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Year : 2019  |  Volume : 62  |  Issue : 5  |  Page : 43-104
E-Poster Presentation

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Date of Web Publication13-Dec-2019

How to cite this article:
. E-Poster Presentation. Indian J Pathol Microbiol 2019;62, Suppl S1:43-104

How to cite this URL:
. E-Poster Presentation. Indian J Pathol Microbiol [serial online] 2019 [cited 2022 Jan 27];62, Suppl S1:43-104. Available from: https://www.ijpmonline.org/text.asp?2019/62/5/43/272762

   PP1: Evaluation of histomorphological patterns of mycosis fungoides and pathologist's diagnostic dilemma Top

Sameer V Nandani, Janak Thakkar

Dr. Nandani Laboratory, Rajkot, Gujarat, India. E-mail: [email protected]

Background: Mycosis fungoides is a distinct clinico-pathological type of cutaneous T-cell Lymphoma and represent 50% of all primary cutaneous lymphomas. Traditionally, M.F. is divided in three stages; premycotic, mycotic and tumorous. The study aims to support that Histomorphological study remains gold standard for diagnosis of M.F. Design: Between 2013 to 2018, Five (5) consecutive cases of M.F. were included in this study. It composed of 4 Males (75%) and 1 Female (25%) aged between 50 to 77 years.Major clinical presentations were erythematous, scaly and pruritic skin. Generalized plaques, tumors and diffuse erythema. We performed H & E stains; and IHC- panel that included CD3, CD4, CD7 and other markers. Results and Discussion: The common Histomorphological patterns seen in our study were patchy cellular infiltrate in the upper dermis consisting of Mycosis cells. The patches are large and show sharp demarcation suggesting strong evidence of M.F. The neoplastic lymphoid infiltrate was composed of small to intermediate sized atypical lymphocytes (Mycosis cells) with enlarged hyperchromatic, cerebriform nuclei and clear cytoplasm. Pautrier's microabscesses which consist of small aggregates of atypical lymphocytes with Langerhans cells within epidermis were useful in diagnosis. Epidermotropism was characterised by presence within epidermis scattered, single mononuclear cells surrounded by clear space. Conclusion: Primary cutaneous Lymphomas are rare with different Clinical, Histomorphological and Immunohistochemical findings. Mycosis Fungoides is frequent primary cutaneous Lymphoma and the disease mimicks different conditions such as Psoriasis, Leprosy, Lichen sclerosus and Lichenoid Pityriasis. However, Histomorphological findings of Epidermotropism and Pautrier's microabscesses provide important clue for diagnosis.

   PP2: Mast cell infiltrations are different in different prostatic lesions: An autopsy study Top

Swapan Kumar Sarkar, Rabiul Alam, Shikha Das1

Murshidabad Medical College, Berhampore,1R.G.Kar Medical College, Kolkata, West Bengal, India. E-mail: [email protected]

Background: The prostate gland is a fibro-musculo-glandular retroperitoneal organ located in male pelvis. We have seen various prostatic lesions such as benign hyperplasia of prostate (BHP), prostatic intraepithelial neoplasia (PIN) and prostatic adenocarcinoma. Mast cells are granulated wandering cells whose granules stain metachromatically with toluidine blue. Mast cells infiltrate in various prostatic lesions in varying concentration. We studied autopsy cases regarding quantitative mast cell infiltrations in normal and different prostatic lesions. Design: Medico-legal autopsy of prostate gland was studied to find out the mast cell infiltration in various types of lesions. Our study was aimed to find out quantitative estimation of mast cell (stained with Toluidine Blue) in and around prostatic lesions with statistical analysis.: In a span of one year sixty autopsy specimens of prostate were dissected out from the deceased male person beyond 30 years of age. Results: Our study was designed to have an assessment of the accumulated mast cell density (MCD) in incidental prostatic lesions found in autopsy with final statistical analysis. Our study shows Mast Cell Density is lowest in poorly differentiated adenocarcinoma of the prostate and significantly highest in prostatitis. Conclusion: MCD is lowest in poorly differentiated Adenocarcinoma of Prostates, possibly due to lack of anti-tumour immunity in higher grade. It is significantly higher in non-specific prostatitis possibly because of inflammatory response and intermediate in PIN. High MCD in glandular element probably can be taken as indicator that lesion is not neoplastic.

   PP3: Hemophagocytic lymphohistiocytosis: A diagnostic challenge Top

Anusree Majumder

Command Hospital, Pune, Maharashtra, India. E-mail: [email protected]

Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare potentially fatal entity resulting from a hyperactivated immune system. Varied patient profiles and clinical presentations often result in misdiagnosis. Here the authors describe ante-mortem and autopsy findings in three patients who succumbed to HLH. Case Series: Our first patient was a 52-year-old male with Chronic Myelomonocytic Leukemia in blast crisis, with neutropenic sepsis and coagulopathy. The second patient was a 45-year-old male with fever, polyarthralgia, rash and septic shock. The third patient was a 22-year-old male with high grade fever, altered sensorium with seizures and severe respiratory distress. The clinical and autopsy findings of all 3 cases are summarized in Tables 1 and 2, respectively. Discussion: Myriad clinical presentations pose a diagnostic challenge in HLH. Cytopenias, hypertriglyceridemia, hypofibrinogenemia and markedly elevated ferritin level are the diagnostic parameters. The histopathological sine qua non is hemophagocytosis in the bone marrow, spleen, lymph nodes and liver. All our patients had varied clinical presentations and laboratory parameters; however, serum ferritin, triglycerides, LDH and liver transferases were significantly elevated in all. At autopsy, the patients had varying histological findings depending on the primary inciting event or disease, however hemophagocytosis was found in the bone-marrow and lymph nodes in all. Conclusion: HLH is a diagnostic conundrum that is compounded by pre-existing inflammatory or neoplastic disorders. Deranged coagulation profile, abnormal liver and renal function tests along with elevated ferritin and triglycerides may be early harbingers of this condition.

   PP4: Hemophagocytic lymphohistiocytosis associated with enteric fever: A rare autopsy case Top

Aishani Tiwari, Gwendolyn Fernandes

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Hemophagocytic lymphohistiocytosis(HLH) is a rare but life threatening hematological disease caused by immune system disregulation leading to severe hypercytokinemia and histological evidence of hemophagocytosis. Background: A 34 year old male presented with low grade fever with chills, cough, breathlessness and generalised weakness since 1 month. On examination-bilateral ronchi present; hemogram: Hb-11.6 gm%, TLC-600 cell/mm3 (only lymphocytes), Platelets: 10000/mm3. A clinical diagnosis of acute febrile illness with thrombocytopenia was made. He succumbed to his illness within 21 hours of admission and a complete autopsy was performed. He had a prominent past history of repeated episodes of fever, significant weight loss and axillary lymphadenopathy over a 8 months period of illness. One episode of enteric fever was diagnosed at the start and treated. Hemograms during this period revealed persistent pancytopenia. Se.Ferritin, Se. triglycerides, LDH, SGOT, SGPT, PT-INR were consistently raised. Dengue, malaria, leptospirosis and blood culture were negative. CT abdomen-pelvis: mild hepatosplenomegaly with retro peritoneal lymph nodes. Clinical impression was ?infective endocarditis?HLH?Lymphoma. Bone marrow revealed normocellular marrow. Significant Autopsy Findings: Stomach-multiple yellowish ulcers (candidial etilogy on microscopy); liver-2.2kgs, yellow greasy; spleen-450g and multiple enlarged mesenteric lymph nodes. Histology: diffuse accumulation of histiocytes with hemophagocytosis in the liver, spleen and lymph node. Kidney showed pigment nephropathy. A diagnosis of HLH was established with 6/8 diagnostic criteria present. Conclusion: HLH should be suspected in patients with unexplained fever, pancytopenia and multi organ failure. A high index of suspicion, detailed analysis of clinical and laboratory findings are required for diagnosis.

   PP5: Retroperitoneal infrarenal ectopic pancreas in case of autosomal dominant polycystic kidney disease with massive fatal gastric haemorrhage: An autopsy case Top

Prajakta Prakash Sakhare, Saroj A Bolde, D N Lanjewar, Sanjay Bijwe

Department of Pathology, Grant Government Medical College and Sir J.J. Group of Hospitals, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Ectopic pancreas are usually found in upper Gastrointestinal tract. Retroperitoneal infrarenal ectopic pancreas is extremely rare. Design: A 55 years female came with complaints of altered sensorium, distention of abdomen and pain. Clinical diagnosis was metabolic encephalopathy in a case of ADPKD and diabetes mellitus. Patient died inspite of all medical treatment. Clinical postmortem was performed. On autopsy, stomach was filled with a huge blood clot. Duodenum showed hemorrhagic necrosis at ampulla of Vater. Liver showed a small cyst. Both kidneys were enlarged and showed multiple cysts filled with serous fluid. There was a retroperitoneal infrarenal brownish firm mass measuring 7x4x2 cm which was diagnosed as a tumor. Cerebral vessels showed Berry aneurysm. Histopathological diagnosis was made as retroperitoneal infrarenal ectopic pancreas (Gasper Fuentes classification - type I) with changes of chronic pancreatitis in both ectopic and orthotopic pancreas with candidiasis at ampulla of Vater and paraduodenal pancreatic tissue in a case of Polycystic kidney with chronic pyelonephritis. Results and Discussion: To date, two cases of retroperitoneal ectopic pancreas with malignant transformation and one case with multiple sites ectopic pancreas have been reported. To the best of our knowledge, this is probably the first case of retroperitoneal infrarenal ectopic pancreas which was clinically asymptomatic and detected in autopsy as an incidental finding. Conclusion: Ectopic pancreas is incidentally diagnosed during surgery or autopsy. If it is seen during surgery, it should be resected to avoid serious complications.

   PP6: Histomorphological spectrum of lung lesions in adults at autopsy Top

Ruchika Chamaria

Grant Medical College and JJ Group of Hospitals, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: A wide spectrum of diseases affect the lungs all through life. Histopathological study of lung at autopsy is important for improving the vision and diagnostic setups for better clinical assessment, timely diagnosis and therapy. Objective: To study spectrum and incidence of various non-neoplastic and neoplastic lung lesions, age and sex wise distribution of these lesions in adults and assess their contribution to mortality. Design: Prospective study of histopathology of lungs in all adult medicolegal and clinical autopsy cases over one year. Autolysed specimen and pediatric specimen were excluded. Results and Discussion: Total 209 cases were studied comprising of 104 males and 105 females. Edema, congestion and hemorrhage were the most common findings (50.24% cases), among which 57.14% were males. Pneumonia was the most common infective lesion, comprising of 29.79% cases of which 39.29 % were interstitial pneumonia. Males and females were equally affected. Diffuse alveolar damage was the primary diagnosis in 3.82% cases and con concomitant with other lesions in 5.74% cases with female preponderance (72.71%), especially in the age group of 18- 30 years, mainly maternal mortality. Tuberculosis and its associated lesions comprised of 7.71% cases. 57.14 % of the cases were females. Other non-neoplastic lesions observed were emphysematous changes, atelectasis, fibrosis, bone marrow emboli, fat emboli, abscess, fungal lesions and chronic venous congestion. 1.44% (3) cases of metastatic malignant lesions were identified. Conclusion: Lung pathology is a significant contributor to morbidity and mortality. Preventable diseases and incidental findings formed a considerable part of the cases studied.

   PP7: Acute chest syndrome.... Where sickling is killing!!! Top

Tejas Vidwans, Varsha Dhume, Kavita Pawar

Topiwala Nair Medical College and BYL Nair Medical Colleges, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Acute chest syndrome (ACS) is defined as distinctive manifestation characterized by chest pain, tachypnea, fever, cough, arterial O2 desaturation, new radio density in chest radiograph. Incidence of ACS in sickle cell disease (SCD) is 12.9/100 patient years and forms leading cause of death in SCD. Design: In autopsy study of 44 SCD deaths which were diagnosed only on PM histopathology, 7 were due to ACS. In all cases complete autopsy was done. Gross and microscopy was studied with clinicopathological correlation. Results and Discussion: Majority of cases occurred in age group of 21 -30 years. Most of patients presented with fever, breathlessness, cough. Hospital stay was of less than 12 hours Clinical diagnosis were acute febrile illness (3 cases) , hepatic encephalopathy (1), pneumonia (1) ,thromboembolism (1),non conclusive (1). In none of the cases underlying SCD was suspected and the diagnosis was established only at autopsy. At autopsy lungs revealed pulmonary edema & consolidation (5 cases), pulmonary thromboemboli (4 cases); of which 2 cases showed bone marrow embolus and 1 case showed fat embolus. ACS have varied presentation mimicking cardiorespiratory events such as pneumonia, pulmonary emboli, myocardial infarction, In non-endemic areas, SCD is not considered as differential and therefore not worked up. Use of specific treatment modalities has been implicated for ACS with SCD. Conclusion: High clinical suspicion of ACS with SCD in patients with cardiorespiratory symptoms along with timely intervention can lead to reversal of events thus preventing mortality.

KEYWORDS: Acute chest syndrome, sickle cell disease

   PP8: Black esophagus, in a case of candidial gastric perforation Top

Monmeeta Srikant, Manjusha Karegar, Balaji Baste, Amita Joshi, Pradeep Vaideeswar, Rachana Chaturvedi

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

“Black esophagus” or acute esophageal necrosis (AEN) is a rare clinical entity which is characterised by diffuse circumferential black mucosal discolouration of the distal esophagus. Presence of co-morbidities and poor clinical conditions are associated with the development of AEN with high mortality rate. We report a case of black esophagus in a patient with candidial gastric perforation. Design: A 72 year old male, a known hypertensive and a chronic alcoholic was admitted for hemetemesis, melena and pain in abdomen. CT scan was suggestive of gastric perforation for which he underwent emergency exploratory laparotomy. We received a specimen of distal gastrectomy having two perforations, one each on the anterior and posterior wall measuring 1.5 cm and 4 cm in diameter respectively, which on histology revealed transmural necrosis and mixed inflammation admixed with plenty of candidial budding yeast forms and pseudohyphae. The patient's condition deteriorated and he expired within 2 days of surgery. A complete autopsy was performed. On autopsy, the distal one third of oesophageal mucosa showed blackish discolouration. The peritoneal surface was completely covered with exudates admixed with similar candidial forms. Histopathological examination showed extensive mucosal ulceration and focal infarction of the esophagus covered with blackish hemosiderin pigment and fresh fibrin thrombi in the submucosal vessels. Rest of the gastrointestinal tract was normal. Conclusion: Black esophagus is mostly seen in patients with severe hemodynamic compromise who present with features of upper gastrointestinal bleeding. AEN though rare should be considered as a differential for hemetemesis to avoid misdiagnosis and its consequences.

   PP9: Angiostrongylus cantonensis infection of the brain Top

Jayashri Chaudhari, Asha Shenoy, Naina Goel, Jabin Yasmin Ullah

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Angiostrongylus cantonensis, the rat lung worm is the most common cause of eosinophilic meningitis. Humans are the incidental host and acquire infection due to ingestion of larvae from molluscs or contaminated uncooked food. It is the only genuine neurotropic nematode as the larva has to pass through the CNS for further development. Very few autopsy reports have been published in literature. Case Report: A 32-year-old mentally challenged male was admitted with sudden onset bilateral lower limbs weakness, abdominal distension, inability to pass urine or stools. On examination, lower limb reflexes were absent along with loss of sensation to touch, pin prick and temperature. He expired the next day before clinical work-up could be performed. At autopsy, the brain was edematous and meninges were mildly hazy. Serial coronal slices of the cerebral hemispheres showed few cavities, largest measuring 1.5x1.0x1.0cms in the basal ganglia probably representing migratory tracks of parasite. Histopathology revealed eosinophilic meningitis and multiple sections of a parasite having cuticle, body cavity, prominent lateral chords, intestine and 2 gonads typical of Angiostrongylus cantonensis. The lungs showed features of bronchopneumonia. The final cause of death was “Bronchopneumonia & Eosinophilic Meningitis in a case of Angiostrongylus cantonensis infection of Central Nervous System.” Conclusion: Infection by Angiostrongylus cantonensis is rare in humans and requires a strong index of suspicion for diagnosis and early initiation of treatment. Since this nematode matures in the brain, it causes early fatal outcome.

   PP10: Intravascular B-cell lymphoma: A rare case diagnosed at autopsy Top

Shailee Trivedi, Pradeep Vaideeswar, Daksha Prabhat, Tejaswini Waghmare

Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Intravascular large B-cell lymphoma (IVLBCL) is a rare and aggressive subtype of Non Hodgkin's lymphoma characterized by preferential proliferation of large tumour cells within the lumina of small to medium-sized vessels with relative sparing of the surrounding parenchyma. The estimated incidence is of less than one person per million based on its rate of appearance in literature. Case Report: A 45 year old female presented with easy fatiguability, generalised weakness and recurrent episodes of fever since one month. She also had a single episode of generalised tonic clonic convulsion. She was pale and disoriented and had received four units of blood transfusions in the past. Investigations revealed, Hemoglobin of 6.0 gm%, Total WBC count 3.9 x 109/L, Platelet count 60 x 109/L. Due to poor general condition the patient expired within one day of ward stay. Autopsy findings: Liver(1.4kg) and Spleen(700gm) were enlarged. Histopathology revealed large malignant lymphoid tumor cells widely disseminated within lumina of vessels and sinusoids of most of the organs. In kidneys, the tumour cells were characteristically seen within the glomerular capillaries. Bone marrow showed infiltration by tumour cells along with hemophagocytosis. The cells were CD20 positive giving the diagnosis of Intravascular Large B Cell Lymphoma. Conclusion: IVLBCL is a rare subset of DLBCL without lymphadenopathy, which renders it's diagnosis elusive. The clinical presentation of the patients is nonspecific, and the course is so rapid that the diagnosis is often made at autopsy.

   PP11: Intracardiac metastatic squamous cell carcinoma Top

Rumela Nayak

Seth G S Medical College and K.E.M Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Metastatic tumours of the heart are more common than the primary tumours. Leading causes of cardiac metastasis are carcinoma lung, breast, oesophagus, melanoma, leukaemia and lymphoma. Many of them are adenocarcinomas. Metastatic Squamous Cell Carcinoma is uncommon with most common primary site being head neck and face. We present 2 cases with intracardiac metastasis forming polypoidal lesion along with involvement of myocardium without any epicardial involvement. Case Report: Case 1: A 32 years male was referred to our institution for medicolegal autopsy with short preceding history of breathlessness before death. He was a known case of squamous cell carcinoma of left buccal mucosa and underwent surgery 5 months ago. At autopsy apex of both the ventricles showed tumour replacing the papillary muscles and extending into interventricular septum and lateral wall. Case 2: A 42 years male underwent near total glossectomy for squamous cell carcinoma of tongue. He also developed a concurrent squamous cell carcinoma of right lung. He was referred to our centre with lower limb deep vein thrombosis and succumbed with preceding history of sudden onset breathlessness. At autopsy left ventricular apex showed tumour extending into the lateral wall and papillary muscles. Both cases showed intracardiac metastatic squamous cell carcinoma on histopathology. Discussion: Cardiac metastasis reflects widespread disseminated malignancy, most frequently involving pericardium followed by epicardium, myocardium and rarely endocardium. Symptoms are variable depending on the involved site. Conclusion: Intracardiac metastasis irrespective of histomorphology should be considered in any patient who has been diagnosed or treated for carcinoma.

   PP12: Coronary artery disease in diabetes mellitus and hypertension: An autopsy study Top

Satish Vasant Tandale, Gayathari P Amonkar, Heena Desai

Topiwala National Medical College and B.Y.L Nair Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Objectives: Incidence of coronary artery disease (CAD) is increasing in the Indian population causing significant morbidity and mortality. Diabetes mellitus and hypertension are major risk factors. We undertook an autopsy study of CAD in diabetic and hypertensive cases. The findings were compared with cases of CAD in non-diabetic and non-hypertensive cases. Methods: A 2-year retrospective autopsy study of 100 CAD cases was carried out. They were divided into 4 groups containing 25 cases in each group.

Group1-CAD with diabetes mellitus

Group 2-CAD with hypertension

Group 3-CAD with diabetes mellitus and hypertension

Group 4-CAD in non-diabetic, non-hypertensive – Control group.

Gross and microscopic examination of all 3 coronaries was done. Features of CAD like percentage of luminal stenosis, pattern of narrowing, composition of plaque, presence of inflammation, calcification, neovascularization, erosion, thrombus, rupture, hemorrhage was studied. Results: Male patients were affected more commonly. Chest pain was the common presenting complaint followed by breathlessness. Fibrous plaque, eccentric pattern and lymphohistiocytic inflammation in plaque were also observed in all four groups. Neovascularization was more commonly seen in Group-1, 48% (12/25) cases followed by Group-2. Intraplaque hemorrhages was most commonly seen in Group-2, 16%(4/25). Thrombus formation was commonly seen in group-3,(16%). Conclusions: Significant morphological changes of CAD were observed in the various study groups. Diabetic cases showed multiple vessel involvement more commonly. Intraplaque hemorrhage was seen more in hypertensive cases. Thrombus formation and erosion were more in diabetic with hypertensive cases.

   PP13: Spectrum of lesions in brain and its clinicopathological correlation: A two year prospective autopsy study Top

Lavanya Raghavan

Grant Government Medical College, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: There is a wide array of intracranial pathologies with high mortality rate. Histopathological study of postmortem findings in brain can throw light into areas of concern. Objective: To study the spectrum of intracranial lesions in the post-mortem findings and to analyse their contribution to mortality. Design: Prospective study of histopathology of brain in all clinical and medicolegal autopsy cases in age group 11 to 80 years, over 2 years. Results and Discussion: Among 2117 cases referred, intracranial causes of death accounted to 11.1 % (235). Males (68.08%) were affected twice as much as the females (31.91%). 21- 30 years (24.25%) constituted the majority while 61-70 years (6.38%) had the least. 71.06% cases had traumatic cause, making it the commonest mode of death, whereas 20.42 % cases had non-traumatic causes and 8.51% cases were due to unknown cause. Road traffic accidents were the major contributor of deaths due to trauma (53.8%), followed by fall from height (20.3%) and assaults (13.1%). Among non-traumatic causes of death, major proportion (52.0%) came under CVA (cerebrovascular accident) category, followed by CNS infections (25.0%). Autolysis was seen in 24.2% cases due to poor brain fixation and/ or delay in autopsy after death. Conclusion: Intracranial pathology is an important contributor to mortality, which can be reduced by proper health care and better implementation of traffic rules.

   PP14: Burkitt lymphoma with disseminated pleuro-peritoneal and visceral lymphomatosis: An autopsy diagnosis of an unusual case Top

Smriti, Ankur Ahuja, G P S Gahlot, Tathagata Chatterjee, Prerna Guleria

Army Hospital Research and Referral, New Delhi, India. E-mail: [email protected]

Introduction: Sporadic Burkitt Lymphoma (BL) commonly has abdominal lymphadenopathy and sometimes solid organs involvement. However, involvement of appendix, gall bladder and peritoneal lymphomatosis is extremely rare. We present a case of BL with multiple solid organ, peritoneal and omental lymphomatosis where diagnosis was established on autopsy. Case Report: 51-year-old male, had painless distention of abdomen, progressive breathlessness and weight loss of 01-month. Examination revealed ascites, bilateral pleural effusion and raised serum and fluid LDH levels (>35,000 U/L). Pleural fluid was exudative with increased ADA. Ascitic fluid was low SAAG and had no malignant cells. Radiology showed diffuse peritoneal thickening with FDG avid cervical and mediastinal lymph nodes, peritoneum, mesentery, omentum and deposits of rectus abdominis. He was started empirically on antitubercular treatment post which he developed drug induced hepatitis. Ultrasonography-guided peritoneal biopsy was planned, however, there was rapid deterioration, and he succumbed to his illness before a definite diagnosis. Post-mortem examination in addition revealed markedly enlarged appendix(17x2.5cm) with 1cm thick wall, hepatomegaly with multiple large nodular deposits(3-4cm), pale enlarged gall bladder and pancreas with bulky head. Microscopically, ascitic fluid smears, sections from lymph nodes and viscera revealed involvement by intermediate sized atypical lymphoid cells diffusely positive for CD20/CD38/CD10/C-MYC. There was brisk mitosis with Ki67 proliferation >90%. The features were suggestive of BL with diffuse visceral and peritoneal lymphomatosis. Conclusion: This autopsy case report highlights unusual presentation of an aggressive BL and the importance of high clinical suspicion and rapid diagnosis in a fatal disease which is potentially curable.

   PP15: Out of sight but not out of mind: Indian childhood cirrhosis Top

Neha Bhardwaj, Kirti Gupta, Arushi G Saini1, Sadhna Lal2, Vikas Bhatia3

Departments of Histopathology,1Paediatrics,2Gastroenterology and3Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]

Background: Indian Childhood Cirrhosis (ICC) has fascinated the scientific community for decades and gained public health importance in 1950s on account of its high prevalence, unique clinical features and high mortality. It became recognized as a distinct clinical entity with peculiar histological features: hepatocellular injury accompanied with deposition of intracellular Mallory hyaline. However, the exogenous toxic agent causing hepatocyte injury in genetically predisposed individuals remains obscure. ICC is said to be disappearing from India but scattered reports of ICC-like cirrhosis are appearing in the West. Case Report: We describe a case of 15-month-old male referred for evaluation of suspected storage disorder on account of developmental delay, massive hepatosplenomegaly, coarse features and a similarly affected twin brother. During admission, varices, liver cirrhosis and portal hypertension were detected with no storage seen in skeletal system, eyes and marrow. He acquired hospital-care associated infection during the stay and subsequently succumbed. At autopsy, the nodular liver revealed features of ICC with bridging and pericellular fibrosis coupled with ballooning degeneration and extensive Mallory body formation. Orcein and Auramine -rhodamine stains highlighted excess of hepatocytic copper. Subsequently, the liver biopsy of his twin brother revealed similar features. Conclusion: The case calls for an appraisal of decline in cases of ICC that could possibly be due to a true decline in incidence related to sociodemographic and economic growth. Furthermore, the cases are being missed because of lack of histologic confirmation and awareness of its protean manifestations and natural history.

