carcinoma were collected; Top II, KI-67, and P53 expression was evaluated. Patients received treatment then tumor recurrence was correlated with the expression of previous markers. Results: There was a significant association between high Top II score, P53, and KI-67 and high tumor grade (P = 0.0001, 0.001, and 0.0001), submucosal infiltration (P = 0.0001 and 0.01), and recurrence (P = 0.01, 0.001, and 0.001). Conclusion: Top II, P53, and KI-67 may predict tumor response to therapy and the clinical outcome in non-muscle-invasive urothelial carcinoma.
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BRAFV600E mutation in hairy cell leukemia: A single-center experience p. 532
Asma Bibi, Shrutika Java, Shruti Chaudhary, Swapnali Joshi, Russel Mascerhenas, Nikhil Rabade, Prashant Tembhare, Papagudi Ganesan Subramanian, Sumeet Gujral, Hari Menon, Navin Khattry, Manju Sengar, Bhausaheb Bagal, Hasmukh Jain, Nikhil Patkar
DOI:10.4103/IJPM.IJPM_484_16  PMID:30303143
Background: BRAFV600E mutation has been reported as a unique genetic lesion of hairy cell leukemia (HCL), a subset of which lacks this lesion and shows adverse outcomes. Aims: To determine the prevalence of BRAFV600E in HCL from our center and derive clinicopathological correlation, if any. Materials and Methods: A 9-year retrospective analysis of 46 consecutive cases of HCL diagnosed on morphology and immunophenotyping was done. Stained smears were used as samples for amplification refractory mutation system polymerase-chain reaction using fluorescent primers for mutation detection. Results: BRAFV600E mutation was detected in 41/46 patients (89.1%) while absent in control samples of chronic lymphocytic leukemia. Cases mimicking HCL-variant clinically or immunophenotypically too showed the presence of this mutation. HCL with mutated BRAF presented at a younger age. No statistical difference in blood counts, tumor load, and immunophenotype patterns existed among BRAF mutated and unmutated group. Nine patients (45%) with mutated BRAF had residual disease following treatment with cladribine. Conclusion: BRAFV600E mutation analysis has a definitive role in the diagnosis of HCL.
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Student perception of peer teaching and learning in pathology: A qualitative analysis of modified seminars, fishbowls, and interactive classroom activities p. 537
Sumit Grover, Neena Sood, Anurag Chaudhary
DOI:10.4103/IJPM.IJPM_297_17  PMID:30303144
Context: Peer-assisted teaching and learning (PTL) is being experimented in different medical universities worldwide. It is a learner-centered approach involving students through active learning strategies. Aims: To study the student perception of PTL in methods such as group-led seminars and fishbowls, in classroom through various interactive activities; compare and find out the student acceptability and efficacy of each of these methods in learning conceptual topics such as various types of anemia. Subjects and Methods: Medical students of second-year professional course were subjected to PTL in classroom during allotted teaching hours for 10 successive sessions using group-led modified seminars, fishbowls, and different formality-level interactive activities such as street plays, prop sessions, quiz sessions, to make them understand the clinical features and presentation of different types of anemia through understanding of etio-pathogenesis. To ascertain the aspects that influenced learning, focus group discussions were conducted in small groups consisting of 14 students and one facilitator in each group. Qualitative thematic analysis was performed on transcripts of the audio recordings by authors. Results: The emerging themes from qualitative analysis of transcripts were pertaining to teacher, student, and organization. We found motivation, interest, and involvement of peer teacher, student behavior and collaboration, contact time between students and facilitator, preparation time, coherence with other curricular activities, group size and composition, suitability of topic for the kind of activity, and availability of material for preparation as few sub-aspects affecting learning. Conclusion: For PTL to be effective, adequate transfer of knowledge through good peer teacher involvement, learner receptiveness, and adequate contact time is needed. Proper preparation with suitability of topics for the type of activity, alignment of seminars with other activities, and course coherence are prerequisites for the same.
