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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 63 | Issue 3
Page Nos. 345-512

Online since Friday, August 7, 2020

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EDITORIAL  

From Editor's desk p. 345
Ranjan Agrawal
DOI:10.4103/IJPM.IJPM_922_20  PMID:32769319
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EDITORIAL INSIGHT Top

Peer review: A critical step in the editorial process p. 347
Ranjan Agrawal
DOI:10.4103/IJPM.IJPM_793_20  PMID:32769320
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REVIEW ARTICLES Top

Guidelines for various laboratory sections in view of COVID-19: Recommendations from the Indian Association of Pathologists and Microbiologists Highly accessed article p. 350
Vatsala Misra, Ranjan Agrawal, Harendra Kumar, Asaranti Kar, Usha Kini, Aruna Poojary, Indranil Chakrabarti, Sharada Rai, Anika Singhal, S Vijay Shankar, Jayaram N Iyengar
DOI:10.4103/IJPM.IJPM_857_20  PMID:32769321
Declared as a pandemic by WHO on March 11, 2020, COVID-19 has brought about a dramatic change in the working of different laboratories across the country. Diagnostic laboratories testing different types of samples play a vital role in the treatment management. Irrespective of their size, each laboratory has to follow strict biosafety guidelines. Different sections of the laboratory receive samples that are variably infectious. Each sample needs to undergo a proper and well-designed processing system so that the personnel involved are not infected and also their close contacts. It takes a huge effort so as to limit the risk of exposure of the working staff during the collection, processing, reporting or dispatching of biohazard samples. Guidelines help in preventing the laboratory staff and healthcare workers from contracting the disease which has a known human to human route of transmission and high rate of mortality. A well-knit approach is the need of the hour to combat this fast spreading disease. We anticipate that the guidelines described in this article will be useful for continuing safe work practices by all the laboratories in the country.
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COVID-19: An up-to-date review – from morphology to pathogenesis Highly accessed article p. 358
Amanjit Bal, Ranjan Agrawal, Pradeep Vaideeswar, Sudheer Arava, Amita Jain
DOI:10.4103/IJPM.IJPM_779_20  PMID:32769322
The entire world is under a devastating pandemic caused by COVID-19 with a high mortality rate. Knowledge of the viral structure, factors that help in its progression and spread, pathological findings, diagnostic methods and, treatment modalities helps in understanding the viral disease and also in treating the patients in a better way besides preventing the community spread of this deadly infection. The causative agent is a single- stranded RNA virus. The clinical spectrum varies in symptomatic and asymptomatic patients, who later become potential silent carriers, thus unknowingly spreading the virus. The virus constantly undergoes recombination, with reports of cross-species infections. Studies have indicated a strong immunological basis of COVID-19 infection. Not only does it weaken the immune system causing multi-organ involvement but also helps in its progression and spread to others.Multiple organs especially lungs, heart, kidney, gastrointestinal and hepatic system, brain and skin are affected varying in their severity. Similarly, persons with associated co-morbidities are likely to be affected more in terms of the number as well as in the severity. Real- time reverse transcription polymerase chain reaction confirms the presence of COVID-19 infection. Serological diagnosis helps in diagnosing an ongoing outbreak or retrospective infection. Furthermore, it also identifies individuals who have been infected or have recovered from the disease especially the asymptomatic. This helps in the development of an effective vaccine indicating the status of herd immunity in the community. Different treatment modalities are being tried and under trial. This review article thus highlights the global epidemiological status, characteristic of the virus, symptomatology of the patients, role of diagnostic tests available, organs affected including their morphological changes and the latest line of treatment of COVID-19.
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OBITUARY Top

Juan Rosai: A tribute p. 367
Anita M Borges
DOI:10.4103/IJPM.IJPM_895_20  PMID:32769323
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ORIGINAL ARTICLES Top

Evaluation of the presence of myofibroblasts and matrix metalloproteinase 1 expression in the stroma of oral verrucous hyperplasia and verrucous carcinoma p. 369
Nazanin Mahdavi, Pouyan Aminishakib, Parisa Nabiyi, Alireza Ghanadan, Maedeh Ghorbanpour, Merva Soluk-Tekkesin
DOI:10.4103/IJPM.IJPM_548_19  PMID:32769324
Background: Oral verrucous carcinoma is a low-grade subtype of oral squamous cell carcinoma that should be differentiated from oral verrucous hyperplasia, a premalignant lesion. Stromal activated myofibroblasts known as cancer-associated fibroblasts have an active role in the initiation and progression of the cancers via secretion of different molecules including matrix metalloproteinases. Aims: This study is designed to understand the differences in the presence of myofibroblasts and expression of matrix metalloproteinase-1 in the adjacent stroma of verrucous carcinoma and oral verrucous hyperplasia (OVH). Settings and Design: Cross-sectional study. Material and Methods: Twenty-seven OVH, 19 oral verrucous carcinoma (OVC), and 8 cutaneous verrucous carcinoma (CVC) specimens were analyzed for immunohistochemical (IHC) expression of α-smooth muscle actin (αSMA) and MMP-1. Results: IHC studies for αSMA expression in nonvascular stromal cells of the adjacent stroma revealed mild or no expression in 81.4%, 73.7%, and 62.5% of the cases of OVH, OVC, and CVC groups, respectively. No significant difference was seen in αSMA expression index between OVH and OVC groups (Adj. Sig. = 0.220) and between OVC and CVC groups (Adj. Sig. = 1.00). Pairwise analysis revealed a significant difference in MMP-1 expression index between the groups. No significant correlation was observed between MMP-1 expression index and αSMA expression index in OVH (pv = 0.358) and OVC (pv = 0.388) groups. Conclusion: The differences in MMP-1 expression between OVH and OVC can be used as an adjunctive aid in challenging cases including disoriented or inadequate samples.