   PP16: An autopsy case of cytomegalovirus ventriculoencephalitis in a child with RAG1 gene mutant severe combined immunodeficiency Top

Khalid Abdul Mannan, Deepti Suri, Rakesh Kumar Pilania, Sandesh Guleria, Amit Rawat, Surjit Singh, Sameer Vyas, Kirti Gupta

PGIMER, Chandigarh, India. E-mail: [email protected]

Severe combined immunodeficiency (SCID) is a heterogeneous group of disorders characterized by gross and functional impairment of both cell-mediated and humoral immune system. Plausibly, it predisposes the body to a host of opportunistic infections. With the AIDS epidemic, the past decades have witnessed a resurgence of cytomegalovirus (CMV) encephalitis which was once considered to be a rare condition. In the brain, besides the classic reaction of microglial nodules, calcification, viral inclusions, and perivascular lymphocytic cuffing, a florid gemistocytic reaction coupled with multiple viral inclusions may rarely be encountered, as exemplified by the present case.

   PP17: Pulmonary embolism leading to maternal mortality Top

Bhagyashri Shastri, Lalita Patil, Kusum Jashnani

Topiwala National Medical College, B.Y.L. Nair Ch. Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]


  • Pulmonary embolism is one of the leading causes of direct maternal deaths.
  • Pregnancy and puerperium are well recognized risk factors.

Design: We report a series of 7 autopsy cases of maternal mortality due to pulmonary embolism over a period of 3 and half years. Total 2113 medical (pathology) autopsies were performed by our department in above period. Of these 147(6.95%) were maternal autopsies, and 7 of these cases were deaths related to pulmonary embolism. Results and Discussion: The age varied from 19 years to 35 years, with mean age of 25 years. All but one were multigravidas. Breathlessness (57.14%) and headache (28.57%) was the most common presentation followed by seizures, weakness, abdominal pain and vomiting. Marked pallor with low hemoglobin levels was the commonest clinical examination findings. Two cases had vaginal delivery and 2 cases were delivered by LSCS. Of 2 cases of IUFD one case had spontaneous vaginal delivery of macerated fetus. Last case was an unregistered case of abortion at 2 and half months. On histopathology, one case showed pulmonary bone marrow embolism with sickled RBCs in spleen, liver and kidneys. Another single case showed pulmonary artery air embolism. There was one case of thrombotic thrombocytopenic purpura with fibrin thrombi in microvasculature of pancreas, adrenals, heart, kidneys, lungs and GIT. Pulmonary thromboembolism was seen in remaining four cases. Conclusion: Pulmonary embolism causes high maternal mortality in multigravida. Proper risk assessment and initiation of heparin therapy with designed protocol will be helpful.

   PP18: Autopsy in cardiac death in transplant and non transplant cases: Four year experience at a tertiary care centre Top

Dwarika Tiwari

Army Hospital Research and Referral, New Delhi, India. E-mail: [email protected]

Aims and Objectives: To ascertain the cause of death in post transplant and non transplantcardiac cases on autopsy. Patients / Materials and Methods: This was a retrospective study over last 04 years (2016-2019), establishing the clinico pathologic correlation of patients who died as a consequence of underlying cardiac diseaseat our tertiary care hospital. Results: There were 18 out of 162(total four year autopsy) patients ( age range 20-60 years) with underlying cardiac diseases who succumbed to their disease and autopsy was conducted at our hospital. Out of a total of 18 patients, two cases were of post cardiac transplant deaths who suffered unusual complications of orthotropic heart transplant. One of them was asymptomatic and had sudden cardiac death(SCD)due to severe antibody mediated rejection at 08 months and other developed ruptured mycotic aneurysm of ascending aorta. Amongst the non transplant group, common cardiac causes of SCD were coronary atherosclerotic disease (62.5%),valvular disease of heart(18.75%), infective endocarditis(12.5%)and dilated cardiomyopathy (12.5%). Discussion and Conclusion: The cause of sudden cardiac death in post heart transplant and non transplant groups has been identified at post mortem in our study cohort. In this study, we found spectrum of cardiac causes which led to sudden cardiac death with varying clinical presentation. Hence, autopsy and final clinico-pathological correlation is of vital importance in providing accurate data, identifying and elucidating new pathological findings.

   PP19: Temporal bone langerhans cell histiocytosis Top

Renuka Verma, Sunita Singh, Rajnish Kalra, Vinay Kumar1, Rajeev Sen

Department of Pathology, Pt. B. D. Sharma, PGIMS, UHS,1Pt. B. D. Sharma, PGIMS, UHS, Rohtak, Haryana, India. E-mail: [email protected]

Background: Langerhans cell histiocytosis is a rare disease characterised by the idiopathic proliferation of abnormal histiocytes, either in one organ or as part of a systemic disease. Temporal bone LCH is confused with ear inflammatory lesions and malignant tumors. Case Report: 4 year old child presented with recurrent CSOM and an external auditory canal polyp. MRI revealed a well-defined expansile lesion involving the skull vault in left parietal region measuring 18x9 mm. Microscopy of polypoidal tissue revealed presence of large round to polygonal atypical cells with convoluted and reniform nucleus, clumped nuclear chromatin and moderate to abundant pale cytoplasm along with few giant cells, eosinophils, neutrophils and plasma cells. On IHC, these atypical cells were positive for CD 68, CD 1a and S-100. Histological features were in favour of LCH. The whole body PET-CT scan revealed metabolically active multiple site lytic bony lesions with soft tissue involvement. Lymphadenopathy, spleenomegaly and centriacinar nodules in both lung parenchyma were also seen. Hence the diagnosis of multifocal multisystem LCH presenting as ear polyp was made and chemotherapy with methotrexate and systemic steroids were started. Discussion: LCH manifestations are most common in the head and neck region and their diagnosis becomes difficult as it mimics other more common diseases such as external ear eczema, acute mastoiditis and gingivitis. Temporal bone disease manifests as recurrent purulent otorrhea, retroauricular edema and external auditory canal polyp. Conclusion: Diagnosis is based upon clinical, radiological and pathological findings. The definitive diagnosis is made on biopsy and by IHC demonstration.

   PP20: Low-grade malignant peripheral nerve sheath tumor of leg: A rare case Top

Sacheeta Babuta, Cheena Garg, Vibhuti Goyal, Nitesh Mohan, Ranjan Agrawal

Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Background: Malignant Peripheral Nerve Sheath Tumors (MPNST) are rare spindle- cell sarcomas having multiple histological origins. MPNSTs are usually located in the peripheral nerve trunk roots, extremities and head and neck region. There is <0.001% incidence in the general population. A case of low grade MPNST of right leg in an elderly male is presented due to its rarity. Case Report: 62/M presented with swelling in the middle 1/3rd of lateral aspect of right leg measuring 5x3 cm. It was firm and non-fluctuant. History of trauma with old surgical scar about 10cm long was present on the anterior aspect. FNAC showed oval to spindle shaped cells exhibiting mild to moderate pleomorphism, irregular nuclear borders, binucleation, finely granular chromatin and prominent nucleoli. Cytoplasm was moderate in amount. Occasional foamy cells were found. MRI showed multifocal elongated lobulated enhancing lesions along the neovascular bundle, some showing target like appearance. Excised specimen was multinodular, creamish–white measuring 6x4x2.5 cms. Microscopy revealed partially encapsulated multinodular tumor with incomplete fibrous septa and myxoid stroma. There was variable cellularity with non-cohesive, plump spindle to stellate tumor cells having ill-defined eosinophilic cytoplasm. Nuclei showed mild to moderate pleomorphism and hyperchromasia. Mitosis was infrequent. There were prominent elongated thin walled blood vessels with perivascular myxoid matrix. No necrosis seen. Capsular invasion was evident. IHC showed focal positivity for S-100. The final diagnosis was LGMPNST - FNCLCC- grade 1. Conclusion: Careful clinical and histological evaluation along with S-100 marker is essential for the accurate diagnosis of low grade MPNST.

   PP21: Primary extraskeletal ewing's sarcoma/primitive neuro-ectodermal tumour: A report of 5 cases Top

Brij Mohan Kumar Singh, Kanthilatha Pai, Manna Valiathan, Swati Sharma

Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India. E-mail: [email protected]

Background: Extraskeletal Ewing's sarcoma / PNET (primitive neuro-ectodermal tumours) is a rare, rapidly growing round cell malignant tumour that can develop in the soft tissues at any location. This retrospective study was done to analyse the clinical, radiological and pathological features of Ewing's sarcoma at the extraskeletal region. Design: All relevant data of five patients diagnosed with extraskeletal Ewing's sarcoma, treated at Kasturba Hospital, Manipal between January 2012 and August 2019 were analysed with the available data from medical record department and archives of the department of pathology, Kasturba Medical College, Manipal. Results: Of Five patients, three male and two were females, aged between 13 and 28 years. The location of the tumour was abdominal wall, right gluteal region, posterior mediastinum, kidney and the anterior aspect of the right thigh. The histomorphological and immune-histochemical findings were in concurrence with the diagnosis of Ewing's sarcoma/PNET. Two cases were positive with FLI 1 immunohistochemical marker. All patients were treated with combined (surgical and chemotherapy) modality of therapy. On follow up of these patients from 1month to 3 years two patients developed metastatic disease and one presented with metastasis in the lung at the initial diagnosis. Two patients were lost to follow up. Conclusion: Extraskeletal Ewing's sarcoma is common in adolescents. It often manifests as a localised mass. The definite diagnosis is made with the help of histomorphology and immunohistochemical examination. A combination therapy mode is recommended for this disease. The presence of metastatic disease at the time of diagnosis is a prognostic factor.

   PP22: A rare case of paediatric solitary plexiform neurofibroma of the lip Top

G Jeevitha, Kiran Agarwal, Gautam Bir Singh1, Indu Shukla1

Departments of Pathology and1Otorhinolaryngology and Head and Neck, Lady Hardinge Medical College, New Delhi, India. E-mail: [email protected]

Introduction: Neurofibroma is a benign nerve sheath tumor of heterogeneous origin. Solitary neurofibroma without other signs of neurofibromatosis (NF) is a rare clinical entity. Further, the presence of plexiform neurofibromatosis (PN) in the oral cavity is very rare. Herein, we present an interesting case of plexiform neurofibroma in oral cavity. Case Report: A 6 year old boy presented to ENT OPD with swelling at right angle of mouth. The swelling was painless and had gradually increased in size over a period of 2 years causing difficulty in eating. General physical examination was normal. On local examination, a firm submucosal swelling was seen at the right angle of mouth, measuring 3cm in maximum dimension. The lesion was well circumscribed and was non-tender on palpation. The mucosa overlying the swelling was intact with no sinus or punctum. Clinical differential diagnoses of pyogenic granuloma, traumatic keratotic lesion and granular cell tumor were considered. Gross examination showed 2 mucosa covered tissue bits; on cut section showed multiple grey white nodules. Microscopic examination revealed multiple nodules in the dermis and subcutis, composed of tortuous proliferation of peripheral nerves including axons, schwann cells, fibroblasts and perineural cells. Hence a pathological diagnosis of plexiform neurofibroma was made. On further evaluation, other features of Neurofibromatosis Type 1 were absent. Thus a final diagnosis of solitary plexiform neurofibroma at the angle of the mouth and lower lip was made. Conclusion: This case is presented in view of its rarity.

   PP23: IDH 1/2 (Isocitrate dehydrogenase) gene mutations in chondrosarcomas and osteosarcomas with cartilaginous differentiation Top

Jesina Samuel, Anne Jennifer Prabhu, Rekha Pai1, V T K Titus2, Thomas Palocaren3, S Patricia4, Rikki John5

Departments of General Pathology,1Molecular Pathology,2Orthopedics,3Pediatric Orthopeadics,4Radiotherapy and5Pediatric Hematology-Oncology, Christian Medical College, Vellore, Tamil Nadu, India. E-mail: [email protected]

Background: The distinction between chondrosarcomas and osteosarcomas with cartilaginous differentiation(CBOS) on small biopsies is essential for management. A few western studies have shown presence of IDH(R132)/IDH2(R172) mutations in ~60% cartilaginous neoplasms and not in osteogenic sarcomas. This can potentially aid in diagnostics. Design : Our objective was to analyse the IDH1/2 mutational profile among cases of chondrosarcoma and CBOS and to correlate the mutational pattern with clinicopathological parameters. IDH gene mutation analysis by PCR sequencing was done on the archived blocks of chondrosarcomas and CBOS, diagnosed in our department from December 2014 to October 2018. Demographic and clinical details were obtained from the clinical workstation and analysed. Results and Discussion : There were a total of 60 cases in our study - 41 chondrosarcomas and 19 CBOS. Mutational analysis revealed that 10/41 (24.4%) of the chondrosarcomas harbored a somatic mutation in either IDH1 or IDH2.The majority of mutations were found in the IDH1 gene (n = 7,63.6%) specifically, R132H, R132G and R132S. In IDH2 gene, R172K and R172M mutations were observed. One case showed mutation in both IDH1 and IDH2 genes. None of the 19 CBOS harbored a mutation in either gene. Conclusions : This is the first IDH mutational analysis of chondrosarcomas in our population. As against western literature: 1.The mutation positive cases were only 24.4%. 2. IDH1R132H was the most prevalent mutation. 3.IDH1R132C mutation was not seen.4.Higher percentage(36.4%) of IDH 2 gene mutations was identified. Thus IDH1/2 mutation can potentially be a biomarker to aid in distinguishing chondrosarcoma from CBOS.

   PP24: Extraskeletal myxoid chondrosarcoma: A rare case report Top

Subhashree Archana Rout, Debiprasad Mishra

MKCG Medical College and Hospital, Berhampur, Odisha, India. E-mail: [email protected]

Introduction: Extraskeletal myxoid chondrosarcoma is a rare soft tissue sarcoma accounting < 2% of all soft tissue sarcoma. Case Report: 45 yr male patient presented with a slow growing mass over right knee since last 2 yrs.Mass had enlarged and become hard since 6 months. Discussion: Extraskeletal myxoid chondrosarcoma is a rare soft tissue sarcoma.most common manifestation is an enlarging soft tissue mass.radiologically there is no bony involvement. Conclusion: A multimodal approach including histopathologic correlation and utilisation of ancillary cytogenetics and molecular testing may be necessary in establishing a more definitive diagnosis.

   PP25: Subcutaneous bronchogenic cyst: A rare presentation Top

Akshita Rattan, Gurpinder Kaur, R P S Punia, Ranjeev Bhagat

Government Medical College, Chandigarh, India. E-mail: [email protected]

Background: Subcutaneous bronchogenic cyst is a rare congenital malformation, arising from the abnormal bud of embryonic tracheobronchial tree. Due to its origins from the primitive respiratory tract the vast majority of them are located in the intrapulmonary region and mediastinum. A few of them have also been reported at unusual places like in skin, diaphragm, pericardium and retroperitoneum. Case Report: A 23 years old adult male presented with a subcutaneous swelling over the upper part of back near the right shoulder since birth. The swelling was associated with occasional serosanguinous discharge. Radiological investigation revealed findings suggestive of a sinus tract traversing the subcutaneous fat pad from the skin along the trapezius muscle. The swelling was excised in toto and the specimen was sent for histopathological examination. Histopathological examination of the excised swelling showed a cyst lined by respiratory epithelium. Cyst wall was composed of fibrocollagenous tissue and shows a few smooth muscle bundles, many congested blood vessels, adipose tissue and mild lymphomononuclear cell infiltrate and an occasional plasma cell. A histopathological diagnosis of subcutaneous bronchogenic cyst was rendered. Discussion: Differential diagnosis of a cyst of the skin lined by ciliated pseudostratified columnar respiratory-type epithelium includes branchial cleft cyst, thyroglossal duct cyst, mature cystic teratoma, and cutaneous ciliated cyst. Knowledge of these rare entities helps in arriving at a correct diagnosis. Conclusion: Bronchogenic cyst is known to occur commonly in mediastinal or intrapulmonary areas with rare occurrence in the subcutaneous region. This case is being presented due to its rarity.

   PP26: Biphasic synovial sarcoma of the thigh: A rare case report Top

Sanghamitra Mukherjee, Mondita Borgohain, Anuradha Sharma

Assam Medical College and Hospital, Dibrugarh, Assam, India. E-mail: [email protected]

Background: Synovial sarcoma belongs to the category of soft tissue tumours with uncertain origin.It is a misnomer as these have been described in virtually every anatomic site.Most show a characteristic chromosomal translocation t(x:18)(p11:q11).Morphologically they are biphasic or monophasic.IHC is helpful in identifying especially the biphasic type because it is positive for epithelial markers. Design: A 39year old female presented with a 5year history of a tender,immobile swelling over the left thigh which was followed by a similar swelling adjacent to the previous site upon surgical removal of the former.Radiological investigations revealed it to be a lobulated,heterogenous,hypoechoic lesion in the intramuscular plane.FNAC reported it to be a spindle cell tumour following which the tumour was surgically excised. Results and Discussion: Histopathological examination revealed biphasic population of both epithelial cells arranged in glandular pattern and spindle cells in sheets. .Synovial sarcoma should be considered in the differential diagnosis of any spindle cell tumour. Conclusion: Traditionally synovial sarcomas are regarded as tumours of ominous prognosis.The 5year survival varies from 25-62% related to the age,site,size,status of surgical margins,mitotic activity,necrosis,rhabdoid cells,microscopic grade,E-cadherin dysfunction and DNA ploidy pattern.

   PP27: Nasal chondromesenchymal hamartoma: A rare cause of dyspnoea at birth Top

Jesty P Tom, Balamurugan Thirunavukkarasu, Debajyoti Chatterjee, Satyawati Mohindra1, Bishan Dass Radotra

Departments of Histopathology and1Otorhinolaryngology, PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: Nasal chondromesenchymal hamartoma (NCMH) is an exceedingly rare, benign lesion of the sinonasal tract comprising of proliferating mesenchymal and cartilaginous elements. The exact pathogenesis is unknown. It most commonly presents as a nasal polyp in infants. Being a benign entity, precise diagnosis and local excision is curative. It is a rare tumor and very few cases have been reported previously. Recently, DICER1 mutation has been described in NCMH. Case Presentation: A three-month old child presented with dyspnea and feeding difficulties since birth. Computed tomography (CT) scan showed a heterogeneously enhancing lobulated mass lesion filling the left nasal cavity, with significant deviation of the nasal septum. The lesion was excised completely. Histopathologic examination showed a polypoidal tissue lined by respiratory epithelium. Subepithelium showed sheets and whorls of oval to plump stromal cells arranged haphazardly, admixed with collagen bundles and hyalinised stroma. Multiple islands of mature cartilage along with focal osteoid formation was seen. These stromal cells were diffusely positive for vimentin and S-100 but was negative for EMA and GFAP and hence a diagnosis of NCMH was made. The child remained recurrence free at 6 month follow up. Conclusion: Nasal chondromesenchymal hamartoma is a very rare differential of a nasal polyp especially in young children. There must be awareness about this entity as misdiagnosis can lead to wrong therapy and morbidity to the patient. In addition, this could be the earliest presentation of the DICER1 mutated tumours.

   PP28: Immunohistochemical evaluation of malignant soft tissue tumors Top

Ravi Kumar Meena, Reeni Malik, R K Nigam, Ashish Koshti, Sharda Balani

Gandhi Medical College, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Immunohistochemistry is the use of antibody-based reagents for localization of specific epitopes in tissue sections. Over the past two decades, immunohistochemistry has become a powerful tool to assist the surgical pathologist in many clinically critical settings. Design: Total 51 malignant soft tissue cases included in the observational study. Panel of four immunohistochemical markers namely VIMENTIN, DESMIN, S 100 and CD 34 was being used for the study. Bondarenko semiquantitative scoring system was used for reporting. Results and Discussion: Malignant soft tissue tumours have male preponderance, most commonly found in lower extremities followed by trunk. Peak incidence in second decade followed by third decade.Tumour of uncertain origin is the most prevalent soft tissue tumour group among our study. Vimentin was found was found positive in most of the cases. All the cases of GIST and dermatofibrosarcoma protuberans were positive for CD 34. Only rhabdomyosarcomas and leiomyosarcomas were positive for desmin. Malignant soft tissue tumours were showing variable positivity for S 100. Conclusion: Immunohistochemistry is remain an adunctive diagnostic tool to histopathology in diagnosis of soft tissue tumours. however in certain cases immunohistochemistry is of great diagnostic significance.

   PP29: Schwannoma mimicking a soft tissue sarcoma Top

Shalaka Prakash Saraf

MIMER Medical College, Talegaon Dabhade, Maharashtra, India. E-mail: [email protected]

Schwannoma, also known as neurilemmoma, commonly occurs as benign tumour of peripheral nerves. Peripheral nerves in the skin and subcutaneous tissue of head and neck or flexor surfaces of extremities are common sites of origin of schwannoma.We are presenting a rare case of schwannoma in popliteal fossa mimicking soft tissue sarcoma. Case Report: 29 year old male presented to Surgery OPD with a popliteal swelling which was slow growing and painful and was mobile horizontally and fixed longitudinally to the site.On local examination a firm swelling measuring 7 x 6 x 4.5 cm was found in popliteal fossa.Clinically, it was thought to be a soft tissue sarcoma.Ultrasonography showed necrosis, hypervascularity and poor tissue differentiation which was suggestive of a possible neoplastic lesion such as soft tissue sarcoma.MRI revealed a possibility of neurofibromas.FNAC suggested a low grade spindle cell tumour with possibility of neural tumour.Grossly,5 tissue masses were received largest being 6 x 5x 3.5 cm,smallest one measured 1 x 1 x 1 cm.It was a well encapsulated tumour mass,soft to firm in consistency.Cut section showed mucoid cystic change peripherally and necrosis centrally.On Histopathological examination, final diagnosis of schwannoma was made. Discussion: Schwannoma most commonly occurs as benign neoplasm of peripheral nerve.It usually is a solitary, encapsulated, painless, well defined slow growing mass.Painful and multiple mass lesions is a rare presentation of schwannoma. Conclusion: Soft tissue tumours like schwannoma may mimick sarcoma clinically and radiologically. Hence, thorough histopathological examination is of utmost importance to differentiate schwannoma from other benign and malignant soft tissue tumours.

   PP30: Cyto histologic correlation of a low grade fibromyxoid sarcoma at an unusual location: A case report Top

Pooja Jain, Annu Nanda, Deepak Kumar Singh

ESI Hospital and Dental College, New Delhi, India. E-mail: [email protected]

Background: Low grade fibromyxoid sarcoma (LGFMS) is a rare tumor of the deep soft tissues of young adults. The histologic features of LGFMS are well established, however the cytologic findings are scantily defined and the distinction from other benign and malignant myxoid soft tissue tumours is difficult. Case Details: A 29 year old male presented with a superficial swelling in the left areola for two months. USG revealed a well-defined 2 X 2 cm hyperechoic lesion extending upto the subcutaneous fat. FNA yielded mucoid material and smears showed spindle cells having round to elongated nuclei with mild anisokaryosis, bland chromatin and wispy cytoplasm in a myxoid background. No significant nuclear pleomorphism or mitoses were noted. A diagnosis of myxoid mesenchymal lesion was made. The excised tumour appeared well circumscribed. The cut surface was grey white showing myxoid areas. Microscopically, the tumour displayed moderate cellularity with storiform, intersecting and parallel bundles of spindle cells showing mild nuclear pleomorphism. The myxoid areas showed cells in a haphazard fashion floating in abundant mucoid matrix associated with capillary network. The mitotic index was low. IHC showed tumor cells positive for vimentin and negative for S-100 & SMA. Conclusion: LGFMS is a rare low-grade malignancy with a high local recurrence rate and late metastasis. On cytology, a possibility of LGFMS should be considered in a spindle cell lesion with myxoid change. Cytohistological correlation and IHC is helpful in arriving at a correct diagnosis.

   PP31: Clinicopathological features of five cases of epithelioid hemangioma of bone: Diagnostic challenge with treatment implications Top

Kavita Khirwal, Bharat Rekhi, Swapnil Rane, Trupti Pai, Ashish Gulia1, Ajay Puri1

Departments of Surgical Pathology and1Surgical Oncology2 (Bone and Soft Tissues, Disease Management Group), HBNI, Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Epithelioid hemangioma(EH) is a benign vascular tumor, predominantly occurs in the subcutis and dermis and lately found to be associated with FOSB immunoexpression. Primary intraosseous EHs are rare. Design: Herein, we report five such cases. Results: Tumors occurred in scapula(n=2), tibia(n=1), hamate(n=1) and radius(n=1), with an age-range of 16-62 years(average=36) and M:F ratio=4:1.Radiologically(n=4), tumors appeared as lytic lesions with cortical breach, including soft tissue component(n=3). A single case showed simultaneous involvement of proximal humerus with scapula, while another case involving the radius showed multifocality. One of the cases was radiologically diagnosed as an angiosarcoma, while another as a giant cell tumor of bone. Histopathologic examination(n=5) revealed a vasoformative tumor, comprising 'slit-like' spaces lined by endothelial cells, exhibiting mild nuclear variation and focal “hob nailing”, along with eosinophil-rich inflammatory infiltrate. While bone infiltration was noted in three cases, significant number of mitotic figures, atypical mitosis and/ or tumor necrosis was not seen in any case. A single case showed plump spindly cells in focal areas, reminiscent of pseudomyogenic hemangioendothelioma(PHE). Immunohistochemically, tumor cells positive for CD31(5/5), FLi1(3/3); focally for SMA(2/3), while negative for TFE3(0/2). CD34 highlighted the vascular channels. A single patient, each, underwent curettage and angioembolisation, respectively. On follow-up (n=3)(47, 21 and 1 month), none of the patients developed metastasis. Conclusions: Clinicoradiological appearance of an EH can be aggressive, mimicking various other tumors. Awareness of this entity and careful assessment of histopathological features are keys for its correct diagnosis, which has significant treatment implications. Rare cases overlap with PHE.