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Infective endocarditis due to Streptococci and Enterococci: A 3-year retrospective study p. 545
Kavita Raja, Molly Antony, S Harikrishnan
DOI:10.4103/IJPM.IJPM_205_17  PMID:30303145
Introduction: Infective endocarditis (IE) is an infection of the heart valves with an aggregation of bacteria in a fibrin plaque called vegetation. Aims and Objectives: This is a retrospective study of all infective endocarditis cases due to alpha haemolytic streptococci and enterococci. Methods: All cases of infective endocarditis cases due to alpha haemolytic streptococci and enterococci in a period of three years from 1st January 2010 to 31st December 2012 were included. Isolation of the same organism from more than one set of blood cultures was taken as a confirmed case of infective endocarditis. Clinical and serological parameters were recorded using a proforma. Results: Native valve endocarditis was more common with only five prosthetic valves being involved. Out of 89 clinically suspected cases of IE in the three years from Jan 2010 to Dec 2012, for which blood was sent for culture, 63(70.78%) samples were positive by culture. Of these, 42/63(66.66%) were due to alpha-lytic Streptococci, enterococci and rare gram positive cocci. The rare ones included Enterococcus gallinarum, abiotropha defective, Vagococcus fluvialis and Nutritionally Variant Streptococci(NVS). High level Aminoglycoside resistance(HLAR) was also encountered. The varied and important features of these isolates are discussed. Complications and treatment are described. Conclusion: From a clinical microbiology point of view, the major challenge faced by the microbiologist in diagnosis of IE is proper aseptic collection of sample before starting antibiotics with a need for multiple samples to detect and also to prove the causative organism. Sensitivity reporting can be a difficult task in the context of NVS, HLAR and gram positives that are slow growing. Congestive failure and embolisation occurs even when the antibiotic treatment is successful.When patients go in for complications, it is very rarely due to wrong antibiotics.
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BRIEF COMMUNICATIONS Top

The clinicopathologic and immunohistochemical features of villoglandular adenocarcinoma of uterine cervix p. 549
Zhuo-Ya Huang, Sisi Zhang, Yao-Zhong Zhang, Jian-Hong An, Jiao Luo, Peng-Juan Liao, Qing Chen, Hong Shen
DOI:10.4103/IJPM.IJPM_144_18  PMID:30303146
Aim: Villoglandular adenocarcinoma (VGA) of the uterine cervix is a variant of endocervical adenocarcinoma. However, the clinicopathologic and immunohistochemical features of VGA are still unclear. The aim of this study was to investigate the clinicopathologic and immunohistochemical features of VGA. Materials and Methods: A total of 20 VGA patients were identified among 852 patients diagnosed with cervical cancer and enrolled in this study. The immunohistochemical levels of Ki-67, P53, P16, progesterone receptor (PR), carcinoembryonic antigen (CEA), vimentin (Vim), and estrogen receptor (ER) were measured by immunohistochemistry. Results: VGA was prevalent in younger women and presented favorable prognosis. Ki-67, P16, and CEA were highly expressed in VGA tissues, while PR expression was hardly to be detected. The positive rates of Ki-67, CEA, and P16 were 90.0%, 90.0%, and 85.0%, respectively, which were significantly higher compared with PR (5.0%, P < 0.001). In addition, the positive rates of P53, Vim, and ER in VGA tissues were 55.0%, 50.0%, and 40.0%, respectively. However, the expression levels of Ki-67, P53, P16, PR, CEA, Vim, and ER were not significantly associated with clinical features (P > 0.05). Conclusion: These data indicate that VGA is a rare cervical adenocarcinoma, which is prevalent in younger women, and presents favorable prognosis. Detection of Ki-67, P53, P16, PR, CEA, Vim, and ER would be beneficial for the diagnosis of VGA.
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Adult T-cell leukemia/lymphoma and acquired immunodeficiency syndrome - CD4+ T-cell malignancy in CD4+ T-cell deficient status: A paradox p. 553
Manu Goyal, M Dinaker, K Gayathri
DOI:10.4103/IJPM.IJPM_119_17  PMID:30303147
CD4 counts along with viral loads are important parameters in the monitoring of human immunodeficiency virus (HIV) infection. Human T-cell lymphotropic virus type I (HTLV-I) is known to be an etiological agent for adult T-cell leukemia/lymphoma (ATLL). Coinfection of HTLV-I and HIV is well known in regions with high seroprevalence, and there is no published data in the Indian scenario. We present an interesting case of occurrence of CD4+ T-cell proliferation in a known beta thalassemia major with acquired HIV seropositivity accompanied by simultaneously increasing CD4+ counts and viral loads. Further workup revealed ATLL with an underlying HTLV infection.