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Immunohistochemical expression of cyclin D1 in invasive breast carcinoma and its correlation with clinicopathological parameters p. 376
Pranoti Vitthalrao Lengare, Siddhi Gaurish Sinai Khandeparkar, Avinash R Joshi, Bageshri P Gogate, Smita Ganeshrao Solanke, Sujit Hanumant Gore
DOI:10.4103/IJPM.IJPM_106_20  PMID:32769325
Introduction: Breast cancer (BC) is the most common cancer and leading cause of death in women. Aim: This study was conducted to study the cyclin D1 expression in BC and its correlation with other clinicopathological parameters such as tumor size, histological grade, lymph node status, estrogen receptor (ER), progesterone receptor (PR), HER2/neu, and Ki67 status. Materials and Methods: Fifty cases of BC diagnosed between 2015 and 2018 were included in the study. A technique of manual tissue microarray was employed for the analysis of expression of immunohistochemical (IHC) markers such as cyclin D1, ER, PR, HER2/neu, and Ki67 in all cases. Results were subjected to statistical analysis. Results: Cyclin D1 positivity was seen in 64% cases of BC cases of which 8% were triple negative BC (TNBC) molecular subtype. Cyclin D1 expression was statistically significantly associated with ER and PR positivity. Maximum cases showing cyclin D1 expression showed negative HER2/neu expression, Ki67 immunopositivity, absent lymphovascular invasion and were of lower grade and stage. 32% cases were TNBC. Cyclin D1 was found positive in 25% TNBC cases. Negative Cyclin D1 expression was seen in TNBC cases of higher grade and higher stage with positive lymph node status, presence of lymphovascular invasion and Ki67 positivity. Conclusion: Cyclin D1 can be potentially used as a prognostic marker and if included in routine IHC workup of BC cases can aid in appropriate patient management with the advent of new targeted therapy that blocks the cyclin D-CDK4/6 axis.
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Role of epithelial - Stromal interaction protein-1 expression in breast cancer p. 382
Apexa P Raval, Urja N Desai, Jigna S Joshi, Franky D Shah
DOI:10.4103/IJPM.IJPM_672_19  PMID:32769326
Background and Aims: Epithelial stromal interaction protein-1 (EPSTI-1) is originally identified as stromal-fibroblast – induced gene in breast cancer. It was found to be involved in promotion of EMT, breast cancer invasion, metastasis and anchorage-independent growth in vitro. Strong expression was observed in various tissues as well as higher expression was observed in invasive breast cancer compared to normal breast. EPSTI-1 expression was evaluated from 106 pre-therapeutic breast cancer patients. EPSTI-1 expression was correlated with known clinico-pathological parameters of breast cancer to explore its role in breast carcinogenesis. Subjects and Methods: EPSTI-1 expression was analyzed from the collected synchronous tissues [tumors, Malignant Lymph nodes (LN) and adjacent normal tissues (ANT)] of breast carcinoma patients (N = 106). The statistical correlation was performed using SPSS 16.0. Results: In this study EPSTI-1 was significantly higher in LN compared to tumors (P < 0.001), and in tumors compared to ANT (P < 0.01) which is also reflected in ROC curve analysis (P < 0.0001). Further the small tumor size, stage I, grade I and tumors without stromal involvement exhibited significant lower expression compared to their counter parts. Conclusion: EPSTI-1 may have significant role in epithelial stromal interaction and disease extension. Moreover, it may be responsible for aggressive tumor behavior and involved in metastatic process which needs to be validated in larger cohort.
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A clinicopathological study of triple-negative breast carcinoma in a patient cohort from a tertiary care center in Sri Lanka p. 388
Harshima D Wijesinghe, Janakie Fernando, Upul Senarath, Gayani K Wijesinghe, Menaka D S. Lokuhetty
DOI:10.4103/IJPM.IJPM_657_19  PMID:32769327
Background: Triple negative breast carcinoma (TNBC) and basal-like breast carcinoma (BLBC) are subtypes of breast carcinoma (BCa) that are associated with poor survival. Aims: To study the prevalence, clinicopathological profile and survival of TNBC among a Sri Lankan patient cohort and to determine the proportion and predictive histological features of BLBC among TNBCs. Study Setting and Design: A cohort of 221 women undergoing primary surgery for BCa at a tertiary-care center in Sri Lanka was studied. Materials and Methods: Clinicopathological and follow-up information were collected by patient interviews and review of slides and clinical records. Estrogen, progesterone, HER2 receptors, and basal markers (CK5/6, CK14, EGFR, 34βE12) were evaluated immunohistochemically. Statistical Analysis: Data was analyzed with Chi-square test, multinomial logistic regression, and Cox regression using SPSS20.0. Results: Fifty-three (24%) tumors were triple-negative (95%CI = 18.37%–29.63%). On multivariate analysis, young age (P = 0.002), high Nottingham grade (P = 0.005), moderate to severe tumor necrosis (P = 0.004), absent ductal carcinoma in situ (DCIS) (P = 0.04), reduced vascular density at tumor edge (P = 0.016) and distinct cell margins (P = 0.047) predicted TNBC over luminal subgroups, whereas reduced vascular density (P = 0.004) and low TNM stage (P = 0.011) distinguished TNBC and HER2. BLBC accounted for 45.28% (95%CI 32.66%–58.55%-24/53) of TNBC. The presence of extensive necrosis in TNBC correlated significantly with BLBC (P = 0.03). The survival among the TNBC subgroup did not differ significantly from other subgroups. Conclusion: Twenty four percent were TNBCs by immunohistochemical analysis, comparable to studies in the Indian subcontinent, however higher than the West. TNBC status correlated with younger age, high tumor grade, necrosis, absent DCIS, reduced vascular density at tumor edge, and distinct cell margins. The presence of moderate to extensive necrosis in TNBC was predictive of BLBC.