   PP32: Clear cell sarcoma: A case report Top

Nishat Ahmad, M A Ansari

RIMS, Ranchi, Jharkhand, India. E-mail: [email protected]

Clear cell sarcoma or Malignant melanoma of soft part is a rare melanin-producing soft tissue sarcoma arising chiefly from large tendons and aponeuroses of the extremities. Melanin is usually not abundant enough to be seen on H&E stain. It can be detected with histochemical stain (Fontana or Warthin Starry) or IHC stains - S-100, HMB-45, Melan-A, Mel-CAM, MiTF. We present a case of a 28 year male who presented to surgery OPD with complaints of gradually increasing lump associated with pain and blood stained discharge over back of left thigh for over 1 year. Microscopy showed cells consisting of nuclei with a vesicular nuclear chromatin pattern and prominent nucleoli and clear cytoplasm with multinucleated gaint cells (resembling malignant melanoma). HPE and IHC of the biopsied mass was reported as Clear cell sarcoma.

   PP33: Histopathological and clinical spectrum of denosumab treated giant cell tumor of bone Top

Phiza Aggarwal, R P S Punia, Uma Handa, Ranjeev Bhagat, Sudhir Garg1

Departments of Pathology and1Orthopedics, GMCH, Chandigarh, India. E-mail: [email protected]

Introduction: Giant cell tumour (GCT ) is a benign but locally aggressive primary osteolytic bone tumour that occurs predominantly in young adults . Surgery is the definite therapy but is associated with recurerence risk. Denosumab, a monoclonal antibody, that specifically inhibits RANK-RANKL interaction, inhibits osteoclast mediated bone resorption. This study was done to evaluate the histopathological and clinical spectrum of denosumab therapy in patients of GCT of bone. Methods: The archival records over the last 4 years were analysed. There were 13 patients of GCT who had received subcutaneous denosumab therapy followed by surgical treatment. Results: The mean age of the patients was 31.3 years with age range of 18 -55 years. There were 9 males and 4 females in our study. The sites of predilection were bones of the upper limb ( 7 cases) followed by tibia and calcaneum( 2 cases each). There was 1 case each of GCT of Patella and metacarpal bone .Pain and swelling were the most common clinical symptoms with the average duration of symptoms of 10.7 months. Histopathological assessment revealed good response in 10 cases with decrease in the giant cells and replacement by fibrous and osseous tissue, minimal in 2 cases with 1 case showing partial response. Conclusion: The pathologist shold be aware of the histopathological response to denosumab treated GCT in order to avoid misdiagnosing these lesions as other fibrous lesions of bone. The therapy is associated with tumor response reducing the recurrence rate and need for morbid surgery.

   PP34: Extra-adrenal pheochromocytoma with metastatic deposits in lymph node: A rare case report Top

Megha Gajendra, Renuka Gahine, Rabia Parveen Siddiqui, Shashi Kala Kosam, Mohd. Jafar Memon

Pt. Jawahar Lal Nehru Memorial Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Paragangliomas are relatively rare endocrine tumors arising from paraganglionic tissue, a widely dispersed collection of specialized neural crest cells. Paragangliomas, also known as extra-adrenal pheochromocytomas, account for 5-10% of pheochromocytomas and can occur in any position between neck and base of pelvis. Case Report: A 32 year female presented with abdominal pain with generalized weakness for 6-8 months. On USG abdomen - large well defined hypoechoic oval shaped mass extending from lower pole of spleen to left iliac fossa, laterally extending upto left lateral wall and displacing bowel loops inferiorly and body & tail of pancreas postero-superiorly, showing vascularity on colour doppler - likely Neoplastic mass. CT abdomen showed a large well defined homogeneous intra-abdominal soft tissue mass of size 19.1 x 14.5 x 13.7 cms extending from gastrosplenic space to left iliac fossa and is abutting posterior wall of stomach and causing mass effect on left kidney with enlarged left para-aortic lymph node - likely GIST/ Lymphoma. Enbloc resected specimen on gross showed large globular firm encapsulated gray-brown mass measuring 25 x 19 x 10 cms with three para-aortic lymph nodes. On microscopy showed features of paraganglioma with metastatic deposits in one of the lymph nodes. Immunohistochemistry showed: Synaptophysin (4+), GATA3 (3+), CK (++), S100 (-) and Ki-67 - 3%. Conclusion: This case emphasizes necessity to include extra-adrenal paraganglioma in differential diagnosis and management of these tumors, despite its rarity. Vimentin may be useful in diagnosis and also can be used to differentiate between malignant and benign tumor.

   PP35: Musculoskeletal metastasis of squamous cell carcinoma: A case series Top

Priyanka Rajiv, Rakeshkumar Ajmera, Priyam Pargaonkar, Hemant R Kokandakar

Department of Pathology, Government Cancer Hospital, Aurangabad, Maharashtra, India. E-mail: [email protected]

Background: Distant musculoskeletal metastasis of squamous cell carcinoma is rare. It may develop in some cases before the primary malignancy is detected where it can be the presenting symptom.The objective of this study is to identify frequency, clinical presentation and clinical course of metastatic disease to musculoskeletal system from squamous malignancies. Design: All cases diagnosed as metastasis of squamous cell carcinoma to bone and soft tissues with known and unknown primary were included in the study. All radiological details, presenting signs and symptoms, previous histopathology reports and treatment history was recorded.Totally 16 cases were studied in a span of 3 years (2016- 2019). Age group included 30-74 years. Results: Of the 16 patients, 10 were males and 6 females.13 cases had a histologically diagnosed known primary and 3 had unknown primary.Distant metastasis was found in bones like humerus, femur, ribs, scapula, tibia, iliac bone and soft tissues like scalp,calf and chest.Apart from lungs being the most common primary other known primaries included oral cavity, cervix, penis and oesophagus. Discussion: SCCs show propensity for locoregional spread. Newer chemotherapy and radiotherapy techniques has lead to increased survival in these patients but has also increased the probability of distant metastasis. Conclusion: Musculoskeletal metastasis in squamous cell carcinoma is a sign of advanced disease, a poor prognostic factor and plays a critical role in the management of patients.Patients with bone and soft tissue involvement should undergo a bone scan and biopsy, this will help reduce morbidity and improve survival.

   PP36: Bone marrow involvement by tuberculosis in an HIV positive case Top

Rajesh Kumar Mishra, S Bijwe, S Agale, S Mishra

Grant Goverment Medical College, Mumbai, Maharashtra, India. E-mail: [email protected]

HIV positive cases in India have a high risk of acquiring disseminated tuberculosis but its presentation as severe anemia and Title: Bone marrow involvement by tuberculosis in an HIV positive case granulomatous inflammation of bone marrow is unusual. This signifies the importance of bone marrow biopsy examination for pyrexia of unknown origin in HIV patients. Our case was a 39 year old male&nbsp;HIV patient with pyrexia of unknown origin. Routine haematological investigations showed severe dimorphic anaemia. On biopsy examination large areas of caseous necrosis and epithelium cell granuloma were seen and presence of acid fast bacilli was confirmed by Zeil Neelsen staining.

   PP37: Clinicopathological spectrum of osteosarcoma: A study of 175 cases spanning a decade Top

Ankita Garg, Reetu Kundu1, Sudhir Kumar Garg, R P S Punia, Purnima Aggarwal

Government Medical College and Hospital,1Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]

Introduction: Osteosarcoma is the most common primary malignant bone neoplasm. It has potential for divergent differentiation and plenty of histomorphological sub-types exist, some of which have a prognostic connotation. Histologic assessment of percentage necrosis and viable tumor cells is a predictor of chemotherapeutic response. Methods: Retrospective analysis of 175 cases reported as osteosarcoma over a period of 10 years (2009-2018) was carried out. Pertinent clinico-radiological details were recorded. Sections were studied for a detailed istomorphological assessment. Tumor categorization into low, intermediate and high risk group categories incorporating the recently proposed scoring criteria for integrated prognostic index was done. Results: 108 were male and 67 were female with age ranged from 9-77 years (mean age: 21.9±11.1 years). Swelling (97) was the most common clinical complaint followed by pain (52) and pathological fracture (26). The most common anatomic site involved was femur (92), followed by tibia (45), humerus (29), iliac bone (3), fibula (3), soft tissue (2), radius (1). The size of the tumor ranged from 2.5 to 25 cm. The various histological variants were osteoblastic (126), chondroblastic (37), fibroblastic (5), telangiectatic (4), small cell (2) and giant cell rich osteosarcoma (1). Good chemotherapeutic response was seen in 34 cases. Osteosarcoma was categorized into low (44), intermediate (103) and high risk groups (28). Conclusions: A tripartite approach is mandatory in all the cases of osteosarcoma which includes clinical, radiological and comprehensive histopathological evaluation. Sub-typing of osteosarcoma and scoring for integrated prognostic index can together aid in risk stratification and predicting the outcome.

   PP38: Does routine preparation of FNA cell-blocks improve cyto-diagnosis in soft tissue sarcoma? Top

Pradyumn Singh, Anurag Gupta, Priyanka Sameer, Ashish Singhal

Dr. RML Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Although FNAC is routinely used screening diagnostic tool, it poses several challenges in diagnosis of soft tissue lesions, which are mostly dependent on biopsy for precise diagnosis and grading. FNA Cell-blocks have become popular as they may improve efficacy of FNA for tumor detection, aided with immunocytochemistry (CB-ICC). Methods: Retrospective evaluation of FNA findings in 60 cases of soft tissue sarcoma vis-à-vis CB-ICC was done. On cytology, soft tissue neoplasms were categorised as spindle, pleomorphic, epithelioid, myxoid, and small round cells type, and Low or High grade. Cell blocks and immunocytochemistry (CB-ICC) were analysed where available. Findings of FNAC and cell block sections with CB-ICC were compared with subsequent biopsy. Results: Most cases (23.3%) were in age group 51-60years(range 13-96years). M:F 2.3:1. Sites involved were Head&Neck 10(16.67%), upper extremity 16(26.67%), trunk&abdomen 12(20%), lower extremity 17(28.3%). On FNAC 37(61.6%) cases could be labelled malignant(sarcoma), of which only 11( 28.20%) could be subtyped. Adequate Cell blocks were prepared in 45(88.2%) cases and helpful for subtyping using immunocytochemistry(CB-ICC) in 25(64.10%) cases. Considering histopathology as gold standard, FNAcytology with CB-ICC showed 95.12% sensitivity, 75% specificity, 97.5% positive predictive value, 60% negative predictive value and 93.33% diagnostic accuracy. Conclusion: FNAC has good role in rapid diagnosis of soft tissue tumors. FNA cytomorphology alone has limitations. Adjunctive method like Cell block immunocytochemistry (CB-ICC) is easy and very helpful in categorisation of soft tissue tumors to guide clinical management. We recommend routine preparation of FNA Cell-blocks and CB-ICC to improve cyto-diagnosis in soft tissue sarcoma.

   PP39: Diagnostic accuracy of core needle biopsy for breast lumps; 4-year study on 582 cases: Interventional pathologist's perspective Top

T G Bindu

Caritas Hospital, Thellakom, Kerala, India. E-mail: [email protected]

Background: Palpable breast lump is a major surgical concern amongst women. Breast cancer ranks as the number one cancer amoung Indian women, rate 25.8/100,100.Early detection to improve outcome and survival remains the mainstay of breast cancer control. The diagnosis of breast lump is based on Triple test , clinical examination,sonomammogram and pathological evaluation. The main tool of pathologist had been FNAC. With the introduction of tru-cut needle,core biospy(CNB) has now replaced FNAC as the better modality for pathological diagnosis of breast lump evaluation including receptors and molecular studies. Trucut bipsy is more often done by the Radiologists or Surgeon. However the Pathologist have a distinct edge over others in this regard, the skill of aspiration technique can be useful in CNB, and the adequecy of the material can be assesed by Rapid On Site Evaluation (ROSE). Design: 582 patients between January 2015 to January 2019 with palpable breast lumps were taken for the study. Patients with mammogram of BIRADS IV &V category were included in the study. CNB and FNAC were done on the same lesion,at same sitting by the same Pathologist. Results:There was a significant improvement of the diagnostic accuracy with CNB in comparison to FNAC.The sensitivity and specificity of CNB were 97% and 100%.while that of FNAC were 97% and 39% respectively.Conclusion;CNB is the better procedure for initial pathological evaluation of breast lump.It is more specific, more sensitive ad provides better tissue volume. Pathologists are better suited for performing CNB and hence should be trained for this procedure.

   PP41: Twlevel years retrospective study of 100 male breast biopsies reported at single tertiary cancer care centre Top

Simran Gilhotra, Anjali Sharma, Bhargav Yagnik, Syeda Firdos Jamil

BMCHRC, Jaipur, Rajasthan, India. E-mail: [email protected]

Introduction: Male breast cancer (MBC) is a rare entity which accounts for approximately 1% of all breast cancer, however incidence has increased in the past few years. Various genetic, hormonal and environmental factors play vital role in pathogenesis. Materials and Methods: Retrospective study was conducted from January 2007 to August 2018. 6,375 breast biopsies received out of which 100 from male patient. H&E staining done and histopathological diagnosis was made. Among 100 cases 74 were malignant and 26 were benign breast lesions. Further IHC was applied on respective tumor blocks. Results: Out of 74 malignant cases 67 (90.5%) were carcinomas and 7 (9.45%) were sarcomas. Out of 74 malignant cases 55 (74.3%) were invasive duct carcinoma, 4 (5.4%) mucinous carcinoma, 2 (2.7%) invasive papillary carcinoma, 2 (2.7%) intraductal carcinoma with microinvasion, 1 (1.35%) invasive lobular carcinoma, 3 (4.05%) poorly differentiated carcinoma & 7 (9.45%) cases include phyllodes, squamous cell carcinoma, round cell tumor, metaplastic/spindle cell neoplasm, undifferentiated pleomorphic sarcoma and metastatic carcinoma. Grading done for 51/74 cases which include 15 (20.27%) well differentiated, 32 (43.24%) moderately differentiated and 7(9.45%) poorly differentiated cases. On IHC – ER & PR was performed on 52/74 malignant cases. ER and PR expression seen in 41/52 cases and 40/52 cases respectively whereas Her2 was applied on 48/74 cases and over expressed only in 9 cases among them. Conclusion: Building a tumor registry and including MBC patients in a prospective design will allow investigators to obtain reliable information related to biology and treatment response of MBC.

   PP42: Is morphology alone sufficient to subcategorize papillary breast lesions Top

Syeda Firdos Jamil, Anjali Sharma, Neha Sethi, Amandeep Talwar

Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India. E-mail: [email protected]

Introduction: Papillary breast lesions constitutes wide spectrum of heterogenous pathological group in benign,atypicaland malignant subtypes. Diagnosis becomes challenging in case of overlapping histomorphology features. However, recognition of a papillary architecture is typically not difficult but further histologic categorization into its subtypes is not always straight forward. Objective: To provide an insight into the diagnosis and classification of papillary lesions of breast by incorporating available variables – clinical, histopathological and immunohistochemical. Materials and Methods: Retrospectively 50 patients were taken into consideration between January 2017 to august 2019 at BMCHRC, Jaipur. The patients were assessed according to age, gender, size, location, gross examination, microscopy and Immunohistochemistry. Results: Cases were divided into four main divisions 1) papilloma 2) papillary ADH/ DCIS 3) encapsulated papillary carcinoma 4) solid papillary carcinoma. Papilloma comprised of 13 patients between 31-72 years of age and lesion varies in size from 0.5 to 1.5 cm. Papillary ADH/DCIS accounted for 6 patients between 42-67 years age group with size of lesion between 0.5 to 4.8 cm, out of which one case was male patient. Encapsulated papillary carcinoma comprised of 2 patients with age 70 and 73 years and lesion size 0.7 & 14 cm. Solid Papillary carcinoma comprised of 29 patients between 39-81 years of age & lesion varies in size from 2 to 8.5 cm. Conclusion: Papilloma and papillary DCIS/ADH can be diagnosed comfortably on morphology. However encapsulatedpapillary carcinoma and expansile invasion is difficult to comment solely on morphology and requires experiencedpathologists and IHC for confirmation.

   PP43: Correlation between modified bloom-richardson grade and lymph node status in infiltrating ductal carcinoma of breast in patients of RIMS, Ranchi Top

Niraj Prasad, Abhishek Verma, Ramesh Kumar Srivastava

Departmen of Pathology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India. E-mail: [email protected]

Background/ Introduction: Brest carcinoma is one of the most common cancer in women. There are various types of breast carcinomas of which infiltrating ductal carcinoma (IDC), not otherwise specified (NOS) is the most common type. Modified Bloom-Richardson (BR) grade and status of metastasis to lymph nodes are two important prognostic factors of breast carcinoma. With this study we intend to find a correlation between the two. Design/ Materials and Methods: This study was conducted from August, 2018 to July, 2019 for a span of 1year. It comprised of 91 cases. The modified radical mastectomy specimen of breast sent to the department of pathology of Rajendra Institute of Medical Sciences (RIMS), Ranchi were grossed properly and were evaluated for histological typing, modified BR grading and lymph node status (using AJCC TNM staging- pN). Statistical correlation were established between modified BR grade and the status of lymph node. Results and Discussion: All the cases included in the study were of IDC-NOS type. Majority of cases in our study belonged to Modified BR grade 3 and lymph node status pN3. A statistically significant correlation (p value<0.05) was found between modified BR grade and lymph node status (Pearson co-efficient=0.59). Conclusion: A statistically significant correlation was found between modified BR score and lymph node status of IDC-NOS type of breast carcinoma. Thus these can be used for prognostic and therapeutic planning in breast carcinoma cases.

   PP44: Metaplastic carcinoma of breast: Two case reports Top

Ruchika Singh, A Choudhury, A K Bal, P K Dash

MKCG Medical College and Hospital, Berhampur, Odisha, India. E-mail: [email protected]

Background: Metaplastic breast carcinoma(MBC) are a heterogenous group of neoplasm characterised by admixture of epithelial elements(adenocarcinoma) with mesenchymal elements and/or squamous or spindle cell elements. MBC is very rare(<1%), aggressive and generally high grade breast carcinoma that occurs mostly in patients older than 50 years. MBCs are usually negative for ER, PR and Her2neu(basal like phenotype). Here are the two case reports. Case Reports: Case 1: A 50 year female presented with swelling in upper half of right breast of size 6cm in diameter for 3 weeks, which was fixed to skin with palpable right axillary lymph node. FNAC suggested a mucinous lesion of breast. Histopathological study of the mastectomy specimen was done. A final diagnosis of Metaplastic Carcinoma of Breast with Chondroid differentiation was signed out based on histomorphology and IHC. Case 2: 60 year male presented with lump in right breast for 7 months. FNAC suggested a spindle cell lesion possibly neurofibroma with ancient change. Then patient underwent simple mastectomy. Then a final diagnosis of Metaplastic carcinoma (Spindle Cell Carcinoma) of male breast was given on the basis of histomorphology and IHC evaluation. Conclusion: Diagnosis of MBC was made on the basis of histopathology and IHC evaluation. IHC is essential to confirm the diagnosis of MBC. Metaplastic carcinoma of breast exhibit a poorer prognosis than other infiltrating carcinoma of breast. However metaplastic carcinoma of breast with chondroid differentiation exhibit a better prognosis than other subtypes of MBCs.

   PP45: Relevance of tumor infiltrating lymphocytes in breast cancer patients treated with neoadjuvant chemotherapy in relation to their ER, PR and HER2 status Top

Pampa Ch Toi, M S Athira Celine Justine, Smita Kayal, D Kadambari

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E-mail: [email protected]

Background: Tumor infiltrating lymphocytes(TILs) in breast cancer is an indicator of pre-existing immune response which may predict response to neoadjuvant chemotherapy(NACT). The outcome of the patient can be assessed as pathological complete response(pCR) which is associated with an increased disease free survival rate. The aim of the study was to determine the prognostic value of TILs in breast cancer patients in achieving a pCR after receiving NACT And association between the ER, PR and HER2 status and TILs in relation to pCR. Design: A retrospective analysis of TILs in pre NACT biopsy slides of 93 patients was carried out..Parameters like age, hormonal status, clinical staging were noted. Post NACT mastectomy slides were studied for pCR and TILs in residual tumours. Relation between,TILs hormonal status and pCR was studied by univariate logistic regression. Multivariate analysis was done to predict if the clinicopathological parameters were independent risk factors to determine pCR. Results and Discussion: 83.3% of Lymphocyte predominant Breast cancer(LPBC) achieved a pCR whereas 38% in the lower TIL group. LPBC had 2.19 times higher chance of attaining pCR compared to the low TIL group(p=0.002).TILs as a continuous variable was associated with a higher pCR univariate analysis(p=0.02) multivariate analysis(p=0.04). Triple negative breast cancer(TNBC) showed 1.68 times higher chance of predicting pCR(p=0.023). TILs is an independent predictor for predicting pCR following NACT with LPBC group showing higher pCR. In TNBC TILs is an independent prognostic factor for achieving pCR. Conclusion: TIL counts in routine biopsy may help to predict prognosis of the patient.

   PP46: Correlation of nuclear morphometry with clinicopathologic parameters in malignant breast aspirates Top

Shivani Kalhan, Shilpa Garg, Sonia Sharma1, Puja, Rahul Satarkar, Sonia Hasija, Bhawna Sethi, Ashok Sangwaiya

SHKM Government Medical College, Gehbar, Haryana,1Army Hospital R and R, New Delhi, India. E-mail: [email protected]

Background: Breast cancer accounts for 7% of global burden and one-fifth of all cancers among women in India. Nuclear size, shape, chromatin pattern, and nucleolar size and number have all been reported to change in breast cancer. Aim: To quantify nuclear changes on malignant breast aspirates using morphometry and to correlate the morphometric parameters with clinico-pathologic features such as cytologic grade, tumor size, lymph node status, mitotic index and histopathologic grade. Methods: Forty five cases of carcinoma breast diagnosed on cytology were included in this study. Cytologic grading was performed as per Robinson's cytologic grading system. Nuclear morphometry was done on PAP stained smears. One hundred non-overlapping cells per case were evaluated. Both geometrical and textural parameters were evaluated. Results: Comparison of cytologic grades with most morphometric features (nuclear area, perimeter, shape, long axis, short axis, intensity, total run length and T1 homogeneity) was highly significant on statistical analysis. Correlation with tumor size yielded significant results for nuclear area, perimeter, long and short axes and intensity with P<0.05. Study of lymph node status, morphometry showed a highly significant statistical association with all the parameters. Mitotic count was significantly associated with all the geometric parameters and one textural parameter (total run length). On correlation of DCIS and histopathological grades 1 to 3 with morphometry, it was found that all the parameters except Long run emphasis were highly significant with P< 0.001. Conclusion: Morphometry as a technique, holds immense promise in prognostication in breast carcinoma.

   PP47: Neutrophil lymphocyte ratio and platelet lymphocyte ratio in patients with benign breast disease and carcinoma breast Top

J Sree Rekha, Hemani Yadav, Tanveer Rehman1

Departments of Pathology and1Preventive and Social Medicine, JIPMER, Puducherry, India. E-mail: [email protected]

Background: Inflammation has an important role to play in tumor progression and dissemination. Neutrophil lymphocyte ratio (NLR) and Platelet Lymphocyte Ratio (PLR) can reflect this inflammatory state and predict the tumor behavior. Aim: To study the difference in the NLR and PLR between 1. Benign breast disease and Carcinoma breast 2. Non- metastatic and metastatic breast carcinoma. Design: Retrospective analysis of clinic-pathological data of patients with benign breast disease and Carcinoma breast in a tertiary care centre in South India for a period of six months was done. Receiver operative characteristic curve (ROC) was used to find the cut-off NLR and PLR in patients with 1. Benign and malignant breast disease and 2. Carcinoma breast with and without metastasis. The association of NLR and PLR with the various clinic-pathological factors was also studied. Results and Discussion: Forty four cases of benign breast disease and 84 carcinoma breast cases were retrospectively analyzed. The mean NLR in benign breast disease is 2.23 ± 0.9 and in carcinoma breast is 2.1 ± 0.8 and a cut-off to distinguish them could not be achieved. The mean PLR in benign breast disease is 91.9 ± 32.7 and in carcinoma breast is 122.7 ± 54.6 with an optimal cut-off of 93.5 with a 71% sensitivity. The optimal NLR cut-off for local and distant metastasis was NLR≥1.9 and PLR ≥105.9. The correlation of NLR and PLR with clinical and pathological tumour stage, grade and immune-phenotype was not found to be significant.

   PP48: Synovial sarcoma of breast: A rare case report Top

Rashim Sharma, Kavita Sharma, Sudeep Khera, Poonam Elhence, Jeevan Ram Vishnoi

All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. E-mail: [email protected]

Background: Breast sarcomas are very rare neoplasms which need to be clearly differentiated from common breast carcinomas. We report a very unusual case of a primary synovial sarcoma of the breast in a 46-year-old woman. Case Presentation: A 46-year-old woman presented with rrght side nipple discharge and pain. On clinical examination overlying skin showed ulceration with prominent vasculature and Nipple areola complex displaced to upper outer quadrant. Mammography revealed that entire breast tissue was obscured by large round to oval well circumscribed isodense mass. extending to all four quadrants of right breast. On core biopsy florid epithelioid and minor spindle cell component with evidence of mild to moderate cytological atypia and conspicuous mitoses noted. The differential diagnosis included malignant phyllodes or primary sarcoma of breast. Simple mastectomy specimen received showed an invasive tumour with spindle cells showing moderate pleomorphism with infiltration into surrounding fat. 11/10hpf mitosis seen. On Immunohistochemistry tumour cells were positive for TLE1. Discussion: Primary synovial sarcoma of the breast is a rare tumour with relatively few reported cases. Synovial sarcoma can arise in almost any soft tissue location. It exhibits two main histological subtypes. Conclusion: Diagnosis of breast sarcomas can be made histologically on percutaneous biopsy. Core biopsy is preferred to fine needle aspiration (FNA), which results in lower material yield and offers lower diagnosis rates. For local staging, mammography, ultrasound and breast magnetic resonance imaging can be used. However, the final diagnosis rests on microscopic examination of the resection specimen.