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Chronic granulomatous disease presenting with small bone osteomyelitis in a young child: A case report p. 557
Preethi S Chari, Prathap Chandra, Sujay Prasad, Sagar Bhattad
DOI:10.4103/IJPM.IJPM_458_17  PMID:30303148
Chronic granulomatous disease (CGD) is a life threatening inherited disorder with varied clinical presentations often characterized by recurrent bacterial and fungal infections along with widespread granulomatous tissue response. The disease results from phagocytic defects characterized by deficiencies in oxidative burst of neutrophils. Nitroblue tetrazolium reduction test (NBT) and Dihydrorhodamine (DHR) with PMA stimulation by flow cytometry are quick, simple, sensitive and specific laboratory tests that help establish early and reliable diagnosis of CGD with an overall improvement in survival and disease prognosis. We report a case of 2-year old child who presented with small bone osteomyelitis involving bilateral feet and was later diagnosed to have autosomal recessive CGD due to mutation in NCF1 gene.
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CASE REPORTS Top

Immunohistochemical differentiation between spindle cell lipoma and neurofibroma of oral cavity using CD34 and SOX10 p. 561
Manas Bajpai, Nilesh Pardhe, Manish Kumar
DOI:10.4103/IJPM.IJPM_473_17  PMID:30303149
Spindle cell lipoma (SCL), also called as pleomorphic adenoma, is a rare variant of lipoma histopathologically characterized by an admixture of mature fat cells with spindle cells and occasionally mast cells with myxoid connective tissue stroma and thick bends of birefringent collagen. Although buccal mucosa is the most common location for oral lipomas, for SCL, it is an exceedingly rare location. We report a case of an asymptomatic swelling of buccal mucosa that simulated the features of neurofibroma on histopathological examination, and the final diagnosis of SCL was made on the basis of immunohistochemical features. This is the first documentation of oral SCL using SOX10 to achieve the final diagnosis.
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Dedifferentiation of oncocytic epithelial–myoepithelial carcinoma to mucoepidermoid carcinoma in parotid gland: A rare case report p. 564
Poonam Rani, Meeta Singh, Chetna Mehrol, Amita Jain Gupta, Nita Khurana, Ravi Meher
DOI:10.4103/IJPM.IJPM_64_17  PMID:30303150
Epithelial–myoepithelial carcinomas (EMCs) account for <1% of all salivary gland malignancies. Till now, 23 cases of dedifferentiated EMC have been reported to the best of our knowledge. However, dedifferentiation of oncocytic EMC to mucoepidermoid carcinoma is extremely rare. A 38-year-old female presented with right post aural swelling 4 cm × 2 cm in size for 6 months. Surgical excision was carried out, and we received partly skin-covered tissue 5 cm × 2 cm in size. Sections examined showed features of oncocytic EMC dedifferentiating into mucoepidermoid carcinoma. Myoepithelial component showed oncocytic change which was highlighted by p63.
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Cutaneous melanoma in childhood presenting as intraparotid lymph node metastasis p. 567
Abhishek Kumar, Lopamudra Deka, Bharti Varshney, Hema Malini Aiyer
DOI:10.4103/IJPM.IJPM_43_17  PMID:30303151
Cutaneous melanoma in childhood is a rare disease. Rendering a clinical diagnosis of melanoma in pediatric patients is confounded by the fact that pigmented lesions in pediatric patients do not conform to the ABCDE rules applicable to adult patients. Furthermore, making a histologic diagnosis of cutaneous melanoma in childhood is also difficult with no universally accepted criteria applicable to pediatric melanomas. We report the case of a 5-year-old child presenting with intraparotid lymph node metastasis who was later found to have melanoma involving periorbital region. It is proposed that careful analysis of histologic features as well as the additional information provided by immunohistochemistry should allow for a correct diagnosis in most cases of melanoma in children.