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Pediatric lupus nephritis – An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India p. 397
Keya Basu, Subhrajyoti Karmakar, Moumita Sengupta, Arpita Roychowdhury, Alakendu Ghosh, Manimoy Bandopadhyay
DOI:10.4103/IJPM.IJPM_995_19  PMID:32769328
Context: Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease. Aims: To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score]. Settings and Design: Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India. Subjects and Methods: We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies. Statistical Analysis Used: Kruskal–Wallis and χ2 tests. Results: Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity. Conclusions: Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.
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Diagnostic utility of amylase α-1A, MOC 31, and CD 82 in renal oncocytoma versus chromophobe renal cell carcinoma p. 405
Nehal S Abouhashem, Eman H Abdelbary, Mohamed M H. Abdalla, Mohamed El-Shazly
DOI:10.4103/IJPM.IJPM_719_19  PMID:32769329
Objective: Renal oncocytoma (RO) and chromophobe renal cell carcinoma (ChRCC) originate from the same cell origin, that is, the intercalated cells of the collecting duct.[1] In most cases, there are clear morphologic differences between RO and ChRCC; however, in some instances, overlapping features may be encountered and the differentiation between the two entities becomes difficult.[2] Several immunohistochemical markers with different expression patterns in ChRCC and RO have been described to rule out this dilemma. Materials and Methods: About 47 primary renal neoplasms that had been diagnosed as RO or ChRCC were submitted for immunohistochemical staining of amylase α-1A (AMY1A), MOC 31, and CD 82. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy have been analyzed. Results: AMY1A positivity was observed in all RO cases in our work with 91.7% sensitivity and 100% specificity in the diagnosis of RO. The PPV of its expression was (100%) and NPV (97.2%) with a diagnostic accuracy of 97.9%. A significant high expression of MOC 31 was observed in ChRCC compared to its expression in RO with a statistical significance (P < 0.001). In addition, we obtained 82.9% sensitivity and 91.7% specificity of MOC 31 expression in the diagnosis of ChRCC. The positive predictive value (PPV) was (96.7%), negative predictive value (NPV) (64.7%) with diagnostic accuracy (85.1%). In our studied cases, we detected positive immunoexpression of CD 82 in 10 cases (83.3%) of ChRCC. However, it was lost in all RO cases (100%). CD 82 sensitivity and specificity in differentiating ChRCC from RO were 100% and 83.3%, respectively. Conclusion: We propose MOC 31 and CD 82 as negative immunostains for RO, as these markers are commonly expressed in ChRCC. In conjunction with AMY1A strong immunopositivity in RO cases, we provide a triple panel of biomarkers (AMY1A, MOC 31, and CD 82) for the distinction between RO and ChRCC.
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The extent of cyclin D1 expression in endometrial pathologies and relevance of cyclin D1 with the clinicopathological features of endometrioid endometrial carcinoma p. 412
Hulya Tosun Yildirim, Dondu Nergiz, Canan Sadullahoglu, Zelal Akgunduz, Senay Yildirim, Selen Dogan, Cem Sezer
DOI:10.4103/IJPM.IJPM_589_19  PMID:32769330
Background: Cyclin D1, a member of the cyclin protein family, is instrumental in the cell cycle due to its influence on the progression from G1 to the S phase. Its overexpression causes reduced doubling time and is also associated with clonogenic growth. The purpose of the present study was to assess cyclin D1 expression in patients with simple hyperplasia (SH), endometrial intraepithelial neoplasia (EIN) and endometrioid endometrial carcinoma, and to evaluate whether there was an association between cyclin D1 expression and the clinicopathological features of endometrioid endometrial carcinoma. Methods: Retrospective data were available for 193 patients (30 SH, 40 EIN, and 123 endometrioid endometrial carcinoma cases). To detect cyclin D1 expression, immunohistochemistry staining was performed with tissue microarrays. Results: The percentage of cases with positive cyclin D1 staining were 30%, 60% and 78%, for SH, EIN and endometrioid endometrial carcinoma, respectively (P < 0.001). Carcinomas with higher nuclear grade, histological grade, and FIGO grade displayed higher mean cyclin D1 expression compared to lower grade carcinomas. In addition, patients with lymphovascular invasion (P = 0.006), myometrial invasion (P < 0.001) and lymph node invasion (P < 0.001) had higher mean cyclin D1 expression compared to those without invasion. There was a significant correlation between cyclin D1 expression and clinicopathological features of endometrioid endometrial carcinoma including tumor grade, FIGO grade, lymphovascular invasion, lymph node invasion and myometrial invasion (P < 0.05 for each). Conclusion: Cyclin D1 expression is significantly higher in patients with endometrioid endometrial carcinoma compared to that of the SH and EIN. The extent of cyclin D1 expression is strongly correlated with nuclear and histological grade, myometrial invasion, lymphovascular invasion and lymph node invasion in patients with endometrioid endometrial carcinoma. These findings contribute in several ways to our understanding of cyclin D1 expression and provide a basis for future research on this topic.