   PP49: A study on carcinoma breast by histological typing, grading and immunohistochemistry based molecular subtyping Top

C B Likhitha

Kerala University of Health Sciences, Thrissur, Kerala, India. E-mail: [email protected]

Background: Breast cancer comprises a heterogeneous group of diseases with specific clinical, histopathological and molecular properties. Genome wide microarray based expression profiling studies have revealed several characteristics of breast cancer biology and are important in determining tumor behavior. The IHC determination of breast cancer subtypes with regard to ER, PR and HER2 status can contribute to improved selection of therapy and patient care. Design: A prospective descriptive study done at a tertiary care centre for a period of 6months with collaboration with surgical department. A total of 17 cases were included after approval from institutional ethics committee and consent from patient. Results and Discussion: 17 cases in the study population included only females. The mean age of the study population was 69 years and median age of 66 years. The common histological type was IDC NOS (41.2%) followed by lobular carcinoma (28.6%). Least common subtype was metaplastic carcinoma and pagets disease accounting for 5.8% each.Details of analysis are provided in the Table 1. Conclusion: On the basis of hormone receptor, breast CA cases are classified into four distinct molecular subtypes which show significant difference in morphological features and thereby predicting possible clinical outcome.

   PP50: Primary angiosarcoma of breast in a young lactating female: A case report Top

Rabia Parveen Siddiqui, Renuka Gahine, Jayanti Chandrakar, Vanita Bhaskar

PT. J.N.M. Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Primary angiosarcoma of breast is a rare vascular malignancy (<0.05% of primary breast malignancies)and highly aggressive tumor with poor prognosis .Cases of Primary Angiosarcoma of breast have been reported in pregnancy and lactation where they are mistaken as benign lesions clinically and radiologically . Case Report: We report a case of primary angiosarcoma of breast in a 23 years old lactating female who presented with a lump of 2×2cm and was diagnosed clinically as galactocele. A lumpectomy was done and was reported outside as galactocele with extensive haemorrhage. Patient presented with recurrence of swelling after 6 months. FNA yielded only blood. USG showed heterogeneously echogenic irregular mass lesion. Core needle biopsy showed interconnecting vascular channels lined by malignant cells and at places forming papillary structures. On IHC tumor was positive for CD34, CD31,ERG,FLI1 and Vimentin , 40%positivity for Ki 67 and negative for ER , PR and Cytokeratin . A diagnosis of grade ll angiosarcoma was made. Patient underwent MRM which on gross examination showed a greyish brown haemorrhagic growth of size 12.5x7.5x5cm in the retroareolar region. Microscopy showed similar picture as biopsy.Base showed infiltration and nodes were negative .Patient has received 30 cycles of Radiotherapy. Discussion: According to some researchers the rapid growth of primary angiosarcoma of breast during pregnancy and lactation is thought to be related to the suppressed immune system and placental growth factors besides hormonal effects. Conclusion: Primary angiosarcoma may mimic galactocele clinically and biopsy is extremely valuable for early diagnosis of primary angiosarcoma of breast.

   PP51: Mucinous carcinoma of the breast with micropapillary pattern and psammomatous calcification: A case study Top

Koushiki Bhattacharjee

KMC, Manipal, Karnataka, India. E-mail: [email protected]

Background: Mucinous Carcinoma with micropapillary pattern is an unusual, aggressive form of Invasive Breast Cancer exhibiting dual mucinous and micropapillary differentiation. This is a more aggressive lesion than Pure Mucinous breast cancer for both Lympho-Vascular Invasion and Axillary Lymph-node metastasis. Study Design: Single Case Study: 47 /F presented with incidental finding of a hard lump in her left breast. Mammography: BI-RADS 4 lesion. MRM was done and specimen grossed as per protocol. Results: Gross: MRM weight: 841 grams , measurement: 21 x 11.5 x 9.5 cm. A unifocal, ill-circumscribed tumor ( 3x2.6x2.6 cms) in upper outer quadrant was found. C/S: homogenous grey-white with haemorrhagic specks. 26 lymph nodes, largest (1.6 x 1 cms), were dissected. Microscopy: Tumor having extracellular mucin pools with floating Psammoma bodies + focal micropapillary pattern. 4/26 LNs had tumor deposits. All margins + base - free of tumor. No LVI/PNI seen. Immunohistochemistry: ER,PR,EMA Positive, HER2-neu Negative TNM staging: pT2N2a. Discussion: Micropapillary mucinous C/A breast has recently received recognition as a unique form of invasive + aggressive C/A breast exhibiting dual differentiation (Incidence < 1%).Psammoma bodies in breast lesions are rare (usually in papillary neoplasms). Salient features to label this variant: (1) > 90% mucinous component (2) tumor cells forming distinctive micropapillary pattern, (3) Hobnail cells, (4) nuclear grade - intermediate to high (5) frequent psammomatous calcifications. In this case 4/5 were positive. Conclusion: Recognising this variant of mucinous C/A breast is important as these tumors are more aggressive than pure mucinous breast lesions.

   PP52: Evaluation of hormone receptor, ER, PR and Her2 and corelation with tumour characterstics in breast carcinoma: Study of 90 consecutive cases Top

Sharda Balani

Gandhi Medical College, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Carcinoma of the breast is the most common non skin malignancy in women and is secondary to lung cancer as a cause of cancer deaths. The immunohistochemical determination of breast cancer subtypes with regard to ER,PR and Her2neu status can contribute to improved selection of therapy and patient care. Aim: The aim of the study was to analyze ER, PR and Human epidermal growth factor receptor 2 status over two years in patients with breast cancer in GMC, Bhopal. Design: Formalin fixed and paraffin embedded blocks of patients diagnosed with primary breast carcinoma were subjected to immunohistochemical assay for the assessment of ER,PR and Her2neu expression. Results and Discussion: Among 90 patients the invasive ductal carcinoma not otherwise specified (IDS NOS) (93.33%) was the most frequent histological type and the tumor grade 2( 58.8% )was predominant. The proportion of positivity of ER,PR and Her2neu was 23.3%, 24.4% and 38.8% respectively. Most common subtype was triple negative, 42.2% followed by Her2neu positive, 38.8%. Conclusion: Since triple negative breast cancer was the most common subtype found in this region and is associated with poor outcomes, additional research is needed to understand the determinants of TNBC in this region.

   PP53: Clinico-pathological profile of malignant breast lesions: A retrospective study from tertiary care cancer institute Top

Neha Singh, Shashikant C U Patne, Ipsita Dhal, Parul Tripathi, Zachariah Chowdhury, Jyoti Swain1, Deepak Kumar Singh1

Departments of Pathology and1Surgical Oncology, Tata Memorial Centre, Homi Bhabha Cancer Hospital, Varanasi, Uttar Pradesh, India. E-mail: [email protected]

Background: Breast carcinoma, the most common malignancy in women accounts for 15.46% of all malignancies, with a mortality rate of 12.11% and an estimated risk of every 1 out of 9 women developing breast cancer during her lifetime. Hence, this study has been undertaken to study the histological and immunohistochemical findings in the breast specimens in relation to clinicopathological parameters. Design: All the patients with breast lesions from May 2018 to August 2019 were included in this retrospective study. Detailed clinical history, results of relevant investigations including histopathology, immunohistochemistry, and radiological data were retrieved and analyzed. Results and Discussion: Total of 615 patients with breast lesions were studied, including 8 male patients. Breast malignancies constituted 7.2% of total female patients registered in our hospital. Malignant lesions comprised 96.2% (592) of all breast lesions with age ranging from 18-84 years and mean size of 4.28cm. Epithelial malignancies were 96.8% (573) and 3.2%(18) were mesenchymal tumors. Radiological findings were available for 348 invasive carcinomas, of which 45% were classified as BIRADS IV. IDC-NOS accounted for 514 cases, with 73.9% grade 3 tumors and 6.5% with positive lymph nodes. Hormone status was available for a total of 528 patients, out of which 61.2%, 56.3% and 31.6% were positive for ER, PR and Her2/Neu respectively and 21.6% were triple-negative. Conclusion: Breast carcinoma presents with a wide range of clinical, histological and immunohistochemical spectrum. Accurate and definite pathologic characterization with subtyping is indispensable for proper patient management, even in the setting of equivocal clinico-radiologic findings.

   PP54: DNA ploidy analysis in HER-2 positive breast carcinoma: Flow cytometry evaluation of fifty cases Top

Shikha Ghanghoria, Sachin Sharma, Ashok Panchonia, Jyoti Namdev

MGM Medical College, Indore, Madhya Pradesh, India. E-mail: [email protected]

Background: Breast cancers show rising incidence in 25 to 40 yrs of females. 48% patients are below 50years and 2 million new cases reported in 2018 worldwide.The recent trends in India show increasing incidence and prevalence, late presentation & aggressive cancer in youngs.This study includes DNA ploidy and Her2 status as prognostic marker to study biological behaviour of breast cancer. Her2 is considered, since it is marked for targeted therapy. ASCO and CAP guideline recommended Her2 testing by IHC & FISH. Her2 positivity is associated with tumor aggressiveness, increased recurrence rate& increased mortality. It is amplified in 30% cases of BC.Although DNA ploidy is associated with development and progression of BC, the value of flow cytometric ploidy as an independent prognostic factor remains controversial. The DNA content of 50cases of BC by flow cytometry is correlated with Her2 positivity, to achieve prognostic significance of this marker in correlation with other recent markers. Design: 50cases of Her2positive BC were evaluated for DNA ploidy analysis. IHC was applied for Her2. Then Her2 positive cases were evaluated by flow cytometric technique and ploidy was assessed. Results: 29% cases are tetraploid with score3(Her2), 62% cases are near tetraploid with score2(equivocal, should be confirmed by FISH) and 3(Her2), 9% cases show aneuploidy with score2(Her2).Conclusion: This correlation of DNA ploidy in Her2 positive cases could help in relating uncertain biological behaviour of BC& predicting the prognosis. Aneuploidy and Her2 expression show poor clinical outcome which help in future therapeutic decision. Aneuploidy is still a potential biomarker for predicting progression of breast cancer.

   PP55: Behaviour of cytokeratin 5 and estrogen receptor immunohistochemistry in spectrum of UDH, ADH and low grade DCIS of breast Top

Harish Kumar, Prateek Kinra

Department of Pathology, AFMC, Pune, Maharashtra, India. E-mail: [email protected]

Background: The spectrum of benign proliferative disorders of breast including Usual Ductal Hyperplasia (UDH), Atypical Ductal Hyperplasia(ADH) & Low Grade DCIS (LGDCIS) pose diagnostic challenges and has high interobserver variability on hemotoxylin- Eosin (H&E) staining even amongst expert breast histopathologists. This study aims at the use of cytokeratin5 (CK5) and Estrogen Receptor (ER) immunohistochemical markers in differentiating these disorders of the same spectrum as the treatment protocol for each varies. Design: Paraffin blocks of 50 patients (19 UDH, 18 ADH & 13 Low grade DCIS) were retrieved from archives. IHC was carried out for CK5 and ER using indirect sandwich conjugate method. Equal number of controls were taken. The immunohistochemistry expression was assessed as per Allred scoring system for ER and staining for CK5 was scored as diffuse(>60%), intermediate (10-60%), negative/ focally positive(<10%). Results and Discussion: For ER staining: 6 out of 19(32%) UDH; 24 of 31(77%) ADH & Low grade DCIS showed diffuse staining. ER was patchy in UDH. There was a statistically significant difference between the ER staining of UDH versus ADH/ DCIS category (p<0.05). For CK5 staining: 8 of 19(42%) UDH & 1 of 31(3%) low grade DCIS & ADH showed diffuse staining. Cytokeratin 5 present in contiguous pattern in usual ductal hyperplasia show staining pattern differentiating UDH versus ADH/LGDCIS significantly. (p<0.001). Conclusion: This study concludes that ER expression increases and CK5 decreases as the breast lesion progresses from UDH category to ADH/Low grade DCIS. Hence, both IHC markers can be used to differentiate these two groups.

   PP56: Biological behaviour of her2 positive breast carcinoma: A 10 year study Top

Varsha Argal, Shikha Ghanghoria, Ashok Panchonia, Vinamrata Soni

MGM Medical College, Indore, Madhya Pradesh, India. E-mail: [email protected]

Background: Breast cancer (BC) is the common female cancer worldwide representing nearly 25% of all cancers. Increased incidence and cancer-associated morbidity and mortality in India is described in global studies. Increasing incidence , late presentation, rising number & aggressive cancer are the things of worry about BC. HER2 gene is responsible for development and aggressiveness of BC, its overexpression results in increased tumor growth. As per the review,HER-2 positive estimates were 19% for women aged ≤49 years and 15% aged ≥50 years. Overexpression of HER-2/ is considered to be a negative prognostic feature because it accompanies an increase in BC mortality. Current study aiming to determine the prevalence of HER2 positive BC diagnosed by IHC and to study their biological behaviour. Design: This study was conducted at a tertiary center in Indore and included 497 cases of BC. HER-2 was performed by IHC in all cases with appropriate controls. Diagnosis and grading was done on histopathology. HER2 immunoreactivity was scored as score 1(negative),score 2(equivocal) and score 3(positive).Results: 497 cases of BC were evaluated for HER2, 75 cases(15%) are Her2 Positive,36 Her2 positive cases are grade II and 39 Her2positive cases are grade III. 60 cases shows lymph node(LN) positivity while 15 cases do not show LN invasion. Conclusions: HER2 over-expression enhances the transformation potential in BC. As they are associated with high grade tumors and a higher rate of axillary LN metastasis, so they should be therapeutically targeted to prevent HER2+ BC progression that will ultimately lead to new treatment

   PP57: Modified improvised pre-embedding method of core needle biopsies: A megaboon in clinical practice Top

Nikita Sunny1, Anupa Thomas1, Suraj Manjunath1, Usha Kini1,2

1St. John's Medical College,2Oncquest Laboratories Ltd., Bengaluru, Karnataka, India. E-mail: [email protected]

Background: Standard guidelines do not exist for practice and processing of Core Needle Biopsies (CNBs). This prospective study is aimed to compare and contrast the outcome of processing technique of CNBs taken for tissue diagnosis by conventional method (control group, A) with those processed by the modified pre-embedded processing protocol (test group, B) over a two year period in a tertiary care hospital. Design: CNBs(n=60) from SOL in various organs were subjected for the conventional free -floating method in formalin (control group,A) for histopathology diagnosis prior to surgery. After surgical resection of the corresponding SOLs, CNBs taken in fresh state, inked with colouring inks were placed between two foam meshes in cassettes, fixed in formalin and transported to laboratory. The biopsies from both groups were evaluated for the intactness, degree of processing, ease of embedding and ease of cutting. Descriptive statistical measures were employed. Results and Discussion: In comparison to control group A, the cores in the test group B were intact, in to-to, linear, found in one plane, easy to handle, well processed with complete sections in the first serial sections of 4. Four CNBs could be placed in one block with ease, thus cutting down the number of blocks and number of serial sections required by one fourth. Conclusion: Designs a cost-effective user-friendly pre-embedding method on CNBs to yield intact cores from breast and various organ lesions and can be extrapolated by surgeons for routine practice for CNBs of breast and prostate malignancies at bedside.

   PP58: Evaluation of pathologic response in post neoadjuvant chemotherapy breast carcinoma specimens using residual cancer burden system Top

P Lakshmi Manasa, K Suseela

Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India. E-mail: [email protected]

Introduction: Many systems have been proposed to classify the degree of tumor response to therapy in post neoadjuvant chemotherapy (NACT) breast cancers. The Residual Cancer Burden (RCB) developed by MD Anderson cancer hospital is an online tool for the quantification of residual disease that is easy to practice, reproducible, and the RCB score has been clinically validated as independent prognostic factor for long-term survival. Aim: To evaluate the methodology for grossing and microscopic examination for assessing pathologic response in post NACT breast cancer specimens in our institute using RCB system developed by MD Anderson cancer institute and its feasibility for routine practice. Materials and Methods: Patients with newly diagnosed histologically proven breast carcinoma who were treated with both NACT and surgery in our institute were included in the study. Before surgery, patients were given either anthracycline-based chemotherapy regimen with or without additional taxanes or targeted therapy with Transtuzumab. Pathologic response was assessed by calculating RCB score and class. Results: The study included 50 specimens of carcinoma breast in females. 49 were invasive carcinoma, no special type (NST) and one was lobular carcinoma. pCR (Pathological complete response) was seen in 9 (18%) and residual disease was seen in 41 (82%) patients. Conclusion: The present study highlights that assessment of pathological response by RCB system is feasible in routine practice The problem of heterogeneously variable cellularity that can cause sampling errors can be overcome by incorporating RCB score and class in the reporting.

   PP59: Immunohistochemical characterisation of leucocytic infiltrate and its correlation with histopathological response to chemotherapy in breast cancer Top

Usha Rani, Nita Khurana, Shramana Mandal

Maulana Azad Medical College, New Delhi, India. E-mail: [email protected]

Background: Increased understanding of tumor development has lead to renewed interest in inflammatory cells in breast cancer. Increased Tumor-infiltrating leucocytes in breast carcinoma tissue can predict the response of patients to neoadjuvant chemotherapy. This study aimed to characterize the leucocytic infiltrate in the breast cancer into T cell, B cell and macrophages using immunohistochemistry and correlate it with the histopathological response to the chemotherapy. Design: 33 Biopsy proven cases of invasive ductal breast carcinoma patients were included in the study. Trucut biopsy tissue was evaluated in H and E stained and immunostained (IHC - CD3, CD20, and CD68) sections for the characterization of leucocytes. The density of total leucocytic infiltrate was semi-quantitatively graded as absent, minimal, moderate and extensive. After chemotherapy patients were reassessed and underwent a modified radical mastectomy. Post chemotherapy mastectomy specimen was evaluated grossly for tumors. The tumor was graded as MILLER AND PAYNE GRADING SYSTEM from grade I- V depending upon response to chemotherapy. Results: There was a significant correlation between the density of total leucocytic-infiltration with the response to chemotherapy. However, no statistical correlation was found between the tumor response to chemotherapy and the extent of different leucocytic infiltrate. Conclusion: This is a limited study in a small number of patients focussing on post-chemotherapy changes in breast carcinoma and its correlation with the composition of leucocytic infiltrate Pathologic response might prove to be a better predictor of survival and may help in deciding the chemotherapy drugs to be used after surgery.

   PP60: Co-existant infarction of breast and infarction of phyllodes tumor with infarction of recurrent phyllodes tumor during pregnancy: A case report Top

Mansi Manishbhai Davda, Nidhi Shah, Riti Dixit, G N Rao, D L Lanjewar

Department of Pathology and Surgery, Gujarat Adani Institute of Medical Sciences, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Infraction occurs in breast, in fibroadenoma and in phyllodes tumor during pregnancy and lactation. We present a case of co-existant infraction of breast and infraction of phyllodes tumor and infarction of recurrent phyllodes tumor in pregnancy. Case Description: Female 25 years, G2P1 complained of lump in right breast at 7th month of gestation. A baby boy was delivered, 6 days after delivery, she noticed enlargement of right breast which was diagnosed as phyllodes tumor for which mastectomy was performed. One year back she delivered a still born baby and 15 days after her delivery she developed enlargement of left breast, mastectomy was performed, the histopathology reported as phyllodes tumor. For present symptoms, right mastectomy was performed, which showed co-existant infarction of breast and infarction of phyllodes tumor. One year after right mastectomy she conceived for third time and at 4th month of gestation, tumor was noted at right mastectomy site which on histology showed recurrence of phyllodes tumor and hemorrhagic infarct.Conclusions: To date only 18 cases of spontaneous infraction of breast are reported during pregnancy. The pathogenesis of this lesion is vascular insufficiency resulting from increase metabolic demands and vascular thrombosis. Spontaneous infraction of phyllodes tumor during pregnancy and in postpartum period is rare. Co-existant infarction of breast and infarction of phyllodes tumor and infarction of recurrent phyllodes tumor as found in the present case is rare and can be related to increased hormone activity especially estrogen.

   PP61: Immunohistochemical study of tumor associated macrophages in breast cancer using CD68 and CD163 and correlation with clinicopathological features Top

Brig Ajay Malik, Col Jasvinder Kaur Bhatia, Tripta Chaudhary, Maj Arun Gopal

Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India. E-mail: [email protected]

Breast cancer is one of the most common malignant diseases globally. Tumour Associated Macrophages (TAMs) are part of tumour microenvironment (TME), important for promoting tumour growth. M1 macrophages have a pro-inflammatory function and M2 macrophages are involved in angiogenesis and tumor progression. CD68 is a pan-macrophage marker and identifies both M1 and M2 macrophages. CD163 is a scavenger receptor and a highly specific marker for M2 macrophages. The aim of this study was to evaluate the type of macrophage infiltration to understand the clinicopathological association and prognostic significance of CD68 and CD163 TAMs in breast cancer. Design: 75 cases of breast carcinoma were studied. Clinicopathological parameters of the patients were retrieved from records. These included age of the patient, grade & stage of the tumour and presence of metastases. Immunohistochemical staining for CD68 & CD163 was performed and infiltrating macrophages were evaluated. Immunohistochemical staining for ER,PR HER2/neu and Ki-67 were also performed. We quantified CD68 and CD163 positive macrophages in three randomized high-power fields (40 X).Two pathologists blinded to the clinicopathological features and immunohistochemical markers of these patients evaluated the slides. Results and Discussion: High expression of TAM was associated with high histological grade, large tumor size, ER negativity, PR negativity, and high Ki-67 proliferating index. Grade 3 had the highest degree of expression of CD68 & CD163. CD 163 was found to be associated with large tumour size. Conclusions: TAMs are associated with various clinicopathologic parameters of breast cancer and play a role in prognosis of breast cancer.

   PP62: Mammary tuberculosis: A case series of six patients Top

Puja Sharma, Rajesh Kumar Chaurasia1, Shilpa Garg, Shivani Kalhan1, Sonia Hasija

Department of Pathology, SHKM Government Medical College, Gehbar, Haryana,1Department of Pathology, KD Medical College Hospital and Research Centre, Mathura, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Mammary Tuberculosis is a rare entity and may be mistaken as carcinoma breast or pyogenic breast abscess because of its non specific clinical and radiological findings. Microscopy and culture are frequently negative and the diagnosis is often one of exclusion. Methods: The study includes six cases with mammary tuberculosis, seen over a six month period at a tertiary care centre. All the patients presented with lump in the breast. The cases were initially subjected to Fine Needle Aspiration Cytology (FNAC). Excision biopsy was done in only four cases. Ziehl-Neelsen staining for AFB was performed in all the cases. Results: The average age at presentation was 29.16 years. FNAC showed features of Necrotizing granulomatous mastitis in four cases and Necrotizing inflammatory lesion in two of the cases. All the four cases subjected to histopathological examination were reported as necrotizing granulomatous mastitis on the basis of presence of epithelioid cell granulomas, Langhan's giant cells and caseous necrosis. Acid fast bacilli were seen on Ziehl-Neelsen (ZN) staining on histopathology in one out of four cases and in two out of six cases on FNAC. Conclusion: Mammary tuberculosis typically presents with lump in breast and being an uncommon disease, can be mistaken as carcinoma breast or breast abscess. Hence, it should be considered in the differential diagnosis of patients in reproductive age group with clinically suspicious breast lumps who are from high risk population and / or endemic areas.The diagnosis can be rapidly established by FNAC in majority of cases?

   PP63: Primary neuroendocrine carcinoma breast: Report of a rare case Top

Divya Singh, Nilotptal Chowdhury, Ashok Singh, Priyanka Gupta1, Bina Ravi1

Department of Pathology, AIIMS,1IBCC, AIIMS, Rishikesh, Uttarakhand, India. E-mail: [email protected]

<p>Introduction: Neuroendocrine tumors in breast have been reported in literature however primary neuroendocrine tumors of breast are extremely uncommon with incidence &lt;1%&nbsp; worldwide. Most commonly seen in 6-7th decade of life.&nbsp; The diagnosis&nbsp; is difficult and requires the use of immunohistochemical markers and are commonly missed as these markers are not routinely used.</p> <p>Case Report: A 40 year old female presented with recurrent breast lump in Integrated Breast clinic. Ultrasound revealed a well defined hypoehoic lesion in the left axilla. Fine needle aspiration perfomed showed cellular smears. Individual cells were small round to oval to plasmacytoid. Mild nuclear pleomorphism was noted with stippling of chromatin. Possibility of Plamacytoma and Neuroendocrine tumor were suggested. Biopsy done was reviewed and a panel of immunohistochemical markers were done. The tumor cells stained with Cytokeratin and Synaptophysin. A diagnosis of Invasive carcinoma breast with neuroendocrine differentiation was provided.</p> <p>Discussion: Neuroendocrine tumors are rare tumors, a possibility of metastasis from other organs needs to be strongly considered and confirmed with the help of immunohistochemical markers. These tumors are often positive for hormone receptors and are negative for ERBB2. Further complicating the scenario are imaging findings which don&rsquo;t correlate with hormone receptor status.</p>

   PP64: An institutional experience on diagnostic accuracy of FNAC and CNB in breast carcinoma Top

Fatima Khan

King George's Medical University, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Breast cancer has become most common malignancy in females in India (surpassing cervical cancer)with an incidence of ~ 25.8 per 100,000 women and mortality rate of 50% among diseased patients.Triple assessment(clinical, radiological and Fine needle aspiration cytology) has been commonly used method for preoperative diagnosis, however in recent years Fine needle aspiration cytology(FNAC) has been abandoned in many institutes and replaced by core needle biopsy (CNB). Being a tertiary care centre we plan to share our institutional experience on the epidemiology of breast cancer along with comparison of the two techniques (FNAC vs CNB),to study their correlation as well as diagnostic difficulties faced. Methods: A retrospective study which includes female patients of breast cancer with FNA and corresponding CNB between June 2016 -2018. Diagnostic values like sensitivity, specificity, diagnostic accuracy, positive predictive (PPV) and negative predictive values (NPV) will be analyzed statistically. Results: Total of 300 breast cases are studied . 272 out of 300 are invasive ductal carcinoma diagnosed on both FNAC and CNB. Histocytological correlation is 89.3% with complete correlation in malignant lesions. Inadequate rates are slightly lower in CNB 3.6% (11/300) than FNAC 5.3% (16/100) but almost comparable. Average age group is 50.9 years with 29.4% below 40 years of age. Discussion and Conclusion: FNAC and CNB represent accurate methods for diagnosis of breast lesions. Though CNB has slightly higher diagnostic accuracy rate than FNAC but FNAC is used as first line test and inadequate FNAC can be largely resolved by using repeat sampling with CNB.