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Bilateral submandibular swelling diagnosed as tuberculous lymphadenitis in an asymptomatic patient: A rare case report p. 570
Apurva Sonu Medhe, Sonal S Mandale, Preeti U Deshpande, Jyoti D Bhavthankar
DOI:10.4103/IJPM.IJPM_655_17  PMID:30303152
In India, tuberculosis (TB) is a prevalent systemic disease and number of people who die with TB is increasing year by year. TB can be life-threatening, and there is a high mortality rate of systemic infection with TB. Although extrapulmonary TB (EPTB) is a rare form of TB, its prevalence is increasing day-by-day. Reported here is a case of a 28-year-old female patient with a painless swelling bilaterally in the submandibular region. She was diagnosed with bilateral submandibular tuberculous lymphadenitis. Tuberculous lymphadenitis, when occurring in the cervical region, continues to be a common cause of EPTB. Thorough knowledge of this condition is important as it can help in early diagnosis leading to prompt treatment of the patient and prevent further complications.
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Pericardial mesothelioma presenting as chronic constrictive pericarditis. A series of three cases from a single institution p. 573
Monalisa Hui, KR Harshavardhana, Shantveer G Uppin
DOI:10.4103/IJPM.IJPM_711_17  PMID:30303153
Pericardial mesotheliomas are rare tumors which often present with features of constrictive pericarditis. We present clinical, imaging, histological, and immunohistochemical findings of three cases presenting with chronic constrictive pericarditis. Two of these cases were initially treated as tuberculous pericarditis. Histologically, all the three cases were of an epithelioid type and showed positivity for more than one mesothelial markers. Two patients had a fatal outcome, and one was lost to follow-up.
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Well-differentiated liposarcoma of the breast arising in a background of malignant phyllodes tumor in a pregnant woman: A rare case report and review of literature p. 577
Swetha Lakshmi Narla, Punitha Stephen, Ann Kurian, S Annapurneswari
DOI:10.4103/IJPM.IJPM_238_17  PMID:30303154
Pure mesenchymal sarcomas and phyllodes tumor with sarcomatous differentiation of the breast are rare tumors. Primary breast sarcomas are a heterogenous group of neoplasms which include malignant fibrous histiocytoma, fibrosarcoma, angiosarcoma, leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and liposarcoma. Sarcomatous differentiation in phyllodes tumor is seen in the form of angiosarcoma, chondrosarcoma, leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and liposarcoma. Here, we report a case of a 28-year-old pregnant woman with a breast lump during her second trimester which drastically increased in size in the postpartum period. Wide local excision revealed a malignant phyllodes tumor with liposarcomatous differentiation. Later, the patient underwent completion mastectomy which showed residual tumor.
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Duodenal gangliocytic paraganglioma: A rare cause for gastrointestinal polyp p. 580
Neha Bakshi, Seema Rao, Shashi Dhawan, Vikas Singla
DOI:10.4103/IJPM.IJPM_479_17  PMID:30303155
Duodenal gangliocytic paragangliomas are rare neoplasms often arising in the duodenum in close proximity to the ampulla of Vater. These neoplasms are considered to have a benign behavior with lymph node metastases being a rare phenomenon and distant metastases even more so. Although a standardized treatment has not been determined, a margin-free tumor resection seems to be the best treatment modality. We report herein the case of a 36-year-old female who presented with abdominal pain and was found to have a polyp in the second part of duodenum which was excised endoscopically. Histopathology and immunohistochemistry revealed characteristic features of this rare tumor.
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Gastric carcinoma and acute myeloid leukemia: A case report of a double malignancy p. 583
Supriya Pradhan, Mingma Sherpa
DOI:10.4103/IJPM.IJPM_423_17  PMID:30303156
A double malignancy involving a solid organ and hematopoieteic system is rare. We report an interesting case of gastric adenocarcinoma with subsequent development of acute myeloid leukemia, in the absence of any therapeutic intervention.
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An unusual case of hepatic lymphoma with multiple epithelial malignancies p. 585
Anuj Khurana, Urmi Mukherjee, Nayana Patil
DOI:10.4103/IJPM.IJPM_509_17  PMID:30303157
Primary hepatic mucosa-associated lymphoid tissue lymphoma (MALToma) is a rare entity. Its coexistence with other malignancies is even rarer. Only few case reports of its association with other malignancies mostly gastric and colon cancer have been published. We report a case of primary MALToma of liver in an unusual setting of dual solid malignancy.