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Can TROP2 be used as a prognostic marker in endometrioid endometrial carcinoma? p. 418
Serkan Y Celik, Özgür İlhan Çelik
DOI:10.4103/IJPM.IJPM_783_19  PMID:32769331
Background: Endometrioid-type endometrial carcinoma is the most common malignancy of the female genital tract in developed countries. The prognosis greatly depends on the grade and stage of the disease. Aims: In some patients, the disease recurs in a short time after the surgical/medical therapy. Hence, it is important to predict the patients who will have worse prognosis at the beginning, to choose the appropriate treatment; resuming the search of new prognostic markers. Therefore, our study aimed to detect trophoblast cell surface antigen 2 (TROP2) as a new prognostic marker. Settings and Design: The patients who underwent a hysterectomy and diagnosed with endometrioid-type endometrial carcinoma were evaluated retrospectively and TROP2 immunostain was performed to their tumoral slides. Materials and Methods: We evaluated TROP2 expressions in 102 patients immunohistochemically who underwent hysterectomy with the diagnosis of endometrioid-type endometrial carcinoma histopathologically and correlated them with the other generally accepted prognostic parameters. Statistical Analysis: The Kolmogorov-Smirnov test and Q-Q plot test were used to verify the normality of the distribution of continuous variables. The Chi-square/Fisher's exact tests were used for categorical variables. Analyses were performed with SPSS Statistics for Windows, Version 20. Results: High overexpression of TROP2 was seen in larger, higher-grade, deeper-invasive tumors, tumors with vascular invasion, and pelvic-lymph-node metastasis. These results were statistically significant (P ≤ 0.05). Conclusion: Overexpression of TROP2 in endometrioid-type endometrial carcinoma seems to be a poor prognostic factor; it may be useful in determining the biologically more aggressive tumors before the treatment. This early determination is very important to choose the appropriate surgery, adjuvant-treatments, and follow-up.
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Eosinophilic metaplasia in transurethral resection of the prostate p. 423
Maria S Koleva, Dorian I Dikov, Veselin T Belovezhdov, Victoria Sarafian
DOI:10.4103/IJPM.IJPM_593_19  PMID:32769332
Background: To investigate prostatic eosinophilic metaplasia (EM) in a large series of cases and their relationship with the basic prostate pathology in TURP-material: benign prostatic hyperplasia (BPH), National Institutes of Health category IV prostatitis (also called histologic prostatitis or HP), and prostatic adenocarcinoma (PCa). Aim: The relation between EM and basic prostate pathology: BPH, PCa, and HP. Materials and Methods: Around 61 consecutive TURP-specimens were reviewed for the presence of EM. The tissue sections were stained routinely with hematoxylin-eosin (HE), hematoxylin-phloxine-saffron (HPS), and periodic acid-Schiff's procedure. Simultaneously BPH, HP, and PCa were evaluated. Results: We found EM in 55.7% of TURP-specimens. EM is located more often in the ductal epithelium (58.8%) and is usually focal (73.5%) and in small groups (88.2%) of secretory luminal cells. They are associated with BPH and with a variable degree of HP in all cases. However, there is no association with PCa. Eosinophilic cytoplasmic granules in EM are better visualized with HPS. Zones induced by tissue electrocoagulation which mimic EM, are seen in the periphery of TURP-fragments. Conclusion: EM in prostate is presented by the presence of eosinophilic cytoplasmic granules in benign secretory epithelium. The study presents the first attempt to investigate EM in a large series of patients. Our results enrich the available information about the histoepidemiology of prostatic EM. Moreover, EM is more common in a focal lesion, found in small groups of ductal secretory epithelial cells while EM in TURP-specimens is associated with BPH and HP in all the cases.
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Evaluation of cell blocks from effusion specimens in Gynecologic Oncopathology: An experience of 220 cases, diagnosed at a Tertiary Cancer Referral Center p. 427
Bharat Rekhi, Srushti Karmarkar, Chhavi Gupta, Kedar K Deodhar, Santosh Menon, Saleem Pathuthara, Amita Maheshwari, TS Shylasree, Sudeep Gupta
DOI:10.4103/IJPM.IJPM_858_19  PMID:32769333
One of the common indications of ascitic fluid examination in gynecological oncopathology is the detection and classification of malignant cells, especially in cases of clinically suspicious tubo-ovarian masses. The present study was undertaken to assess and validate the diagnostic utility of cell blocks (CBs) and compare its results with the corresponding conventional smears, prepared from effusion samples. CBs were prepared by thromboplastin technique in 220 cases. In 208 cases, diagnostic concordance between results obtained from smears and corresponding CBs was evaluated. Various antibody markers were tested, as per individual case. The average age of patients was 52.2 years. Positive immunohistochemical (IHC) staining for various markers was observed in 182 cases (82.7%) The most frequently positive antibody marker was PAX8 (101/134), followed by p53 (85/92) [mutation type (either diffusely positive or completely negative)], WT1 (tumor cells) (80/112), calretinin (2/87) (diffuse), BerEP4 (21/49), CA125 (21/24), CK7 (31/39) and CK20 and CDX2, together (5/16). Various other IHC markers utilized, including their positive expression, were TTF1 (1/10), p40 (3/3), p63 (2/4), ER (21/29), HBME1 (1/7), GATA3 (1/4), and MIC2 (1/1). Complete diagnostic concordance between CBs and smears was observed in 170/208 cases (81.7%). There were 20 major discordances, 10 minor and 8 cases with sampling errors. IHC was useful in classifying 158/182 (86.8%) cases, including serous or Müllerian adenocarcinoma (n = 123), mostly high-grade (121); metastatic squamous carcinoma (3); gastrointestinal-type adenocarcinoma (8); pulmonary adenocarcinoma (1); breast adenocarcinoma (1); Ewing sarcoma (1); and mesothelioma (2). CBs are complementary to smears in the detection of gynecological malignancies, mostly high-grade serous adenocarcinomas. These provide an opportunity for testing several IHC markers, for a precise diagnosis, including in various uncommon case scenarios, associated with significant therapeutic implications.