   PP65: Histocytological indicators of mucinous carcinoma of breast: Experience at a tertiary care center Top

Anoushika Mehan, M L Anthony, Vandna Bharatai, Arathi Prabha, Nilotpal Chowdhury, Shalinee Rao

AIIMS, Rishikesh, Uttarakhand, India. E-mail: [email protected]

Background: Mucinous carcinomas of breast represent 1 to 4 % of all carcinomas of breast and are difficult to diagnose on cytology due to low grade features of tumor cells. It is important to diagnose this entity as it has less aggressive behavior and a favourable prognosis compared to other subtypes. It is found in postmenopausal females. Only 1 % of mucinous carcinomas are reported in patients less than 35 years of age. Design: All benign and malignant breast lesions reported in Department of Pathology at AIIMS Rishikesh during 2016-2019 October were reviewed. Results: Of 27,116 overall samples, 1077 breast biopsies were received of which 698 cases were of primary malignancies in breast and 379 cases were benign lesions in breast. There were 11 cases of mucinous carcinoma reported. Mucinous carcinomas of breast represented 0.01 % of primary malignancies of breast at our centre. Discussion: Three cases of pure mucinous carcinoma were diagnosed on mastectomy specimens and eight cases with mixed morphology along with areas of mucinous differentiation, diagnosed on trucut biopsy. One of these cases in a 32 year old female showed metastases to ovaries, confirmed on immunohistochemistry. Conclusion: Cellular discohesion, mild increase in size and a mucinous background are important discriminators allowing a diagnosis of malignancy on cytology. Pure mucinous carcinoma is very rare and carries a good prognosis with a survival rate of 94% at five years in comparison with mixed mucinous carcinoma. It should be distinguished from benign mucinous lesions of breast.

   PP66: Impact of recent 2018 ASCO/CAP guidelines on monosomy-type HER2 gene amplification by Fluorescence in situ hybridization test in breast carcinoma Top

Prarthna Shah, Trupti Pai, Nupur Karnik, Mandar Ankolkar, Omshree Shetty, Asawari Patil, Sangeeta Desai, Tanuja Shet

Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Monosomy-type HER2 gene amplification is defined as HER2/CEP17 ratio ≥2, with an average HER2 copy numbers <4. We sought to assess the impact of the 2018 ASCO/CAP guidelines change in this patient group if they had unique clinicopathological features. Design: We retrospectively evaluated the HER2 FISH cases of breast carcinomas tested by PathVysion (Abbott Molecular Inc.,IL, USA) in between October 2013- June 2018, interpreted by 2013 ASCO/CAP guidelines. Cases with monosomy-type amplified (Group A) were further interpreted by ASCO/CAP 2018 guidelines. The clinicopathological features were compared with the classically HER2 amplified cases (HER2/CEP17 >2, HER2 >6- Group B) using Chi-square test. Results: Out of total 2713 breast cancers, 995 were amplified, of which 64(6.4%) cases belonged to Group A. Applying 2018 guidelines, all 64 cases were non-amplified. All were females with age range of 31-74 years. Majority were grade 3 tumours(95%) and all were equivocal(2+) by IHC. With available follow-up of 6-73 months, trastuzumab was taken by 70%(45/64)cases. Though not statistically significant, in comparison with Group B cases, Group A had higher incidence of intratumoural genomic heterogeneity(28% vs 7%),locally advanced breast cancers(49% vs 22%), progressive disease on Herceptin(9.6% vs 7.3%) and residual viable invasive component in neoadjuvant settings(73% vs 56%). Conclusions: Group A formed approximately 2.4 % of breast cancers, all of which were IHC negative. This subgroup tends to be distinct as compared to Group B. In all, 2018 ASCO/CAP guidelines have impacted our cohort by decrease in HER2-positive status in this subgroup thus preventing over treatment by anti-Her2 agents.

   PP67: HPV and carcinoma breast: An institutional experience Top

Manjit Kaur Rana

ACI (BFUHS), Bathinda, Punjab, India. E-mail: [email protected]

Background: Breast cancer is the leading cause of death among women. The presence of human papillomavirus (HPV) as risk factor has been proposed for breast cancer, however potential causal association is still not clear. Design: The present study was aimed to evaluate the expression of P16 with immunohistochemistry (IHC) in pre-chemotherapy 10% neutral buffered formalin fixed paraffin embedded breast carcinoma tissues of 93 cases and its correlation with histopathological type, grade, lymph node status (LNS) along with p53, estrogen receptor (ER), progesterone receptor (PR) and Her 2neu expression with IHC in tumor cells. Patients were divided into groups G1 (with P16 expression) and G2 (without P16 expression). Results and Discussion: Total number of the cases were 93 (90% females, 3% males) age range of 27-98 years 55.4±15.9 (mean±SD). P16 expression was detected in 18.2% cases. P16-positive was defined as >50% of cells showing strong nuclear and cytoplasm. Positive expression of p16 was seen significantly associated with p 53 and Her 2 neu positivity. Also insignificant positive correlation was seen with IDC mixed type, grade III, >3 lymphnodes metastasis and ER status. Conclusion: P16 expression showed positive correlation with p53 and Her 2 positivity, so can be used as prognostic marker

   PP68: Pleomorphic adenoma of upper eyelid: A rare case report Top

Seema Singh, Sanjeev Kumar Singh, Pinki Pandey, Seema Dayal, Roopak Aggrawal

Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India. E-mail: [email protected]

Background: Pleomorphic adenoma is most common neoplasm of the salivary gland (mainly parotid gland).Occasionally it can be found in the cervico-facial area, outside the major and minor salivary glands.However it is very rare in eyelid.We report a case of Pleomorphic adenoma of left upper eyelid in middle aged man which was excised and confirmed histologically. Case Report: A 35 year old male presented with nodular painless mass at left upper eyelid since 1 year. Which gradually increaed in size.On radiological examination, it was a well circumscribed mass with no evidence of invasion in adjucent structures.On examination, mass was nodular, surface was irregular. Fine needle aspiration cytology (FNAC) was performed. On examination, cytology smear showed plasmacytoid myoepithelial cells with scanty myxoid matrix. So provisional diagnosis of pleomorphic adenoma had been made.Tumour was removed surgically and sent for histopathological examination. On Gross examination it was gray-brown firm mass measuring1.5x1x1 cm. On cut section tumour was pale white in colour. On microscopic examination, sections showed chondomyxoid stroma with epithelial components. Findings were consistent with Pleomorphic Adenoma. Patient was advised to follow up for any recurrence. Conclusion: Pleomorphic Adenoma is rarely arised from eyelid. Pleomorphic Adenoma accounts for only 0.48 percent of eyelid tumour. Early diagnosis by FNAC is important because complete excision is necessary due to the possibility of recurrence or malignant transformation.

   PP69: Chondroid syringoma: A case series of three cases Top

Ruchi Agarwal, Swarn Kaur Saluja, Deepti Agarwal, Parveen Rana, Monika Gathwal, Kulwant Singh, Amrita Kulhria

Department of Pathology, BPS GMC for Women, Sonepat, Haryana, India. E-mail: [email protected]

Background: Chondroid syringoma or cutaneous mixed tumor is rare benign adnexal tumor of the skin accounting for only about 1% of skin tumors. It comprises both epithelial and mesenchymal component, similar to pleomorphic adenoma of salivary gland. Head and neck is the most common site involved. Case Reports: Case 1: A 52 years old female presented with a slowly progressive swelling over tip of nose since last 3 yrs. The swelling was nodular, firm, non-tender and measuring 5x5 cm in size. FNA smears showed groups and singly scattered epithelial cells embedded in fibrillary chondromyxoid ground substance. Cytological diagnosis of chondroid syringoma was offered and confirmed on histopathological examination. Case 2: A 71 yrs old male presented with a solitary painless swelling in postauricular region since 6 months. FNAC smears revealed loose cohesive clusters of round to oval cells admixed with eosinophilic fibrillary stromal material. Histopathological examination of excised swelling revealed histological features consistent with chondroid syringoma. Case 3: A 47 yrs old female presented with a painless swelling on tip of nose since 2 months. Cytology smears are cellular and showed plasmacytoid cells embedded in abundant eosinophilic stroma. Excision biopsy confirmed the diagnosis of chondroid syringoma. Conclusion: Fine needle aspiration can help in reaching the pre operative diagnosis and guide the surgeon in planning the extent of surgery.

   PP70: A study on cytological and biochemical profile of thyroid lesions using fine needle aspiration and non aspiration technique in Bathinda Top

Vainy Aggarwal

Adesh Institute of Medical Sciences and Hospital, Bathinda, Punjab, India. E-mail: [email protected]

Background: Prevalence of goiter is more than 40 million in India. Accurate diagnosis of thyroid nodules is necessary for appropriate management and to avoid unnecessary surgical interventions. Fine-needle aspiration is accepted as a first-line screening test. However, a newer technique of using only needle without aspiration is used known as fine needle non aspiration cytology. Aim: To see the relation between clinical and cytological profile, cytological and biochemical profile in a palpable thyroid lesion and to compare the results of Fine needle non aspiration cytology with Fine Needle Aspiration Cytology. Design: The study was conducted from 1st April 2016 to 30th September 2017. 72 patients were included. History was taken, biochemical thyroid profile estimated. The swelling was sampled by both aspiration and non aspiratioechnique. Results and Discussion: The mean age was 38.02±13.86 years with female to male ratio of 7:1. Most common presentation was solitary thyroid nodule (51.4%). Non neoplastic lesions (80.5%) were more common then neoplastic (16.7%). Colloid goiter being commonest in non neoplastic category (30.5%) and follicular neoplasm in neoplastic (8.3%). Maximum patients were euthyroid (75%). Non aspiration technique performed better then aspiration in all parameters i.e background blood, cellular material retrieved, cellular degeneration, cellular trauma, retention of appropriate architecture. Both the techniques produced adequate smears with more superior smears by non aspiration technique. Conclusion: Thyroid swellings are diseases of young adult females. Maximum of these lesions are non neoplastic. Adequate and superior smears are produced by non aspiration technique and causes less pain and discomfort to patient.

   PP71: Cytological diagnosis of multiple normolipemic tuberous xanthoma: An unusual occurrence Top

Biswajit Padhy, Ashok Kumar Dash, Shushruta Mohanty, P K Das, Debi Prasad Mishra1

MKCG Medical College and Hospital,1Department of Pathology, MKCG Medical College, Berhampur, Odisha, India. E-mail: [email protected]

Introduction: Tuberous xanthomas are large nodular lesions those develop in patients with underlying hyperlipoproteinemias. We present a case of normolipemic tuberous xanthomas with its association with thyroid disorder (hypothyroidism),which is an uncommon occurrence. Case Report: A 26/F presented to our hospital with multiple tuberous swellings on the extensor surface of the body since 15 years. We also incidentally detected presence of Nodular thyroid swelling.Routine investigations along with Lipid profile were within normal range and serum protein electrophoresis showed normal pattern. FNAC from few Tuberous nodules and multiple sites of thyroid nodule was then performed .Cyto Smears in all tuberous nodules showed good number of foamy histiocytes in clusters and discretely admixed with plenty of giant cells and collections of cholesterol crystals over a dirty haemorrhagic background. Surprisingly FNAC done from thyroid smears shows good number of epithelioid cell clusters ,group of benign follicular cells and other features similar to aspiration of tuberous nodules .Thyroid function revealed increased TSH with low normal T3,T4. Histopathology from a single excised nodular lesion showed attenuated epidermal lining with collection of foamy macrophages in the dermis with plenty of giant cell reaction and cholesterol crystals that confirmed our findings to be Tuberous xanthoma. Conclusion: Our case is unique as tuberous xanthomas has occurred in a normolipemic subject , and its association with thyroid swelling as a systemic manifestation which is a rare occurrence. FNAC plays an indispensable role in diagnosis as it helps to avoid the need for surgical biopsy in these multiple lesions.

   PP72: Utility of the Milan system for reporting salivary gland cytopathology: A retrospective 5 years study Top

Jyoti Chirmade, Kanchan Kothari, Leena Naik1

Seth G S Medical College and KEM Hospital,1Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Fine-needle aspiration cytology (FNAC) is an established technique for preoperative diagnosis of salivary gland lesions however lack of a uniform reporting system has been a handicap. Design: The study aimed to evaluate utility of the recently developed classification system - 'The Milan System for Reporting Salivary Gland Cytopathology' (MSRSGC). To assess the diagnostic accuracy of FNAC and ascertain the risk of malignancy (ROM) for each category. A retrospective analysis in which slides from all salivary gland FNACs received between January 2012 and December 2016 were reviewed and assigned a diagnostic category from the MSRSGC. Clinical data was taken from Cytology records. Cytodiagnosis was correlated with histopathology wherever available & ROM was calculated. Results and Discussion: 120 salivary gland FNACs were studied. Age ranged between 5-85 years, Male:Female ratio was 2:1 and Parotid was the commonest gland aspirated. Cases were reclassified as I Non-diagnostic (2.5%), II Non-neoplastic (15%), III Atypia of uncertain significance-AUS (1.7%), IV A Neoplasm benign (50%),IV B Neoplasm of uncertain malignant potential (12.5%), V Suspicious for malignancy (5%) and VI Malignant (13.3%). Follow up was available in 70 (58.3%) cases. The sensitivity, specificity, negative predictive value, and positive predictive value were 92.3%,100%, 100%, and 98.27% respectively. ROM was non-neoplastic (0%), AUS (50%), neoplasm benign (0%), neoplasm of uncertain malignant potential (28.6%), suspicious for malignancy (100%) and malignant (100%). Conclusion: Salivary gland FNAC is a reliable diagnostic tool and the 'Milan system' will further increase FNA reliability, help risk stratification and improve patient care.

   PP73: Milan system for reporting salivary gland cytopathology with its application to stratify malignancy risk: A 5 year institutional experience Top

Jai Kumar Chaurasia, Deepti Joshi, Garima Goel, Ujjawal Khurana, Neelkamal Kapoor

All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Fine-needle aspiration (FNA) cytology of salivary glands is a widely acceptable technique for preoperative diagnosis. It is challenging as salivary gland tumors show diversity and many times morphological overlap, with lack of a standardized, tiered reporting system. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) is an evidence-based system developed by an international consortium with objective for better communication between clinicians and pathologists for improving overall patient care. Aim: The aim of this study was to apply the proposed Milan system for reporting salivary gland lesions for enhancing diagnostic accuracy and to evaluate risk stratification for malignancy. Also to compare it with previous reporting system. Design: A retrospective analysis of FNA specimens of salivary gland lesions reported at AIIMS, Bhopal for a period of 5 years was performed. 100 cases with available histopathology were included. The aspirates were then categorized according to the Milan system. Furthermore, the risk of malignancy and the risk of high-grade malignancy were calculated for all diagnostic categories. Discussion: FNA of salivary gland is challenging. The performance depends on variety of factors such as technical experience of the operator, quality of the cytologic preparations, experience of the evaluating cytopathologist, morphologic heterogeneity of the lesion, and presence of a cystic component. Results and Conclusion: Salivary gland FNA continues to have high diagnostic accuracy. Milan system is useful in reporting challenging tumors showing morphologic overlap.

   PP74: Chronic lymphocytic thyroiditis: Cytology looks tricky Top

Varsha M Dhume, Aarti Pachrupe, Vikas Kavishwar, Ashwini Khadatkar

T.N. Medical College, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: There is rise in the incidence and diagnosis of chronic lymphocytic thyroiditis (CLT) due to iodine supplementation of diet and improved diagnostic techniques respectively. A change in trend has been observed in its clinical presentation and functional status. Correct diagnosis of thyroiditis is essential as therapeutic management is recommended.


  • Analysis of cytomorphological spectrum of CLT along with cytological grading
  • Correlation of cytological grading with clinical presentation and other investigations
  • Assessment of diagnostic pitfalls on cytology of CLT.

341 cases of CLT were studied in 2 groups. Group 1, included cases diagnosed on FNAC. Detail cytomorphology with cytological grading was assessed. Group 2 included cases, diagnosed only on histopathology. In these cases, cytological findings were reviewed. Results and Discussion: Clinically majority of patients were females in third to fourth decade presenting as diffuse enlargement (64.4%) followed by nodular (35.6%). Only 46% of patients were hypothyroid. Anti-TPO antibody was positive in 75% of cases. Grade II follicular destruction was commonest and correlated with anti-TPO antibodies. Increased lymphoid: epithelial ratio, clusters of follicular cells with moderate anisonucleosis and infiltration by lymphocytes were important cytological findings. In group 2, majority of patients were euthyroid with nodular presentation. Presence of abundant colloid, macrophages and lack of background lymphocytes were misinterpreted as spectrum of goitre in 15 cases. Abundant hurthle cells and repetitive microfollicular pattern raised suspicion of neoplasm. Conclusion: Thorough cytological sampling and integrated approach is necessary to clinch the diagnosis of CLT and avoid unnecessary thyroidectomy.

KEYWORDS: Chronic lymphocytic thyroiditis, FNAC

   PP75: Filariasis of breast: A report of two cases Top

Suneet Singh, Santosh Tummidi, Ashvini Kolhe, Roshni Patil, Kanchan Kothari

Department of Pathology, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Filariasis is a major health problem in tropical and subtropical regions, and is fairly endemic in South Eastern countries like India. There are several reports of microfilariae in fine-needle aspirates from varied sites like lymph nodes, testis, epididymis, soft tissues etc. The detection of adult filarial worms with host response in an aspirate from the breast is very rare. Design: Data collected included clinical history and laboratory findings, local examination, ultrasonography, mammography etc. Fine needle aspiration cytology was performed by standard technique without radiologic guidance. Both Giemsa and Papanicolaou stained smears were made. Wet mount was prepared in one case. Results and Discussion: The patients were females, aged 35 years and 41 years respectively and both presented with a firm, 1x1cm lump in the left breast. Ultrasonography was not done for case 2 while the classical “Filarial dance” sign was seen on sonography in case 1.Two adult gravid worms were aspirated in case 1 while a single worm was seen in case 2. Embryonated eggs were detected in case 1 while unfertilised eggs were seen in case 2 . A granulomatous response, microfilariae, eosinophils and giant cells were seen in both the cases. Morphology of microfilaria was suggestive of W. bancrofti. Conclusion: Filariasis of the breast can mimic neoplastic lesions clinically. FNAC is a relatively quick, cost effective and minimally invasive procedure that helps rule out malignancy and gives a definite diagnosis in case of Filariasis, thus allowing for specific therapy without need for surgical intervention.

   PP76: Evaluation of visual inspection using acetic acid, exfoliative cytology and cytomorphomery in chronic tobacco users in Allahabad region Top

Vasudha Singh, Kachnar Varma, Vatsala Misra, Mudita Bhargava, Himansha Pandey

M.L.N. M.C., Prayagraj, Uttar Pradesh, India. E-mail: [email protected]

Background: Chronic use of tobacco leads to chronic inflammation, oral premalignant disorders (OPMD) and oral squamous cell carcinoma(OSCC) due to several carcinogens in these tobacco products. Screening of such tobacco users for an early diagnosis is, therefore, of paramount importance . Several screening modalities have been used in the past, but none has been validated as a definitive and cost-effective screening modality.VIA screening has drastically changed the morbidity and mortality related to cancer cervix,However its role as screening tool in oral lesions has not yet been truly validated. The aim of this study was to evaluate the use of 3% acetic acid as a vital staining agent in tobacco-associated oral lesions. Design: A total of 150 patients with history of chronic tobacco intake were included in this study. Group one comprised of cases with normal oral mucosa on clinical examination. Group two had 100 cases with lesions suspected of having OPMD and OSCC. After applying acetic acid in each case, change in colour of oral mucosa was noted. Exfoliative cytology and cytomorphometry was done in each followed by biopsy wherever possible. Results and Discussion: Sensitivity and specificity of VIA was 67.86% and 62.12% respectively. Findings of VIA and cytomorphometry showed a strong association (p value<0.05). Conclusion: A strong association was seen between results of VIA and exfoliative cytology, cytomorphometry and histology (p value<0.05). Acetic acid can thus be used as a simple, cost effective and convenient preparation for mass screening of oral premalignant lesions along with exfoliative cytology and cytomorphometry.

   PP77: Cytodiagnosis of granular cell tumor over mons pubis: Report of a rare case Top

R M Pimpalkhute, A R Anvikar, Y A Momin, N A Ramteerthakar

Government Medical College, Miraj, Maharashtra, India. E-mail: [email protected]

Background: Granular cell tumor is a tumor of neuroectodermal origin. It primarily affects adults between second to sixth decades with female predilection. Granular cell tumors can affect all parts of body, most common site being oral cavity. Mons pubis is a rare site for granular cell tumor. Although most granular cell tumors are benign, about 1-2 % cases are malignant. Very few cases of granular cell tumor have been reported on cytology. Design: We report a case of granular cell tumor over mons pubis diagnosed cytologically and later confirmed on histopathology. Results and Discussion: A 58 year old female presented with swelling over mons pubis since 2 years. Clinical examination revealed 3x2cm firm, immobile, tender mass over mons pubis. FNAC was performed. Cytological examination showed sheets, clusters and singly scattered oval to polygonal cells having small round to oval bland nuclei with clumped chromatin and abundant granular eosinophilic cytoplasm with indistinct cell margins. Few of the cells showed mild nuclear atypia. We rendered a diagnosis of granular cell tumor and advised excisional biopsy. Histopathological examination of the excised specimen confirmed the diagnosis of benign granular cell tumor. Conclusion: Cytodiagnosis of granular cell tumor poses a problem due to the wide spectrum of differential diagnoses ranging from non neoplastic granular histiocytic reaction to neoplasms like hidradenoma, melanoma and alveolar soft part sarcoma. A cytopathologist should be aware of distinctive cytomorphological features of granular cell tumor and its mimickers to arrive at a diagnosis.

   PP78: Cytomorphological spectrum of lymph node lesions Top

Neha Mathew, Shubhangi V Agale, Shilpa Mishra, Sanjay Bijwe

Department of Pathology, Grant Government Medical College and JJ group of Hospitals, Mumbai, Maharashtra, India. E-mail: ne[email protected]

Background: Lymphadenopathy is a common presentation seen in all age groups and the etiology includes a wide spectrum of diseases. The easy accessibility of lymph nodes makes fine needle aspiration cytology (FNAC) the first line of investigation in lymphadenopathies. Objectives: 1) To assess various etiologies, incidence and cytomorphological features of lymph node diseases on fine needle aspiration cytology. 2) To assess the frequency of causes of lymphadenopathy in different age group and genders. Design: A prospective study of FNACs in cases of lymphadenopathy was undertaken over a period of six months from January 2019 to June 2019 at a tertiary care hospital. Results: Among the 235 cases studied, maximum number of patients (62) belonged to the age group of 10 to 20 years (26.4 %). Tuberculous lymphadenitis comprised the majority (55%) followed by reactive hyperplasia (24%), metastatic malignancy (10.20%) and suppurative lymphadenitis ( 6.50%). Other cases include lymphoproliferative disorders including lymphoma, Rosai dorfmann disease and viral lymphadenitis including infectious mononucleosis. Conclusion: Maximum number of cases belonged to the age group of 10-20 years and females were mostly affected. Cervical lymph nodes were most commonly involved with tuberculous lymphadenitis being the most common diagnosis. Fine needle aspiration cytology is a safe, minimally invasive investigation for the early diagnosis of lymph node disorders.

   PP79: Renal cell carcinoma in ascitic fluid: A diagnostic dilemma Top

Suruty Chandran, Nilam M More, Abeer Mohd Ilyas, Leena P Naik

Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Renal cell carcinoma accounts for 3% of all adult malignancies. Peritoneal effusions are seen in less than 1% of patients with renal cell carcinoma. Although conventional renal cell carcinoma is the commonest type, several studies show papillary renal cell carcinoma has more tendency to present with ascites .There are very few studies on renal cell carcinoma with involvement in serous effusions and those two have not been dealt with in great detail. Design: Forty year old male, known operated case of renal cell carcinoma presented with abdominal distension. Ultrasound abdomen showed gross ascites, and multiple metastatic deposits in both lobes of liver and spleen. PET CT showed disease progression with increasing ascites and new pulmonary metastasis. On examination, ascitic fluid was yellow and hazy. Results and Discussion: Cytology showed some polymorphs, lymphocytes, macrophages, mesothelial cells, few singly scattered and small clusters of cells looking like macrophages and mesothelial cells, having subtle atypical nuclear features. In view of radiological and cytological findings diagnosis of metastasis of renal cell carcinoma in ascitic fluid was made. Conclusion: The cytopathologist has to be vigilant as renal cell carcinoma is a very rare cause of ascites and often the malignant cells are confused with macrophages and reactive mesothelial cells. Careful cytological examination of malignant cells of renal cell carcinoma and to differentiate them from mesothelial cells and macrophages is utmost important for accurate diagnosis.