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Adrenal medullary hyperplasia with coexistent cerebral angiomas p. 587
Latika Gupta, Anusha S Bhatt, Varuna Mallya, Nita Khurana, Pawanindra Lal
DOI:10.4103/IJPM.IJPM_707_17  PMID:30303158
Sporadic adrenal medullary hyperplasia (AMH) is a rare entity and mimics pheochromocytoma clinically as well as pharmacologically. It is characterized by increase in adrenal medullary cells with the expansion of cells into areas normally not seen. A 59-year-old male presented with chronic hypertension and raised 24-h urinary normetanephrine levels. Radiological and clinical possibility of pheochromocytoma led to left transperitoneal laparoscopic adrenalectomy. Histopathology, however, showed increase in adrenal medullary to cortical ratio, further confirmed by immunohistochemistry. The absence of any well-defined lesion led to the diagnosis of AMH. Furthermore, on routine imaging, two asymptomatic cavernous hemangiomas were seen. We present this case to reiterate that AMH is an entity which should be considered as a differential for pheochromocytoma. Furthermore, the presence of asymptomatic cavernous hemangiomas in the cerebrum, in this case, makes it rarer since this sporadic association is seldom seen.
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Primary intrauterine dysgerminoma in a pregnant woman: A rare case report p. 590
Mojgan Akbarzadeh-Jahromi, Fatemeh Sari Aslani, Fatemesadat Najib, Shahla Hosseini
DOI:10.4103/IJPM.IJPM_598_17  PMID:30303159
Primary extraovarian dysgerminoma is very rare. Nearly all reported uterine germ cell tumors are nondysgerminoma. Herein, we reported a primary intrauterine dysgerminoma. A 21-year-old pregnant woman G2 L1 with a gestational age of 33 weeks referred to an obstetric ward with a chief complaint of labor pain and membrane rupture. Ultrasonography showed a large hypoechoic lobulated area adjacent to the lower part of her uterus. She underwent an operation and a huge mass was detected in her uterus, which was extended to her pelvic floor. Histopathological and immunohistochemical examinations were consistent with dysgerminoma.
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Polyp of the uterine cervix with heterologous fatty tissue p. 593
Irene Pecorella, Marco Monti, Maria Luisa Framarino Dei Malatesta, Gaia Ciardi
DOI:10.4103/IJPM.IJPM_105_17  PMID:30303160
This report documents an uncommon case of choristomatous cervical polyp-containing fat tissue. The patient was a 24-year-old female who presented with irregular intermenstrual bleeding. On examination, a polypoid lesion with smooth outlines, measuring 1 cm in diameter was removed. Microscopic examination demonstrated abnormal fibrous stroma, devoid of endocervical glands, containing mature adipose tissue, and thick-walled blood vessels. The lesion was covered by a typical mature squamous cell outer lining. To the best of our knowledge, this is only the second report of an adipose tissue arising from the cervical wall. Further clinicopathologic considerations are needed to elucidate the origin of the fatty component in cervical polyps.
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Malignant Sertoli cell tumor of the testis masquerading as seminoma with bone metastasis p. 596
Chaturbhuj Ramanand Agrawal, Venkata Pradeep Babu Koyyala, Vineet Talwar, Juhi Tayal, Dharma Ram Poonia
DOI:10.4103/IJPM.IJPM_492_17  PMID:30303161
Sex cord–stromal tumors of the testes are rare malignancies as compared to germ cell tumors. Pure Sertoli cell tumors are still rare representing <1% of testicular cancers and the malignant forms are too rare. Furthermore, the occurrence of metastasis in such cases is extremely rare with <30 cases reported in literature so far to the best of our knowledge. We present herein a case of malignant Sertoli cell tumor in a 48-year-old male who was initially misdiagnosed as seminoma based on histology and clinical presentation. Four months later, he presented with symptoms due to bony metastasis and found to have widespread metastatic disease which is a very rare presentation of Sertoli cell tumors. Diagnosis of sex cord–stromal tumor requires high index of suspicion as these tumors are most of the times misdiagnosed as germ cell tumors due to their rare incidence and atypical presentation leading to mismanagement. Timely diagnosis at an early stage can provide therapeutic benefit due to lack of well-defined treatment options at advanced stages.