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Finish before the start: Analyzing preanalytical sample errors in a tertiary care hematology laboratory p. 435
Kavita Gaur, Vandana Puri, Shailaja Shukla, Sunita Sharma, Santosh Suman, Renu Singh
DOI:10.4103/IJPM.IJPM_191_19  PMID:32769334
Aims: (a) To evaluate the types and frequencies of preanalytical errors occurring in a tertiary care hematology diagnostic center and (b) To evaluate differences if any, across groups [outpatient data (OPD) vs inpatient data (IPD), type of test requested [complete blood count (CBC) vs coagulation] and laboratory (routine vs emergency). Settings and Design: A prospective study was conducted over a period of nine months (August 2017–April 2018) to address the above objectives. All samples received in the clinical hematology division of our institute were included in the analysis. Materials and Methods: Categories of preanalytical errors were defined. This included insufficient, clotted, diluted, and lipemic samples. Clerical errors such as wrong/absent sample labeling, requisition form-sample mismatch, and wrong vacutainer selection were also documented. IPD and OPD data, as well as data pertaining to samples sent for different tests [complete blood count (CBC)/coagulation] and in the routine and emergency laboratories, were segregated. Statistical Analysis Used: All errors in each category were recorded as numbers and corresponding percentages (proportions). The two-tailed z-test was applied to assess the significance of the difference in proportions across all groups. Statistical significance was kept at P < 0.05. Results: A total of 189,104 samples were received in the clinical hematology laboratory during the aforementioned period, out of which preanalytical errors were found in 4052 (2.14%) samples. Inadequate sample quantity (ISQ) comprised the bulk of preanalytical errors in our laboratory (1.11% of total samples) followed by sample clots (0.88%). There was no significant difference in the error frequencies in OPD and IPD (P = 0.1031). The proportion of errors was higher in routine vis-à -vis emergency samples and also in samples sent for coagulation analysis vis-à -vis CBC.
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BRIEF COMMUNICATION Top

Inflammatory myofibroblastic tumor manifesting as recurrent generalized gingival enlargement: Report of a rare case p. 441
Vikender S Yadav, Prasenjit Das, Renu Yadav, Nitesh Tewari
DOI:10.4103/IJPM.IJPM_431_19  PMID:32769335
Oral inflammatory myofibroblastic tumor (IMT) is extremely rare and its manifestation as generalized gingival enlargement (GGE) has never been reported. We are reporting the case of 50-year-old female patient presenting with recurrent GGE for 4 years. Panoramic radiograph revealed severe bone loss in posterior sextants and root resorption in some teeth. Initial incisional biopsy was suggestive of chronic inflammatory infiltrate with fibrocollagenous tissue. Definitive treatment comprised of surgical excision of the enlarged gingiva with a tapering dose of steroid therapy. Histopathological and immunohistochemical examination from a repeat biopsy of deeper tissues was suggestive IMT. No recurrence was found at 2 years follow up. Recurrent GGE with advanced bone loss and external root resorption should raise the suspicion of a locally aggressive lesion. Dentists should be aware of oral IMT and include it in differential diagnosis of gingival enlargements for comprehensive management to avoid recurrence of the lesion.
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CASE REPORTS Top

Intracranial bony ball – An ossified variant of meningioma p. 445
Gayathri Priyadharshini, Manjiri Phansalkar, Dilip Phansalkar, Vellore Seetharam Hari
DOI:10.4103/IJPM.IJPM_285_19  PMID:32769336
An ossified variant of meningioma in the intracranial region is very rare. We report a case of a 28-year-old female who presented with headache for 4 years. Imaging revealed an extra-axial calcified mass in the left parieto-occipital lobe. The differential diagnosis included osteoblastoma both intracranial and periosteal, calcifying pseudotumor of the neural axis, hyperostosis of the cranium, and ossifying fibroma. She underwent excision of the calcified space occupying lesion. Histopathology was suggestive of an ossified meningioma. At the end of 2-year follow-up, she was asymptomatic with no signs of recurrence.