   PP80: Role of cytopathology in salivary gland lesions with the application of milan system Top

Shilpa Kapoor

Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Background: FNAC offers a minimally invasive, rapid pre-operative diagnostic procedure for salivary gland lesions. Addressing the limitations to reporting of these lesions “The Milan System for Reporting Salivary Gland Cytopathology” was proposed which is based on risk stratification scheme. The present study was carried out to validate and elucidate the benefits of this newly proposed system. Study Design: Prospective observational study on 151 salivary gland aspirates. Categorization of aspirates according to Milan system was as follows: nondiagnostic, non neoplastic, atypia of undetermined significance, benign, neoplasm of uncertain malignant potential, suspicious for malignancy and malignant. Correlation with histopathology and overall FNA follow up was done wherever possible and risk of malignancy based on both criterias was calculated. Results and Discussion: Cytomorphological evaluation divided 151 aspirates as: 1.32% ND, 24.5% NN, AUS 1.98%, Benign 41.05%, SUMP 6.62%, SM 2.64% and 21.85% Malignant. Histopathology was available for 46 cases (30.4%) and an overall FNA follow up for 96 (63.57%) cases. FNA had 88.23% sensitivity, 95.7 % specificity with diagnostic accuracy of 92.5%. Based on histolopathology ROM for individual categories i.e NN, AUS, Benign, SUMP, SM and malignant were 0%, 66.6%, 10%, 100%, 66.6% and 100%. Based on overall FNA follow up ROM for individual categories of ND, NN, AUS, Benign, SUMP, SM and malignant were 0%, 0%, 66.6%, 6%, 100%, 66.6% and 100%. Conclusion: Though using Milan system resulted in better communication between cytopathologist and clinician resulting in better patient care, further such studies are required to predict ROM and define appropriate management.

   PP81: Unfolding the mystery of multiple swelling s including eye and breast Top

Saptami Saikia, Mondita Borgohain, Aseema Das

Assam Medical College and Hospital, Dibrugarh, Assam, India. E-mail: [email protected]

Background: We present a case of Acute Myeloid leukemia, which subsequently progressed to Myeloid sarcoma. Design: A 23 year old female presented with a swelling in the left eye with proptosis and diminished vision, another swelling in her left breast as well as with bilateral axillary lymphaedenopathy. She came for fnac of the multiple swellings. Results: Clinically, pallor was evident with no organomegaly. Radiology findings in the CEMR of orbit suggested diffused infiltrative systemic disorder. FNAC of the swellings were done. The smears were composed of immature cells and were MPO stain positive. Complete blood count showed high leucocytosis (120000) and on peripheral blood smear there were 95% of blasts seen. Bone marrow examination revealed blast cells with increase in monocytic lineage. Discussion: Myeloid sarcoma also known as chloroma is a neoplasm of myeloid cells that can arise before or concurrent with or following Acute Myeloid leukemia. In this case on elaborate history taking it was found that she was diagnosed as a case of Leukemia 6months back and now presented with Myeloid sarcoma. Discussion: Myeloid sarcoma is a neoplasm composed of immature and mature granulocytes or monocytes that occurs at an extramedullary anatomical sites. The treatment is not definite but to treat leukemia.

   PP83: Cytological diagnosis of neuroendocrine carcinomas including carcinoid tumours: A retrospective study Top

K Lakshmi, Nileena Nayak, S Renu, K Jayasree

Regional Cancer Centre, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: The classification of Neuroendocrine neoplasms has evolved substantially over time,but remains a topic of controversy and debate.. Cytology has become one of the mainstay of diagnosis for these tumours and the treatment may be entirely based on the FNA report. Materials and Methods: Cases of Neuroendocrine neoplasms diagnosed by cytology during 2018 are included in this study. The slides of these cases were retrieved, cytological features reviewed and clinicopathological features evaluated. Histopathological correlation was done wherever possible. Results: In this retrospective study,there were 43 cases which included FNA(n=38),Fluid cytology(n=3),Bronchial washings and Brushings(n=2). FNA sites included lung, cervical lymph nodes, scalp, liver, pancreas, and mesentery with the cytological diagnoses of Small cell carcinoma(n=22) Neuroendocrine tumour (n=7), Large cell Neuroendocrine carcinoma (n=3) and Poorly differentiated carcinoma with neuroendocrine features (n=11).Features that are of help include scanty cytoplasm, fine or coarse granular chromatin, nuclear moulding and streaking ,cells adhering to vessels, inconspicuous nucleoli, nuclear debris in Small cell Carcinomas; larger cell size,moderate amount of cytoplasm,coarse granular chromatin in Large cell Neuroendocrine Carcinomas; Uniformity of cell size,round to plasmacytoid cells with stippled chromatin,rosette formation in Carcinoid tumours. Conclusion: The cytologic diagnosis of Neuroendocrine neoplasms, both high and low grade can be difficult.Proper recognition of the neuroendocrine morphology along with adjuncts like cell block and IHC help in avoiding errors and arriving at a correct diagnosis.

   PP84: Recognizing histological patterns in the endometrial scrapings cytology of hysterectomy uteri Top

Sneha Debbarma, Kusum Jashnani, Shivangi Trivedi

Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharastra, India. E-mail: [email protected]

Background: Endometrial aspiration, a simple modality, remains unpopular due to absence of any diagnostic criteria for endometrial cytology. This study evaluates the various patterns seen in the cytology of endometrial scrapings against histopathological features. Design: Consecutive uteri received in surgical pathology laboratory were cut and gross features documented. The endometrium was scraped by a scalpel, four smears each were taken, fixed in 95% ethyl alcohol, thereafter stained with H&E and PAP stains. Abnormal uterine bleeding, prolapse uterus or abdominal pain due to fibroids were the presenting complaints. Smears were evaluated and reported as:

  • Benign endometrium: Uniform epithelial cells present in mono-layered sheets with many isolated, tall columnar cells
  • Atrophic endometrium: Epithelial cells had scanty cytoplasm
  • Decidual change: Small clusters or isolated, large round to polygonal cells, abundant cytoplasm, distinct cell borders and large vesicular nuclei
  • Endometrial hyperplasia: Nuclear overlapping in sheets, cell clusters with nucleoli
  • Malignancy: Papillary pattern was a prominent clue. Nuclear pleomorphism with prominent nucleoli and mitosis were other features.

Results: Table 1. Conclusions: Differentiating proliferative from secretory endometrium was difficult, so calling them as benign endometrium was sufficient. Endometrial hyperplasia was missed on cytology because the cellularity in cases of benign or hyperplastic endometria were not different. Enlarged vesicular nuclei with prominent nucleoli were seen on review. Diagnosis of adenocarcinoma was possible on cytology.

   PP85: Cytomorphological study of ascitic fluid to assess diagnostic efficacy of cytospin vs cell block Top

Smita Dharmsktu, Dushyant Singh Gaur

Himalayan Institute of Medical Sciences, Baksar Wala, Uttarakhand, India. E-mail: [email protected]

Background: Cytological evaluation of body fluid is diagnostically challenging and it may require meticulous screening to differentiate between benign and malignant In most malignant effusion cytology give first indication of malignancy and it is difficult to achieve .Our study was onCytomorphologyof Ascitic fluid and to compare diagnostic efficacy of Cytospin versus Cell Block. Materials and Methods: Observational cross-sectional study was done on 70 ascitic fluid samples. Ascitic fluid obtained were first examined by naked eye for physical characteristics and then divided into two halves. These specimens were processed by cytospin and cell block technique and slides were prepared for the assessment of their quality. Results and Discussion: Study showed out of 70 cases of ascitic fluid, with cytospin method only 20(29%) cases were diagnosed to be positive for malignancy, while cell block technique increased the diagnostic yield of the malignancy to 31(44%) cases .Additional 10 cases which were diagnosed atypical and 1 case which was negative for malignancy in cytospin was found to be positive for malignant cells in cell block method. Conclusion: Thus this study showed that there is increase in the sensitivity to a considerable extent when cell block method is used as a supplement to standard cytospin of ascitic fluid.

   PP86: Cyto histological in extra hepatic intra abdominal masses Top

Sonia Jain, Pavneet Kaur Selhi, Harpreet Kaur, Siddharth Parkash

DMCH, Ludhiana, Punjab, India. E-mail: [email protected]

Introduction: Abdominal mass can arise from a variety of intra abdominal parenchymal organs like liver, pancreas, gall bladder, spleen, kidney and lymph node. Symptoms are non specific and management could be medical or surgical depending on the site of involvement and etiology. Fine needle aspiration cytology is an accurate and rapid technique used for diagnosis of intra abdominal masses. Aim: To study the clinicopathological features of extra hepatic intra - abdominal masses and correlate with histopathology wherever possible. Material and Methods: A prospective study of 1.5 years duration during which FNAC slides from intra - abdominal extra hepatic masses were analysed. The cytological diagnosis was classified into Non diagnostic, Non neoplastic, Atypical, Suspicious for malignancy and Malignant . The results were correlated with cell block/surgical pathology and immunohistochemistry findings, wherever available. Results: A total of 414 cases were analysed out of which 58 cases were endoscopic guided and remaining 356 were ultrasound guided Age ranged from 61-70 years with slight female predominance. In the present study, lymph nodes were most common intra - abdominal masses involved followed by pancreas and gall bladder. According to the etiology, maximum number of cases were categorised as malignant on FNAC. Overall concordance of histopathology and cytology was found to be 76.43%. Conclusion: FNAC is a reliable, cost effective and time saving tool in the diagnosis of intra abdominal masses.

   PP87: Diagnostic utility of fine needle aspiration cytology in pediatric age group Top

Tanupriya Bindal, Phiza Aggarwal, Uma Handa

Department of Pathology, GMCH, Chandigarh, India. E-mail: [email protected]

Introduction: Fine needle aspiration cytology is a well accepted diagnostic procedure in adults and is being increasingly recommended for pediatric patients. The aim of this study was to determine the utility of fine needle aspiration cytology and spectrum of different lesions in pediatric age group. Materials and Methods: A retrospective study was done in the Department of Pathology over a period extending from January 2018 to December 2018. All pediatric patients aged 0-18 years with palpable or deep seated lesions were included. Histopathological correlation was done wherever possible. Results: 353 out of 3473 cases were in pediatric age group. Male to female ratio was 1.1:1.Pediatric lesions were categorized into non-neoplastic (70.5%), benign (14.7%) and malignant conditions (1.6%). A preponderance of lymph nodes over other sites (46.7%) was noted followed by breast. Among non-neoplastic lesions, reactive lymphoid hyperplasia (90/249) comprised the majority of cases. Lymphomas (4/6) were most common of all malignant tumors and fibroadenoma (27/52) was the commonest in benign lesions. Cyto-histopathological correlation was possible in 46 cases. Conclusion: FNAC proved to be an effective method for evaluation and screening of pediatric lesions.

   PP88: Role of argyrophilic nucleolar organizer region count study in cytological evaluation of serous fluid for detection of malignancy Top

Abhinav Junwal, Reeni Malik, Sharda Balani

Gandhi Medical College, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Serous effusion smears reported as “suspicious for malignancy” pose problems in clinical management. Silver staining for argyrophilic nucleolar organizer regions (AgNOR) has proved useful in making a cytopathologic differential diagnosis between benign and malignant cells. Nucleolar organizer regions(NORs) are loops of DNA located in acrocentric chromosomes. These NORs are visualized by silver staining technique that recognizes these argyrophilia associated proteins which are increased in malignancy. Design: A total of 85 serous effusions received at the Department of Pathology, GMC, Bhopal during a period of one and a half year were included in the study. Smears were studied by conventional Papanicolaou and H&E stains. AgNOR counts, variation in size and dispersion of AgNOR dots in smears were graded and compared in malignant and non-malignant effusions. Results: Mean AgNOR score in malignant peritoneal and pleural effusions were found to be 3+ Dispersion and 2 to 3+ size variation having large numerous dots scattered throughout the nucleus comparable to the reactive and benign effusions. Discussion: AgNOR distribution was irregular and had a grade of 2+ to 3+ in the majority of the malignant effusions ( in accord to Akhtar et al) , AgNORs were heterogeneous in size and graded 2+ to 3+ in most malignant cases. (Gulnaz et al). Conclusion: AgNOR study appears to be clinically useful as an additional diagnostic tool for use in serous effusion when the cytologic diagnosis is difficult.

   PP89: Comparison of fine needle aspiration findings with radiological findings in various organs at tertiary care centre Top

Priyanka Arvind Prasad, Kalyani Prabhakar, N Rachegowda, Anil Kumar Sakalecha

Department of Radiology, SDUMC, Kolar, Karnataka, India. E-mail: [email protected]

Background: Fine needle aspiration cytology [FNAC] is an accurate & cost effective pre-operative diagnostic modality in clinical practice. In most of the pathological conditions where FNA is required radiological imaging also plays an important role to localise the lesion prior to aspiration and make precise diagnoses. The correlation of FNA and radiological findings are accurate in many conditions. However, in some cases discordance do occur. Objective: To evaluate the concordance and discordance of cytology and radiological diagnosis in different organ lesions. Methods: A cross sectional was done for a period of 10 months from September 2018 to October 2019. 29 cases were considered for the study which had radiological diagnosis and subjected for FNAC. The radiological diagnosis with category was compared with cytologic diagnosis with grades. The concordance or discordance between the two diagnostic methods were compared and confirmed with histopathology diagnosis in available cases. Results: Out of 29 cases, 27 cases were females and 4 cases were males. Among these 27 cases, 11,5,3,3 were from thyroid, breast, soft tissue and bone respectively and 2 cases each from gall bladder, liver and 1 case each from ovary, lymphnode and parotid gland. 23 cases showed correlation and 6 did not show correlation. Conclusion: The radiological and cytological findings should be complimentary to each other for early and precise diagnosis which is requirement for specific treatment of the patients.

   PP90: Syringocystadenoma papilliferum with nevus sebaceous Top

Era Bhardwaj, Ranjan Agrawal, Cheena Garg, Divya Bajpai

Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Background: Syringocystadenoma papilliferum is a rare benign hamartomatous adnexal tumor, which often arises from a nevus sebaceous. 50% of the cases are present at birth while 15-30% are present during puberty. Case Report: An 18 yr old female presented in OPD with an erythematous swelling over the scalp present since birth, with a recent increase in size , from last two months. On examination a small papillomatous growth of 3.5 x 2 cms was seen that bled on touch. Grossly, a skin covered soft tissue piece measuring 3.2 x 1.8 x 1 cms was received. Microscopy revealed papillomatous projections arising from the epidermis that was lined by two rows of cells. Luminal row consisted of high columnar cells with oval nuclei and faintly eosinophilic cytoplasm. Outer row consisted of small cuboidal cells with round nuclei and scanty cytoplasm. Dense cellular infiltrate predominantly plasma cells were seen in the stroma. Immature hair follicles with nodular proliferations of sebaceous glands were seen in dermis. Conclusion: Syringocystadenoma papilliferum is a rare tumor that usually occurs in trunk but sometimes can be seen in the scalp also, and has varied variety of differential diagnosis. As it is a challenging entity to diagnose clinically, a histological confirmation is required.

   PP91: Fallacious carcinoma in the neck: A case report Top

Dennis John, Jayalekshmi B, Apuca Susan Mathew, Sherin Susheel Mathew

Somervell Memorial CSI Medical College, Trivandrum, Kerala, India. E-mail: [email protected]

Introduction: Spindle cell carcinoma is a rare poorly differentiated variant of squamous cell carcinoma. It is commonly encountered in oral cavity but rarely seen on neck as skin induration. It's high frequency of recurrence and metastasis prompts correct and timely diagnosis. Background: 43 year old male patient, complaints of swelling, neck - left side. O/E :- Induration & blackish discoloration of skin. Investigation: 1) CT scan :. Impression : ? Cold abscess, Metastasis in nodes with central necrotic area, ? Soft tissue sarcoma. 2) FNA Cytology :- Cellular spindle cell lesion with atypia. 3) Biopsy neck mass :- Spindle cell neoplasm with atypia and increased mitosis. 4) Wide local excision biopsy: Gross: Elliptical piece of skin with underlying soft tissue. C/s shows grey white multinodular mass with haemorrhage and necrosis. Microscopy: An infiltrating neoplasm composed of round spindly cells with moderate eosinophilic cytoplasm, vesicular nucleus with prominent nucleoli. Diagnosis – Poorly differentiated malignant spindle cell neoplasm. 5) IHC: CytoKeratin , Vimentin, P40 + ve. S100, P16, CD 34 – ve. Final Diagnosis: Poorly differentiated squamous cell carcinoma, spindle cell variant. Discussion: The present case marks its uniqueness in this patient regarding its presentation in middle age , seen as an indurated skin lesion on neck region which are extremely rare in case of spindle cell carcinoma variant of squamous cell carcinoma. Conclusion: Spindle cell variant of squamous cell carcinoma is an aggressive tumour associated with high rate of death due to metastatic disease.

   PP92: Giant congenital melanocytic nevus: A rare entity Top

Sujit Manohar Swain, Prashant Kumar Das, Ashok Kumar Dash, Debiprasad Mishra

M.K.C.G Medical College, Berhampur, Odisha, India. E-mail: [email protected]

Background: GCMN are defined as benign nevomelanocytic proliferation present at birth. They occur in 1-2% of newborns and is rare entity with incidence ranging 1 in 200,000 to 500,000 and shows females preponderance. It is defined as melanocytic nevus that are greater than 20 cm in largest dimensions .They are usually deeply pigmented, covered with moderate amount of hair and associated with many satellite lesions. Case Report: We here in report about a 6 yr old male child who presented with history of multiple swellings ,several black pigmented patches and hairy growth over the face ,right side of the chest and legs since birth that was gradually increasing in size . Histopathological study following excision showed broad nests of nevus cells extending from the epidermis through the reticular dermis into the subcutaneous fat along with involvement of dermal appendages. Biopsy findings were consistent with GCMN without malignant changes. It was further confirmed by IHC S-100 that showed positivity for Nevus cells. Conclusion: Giant congenital melanocytic lesions is very rare lesion .Patient should be kept under surveillance due to increased risk of malignant transformation. Most common malignancy associated with this entity includes malignant melanoma and neurocutaneous melanosis. Regular follow up and proper specialised management is required.

   PP93: Histopathological spectrum of skin lesions in a tertiary care center of central India Top

Mohd Jafar Memon, Renuka Gahine, Jyoti Chaudhary

Department of Pathology, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Introduction: Skin lesions are very much prevalent in developing countries with varying patterns due to different ecological factors, genetics, hygiene standards and social customs. The clinical presentations of skin lesions are restricted to only a few changes such as hyperpigmentation, hypopigmentation, macules, papules, nodules etc., and each clinical presentation is common to have different histopathological pictures. Materials and Methods: This is a cross sectional study carried out in Department of Pathology, Pt. J.N.M. Medical College & associated Dr. BRAM Hospital, Raipur, Chhattisgarh. All skin biopsies received in histopathological section from Jan 2014 to June 2019 were reviewed retrospectively. Results: A total of 486 cases were included with 301 (61.9%) males and 185 (38.1%) females. Of total lesions 331 (68.11%) were non neoplastic and 155 (31.89%) were neoplastic. In both males and females, commonest lesion was epidermal cyst (n=83, & n=59 respectively) followed by Squamous cell carcinoma (n=39, n=13 respectively). Conclusion: Even though skin lesions are commonly reported and are widely distributed in both sexes, majority are found in males. Clinical features alone cannot help in diagnosis of skin lesions. Histopathological examination plays a major role in analysis, classification and management of skin lesions. But, to analyze and stratify the spectrum of skin lesions – a wider aspect study including larger population groups is needed.

   PP94: Papular acantholytic dermatosis: A histopathological mimicker of darier disease Top

Deepak Vedant, Kavita Sharma, Deepshikha Dharamsaktu, Anupama Bains1, Poonam Elhence

Departments of Pathology and1Dermatology, AIIMS Jodhpur, Rajasthan, India. E-mail: [email protected]

A 41-year-old female presented to Dermatology Outpatient Department with multiple asymptomatic gradually progressive, grey coloured, grouped, flat-topped papules over groins, medial aspect of thighs and inframammary areas for the last five years. Her nails, oral and genital mucosa were normal. There was no family history of similar lesions. The histopathology of 4mm punch biopsy from cutaneous lesion revealed suprabasal bulla with presence of acantholytic cells. There were dyskeratotic cells in the epidermis. In view of clinical history, the diagnosis of papular acantholytic dermatosis, Darier-like was made. The case is being presented because of its rarity and unique presentation. This case also emphasizes on the importance of clinicopathological correlation in Dermatopathology.

   PP95: Eccrine angiomatous hamartoma: A rare skin lesion, a review of six cases Top

Leena Shrikant Salunke, B D Deshmukh, P S Murarkar, M P Kulkarni, N A Ramteerthakar

Government Medical College, Miraj, Maharashtra, India. E-mail: [email protected]

Background: Eccrine angiomatous hamartoma(EAH)is an exceedingly rare benign malformation characterized by proliferation of eccrine and vascular structures in the mid and deep dermis. It is usually congenital or arises during prepubertal years and rarely arises in adulthood. Clinically it appears as solitary or multiple bluish to reddish brown, nodular, plaque- like or macular lesion, affecting mainly distal extremities. It may be associated with local pain and hyperhidrosis. Design: We present six cases of EAH diagnosed from April 2017 to July 2019. The clinical information of the patients was retrieved from the records. Hematoxyline and eosin stained slides from formalin fixed, paraffin embedded tissue blocks were reviewed for histopathological evaluation. Results and Discussion: The age range of patients was between 7 to 37 years, with an equal number of male and female patients. The majority of lesions were nodular in appearance. Three cases were located in upper while three were in lower extremity. The size range was 0.3 to 3.5cm. The histopathological findings were similar in all the six cases and were typical of EAH, showing proliferation of eccrine and vascular structures in the mid and deep dermis. Other interesting features were presence of adipose tissue in four cases and increased nerve bundles in one case. In two of the cases, EAH was associated with verrucous hemangioma while in one case it was associated with arteriovenous malformation. Conclusion: EAH is a benign, typically slow growing lesion. Though radiological evaluation may help to confirm the clinical suspicion of angiomtous lesion,the definitive diagnosis of EAH is based upon histopathology.It is important to recognize EAH to avoid aggressive treatment.

   PP96: Unusual presentations of disseminated cutaneous rhinosporidiosis masquerading as tumor like lesions: A case series Top

Sunanda Nayak

VIMSAR, Burla, Odisha, India. E-mail: [email protected]

Background: Rhinosporidiosis is an infective chronic granulomatous disease caused by Rhinosporidium seeberii.It frequently involves nasal mucosa,nasopharynx, oropharynx followed by lip,palate,uvula,epiglottis,larynx,trachea,bronchus,maxillary antrum,conjunctiva,lacrimal sac. Cutaneous dissemination although known, is quite rare.They may present with varied clinical presentations. Here ,is a report of 3 cases of Disseminated cutaneous rhinosporidiosis presented with unusual presentations masquerading as tumor like lesions. Case Report: Case-1: 70yr old female presented with multiple nodules all over body ,at places undergoing ulceration mimicking Squamous cell carcinoma. Case-2: 40 yr old female presented with multiple subcutaneous nodules all over body along with polypoidal growth arising from nasal cavity. Case-3: 45 yr old male presented with a cutaneous swelling having a rough surface clinically mimicking a verrucous warty growth. FNACdone from multiple sites showed similar cytomorphology suggestive of Rhinisporidiosis later confirmed by Histopathology. Conclusion: Disseminated cutaneous rhinosporidiosis have varied clinical presentations ,mimicking other cutaneous lesions.Hence,proper diagnosis of the patient is necessary,that is done by FNAC &Histopathology.

   PP97: Clinico-histological spectrum of Hansen'sdisease: A multicentric study Top

Nitesh Mohan, Nitin Mishra1

Rohilkhand Medical College and Hospital, Bareilly,1SRMS Institute of Medical Sciences, Abheypur Keshonpur, Uttar Pradesh, India. E-mail: [email protected]

Background: Leprosy is one of the oldest and chronic infectious diseases known to human being caused by Mycobacterium leprae. Leprosy is widely prevalent in all parts of India and it presents with different clinico-pathological forms. However a great variation is seen in interpretation of clinical and histopathological examination of these lesions. The present research was taken to study the correlations between the clinical and histological diagnosis and to evaluate the importance of skin biopsy as an important diagnostic and spectrum defining tool. Methods: A prospective hospital based study was conducted among patients attending Dermatology OPD of two tertiary care centres in this region over a period of two years. All clinically suspected new leprosy patients were included in the study. A detailed clinical history and examination was carried out and skin biopsies were taken from most active part of lesions. Sections were stained with Hematoxylin & Eosin stain and Fite-Feracco stain. Histopathological findings were compared with clinical diagnoses. Results: A total of 380 cases were studied, out of which 274(72.10%) were males and 106(27.9%) were females. The histopathological diagnosis of leprosy was established in 99.47% of clinically diagnosed cases. Clinico-histopathological concordance was seen maximum in LL(97.22%), followed by BT(79.76%), TT(71.43%), BL(66.67%), BB(66.67%) and least in IL(50.00%). Overall concordance was 56.54%. Conclusion: Clinical diagnoses of Leprosy still pose a significant problem. Histopathological examination of the active skin lesions should be done in all new cases to confirm the spectrum of disease and expected duration of therapy.