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Orchitis: An unusual presentation of polyarteritis nodosa p. 600
Nelofar Islam, Debanjali Sinha, Parasar Ghosh, Chhanda Datta, Uttara Chatterjee
DOI:10.4103/IJPM.IJPM_569_17  PMID:30303162
Polyarteritis nodosa (PAN), a systemic necrotizing vasculitis with multiorgan development, is generally restricted to the medium-sized muscular arteries. The varied initial clinical presentations of PAN can lead to a delayed diagnosis. We present the case of a middle-aged male patient who presented with an acute onset right-sided testicular pain as the initial clinical symptom with ischemic changes on ultrasonogram, thereby requiring orchiectomy. This was reported to be a case of tubercular epididymo-orchitis. On review, the biopsy revealed features of necrotizing arteritis as seen in PAN with fibrinoid necrosis and giant cells, thus highlighting the fact that vasculitis due to PAN may have a localized presentation at the time of diagnosis. PAN should be distinguished from other causes of epididymo-orchitis and other vasculitis lesions, the most common being tubercular etiology in the Asian population.
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Synovial hemangiomas of wrist and ankle joint: A report of two rare cases p. 604
Priyanka Saxena, Radhika Agarwal, Gunjan Nain, Nita Khurana, Pawanindra Lal, Sanjeev Kumar Tudu
DOI:10.4103/IJPM.IJPM_603_17  PMID:30303163
Synovial hemangioma is a rare, benign, vascular tumor of synovium leading to joint pain and swelling. The most common site is the knee joint, but rare cases involving other sites have also been reported. We report two rare cases of synovial hemangioma, one involving the ankle joint and other involving the wrist joint. Histopathology is the gold standard for diagnosis of these cases. Early treatment is warranted to prevent the risk of permanent joint damage.
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Keratomycosis due to Purpureocillium lilacinum: A case report from Sub-Himalayan region of Uttarakhand p. 607
Deepak Juyal, Shekhar Pal, Munesh Sharma, Vikrant Negi, Shamanth Adekhandi, Manoj Tyagi
DOI:10.4103/IJPM.IJPM_404_17  PMID:30303164
The fungus Purpureocillium lilacinum previously known as Paceliomyces lilacinus is an emerging pathogen that can cause severe human infections including devastating oculomycosis. Treatment with traditional antifungals often fails, and the organism shows variable susceptibility to novel triazoles. We hereby report a case of keratomycosis caused by Pur. lilacinum in an immunocompetent male patient following trauma. The patient was successfully treated with voriconazole. The drug shows good activity against Pur. lilacinum and could be a promising therapeutic alternative to treat infections caused by this fungus, which generally shows resistance to conventional antifungal agents including novel triazoles.
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Fibrillary glomerulonephritis in a human immunodeficiency virus-positive, hepatitis C-negative Indian patient: Expanding the profile of renal involvement in human immunodeficiency virus infection p. 610
Smita Mary Matthai, Anna T Valson, Neelaveni Duhli, Priscilla Rupali, Anna B Pulimood, Santosh Varughese
DOI:10.4103/IJPM.IJPM_52_18  PMID:30303165
Highly active anti retroviral therapy (HAART) has dramatically improved life expectancy of human immunodeficiency virus (HIV) infected patients, converting HIV infection into a chronic illness with associated changes in its attendant renal complications. The past two decades have witnessed a decrease in the prevalence of HIV associated nephropathy (HIVAN), traditionally considered to be the hall mark of renal involvement in HIV infection. Simultaneously a host of other glomerular and tubulo-interstitial diseases have emerged, expanding the spectrum of HIV associated renal diseases, predominant among which is HIV associated immune complex mediated kidney diseases (HIVICK). Of the diverse glomerular diseases constituting HIVICK, fibrillary glomerulonephritis (FGN) remains a rarity, with only two existing reports to date, confined to patients co-infected with Hepatitis C virus (HCV). The pathogenetic role of HIV in these patients remains under a cloud because of previously well established association of HCV infection and FGN. We report a case of FGN in a HIV seropositive, HCV negative Indian patient, highlighting the diagnostic electron microscopy (EM) findings of FGN and strengthening the causal association of HIV with FGN. In view of increasing heterogeneity of renal complications in HIV infection, the diagnostic utility of a comprehensive renal biopsy evaluation inclusive of EM is emphasized for appropriate selection of treatment modalities.