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New defining body (Ugras body) in polypoid dedifferentiated liposarcoma of the vallecula. Histomorphological, immunohistochemical and molecular genetic findings p. 449
Serdar Ugras, Markku Miettinen
DOI:10.4103/IJPM.IJPM_625_19  PMID:32769337
This is a description of a dedifferentiated liposarcoma seen in a 27-year-old female patient. The tumor originated from the vallecula and contains distinctive bodies. These bodies, which are formed by the aggregation of tumor cells, contain collagen in several regions and are oval or elongated in shape. Immunohistochemically, the tumor cells showed staining for MDM2, p16, Vimentin, beta catenin, smooth muscle actin, bcl-2 and p53. Ki-67 ratio was 17% in hypercellular areas of the tumor. Molecular genetic studies have found copy number increase for CDK4 and MDM2 genes. Final histopathological diagnosis was dedifferentiated liposarcoma with unique bodies. Although meningothelial-like whorls is defined in dedifferentiated liposarcoma, this body has not been defined until now. To our knowledge, this is the first case of a DDL containing a cellular spindle cell component seen as rare sheet-like areas and distinctive ball-like, or elongated, serpiginous formations in the middle of paucicellular, collagenous areas.
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Multiple intracranial cryptococcomas in an immunocompetent patient with pulmonary involvement p. 453
Sarojini Raman, Nilanjan Mukherjee, Kanakalata Dash, Kamal K Sen
DOI:10.4103/IJPM.IJPM_331_19  PMID:32769338
Opportunistic infections affecting central nervous system (CNS) have high prevalence in developing countries and cryptococcosis is one of them. It is associated with myriad of signs symptoms and clinical behavior. Though commonly associated with AIDS/HIV infection, it has been reported to be pathogenic in immunocompetent patients. Leptomeningitis is most common presentation in CNS, but unusual tumor like mass lesions have been reported. Lungs are primary site of infection, but it can affect different organs with varied clinical presentations. Therefore, correct diagnosis and proper management is essential in such cases excluding the differentials as fatality rate can be quite high. We report such an unusual case of multiple cryptococcal mass lesions in brain in a healthy immune competent individual with bilateral pulmonary involvement.
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Schwannoma: An uncommon dweller in the adrenal gland p. 456
Chaithra G Venkataramana, Saraswathy Sreeram, PV Santosh Rai, GG Laxman Prabhu, KN Sanman, Shrinath P Shetty
DOI:10.4103/IJPM.IJPM_267_19  PMID:32769339
An elderly adult woman presented with upper abdominal pain to the urology department. Imaging studies revealed a right adrenal lesion with central necrosis, abutting the large vessels and suggestive of malignancy. Histopathology showed an encapsulated spindle cell tumor with marked nuclear atypia, cystic change, and hemorrhage. S100 immunomarker was strongly and diffusely positive. Final diagnosis was ancient schwannoma with secondary change. Schwannomas are rare in the adrenal gland, with <50 cases reported in the literature. These incidentally detected nonfunctional adrenal tumors need confirmation with histopathology and ancillary studies.
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Aggressive angiomyxoma of renal pelvis in a horseshoe-shaped kidney: Rare tumor at an unusual site p. 460
Nishant Sagar, Prerna Arora, Nita Khurana, PN Agarwal
DOI:10.4103/IJPM.IJPM_74_19  PMID:32769340
Mesenchymal neoplasm is rare in renal pelvic region. Aggressive angiomyxomas are the neoplasms seen predominantly in female genital region. These tumors are locally aggressive with rare cases presenting with metastasis. Its occurrence in renal pelvis is extremely rare with only five cases reported in the literature. The present case is the sixth case reported in a 15-year-old girl who presented to the surgery department as a case of horseshoe kidney. The mass was excised and a diagnosis of aggressive angiomyxoma was rendered.
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Crystals, crystals everywhere but not a clue till late… Light chain crystalline proximal tubulopathy with concomitant myeloma cast nephropathy p. 463
Smita Mary Matthai, Suceena Alexander, Shibu Jacob, Neelaveni Duhli, Vinoi George David, Santosh Varughese
DOI:10.4103/IJPM.IJPM_756_18  PMID:32769341
The renal diseases commonly associated with myeloma include primary amyloidosis, cast nephropathy, and light chain deposition disease. Less frequent forms of renal involvement encountered in the course of myeloma are crystalline and non-crystalline proximal tubulopathies, neoplastic plasma cell infiltration, and immunoglobulin crystallization in interstitial histiocytes and glomerular cells including podocytes. Light chain proximal tubulopathy (LCPT) caused by aggregation of non-crystalline and rarely crystalline deposits of monoclonal light chains in the cytoplasm of proximal tubular epithelial cells, accounts for less than 5% of monoclonal gammopathy-associated kidney diseases. We report the case of a 48-year-old Indian woman with multiple myeloma, who presented with acute kidney injury and nephrotic syndrome, in whom the renal biopsy revealed widespread crystalline inclusions in extraglomerular and glomerular compartments. We present illustrative light microscopic (LM) and diagnostic electron microscopic (EM) findings of this case which enabled a diagnosis of crystalline LCPT, crystal storing histiocytosis, and crystalline podocytopathy occurring synchronously with myeloma cast nephropathy. While documenting this unique juxtapositioning of multicompartmental paraproteinemic renal injury in multiple myeloma, diagnosed after EM analysis of the patient's renal biopsy, we discuss the pathogenetic pathways of this condition along with the clinical implications. Due to intrinsic structural properties of the crystals, they frequently escape detection by routine LM, necessitating EM analysis for their diagnosis. Given the prognostic implications of tubulopathies complicating myeloma, LCPT is a critically important diagnosis, highlighting the need for a comprehensive renal biopsy evaluation inclusive of EM for the practice of precision medicine in such scenarios.