   PP98: Abstract-primary cutaneous alk positive anaplastic large cell lymphoma: A rare case report Top

Ashutosh Mishra

King George's Medical University, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Background: Anaplastic large cell lymphoma (ALCL) limited to the skin is a distinct disease that is designated primary cutaneous ALCL (pcALCL). It has indolent course with better prognosis compared to systemic ALCL. ALK positive pcALCL is diagnosed at younger age and has an excellent prognosis. Case Report: A 14 year old female had a cutaneous mass excised 2months back, now presents with ulceroproliferative mass (on the same region) associated with pain, blood mixed pus discharge at epigastric region for 3 months and fever, vomiting for 2 weeks. On CECT, a soft tissue space occupying lesion arising from skin was detected. There is no evidence of intraabdominal extension and calcification. FNAC tried but it yielded only inflammatory exudates. Excision biopsy was done , which revealed diffuse sheets of atypical cells of large sized with round to irregular nucleus, occasional prominent nucleoli and moderate cytoplasm. Brisk mitotic activity and increased number of macrophages are seen along with hemorrhage and inflammatory exudates. Immunohistochemistry revealed positivity to LCA, ALK, EMA, CD30, CD99 and Negativity to CD3, CD20 ,CK and PAX 5. Proliferative index was 95%. Conclusion: Uncommon presentation of ALCL confused with cutaneous tuberculosis. The patient should be closely monitored because of the potential risk of dissemination or extracutaneous spread, beside recurrence of the disease or even development of other malignancies such as mycosis fungoides, Hodgkin or NHL.Close monitoring & tissue biopsy should be done to find out final diagnosis and further management.

   PP100: Mixed medullary and papillary carcinoma thyroid: An uncommon variant of carcinomas Top

Sushma Chourasia, Mohini Kucheria, Amit Varma, Shivangi Maru

SAIMS, Indore, Madhya Pradesh, India. E-mail: [email protected]

Background: Mixed medullary; papillary carcinoma of the thyroid ,a variant of medullary carcinoma is a rare thyroid malignancy accounting for less than 1% of the thyroid malignancies. Case Report: A 60 year old female patient presented with a neck mass. On examination, swelling of about 15x20cm in size was palpated on the left side of the neck with 5x5cm swelling on sternum. Serum calcium &amp; thyroid profile were normal. Baseline serum calcitonin level was decreased (78pg/ml). Sonography of neck showed heterogenous nodule 15x20cm in size, in the left lobe of the thyroid with calcification. FNAC of left nodule was suggestive of papillary carcinoma and of sternal lesion was suggestive of medullary carcinoma thyroid. Total thyroidectomy plus central compartment lymph node neck dissection with sternal mass excision with reconstruction with titanium plates and PTFE mesh was performed. Histopathological and IHC findings confirmed cytology findings. Conclusion: This case suggested that these two tumors of thyroid are usually independent and coincidental events.The cell of origin, histopathological features, prognosis and treatment of both the carcinomas are completely different. These two carcinomas are although rarely occur simultaneously.

   PP101: Collission tumors of thyroid, it takes two to tango Top

Ann Thomas, Neha Mittal, Munita Meenu Bal, D Swapnil Rane, Asawari Patil

Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Collision tumors of thyroid are extremely rare constituting < 0.5 % of thyroid tumors. They may occur synchronously within the same lobe or can occur in 2 separate lobes. Design: Clinical profiles and pathological features of Collision tumor of thyroid diagnosed between 2009 – 2019 were retrospectively analyzed. Results and Discussion: A total of 17 cases (7males, 10 females) of collision tumors of thyroid were retrieved, of mean age 41.53years. Medullary carcinoma thyroid (MTC) co-existing with papillary thyroid carcinoma (PTC) constituted 16 cases. One case was a follicular adenoma with PTC. Pre-operative FNAC was done in 5 cases and all were diagnosed as MTC. Specific lobe predilection was not seen. Two–thirds (62.5%) of MTCs affected the left lobe. Three-fourths of PTCs involved the right lobe of thyroid (76.47%). Three cases presented with micropapillary thyroid carcinoma with one multifocal micro PTC.The MTC component was found to have average size of 2.79cm and the variants included – 3 epithelioid,1 oncocytic ,1 spindle and rest were classical type MTC. While in PTC average size was 0.72cm and variants included 7 follicular variant of PTC (FVPC) ,2 hurthel cell variant,1 tall cell variant ,3 microPTC and rest were classic PTC.Ten cases showed extrathyroidal extension and lymphovascular emboli.Eleven cases showed lymph node metastasis out of which 9 were that of MTC and 2 of PTC and 1 case showed metastasis from both MTC and PTC. Conclusion: Knowledge of this rare entity is important to avoid diagnostic dilemma and for correct treatment of such tumors.

   PP102: Papillary thyroid carcinoma arising in thyroglossal duct cyst: Report of 2 cases Top

Kshama Govindrao Darunde, A S Jujgar, M P Kulkarni, N A Ramteerthakar

Government Medical College, Miraj, Maharashtra, India. E-mail: [email protected]

Background: Thyroglossal duct cyst (TGDC) is a common congenital anomaly in the development of thyroid gland. Thyroid gland descends from foramen caecum to thyroid cartilage leaving behind the thyroglossal tract which normally disappears during 5th-10th gestational weeks. Failure of involution of the tract results in a cyst, a duct or ectopic tissue which is localised in the midline of neck. Malignancy in TGDC is rare and accounts for only 1% of cases of thyroid carcinoma. Design: We report two rare cases of papillary thyroid carcinoma diagnosed postoperatively in TGDC. Result and Discussion: Two cases, 35yrs female and 75yrs male, presented with mass in midline of neck. Clinically and sonologically the masses were diagnosed as thyroglossal duct cysts and the thyroid gland was unremarkable. We received excision specimens measuring 3.5x3x2cm and 5x3.5x2cm respectively. Cut surface of both showed cyst with papillary excrescences. Microscopy of both the cases revealed similar histomorphological features. Sections showed a fibrocollagenous cyst wall lined by cuboidal cells along with a tumour composed of complex branching papillae with central fibrovascular cores. Papillae were lined by cuboidal cells having enlarged optically clear nuclei showing crowding, overlapping and occasional nuclear grooves. Few psammoma bodies were seen. The cyst wall contained few thyroid follicles and was free of tumour invasion. Conclusion: Papillary carcinoma in TGDC is rare and should be considered in the differential diagnosis of cystic midline neck masses. Sistrunk procedure is the gold standard for management.

   PP104: BRAFV600E mutation in papillary thyroid carcinoma with clinical correlation in north Indian population Top

Sohini Banerjee, Uma Nahar Saikia, Divya Dahiya, Sanjay K Bhadada, B D Radotra

PGIMER, Chandigarh, India. E-mail: [email protected]

Background: Papillary thyroid carcinoma (PTC) is the most common subtype of thyroid carcinoma with increasing incidence. It may present as lymph node (LN) metastasis with 10% distant metastasis to lung and bone. The most common genetic aberration is BRAF V600E mutation which is T1799A transversion by substituting valine to glutamic acid in codon 600 (V600E), further activation of mitogen-activated protein kinase (MAPK) pathway. Our aim was to identify BRAF V600E mutation in PTC and its clinical correlation to form a clinical strategy in thyroid cancer for a target therapy and reducing morbidity. Design: Total 23 samples of PTC were included including FFPE tissue blocks (n=10) and fresh (n=13) of tumour size is ≥ 1cm. Genomic DNA was isolated from both fresh and FFPE tissues. The BRAF gene was amplified by conventional Polymerase Chain Reaction (PCR) and Sanger sequencing for BRAF V600E mutation was done after for identification of mutation. Results and Discussion: There were 12 out of total 23 (52.2%) patients showed BRAFV600E mutation, of which 7 (58.3%) had associated LT and 4 (33.3%) had LN metastasis. The recurrence rate was 16.7% (2 out of 12) within 3 years of surgery. Conclusion: BRAFV600E is significantly correlated with aggressive clinicopathological characteristics of PTC including larger tumour size and LN metastasis. It may be used for assessing aggressive behaviour of PTC variants before surgical intervention to avoid morbidity in these patients and improve quality of life. Additionally we observed associated LT with PTC as an independent predictor for aggressive clinical behaviour.

   PP105: Clinico-pathological spectrum of patients presenting with adrenal mass: A single institution experience over 8 years duration Top

Amrita Talwar, Purnima Bharati, Arvind Ahuja, Purnima Malhotra, A K Sen, Minakshi Bhardwaj, D.S Chauhan

ABVIMS and Dr RML Hospital, New Delhi, India. E-mail: [email protected]

Background: Diagnosis and management of adrenal tumours has undergone a significant change with the advances in biochemical evaluation and diagnostic imaging techniques. However, histopathology remains the gold standard for the definitive diagnosis and prognosis. Histomorphology supplemented by immunohistochemistry plays a major role in diagnosis of many tumours. The aim of this study was to evaluate morphological spectrum of adrenal masses and correlation with clinical and radiological findings. Design: A retrospective study conducted at a tertiary care hospital over a period of 8 years. A total of 49 patients presented with adrenal mass or were diagnosed on imaging. Clinical data of these patients were collected, H&E and immunohistochemistry slides were screened. Various parameters such as gender, age, size of tumour, functional status, histopathology and immunohistochemistry were reviewed. Results and Discussion: A total of 49 cases of adrenal mass presented to our hospital over 8 year duration (2012-2019). Females composed 77.5% of the population. Mean age was 36.2 years (range 8 months to 58 years). Mean tumor size was 8.0 cm. Adrenal carcinoma accounted for 14% of all cases,28.5% cases were of adrenal myelolipoma,24.4% cases were pheochromocytoma, 8.1% cases of adrenocortical adenoma and adrenal hyperplasia each. There was one case each of adrenal oncocytic neoplasm, adrenal oncocytic neoplasm of undetermined malignant potential, gastrointestinal tumour(GIST), leiomyosarcoma, pseudocyst and neuroblastoma. Conclusion: Myelolipoma (cortical) and pheochromocytoma (medullary) were the most common lesions diagnosed. Immunohistochemistry plays a significant role in substantial number of cases.

   PP106: Mixed anaplastic-insular carcinoma of thyroid arising in a background of follicular carcinoma: A case report Top

S Neha, Debajyoti Chatterjee, Bishan Dass Radotra, Jaimanti Bakshi

PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: Both anaplastic carcinoma and insular carcinoma of thyroid are aggressive thyroid malignancies. While anaplastic thyroid carcinoma follows an extremely aggressive course, insular carcinoma has an aggressive behavior intermediate between anaplastic and well differentiated carcinomas. Both these malignancies are morphologically, immunophenotypically and genetically distinct from each other. Here we present a rare case of combined anaplastic and insular thyroid carcinomas arising in the same patient in a background of follicular carcinoma. Case Description: 68y/F presented with pathological fracture of right femur and neck mass. FNA done showed follicular neoplasm following which total thyroidectomy was done. Sections from the specimen showed a well encapsulated tumour arranged in insular (45-55%), sarcomatous (35-45%) and microfollicular (10-15%) patterns. The anaplastic carcinoma component showed sarcomatous component with cells arranged in fascicles, with cells showing significant nuclear pleomorphism and frequent mitoses. The anaplastic carcinoma cells expressed vimentin and p53 while being negative for Thyroglobulin, TTF1, Bcl-2 and pan CK. The anaplastic carcinoma was intimately admixed with insular carcinoma component. The insular component was positive for Thyroglobulin, TTF1, Bcl-2 and pan CK and negative for vimentin and p53. Conclusion: Among the mixed thyroid carcinomas, the combination of mixed anaplastic and insular carcinoma is the rarest. Both anaplastic and insular thyroid carcinomas have distinct morphological, immunophenotypic and genetic features. This case report highlights a rare case of mixed Anaplastic-Insular carcinoma. Immunohistochemistry may be useful to differentiate these two components in cases showing morphological overlap.

   PP107: GATA3 expression in solid cell nest of thyroid: A new marker to solve the diagnostic conundrum Top

N R Shruthi, Pavithra Ayyanar, Suvradeep Mitra, Suvendu Purkait

Department of Pathology, AIIMS Bhubaneswar, Odisha, India. E-mail: [email protected]

Background: Solid cell nest (SCN) of thyroid is an ultimobranchial remnant that histologically mimics many preneoplastic and neoplastic entities like papillary microcarcinoma, C-cell hyperplasia, microscopic focus of medullary carcinoma, and micrometastasis to the thyroid. This non-neoplastic lesion can be associated with similar preneoplastic and neoplastic conditions that it mimics. Hence, it should be confidently distinguished from its mimickers. Aim: To identify a panel of immunomarker that can distinguish SCN from its mimickers. Materials and Methods: We have identified seven cases of SCN and applied a battery of immunohistochemical markers comprising of p63, Bcl2, calcitonin, synaptophysin, thyroglobulin, TTF1, and GATA3. Results: Four cases were morphologically classified as type 1 SCN (solid), and three cases were classified as type 3 SCN (solid-cystic). Morphologically, type 1 SCN comprised of solid nests of “main” cells that were relatively monomorphic with elongated nuclei, occasional nuclear grooving and bland chromatin. All cases showed strong nuclear p63, and cytoplasmic Bcl2 positivity. Calcitonin, synaptophysin and thyroglobulin were negative. TTF1 showed focal moderate intensity nuclear positivity in two cases. All these cases showed moderate intensity nuclear GATA3 positivity. Conclusion: GATA3 can be consistently positive (nuclear) in the SCN of thyroid aiding in its distinction from other preneoplastic and neoplastic conditions. It can provide valuable information related to the embryological origin and molecular morphology of SCN.

   PP108: A tertiary care experience on adrenal lesions: Unusual presentation and diagnostic challenged faced Top

Shalini Rawat

King George's Medical University, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Adrenal lesions are rare with prevalence range from 1.4% to 2.9% worldwide. There are very few studies from India with a documented incidence of 0.6-9.76 per 10,000 cases. We plan to share our experience on adrenal tumors along with discussion on certain atypical presentations and various diagnostic challenges faced. Methods: A retrospective study, including adrenalectomy specimens received between January 2016 to September 2019 in department of pathology KGMU. The demographic, clinical, radiological, biochemical and follow up details were collected from the records. Reporting of Adrenocortical carcinoma and pheochromocytomas were done as per The modified Weiss criteria) and PASS score (Pheochromocytoma of the Adrenal gland Scaled Score) respectively. Results: Of the 9814 surgical specimens received during this span of 4 years, a total of 44 specimens of adrenal tumors hence has an incidence of 44 per 10,000 cases. The age ranged from 1.5 yrs – 58 years (mean 38 yrs ) with female predominance (M:F=2:3). 10% of these patients were <10 years. Among the neoplastic etiologies the most common lesion reported was pheochromocytomas (14) followed by myelolipoma (8) and adrenocortical carcinoma (6). Other lesser common entities diagnosed included adrenocortical adenoma(2), paraganglioma(2), neurobalastoma(2), mature teratoma(1), metastatic adenocarcinoma(1) and primitive neuroendocrine tumor(1). Benign lesions like bilateral adrenal histoplasmosis, pseudocyst and endothelail cyst were also diagnosed (1 case each). Four cases had unusual presentation and will be discussed later. Conclusion: In our institute the incidence of adrenal lesions was much higher with a wide variety of neoplastic and non-neoplastic lesions.

   PP109: Anaplastic carcinoma of thyrpoid: Is there scenario and incidence changing? Top

Vaibhav Gupta

King George Medical University, Lucknow, Uttar Pradesh, India. E-mail: [email protected]


  • Anaplastic carcinoma of thyroid(Undifferentiated tumor) inspite of being constituting <2% of all thyroid neoplasm, is the major cause of mortality;15-40%.
  • More common in older age females >60 years of age.
  • Patients usually present with short history of symptoms
  • Inspite of being availability of all the therapeutic options, average survival rate was around 6 months.
  • We plan to share our institutional experience on Anaplastic carcinoma of thyroid (ATC).

Materials and Methods:

  • A retrospective study including all the case of ATC diagnosed over histopathological and cytopathological examination between June 2016- October 2019.
  • The demographic, clinical, radiological and outcome profile details obtained from hospital information system.


  • 178 thyroid malignancies were diagnosed during these years in which most common was papillary thyroid neoplasm (39%), which was followed by ATC(33%) and follicular carcinoma
  • Female: Male = 2:1
  • Mean age of presentation: 51years
  • Patients presents with <45yrs of age: 30%
  • Follow up details shown that only 7 patients are alive only


  • Very high incidence rate were noted that cover up approx 1/3rd of all thyroid neoplasm in our demographic region
  • Around 30% cases had been reported before the age of 45 years with a mortality rate found to be 88-90% in our study.
  • Mean survival rate was found to be approximately 4 months after the time of diagnosis
  • ATC possess a major challenge in our zone with a very high mortality rate and short survival time, so it's a urgent requirement to investigate for a better therapeutic, prognostic biomarkers panel and multimodality therapy.

   PP110: Study of bethesda category III and IV thyroid nodules Top

Saumya Brij

Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India. E-mail: [email protected]

Aim: To study the outcome of Bethesda category III and IV thyroid fine needle aspirates on histopathology. Introduction: The Bethesda system for reporting thyroid aspirates categorizes thyroid nodules into six categories based on cytological features. Category III and IV lesions are heterogenous group including both non neoplastic and neoplastic lesions. Risk of malignancy in these categories are highly variable. Correlation of these two categories with surgical specimen report helps to analyse possible pitfalls in cytology diagnosis of thyroid lesions. Methodology: Eighteen cases of thyroid nodules reported as category III/IV was evaluated out of 2120 cases of thyroid aspirates. Relevant data were collected. Only Category III and IV lesions followed by surgical excision with histopathology report were included in the study. Cytology and histopathology diagnosis of these cases were analysed. Results: Total of 18 thyroid nodules were studied with 4 category III and 14 category IV lesions. Half of category III lesion were reported as nodular goitre and half were reported as follicular adenoma on histopathology. In category IV lesions 42.8% were reported as hyperplastic nodule and 57.2% were reported as thyroid neoplasm on histopathology. Majority of these lesions were malignant, accounting for 50% of category IV lesions. Conclusion: Bethesda Category IV lesions had high malignancy rate. Non neoplastic and neoplastic thyroid nodules were in equal proportion in Bethesda category III lesions. These cases should be followed according to Bethesda guidelines with repeat FNA or lobectomy as significant number of cases are neoplastic in category III and IV thyroid lesions.

   PP111: Medullary thyroid carcinoma and follicular adenoma in an adult female: A rare collision tumor Top

Nisha Duggal, Uma Nahar Sakia, Bishan Das Radotra, Mayur Parkhi

Department of Pathology, PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: Thyroid malignancies are known to be the most common endocrine malignancies. The presence of two distinct primary thyroid neoplasm in the same patient (i.e., collision tumor) is very uncommon especially a combination of medullary thyroid carcinoma (MTC) and follicular adenoma. More commonly MTC occurs in association with papillary thyroid carcinoma (PTC). Case: We report a 46-year-old woman with a palpable swelling on the right side of neck. The CECT revealed heterogeneously enhancing lesion in the right lobe of thyroid. Fine needle aspiration (FNA) suggested the diagnosis of medullary carcinoma of thyroid with raised serum calcitonin levels. Total thyroidectomy was performed with large circumscribed lesion in the right lobe along with sub-centimetric whitish lesion in the left lobe grossly. Histomorphologically confirmed medullary thyroid carcinoma of right lobe and follicular adenoma of left lobe. Immunohistochemistry (IHC) showed MTC positive for calcitonin and negative for thyroglobulin. Conclusion: Collison tumor is extremely rare in thyroid gland. The commonest being papillary carcinomas – medullary carcinomas collision tumor. The FNA has limited role in diagnosis of such tumor. The histopathologist needs to be aware of co-existing two tumors. The final diagnosis is offered considering the serum calcitonin and thyroglobulin levels along with IHC for MTC and follicular adenoma. A precise diagnosis is necessary in such patients as total thyroidectomy is advised.

   PP112: Pleomorphic adenoma of the tongue: A common entity at the uncommon location Top

Promil Jain, Meenu Gill, Sonia Chhabra, Namita Bhutani, Rajeev Sen

Department of Pathology, Pt BD Sharma PGIMS, Rohtak, Haryana, India. E-mail: [email protected]

Background: The salivary gland tumors comprise of 3% of head and neck tumors. Pleomorphic adenoma, also known as mixed tumor, is the most common benign neoplasm of the major and minor salivary glands. Prime site of involvement is the parotid gland, and the minor salivary glands are the least involved. The occurrence of pleomorphic adenoma of the tongue is very rare, accounting for 0-2.5% of the cases, and very few cases have been reported in the literature. Design: A 41-year old male presented with swelling on tongue. Fine needle aspiration cytology of the mass was done which revealed round to oval benign epithelial cells embedded in dense eosinophilic chondromyxoid material. Histopathological examination of the specimen revealed a well encapsulated tumor composed of islands and trabeculae of epithelial cells in chondromyxoid stroma. Cytological and histological findings favoured the diagnosis of pleomorphic adenoma. Complete excision of the mass was done transorally under general anaesthesia. Result and Discussion: Tumors of the salivary glands are of intricate origin consisting of epithelial and connective tissues. The origin of the pleomorphic adenoma is myoepithelial cells and intercalated duct cells. Although these tumors are well encapsulated, resection of the tumor with an adequate margin is essential to avoid recurrence. High index of suspicion and an adequate clearance of the tumor with a cuff of surrounding dispensable normal tissues is the key to successful treatment of such tumors. Conclusion: The authors consider the rarity of this case and present a rare case of pleomorphic adenoma of the tongue.

   PP113: Primary extra-gastrointestinal tumour: A rare entity Top

Deepika Sahu

MKCG Medical College, Berhampur, Odisha, India. E-mail: [email protected]

Background: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal tract. GIST rarely occurs outside the gastrointestinal tract ( omentum ,mesentery and retroperitoneum) so called as Extra-gastrointestinal tumours (EGISTs) . EGISTs arising in the retroperitoneum are extremely rare till date , only 58 cases have been reported in the literature. Case Report: We herein report a CASE -1 of : - 60 yr male presented with abdominal pain since 3 months and pain was gradually increases in intensity with provisional diagnosis of GIST / Small bowel lymphoma. On pre-operative radiological evalution ( CECT ) shows a ill-defined , exophytic mesenteric mass measuring 11× 9.3×10.9 cm ( AP×TRANS×CC). Case-2: - 65yr female presented with loss of appetite since 3months on gross a globular mass with attached omentum. Conclusion: As a result of rare report of primary extra-gastrointestinal stromal tumour ,we need to analyze the data of reported cases in order to get a better understanding about the pathogenesis , prognosis and optimal treatment of the disease at a single centre .

   PP114: Purple splash in the abdomen Top

K Gayathri, B Archana, S Rajendiran1, J C Bose2

Sri Ramachandra institute of Higher Education and Research Institute, Departments of1Pathology and2Surgical Oncology, Sri Ramachandra institute of Higher Education and Research Institute, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Pseudomyxoma peritonei (PMP) is a clinically distinctive term characterized by relentless accumulation of mucinous tumor deposits in the peritoneal cavity. It typically arises from the appendix. Mucinous appendiceal tumors have a potential to spread to the peritoneum and viscera in the form of gelatinous material with or without neoplastic cells resulting in PMP. PMP have persisted from decades. Recently, a unified nomenclature has been proposed to follow a uniform terminology for clinical relevance to institute an optimal treatment. Design and Results: Ours is a retrospective analysis of 10 cases of Appendiceal mucinous neoplasm with or without PMP over a period of 3 years from 2016-2019. The mean age being 53.8 years, ranging from 42-70 years with M:F sex ratio of 1:1. Most patients presented with symptoms of abdominal pain and distension. 9/10 (90%) cases were low grade appendiceal mucinous neoplasm and 1/10 (10%) showing high grade appendiceal mucinous neoplasm. We received peritoneal biopsy for 5/10 (50%) cases of which 4/5(90%) cases showed low grade mucinous carcinoma peritonei, 1/5(10%) showed only mucinosis. Conclusion: Neoplasms of the appendix associated PMP are rare, because of their unusual presentation and unpredictable biologic behavior hence it is important to diagnose them correctly. Proper histopathologic classification and predicting the tumor behavior requires a close interaction between the pathologist, the surgeon and the oncologist, The use of combined modality treatment of cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy (HIPEC) has increased the 5 year survival rate.

   PP115: Metastatic micropapillary carcinoma presenting as an obstructive colonic mass: A diagnostic conundrum Top

Koushiki Bhattacharjee

KMC, Manipal, Karnataka, India. E-mail: [email protected]

Background: Invasive micro papillary carcinoma (IMPC) are aggressive, rare histological adenocarcinoma variants in – breast, lungs, urinary bladder, ovaries, salivary gland and colon. This unusual case presented as a colonic mass with clinical impression being advanced stage colonic carcinoma. Design: Single Case Study: 70/F presented with abdominal distension, pain, vomiting for 3 weeks. P/A : palpable mass in right iliac fossa. CT abdomen : well-defined minimally enhancing mass in hepatic flexure + proximal third of transverse colon causing luminal narrowing. B/L ovaries + uterus were atrophic. CA125 - 582.2U/ml; CEA, CA19-9 and AFP were normal. Results: Gross: Large abluminal growth in colon (6.5x6cms) extending into mesocolon, together measuring 17x9.5cms. C/S - grey white infiltrating growth with yellow areas. Microscopy: Widely invasive tumor (pT4,N2b,M1) with micropapillary nests of tumor cells having high N:C ratio, hyperchromatic nucleus, arranged in “inside out” pattern, surrounded by empty space. Brisk mitosis and florid LVI noted. IHC: CK7, EMA , ER, WT1, CK19 positive. CK20, CDX2, TTF1, Mammaglobin negative. Diagnosis: Metastatic Micropapillary Carcinoma of ovarian/peritoneal primary. Patient was receiving adjuvant chemotherapy on last F/U since she had residual tumor in peritoneum and lung metastasis. Conclusion: IMPCs are rare, aggressive tumors and can present with advanced stage, as observed here, where it was mistaken for a colonic primary. However the abluminal nature, with major bulk of tumor lying in the mesocolon, pointed to it's metastatic nature. IHC, radiological findings and serum markers proved useful in solving this bewildering puzzler.