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Extensive trophoblastic differentiation in case of an endometrial carcinoma p. 614
Surekha Yadav, Nishant Sagar, Varuna Mallya, Sharmana Mandal, Nita Khurana, Sangeeta Gupta
DOI:10.4103/IJPM.IJPM_228_17  PMID:30303166
Trophoblastic differentiation of endometrial carcinoma is extremely rare, till date 18 cases reports are there in the literature. A 68-year-old postmenopausal female presented with abnormal vaginal bleeding. Histopathologically, there were areas of serous carcinoma with trophoblastic differentiation (~90%). On immunohistochemistry, the trophoblastic component was positive for β-human chorionic gonadotropin (hCG), HPL and EMA. IHC confirmed the diagnosis of serous carcinoma with trophoblastic differentiation. The clinicopathological features of 18 previously reported cases of trophoblastic differentiation in the uterine tumor were analyzed in addition to the present case.
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IMAGES Top

Bilateral renal fungal balls in an infant p. 617
Pradeep Vaideeswar, Sunil Karande, Lamk Kadiyani
DOI:10.4103/IJPM.IJPM_57_18  PMID:30303167
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MiT family translocation-associated (TFE3 positive) renal cell carcinoma of childhood p. 620
Richa Katiyar, Shashikant C U. Patne, Sarita Chowdhary
DOI:10.4103/IJPM.IJPM_279_17  PMID:30303168
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Bone marrow edema mimicking amyloid p. 623
Neha Garg, Divya Bansal, Gunjan Mangla, Mrinalini Kotru
DOI:10.4103/IJPM.IJPM_89_18  PMID:30303169
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Partial “fetus-in-fetu” p. 626
Manoj Gopal Madakshira, Nandita Kakkar, Prema Menon
DOI:10.4103/IJPM.IJPM_143_18  PMID:30303170
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Abnormal morphological appearance of Klebsiella pneumoniae in blood culture: A microscopic observation p. 628
Kumar Saurabh, Vijaya Lakshmi Nag, Anuradha Sharma, Anand Kumar Maurya, Vivek Hada
DOI:10.4103/IJPM.IJPM_447_17  PMID:30303171
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LETTERS TO EDITOR Top

Lipofibroadenoma with B1 thymoma: A case report of a rare thymic tumor p. 630
Monalisa Hui, Tara Roshni Paul, Shantveer G Uppin, Nirmala Jyothi
DOI:10.4103/IJPM.IJPM_443_17  PMID:30303172
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Canalicular adenoma arising from the nasal septum in a child: First case report p. 632
Manjusha Ray, Pragati Sathe, Ratnaprabha Ghodke, Monica Suryavanshi
DOI:10.4103/IJPM.IJPM_137_18  PMID:30303173
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Primary pulmonary pleomorphic adenoma: A rare case report p. 634
Vandana Raphael, Bidyut B Gogoi, Jaya Mishra
DOI:10.4103/IJPM.IJPM_73_18  PMID:30303174
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Primary pulmonary melanoma: An unexpected diagnosis p. 636
Chaturbhuj Ramanand Agrawal, Vineet Talwar, Juhi Tayal, Venkata Pradeep Babu Koyyala, Pankaj Goyal
DOI:10.4103/IJPM.IJPM_490_17  PMID:30303175
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Tumefactive demyelination versus tumor; A diagnostic dilemma: Role of electron microscopy p. 638
Paresh Doshi, Raghvendra Ramdasi, Smita Thorve, Shaila Khubchandani
DOI:10.4103/IJPM.IJPM_677_17  PMID:30303176
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Isolated spinal epidural hydatid disease: A diagnostic challenge in a needle core biopsy p. 640
Arpita Saha, Kaushik Saha, Vinita Agrawal, Zafar Neyaz, Awadesh Kumar Jaiswal
DOI:10.4103/IJPM.IJPM_764_17  PMID:30303177
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ERRATUM Top

Erratum: Primary follicular lymphoma of disguised as multiple miliary like lesions: A case report and review of literature p. 643

DOI:10.4103/0377-4929.243009  PMID:30303178
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NEW HORIZON Top

Catechism (Quiz 2) p. 644
Bharat Rekhi
DOI:10.4103/IJPM.IJPM_433_18  
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