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Cervical rhabdomyoma a rare entity: Case report with review of literature p. 467
Nishant Sagar, Shramana Mandal, Nita Khurana, Ashok Kumar
DOI:10.4103/IJPM.IJPM_73_19  PMID:32769342
Genital rhabdomyomas are extremely rare benign tumors of skeletal muscle origin, majority of them being reported in vaginal location. Extensive literature search revealed only three such cases reported in cervix. We hereby report fourth such case of cervical rhabdomyoma in a 35-years-old female patient. The diagnosis was confirmed by histomorphology with desmin and myoD1 positivity on immunohistochemistry. Due to paucity of cases no definite treatment guidelines are available. Differentiation from identical and more common malignant counterpart which is rhabdomyosarcoma is essential to avoid unnecessary aggressive therapy.
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Malignant granulosa cell tumor of testis with metastasis to liver: Case report and review of literature p. 470
Sandhya Bordiya, Kumari Priyanka, Dharmendra Garg
DOI:10.4103/IJPM.IJPM_436_18  PMID:32769343
We report a case of testicular granulosa cell tumor of adult type in a 65-year-old male patient who has presented with hepatic metastasis. Although, this type of sex cord stromal tumor is relatively common in the ovaries, it is extremely unusual in the testis, and it probably represents the rarest type of testicular sex cord stromal tumor.
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Seminoma with focal gonadoblastoma in anatomically normal male: A rare case report p. 472
Sujata S Giriyan, MB Bharati, Nahida Afshan Shigli
DOI:10.4103/IJPM.IJPM_626_18  PMID:32769344
Gonadoblastomas are unusual gonadal neoplasias that frequently appear in dysgenetic gonads. Approximately 80% of patients are phenotypic females and 20% are males. A very high frequency is associated with malignant germ cell tumor. We present a case of 37-year-old normal fertile man with descended testis who presented with swelling and pain in left testis since 6 months. On examination, left testis was swollen, hard, and tender. Ultrasound examination of left testis showed hypoechoic lesion neoplastic with multiple enlarged lymph nodes in pre- and para-aortic region. After high left inguinal orchidectomy, histopathology of specimen showed tumor tissue composed of cells arranged in large nests separated by fibrous stroma infiltrated by lymphocytes with focal area showing nests of cells with vesicular nucleus and moderate amount of eosinophilic cytoplasm with eosinophilic material which was calcified, suggestive of seminoma testis with focal area of gonadoblastoma.
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Mesothelioma of the tunica vaginalis testis: A case report p. 475
Ilke O Kazaz, Ahmet S Teoman, Sevdegul Mungan
DOI:10.4103/IJPM.IJPM_780_18  PMID:32769345
Primary mesotheliomas of the tunica vaginalis testis are very rare malignant tumors. They are generally associated with exposure to asbestos. They may manifest as hydrocele, testis tumor, inguinal hernia, or epididymitis. After differential diagnosis, treatment is primarily surgical. Adjuvant therapeutic methods for mesotheliomas of the tunica vaginalis testis, with their high mortality, are controversial. Here, we present a mesothelioma case derived from tunica vaginalis testis acting as long-term pyocele with no known asbestos exposure.
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Granular cell tumor in a child: A rare case report p. 478
Zeynep Sagnak Yilmaz, Safak Ersoz
DOI:10.4103/IJPM.IJPM_495_19  PMID:32769346
A granular cell tumor (GCT) is a rare, usually benign soft tissue neoplasm that is commonly seen in the head and neck region. It is derived from the Schwann cells of the peripheral nerves. GCT is uncommon in children. 6-year-old girl was referred to our hospital for swelling over her left scapula, and a surgical excision was performed to remove the mass. Microscopically, the tumor was composed of cells with large granular cytoplasm and small oval to round nuclei. These cells stained positively for the following proteins: S-100, CD68, neuron-specific enolase, calretinin, and inhibin A. A GCT is usually benign, with a good prognosis, and less than 2% of the cases are reported to be malignant. It is worth noting that such tumors may arise in atypical locations and there is a possibility of malignancy.
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Case series of HbQ-India, a rare alpha globin variant in a referral laboratory setting in South India p. 481
Ayeesha Shaik, Sreeja T Thekkelakayil, Vijay Kumawat, Anurag Gupta, Manu Goyal
DOI:10.4103/IJPM.IJPM_465_19  PMID:32769347
HbQ variants are rare alpha globin chain variants commonly found in Sindhi community. It results from a point mutation of α-1 globin gene at position 223 of the coding region of exon 64. It is inherited in an autosomal dominant fashion. HbQ-India is usually clinically silent in heterozygous state unless associated with other conditions like beta thalassemia, alpha thalassemia, HbE disease, or nutritional anemia. High performance liquid chromatography (HPLC) identifies HbQ-India with a prominent peak present just after the Sickle window. We present five cases of HbQ-India from a retrospective analysis of 6034 cases over a period of 3 years, a rarity in a referral setting of South India. Awareness of this entity is important for appropriate recognition to prevent clinically symptomatic hemoglobinopathies. This study also highlights the retention time (RT) and characteristic chromatographic HPLC pattern seen in HbQ-India.
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Rare case of plasma cell myeloma with megakaryoblastic morphology mimicking acute leukemia p. 485
Keyu Liu, Huijuan Song, Jie Shi, Weijun Zhang, Rui Mu, Li Li
DOI:10.4103/IJPM.IJPM_282_19  PMID:32769348
Myeloma plasma cells vary from mature forms to immature, plasmablastic, and pleomorphic cells. Only a few cases of morphologic variant of plasma cell neoplasm have been reported, in which the plasma cell neoplasm presented with lymphoplasmacytic, megakaryocytic, plasmablastic, lymphocytosis-like, and variant hairy cell leukemia-like morphological features. A 66-year-old man sought medical attention with a previous 2-month history of lower back and chest pain. Magnetic resonance imaging (MRI) of the thoracic spine showed thoracic vertebral body shape and disc degeneration, and bone lesion. Blood work showed mild anemia (hemoglobin, 101 g/L; white blood cells, 6.98 × 109/L; platelets, 146 × 109/L.), hyperuricemia (UA 671 umol/L), and immunoglobulin G kappa [IgG(κ)] paraproteins. Bone marrow study revealed diffuse invasion by sheets of megakaryoblast-like cells. Flow cytometric analysis and bone marrow biopsy revealed plasma cell myeloma (PCM), and thoracic puncture biopsy indicated plasma cell neoplasms. Overall, the findings were in accordance with a PCM. To date, this is the first reported case of PCM with megakaryoblastic morphology mimicking acute leukemia. Recognizing the morphological variant of PCM is important in differentiating it from acute leukemia.
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Aspergillus fumigatus meningitis in an immunocompetent young woman p. 488
Balram Rathish, Arun Wilson, Anup Warrier, Roshni Pillay, Joe Thomas
DOI:10.4103/IJPM.IJPM_252_19  PMID:32769349
Aspergillus meningitis is a rare clinical entity that is much more frequently observed among immunocompetent patients. Here we present the case of a 28 year old immunocompetent lady with Aspergillus fumigatus meningitis possibly following spinal anaesthesia for her caesarean section. The diagnosis of Aspergillus meningitis is very difficult and challenging. Even after diagnosis, clinical outcomes remain poor with treatment. We wish to highlight the need for high index of suspicion for Fungal meningitis in patients presenting with meningism after Neurosurgeries and procedures involving invasion into the CSF compartment.
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IMAGES Top

Spherical amyloid deposition in prolactinoma p. 491
Monika Gupta, Nitika Grover, Rajeev Sen
DOI:10.4103/IJPM.IJPM_178_19  PMID:32769350
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GATA3 expression in the solid cell nest of thyroid p. 493
Pavithra Ayyanar, Suvradeep Mitra, Suvendu Purkait
DOI:10.4103/IJPM.IJPM_651_19  PMID:32769351
Solid cell nest (SCN) of thyroid is a benign histomorphological mimicker of papillary microcarcinoma. Previous studies have elucidated a few immunohistochemical markers of SCN that aid in its distinction from papillary microcarcinoma. The positivity of GATA3 in SCN has been demonstrated only recently. We also document GATA3 positivity in three cases of SCN.
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Myocardial bridging: An unexplained cause of sudden cardiac death in an explanted donor heart p. 495
Ravi H Phulware, Sudheer Arava, P Rajashekar, Milind P Hote, Sarvesh P Singh, Sandeep Seth, Ruma Ray
DOI:10.4103/IJPM.IJPM_370_19  PMID:32769352
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Urothelial carcinoma of the renal pelvis with synchronous ipsilateral papillary renal cell carcinoma p. 497
Neha Bagga, Sudeep Khera, Gautam R Choudhary, Rajat K Tuteja
DOI:10.4103/IJPM.IJPM_617_18  PMID:32769353
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LETTERS TO EDITOR Top

Hydatid cyst of kidney in a 60-year-old female: A rare case report p. 499
Varughese P George, Kathirvelu Shanmugasamy, Sowmya Srinivasan, Anandraj V Krishnamurthy, A T. M Venkat Raghavan
DOI:10.4103/IJPM.IJPM_236_19  PMID:32769354
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Endometrial glandular dysplasia: A finding not to be missed p. 500
Kriti Chauhan, Varun Hatwal
DOI:10.4103/IJPM.IJPM_573_19  PMID:32769355
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High-grade transformation in nodular lymphocyte predominant Hodgkin lymphoma p. 503
Sonali Susmita Nayak, Sangeetha K Parthiban, Peter Paul, Sumeet Gujral
DOI:10.4103/IJPM.IJPM_343_18  PMID:32769356
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Levels of expression of CD45 for normal lymphocytes in different leukemic cases by flowcytometry p. 505
Sandeep Rai, Saroj Singh, Ritu Gupta
DOI:10.4103/IJPM.IJPM_188_19  PMID:32769357
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Multiple myeloma associated with GI tract amyloidosis – Some queries p. 506
Sanjay A Pai, Reinhold Paul Linke
DOI:10.4103/IJPM.IJPM_962_19  PMID:32769358
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Multiple myeloma with secondary light chain deposition disease p. 509
Sujata S Giriyan, Purushotham Reddy, Mithraa D Sekar
DOI:10.4103/IJPM.IJPM_429_18  PMID:32769359
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Catechism (Quiz 9) p. 511
Bharat Rekhi
DOI:10.4103/IJPM.IJPM_436_20  PMID:32769360
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