   PP117: A study to correlate histological disease activity score with endoscopic, clinical and serological parameters in patients with ulcerative colitis Top

Vaneet Kaur Sandhu, Rama Kumari Badyal, Sarita, Ravinder Garg1

Departments of Pathology and1Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India. E-mail: [email protected]

Background: Ulcerative colitis is chronic inflammatory disease characterized by mucosal inflammation in the colon and rectum. The aim of the present study was to assess histological disease activity in patients with UC using the Geboes Grading System and to investigate relationship between histological activity and endoscopic, clinical and serologic parameters. Design: This was a four year study from 2014 to 2018 comprising of 154 biopsy from 100 endoscopies in 82 patients.The clinical and endoscopic disease activities were determined using Mayo score. Each patients WBC count, Hematocrit,ESR and CRP were recorded . The biopsies were fixed in formalin and sections were stained with H& E and were graded using the Geboes Grading System by two blinded pathologists.The Geboes Score ranges from 0- 5.4. Results: The histological activity index was closely correlated with the endoscopic AI (r=0.774,p<0.001),clinical AI (r=0.403,p <0.001) and CRP levels (r=0.422, p<0.001). The histological disease activity score was divided in accordance with Geboes score as inactive (<3.1) and active (≥3.1). The endoscopic AI,clinical AI and CRP levels were significantly higher in patients with active histological disease.Histologically active inflammation was seen in 6% of the endoscopically normal mucosa . 66% biopsies exhibited endoscopically mild disease in comparison to active disease on histology. Conclusion: The histological activity exhibited strong correlation with endoscopic activity and moderate correlation with clinical and serological parameters.In our study several patients with mild or normal endoscopic findings exhibited active histological inflammation. Therefore Histological assessment is considered gold standard in patients with UC regardless of their endoscopic activity.

   PP119: Endoscopic correlation with histopathological findings in upper gastrointestinal biopsies Top

Shaheena Perween

Ramakrishna Mission Seva Pratishthan, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Upper gastrointestinal tract is a common site for wide variety of lesions accessible by endoscope. Design: Cross-sectional study has been carried out in 122 cases. Results: Stomach has been the most common 57%(70/122) biopsied site,followed by duodenum 26.2% and oesophagus 16.39%. In oesophagus-Most cases 60%(12/20) diagnosed as Moderately Differentiated Squamous Cell Carcinoma detected as ulceroproliferative growth situated 25 to 32 cm from incisor endoscopically.Few 10%(2/20) diagnosed as Poorly Differentiated Adenocarcinoma seen as growth at 35 cm from incisor.20%(4/20) female diagnosed as Barrett's oesophagitis without atypia appeared as ulcer and inflamed mucosa.Few were diagnosed as acute on chronic oesophagitis 5%(1/20) and chronic esophagitis(5%) seen as endoscopically ulcers at 30 and 32 cm respectively. In stomach-64.28%(45/70) gastric biopsies were non neoplastic of which Hyperplastic Mucous Polyp were most common 51.1%(23/45) findings diagnosed most commonly as antral polyp endoscopically. 35.71%(25/70) were malignant,more common in male patients in which 40%(10/25) diagnosed as Moderately Differentiated Adenocarcinoma ,detected as ulceroproliferative growth occuring in body,antrum and pylorus.Most of the female pateints 28%(7/25) diagnosed as Signet Ring Cell Adenocarcinoma seen as ulceroproliferative annular lesions occuring in the antrum and occupying whole of the pylorus.Few patients 8%(2/25) diagnosed as Poorly Differentiated Adenocarcinoma detected as prepyloric ulcer. In duodenum-Most 96.87%(31/32) diagnosed as non neoplastic lesions of which most diagnosed as PVA.3.12%(1/32) diagnosed as Moderately Differentiated Adenocarcinoma. Our study showed,2.45% endoscpically malignant that turned to be non neoplastic.Rest parts of study showed a good correlation between endoscopic and histopathological findings. Conclusion: Histopathology is the gold standard for the diagnosis of endoscopically detected lesions.

   PP120: A case of primary hepatolithiasis in young male masquerading as cholangiocarcinoma Top

Kunal Bagul, Madhukar Kumar, Vanmalini Tewari1, Pragya Sharma, Raka Maitra1, K R Rathi

Military Hospital, Ahmednagar, Maharashtra,1CHAF, Bengaluru, Karnataka, India. E-mail: [email protected]

Here we report an incidental case of hepatolithiasis in a left lobe hepatectomy specimen from a young man who presented with insidious abdominal pain. The condition was mimicking as space occupying lesion of the liver and computed tomography scan was suggestive of cholangiocarcinoma. Histopathological analysis confirmed this to be hepatolithiasis. Primary hepatolithiasis presents to be a diagnostic challenge to clinicians, radiologists as well as pathologists because of its uncommonness. Therefore it must be included as a differential diagnosis in cases with nonspecific pain and radiological space occupying lesion of liver. This case highlights that hepatolithiasis can present with varied clinical features. A high index of suspicion is required for its diagnosis.

   PP121: Neuromuscular and vascular hamartoma: Is it a vasculopathic phenomenon? Top

Pavithra Ayyanar, Suvradeep Mitra, Suvendu Purkait, Susama Patra, Tushar Subhadarshan Mishra

AIIMS, Bhubaneswar, Odisha, India. E-mail: [email protected]

Background: Neuromuscular and vascular hamartoma (NMVH) is an unusual lesion presenting as intestinal obstruction by stricture formation. It is characterized by a hamartomatous mass comprising of haphazardly arranged mesenchymal tissue native to the intestinal mucosa and submucosa. Design: We tend to characterize the clinico-histopathological spectrum of NMVH in adult subjects with a search for an etiological clue. We reviewed 84 resected specimens (adult cases) of intestinal obstruction in our institute and diagnosed four cases with NMVH. A panel of special stains (Masson trichrome, Verhoeff-van-Gieson, and periodic acid Schiff) and immunohistochemistry (SMA, S100p, Bcl2, CD34, Vimentin, Desmin, CD117, and CD3) were performed in all cases. Results and Discussion: All cases of NMVH showed characteristic hamartomatous mounds comprising of haphazardly arranged smooth muscle, nerves, ganglia, vessels, and collagen with overlying mucosal ulceration. Adjacent bowel showed submucosal fibrosis, muscularis mucosae thickening, and duplication along with vasculopathy. A typical vasculopathy (“vessel-in-vessel” appearance) was seen in the submucosal and/ or subserosal veins. In addition, different other forms of vasculopathic changes like obliterative venopathy, concentric myohypertrophy were also seen. One case had vasculitis and the patient died despite a successful surgery. One other case was associated with lymphocytic ganglioneuronitis and granulomatous etiology. Conclusion: We conclude that NMVH can be multifactorial in origin although ischemia resulting from vasculopathy appears to be directly causative. The characteristic vasculopathy in the submucosal location may aid in the diagnosis of NMVH in small biopsy samples.

   PP122: Inflammatory fibroid polyp of the gastric antrum Top

Pranali Kisandas Shende, Renuka Gahine, Rabia Parveen Siddiqui, Shashikala Kosam, Mohd. Jafar Memon

PT. Jawahar Lal Nehru Memorial Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Inflammatory fibroid polyps (IFP) are an extremely rare entity that arise within the gastrointestinal tract and represent <0.1% of all gastric polyps. These lesions most commonly affect older adults, especially those localizing to the gastric antrum. In children, IFPs more commonly occur in the small intestines and present as intussusception. IFPs arise from the submucosa and penetrate through the lamina propria leading to bulging of the mucosal layer. Rarely, they can ulcerate through the mucosa causing hemorrhage and symptoms related to hypovolemic shock. Herein, we discuss a case of an adult woman who initially presented with a recent history of pain in abdomen who was evaluated by CECT Abdomen, biopsy and immunohistochemical analysis. Case Report: A 25 year old female patient presented with complaint of pain in abdomen since 6months. CECT Abdomenrevealed large polypoidal mass in the lumen of stomach measuring 10.2x7.2cm & is isodense showing areas of necrosis likely representing Gastrointestinal Stromal Tumour. Biopsy Reportshowed mixed proliferation of loosely arranged benign spindle cells, blood vessels & mixed inflammatory cells. A hypocellular zone is present around the blood vessels with presence of edematous areas. Mitotic figures not seen. Overlying mucosa shows mixed inflammatory cell infiltration in lamina propria. Features are suggestive of Inflammatory fibroid polyp. Conclusion: Inflammatory fibroid polyp (IFP) remains one of the rarest benign tumors of the gastrointestinal tract.It is now widely viewed as PDGFRA driven benign neoplasm.Diagnosis is made primarily with endoscopic biopsy, however additional studies including immunohistochemistry analysis may be required.

   PP123: Gastric schwannoma-A mimic of gastro intestinal stromal tumour Top

Deep Kumar Raman, Samir Agarwal, Maj Nidhin Rehman

Command Hospital Central Command, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Gastric schwannoma (GS) is a rare mostly benign, slow-growing mesenchymal neoplasm accounting for 0.2% of all gastric tumours. Due to its rarity GS is not widely recognized by clinicians with most being misdiagnosed as gastrointestinal stromal tumours (GIST). Case Description: We report the case of a 42 year old male who presented with chronic epigastric pain. Investigations revealed a heterogeneously enhancing, hypodense sub-mucosal tumour in the posterior wall of the antrum measuring 13.4x18.3x10.6mm. An EUS guided FNAC was reported as benign spindle tumour. The patient underwent resection with a preoperative diagnosis of GIST. Gross examination revealed an unencapsulated whitish homogenous tumour. Microscopically the tumour was composed of spindle cells in whorled patterns with vague palisades and peritumoral cuff of lymphocytic tissue. No proper Verrocay bodies were identified. Immunohistochemical (IHC) staining showed that the spindle cells were positive for S-100 and negative for CD34, CD117, desmin, DOG1 and SMA. A final diagnosis of Gastric Schwannoma was made. Conclusion: Among gastric sub-mucosal tumours, GISTs form the overwhelming majority comprising upto 3% of all gastric neoplasms. However, Gastric leiomyoma and GS need to be considered in the DDs. GS are rare spindle cell tumours that have palisaded spindles cells, with or without Antoni A and B areas and a characteristic lymphoid cuff. They typically lack the Verrocay bodies seen in peripheral schwannomas. IHC will clinch the diagnosis with GS being positive for S100 and negative for CD34, CD117, desmin, DOG1 and SMA.

   PP124: An extramural gastric gastrointestinal stromal tumour (epithelioid variant) masquerading as pancreatic head mass: An uncommon presentation Top

Vaishali Ghungarwar, Sangeeta Kini, Mayura Kekan, Rima Kamat, Vikas Kavishwar

Topiwala National Medical College, B.Y.L. Nair Ch. Hospital, Mumbai, Maharastra, India. E-mail: [email protected]

Objective: Gastrointestinal stromal tumours (GIST) which form less than 3% of primary tumours of stomach are the commonest mesenchymal tumours of gastrointestinal tract and favoured sites of occurrence being stomach and small intestine. An extraluminal presentation of GIST, with its preoperative investigations and variable histomorphology can often cause a diagnostic dilemma mimicking primary tumour of origin from adjacent organs. Case Report: A 23 year old male presented with pain in abdomen associated with intermittent vomiting since one and half years. Radiological investigations done a year ago revealed heterogeneous mass arising from head of pancreas with indentation of posterior wall of stomach. Endoscopic ultrasound guided FNA and USG guided biopsy were suggestive of differential diagnosis of neuroendocrine tumour and solid pseudopapillary neoplasm of pancreas. In view of inoperability of the mass, patient was given 12 cycles of chemotherapy. A follow up CECT scan after one year revealed an exophytic large heterogeneous mass arising from lesser curvature of stomach and pancreas was normal. The histomorphology of the excised mass showed features of low grade epithelioid GIST which was confirmed on immunohistochemistry with strong c-Kit positivity. Patient is doing well with imatinib therapy. Conclusion: This case highlights a rare presentation of gastric GIST epithelioid variant with exclusively extramural growth mimicking a pancreatic head mass preoperatively.

   PP125: Lipid rich variant carcinoid of the appendix: A case report Top

Riddhi Parmar, Dhruvi Shah, D N Lanjewar

Department of Pathology, Gujarat Adani Institute of Medical Sciences, Bhuj, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Carcinoid is the most frequent tumour arising from the appendix and is usually discovered after appendectomy. Lipid rich variant or clear cell carcinoid is a rare morphologic variant of carcinoid. Only 17 cases of lipid rich variant of carcinoid of the appendix has been described in the literature, and no report is described in indian literature. In this paper we describe the first case of lipid rich carcinoid in appendix. Case Description: Female 27 years, presented with fever, vomiting and pain in right iliac fossa for which appendectomy was performed. Appendix near the distal tip showed a single, yellowish, well circumscribed tumour of 0.3 cm size. Microscopic examination of it showed proliferation of small, uniform cells arranged in solid nests with peripheral palisading. The nuclei of tumour cells were round, had finely granular chromatin and inconspicuous nucleoli and did not show nuclear atypia. The cytoplasm of all most all tumour cells showed numerous small, round clear vacuoles, having distinct boundaries. Immunohistochemistry showed positivity for chromogranin A and synaptophysin, Ki67 proliferation index was 1%. With above morphologic features a diagnosis of lipid rich carcinoid of appendix was made. Conclusions: Lipid rich carcinoid is morphologic variant with IHC profile and clinical behaviour similar to those of classic carcinoid tumour of appendix. Other than appendix, lipid rich carcinoid have been reported in stomach, gall bladder, bile ducts and pancreas. Lipid rich carcinoid should be differentiated from goblet-cell carcinoid or metastatic renal-cell carcinoma.

   PP126: Diagnostic utility of segmental duodenal biopsies in celiac disease Top

Ajit Sood, Akriti Jindal1, Vikram Narang1, Neena Sood1

Departments of Gastroenterology and1Pathology, DMCH, Ludhiana, Punjab, India. E-mail: [email protected]

Background: Celiac disease is an immunologically determined enteropathy affecting small intestine in genetically predisposed individuals. It is a patchy disease and there are no uniform guidelines for the number of biopsies required for diagnosis. Earlier, biopsies from the second part of the duodenum are sufficient for diagnosis without loss of sensitivity or specificity. However,nowadays duodenal bulb is also the most sensitive site to detect mucosal injury and isolated mucosal abnormalities at this site can be seen in up to 10% of cases. Design: This study was conducted for 1.5 years in Pathology Department, DMCH. 84 cases of suspected celiac disease were analysed with respect to the light microscopy (D1, D2 and D3 biopsy) and serology (anti tTG). Results: A total of 84 cases with increased anti tTG levels were included in this study and their segmental biopsies from D1, D2 and D3 were taken. A female predominance was seen with M:F ratio of 1:1.7. 14 cases out of 84 were showing normal histology, 26 cases with Type 1 histology, 3 cases with Type 2 histology and 41 cases with Type 3 histology. If only D2 biopsy was evaluated, the number of cases showing histology of celiac disease were 39 (46.4%). Diagnostic yield increased from 39 cases (46.4%) to 43 cases (51%) and 44 cases (52.4%) when D1+D2 and D1+D2+D3 biopsies were evaluated respectively. Conclusion: It is suggested that biopsies should be taken either from all the parts of duodenum or atleast from duodenal bulb and D2 to increase the diagnosis rate.

   PP127: Clinicopathological spectrum of intestinal tuberculosis Top

Reetu Kundu, Rajpal Singh Punia1, Robin Kaushik2, Purnima Aggarwal3, Jagdish Chander4

Department of Cytology and Gynecological Pathology, PGIMER, Departments of1Pathology, 2General Surgery,3Radiodiagnosis and4Microbiology, Government Medical College and Hospital, Chandigarh, India. E-mail: [email protected]

Background: Abdominal tuberculosis has an extremely variable presentation, often mimicking other diseases. Variable presentation and non-specific radiology make tissue diagnosis essential to confirm or exclude tuberculosis. Design: A retrospective analysis of 100 cases diagnosed as intestinal tuberculosis over a period of 5 years based on histopathology of resected specimens was done in Government Medical College and Hospital, Chandigarh. Clinico-radiological and histopathological findings were noted. Results and Discussion: There were 59 males and 41 females. The mean age was 30.97 years. The commonest presenting symptom was abdominal pain (98). Clinical diagnosis in majority was intestinal obstruction. Radiological findings were available in 38 cases and suggested intestinal tuberculosis (36) and carcinoma colon (02). On gross examination, ileum (82) was most commonly affected. The usual pattern of involvement was solitary, but multiple sites of involvement were seen in 16 cases. Lymphnode enlargement was seen in 52 cases. On microscopy, superficial ulcers (42) and perforation with exudates (29) were seen. Epithelioid cell granulomas (87), transmural granulomas (29), caseation (76), Langhan's giant cells (79), foreign body giant cells (18) were noted. Acid fast bacilli (AFB) was demonstrated on Zeihl Neelsen staining in the resected segment of intestine (07) and lymphnodes (16). Conclusion: A high index of clinical suspicion coupled with endoscopic and radiologic findings may be helpful in arriving at a correct diagnosis in tuberculosis of the intestine. Sectioning of lesional area during grossing and diligent search for granulomas on microscopy is essential. Demonstration of AFB is confirmatory. Histopathology remains the 'gold standard' for diagnosis.

   PP128: Goblet cell adenocarcinoma of the appendix: Case-series of a rare, unique and often-missed diagnosis, redefined by WHO Top

Sagar Ranjan Tripathy, Rajiv Kumar, Mukta Ramadwar, Kedar Deodhar, Munita Bal

Department of Pathology, Tata Memorial Hospital, Mumbai, Maharastra, India. E-mail: [email protected]

Background: Goblet cell adenocarcinomas (GCA) are unique neoplasms accounting for <5% of appendiceal malignancies. In the new WHO 2019, nomenclature has been revised from 'Goblet-cell carcinoid (GCC)' to 'Goblet-cell adenocarcinoma' and a new grading is provided. Design: Pathology material of all GCC, carcinoma ex-GCC and GCA at our tertiary-care oncology centre (2010-2019) was retrieved and diagnosis confirmed (WHO 2019). Clinical and histopathological features including grading (WHO 2019) were recorded. Results and Discussion: Study included 9 cases. Median age was 51years (range 24-65 years) with a male-to-female ratio of 2:1. All cases were appendicular in origin. 1 patient with Pouch-of-Douglas metastasis presented as a rectal mass. 3 patients presented with distant metastasis. Median tumor size was 2.5cm. Low-grade pattern comprising of tubules with goblet-like mucinous cells was present in all cases. High-grade pattern (HGP) included signet ring (n=5) and mucinous carcinoma (n=1) areas. Majority (67%) tumors were grade-3 (>50% HGP); there were two grade-2 (>25-<50% HGP), and one grade-1 (<25% HGP). Majority (67%) were pT4. Lymphovascular and perineural invasion was identified in 44% and 56% cases, respectively. Synaptophysin and chromogranin positivity was focal (range 10-50% cells); MIB1 ranged from 5-35%. Mismatch repair protein proficiency (2/2) and p53 wild type (2/2) expression was observed. Three patients developed distant metastasis; sites included: omentum, peritoneum and supraclavicular and retroperitoneal nodes. Conclusion: Goblet cell adenocarcinoma is a rare albeit unique appendicular malignancy. Diagnosis may be missed in cases with dominant high-grade pattern. Recognition of its unique histopathological and immunohistochemistry profile is essential for accurate diagnosis.

   PP129: PD-L1 expression in ampullary cancer Top

Saima Haleem Siddiqui, Niraj Kumari, Shravan Mishra, Narendra Krishnani, Samir Mohindra, Rajneesh K Singh

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Ampullary cancers (AC) are heterogeneous cancers harboring intestinal (INT) and pancreatobiliary (PB) differentiation. PD-L1 expression in tumor cells (TC) and immune cells (IC) predict response of immunotherapy. We studied prevalence of PD-L1 and its relation with histological differentiation in AC. Materials and Methods: Fifty cases of AC were reviewed. PD-L1 immunohistochemistry was done (clone E1L3N) at 1:150 dilution. Cytoplasmic and/or membranous staining of >5% was considered positive. Results: M:F ratio was 2.5:1 (age range – 43-89 years. Thirty cases (60%) were INT, 19 (38%) PB and 1 (2%) had mixed differentiation. PD-L1 was expressed in 21/30 (70%) cases in TC and 23/30 (77%) in IC in INT type while in PB it was 15/19 (79%) in TC and 8/19 (42%) in IC. PD-L1 was higher in TC in well and moderately differentiated cancers in PB compared to INT type (grade I - 88% Vs. 69%, grade II – 71% Vs. 60%) while it was comparable in both types related to T-stage, perineural invasion (PNI), lymphovascular invasion (LVI) and lymphnode metastasis (Table 1). IC showed lower PD-L1 in PB compared to INT type in all grades, stage and tumors with PNI, LVI and lymphnode metastasis (Table 2). TILs were present in 90% cases in INT and 84% in PB with PD-L1 expression in 74% and 81% respectively. Conclusion: PD-L1 expression is comparable in TC of both pancreatobiliary and intestinal type while it is higher in intestinal than pancreatobiliary type.

   PP130: De-novo jejunal myeloid sarcoma: A rare entity Top

Pratibha Amritrao Kadam, S V Agale, Saroj Bolde, Pratik Chide, Sanjay Bijwe

Department of Pathology, Grant Medical College and J.J. Group of Hospitals, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Myeloid sarcoma (MS) is an extramedullary tumor of myeloblasts or immature myeloid cells. It is a rare disease and can occur de novo or in association with acute myeloid leukemias. It occurs in an age range of 3 months to 89 years. Design: A 27 year female patient of abdominal Koch's presented with abdominal pain, vomiting and constipation; clinicoradiologically diagnosed as intestinal obstruction due to intussusception. Hematological investigations were normal. Patient underwent reduction of intussusception with resection- anastomosis. Grossly jejunum revealed a mass measuring 3.2x3x2cm in the wall with homogenous, greyish white appearance. Microscopy shows diffuse sheets of tumor cells with pleomorphic large, round to oval hyperchromatic nuclei with scanty eosinophilic cytoplasm. Few immature cells with multinucleated tumor cells are seen. On H & E , differential diagnosis were given as diffuse large B cell lymphoma and myeloid sarcoma. Results and Discussion: Immunohistochemically Myeloperoxidase was positive and CK, EMA and CD20 were negative. Final diagnosis was confirmed as primary myeloid sarcoma of jejunum. MS has poorer prognosis than those with associated leukemias. It can arise commonly in soft tissue, skin, breast, lymph node and intestine. Histomorphological types are Blastic MS, Immature MS and Differentiated MS which can be confirmed immunohistochemically by an IHC panel of CD 43, MPO, lysozyme, CD68, CD117, CD20. Conclusion: MS presenting as intestinal intussusception is very rare. Jejunal involvement in myeloid sarcoma is unusual. Its varied clinical presentation and histomorphology warrants a high index of clinical and pathological suspicion for diagnosis.

   PP131: Clear cell sarcoma-like gastrointestinal tumor/malignant gastrointestinal neuroectodermal tumor of jejunum: A case report Top

Aditi Damle, Roopa Paulose

Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: [email protected]

Background: Clear cell sarcoma-like gastrointestinal tumor (CCSLGT) / malignant gastrointestinal neuroectodermal tumor(GNET) is a rare malignant sarcoma in the gastrointestinal tract arising from neuroectodermal precursor cells, affecting younger age, and commonly associated with EWSR1-CREB1 / EWSR1-ATF1 gene fusion. Only 16 cases have been reported worldwide. Case Scenario: A 56 year old man, previously well, presented with intestinal obstruction and was found to have thickened jejunum on imaging, which was resected. The 8cm segment of small intestine showed a 2.5cm grey-tan tumor confined to the wall with focal mucosal ulceration. Microscopically it was composed of medium sized monotonous tumour cells with round / ovoid nuclei, small nucleoli, pale cytoplasm, in lobules and nests separated by thin vascular channels. Focal areas of clear cell change and interspersed multinucleated (osteoclast- like) giant cells noted. Tumour cells showed strong positivity for S100, patchy positive for synaptophysin and negative CD117, DOG1, CK, HMB45, CD34, S100, SMA, desmin, synaptophysin. CD68 was positive in osteoclast giant cells. Ki67 index was 10-12%. The immunoprofile confirmed the morphological diagnosis of CCSLGT (GNET). EWSR1 rearrangement was present in the tumor. Results: Jejunal resection specimen: Malignant Gastrointestinal Neuroectodermal tumour - Clear cell sarcoma-like gastrointestinal tumor. Conclusion: CCSLGT is an extremely rare malignant tumour in the gastrointestinal tract which can mimick other common neoplasms. This complex tumour with S100 positivity and osteoclast giant cells highlights the importance of morphological diagnosis with immunohistochemical and molecular confirmation. Recognition of the tumour is important because of its aggressive nature and poor survival.

   PP132: The cancer mimic-malakoplakia of the gallbladder Top

Anusree Majumder

Command Hospital, Pune, Maharashtra, India. E-mail: [email protected]

Background: Gallbladder malakoplakia is a rare chronic granulomatous inflammatory condition that may occasionally affect immunosuppressed individuals. The underlying pathogenesis is an incomplete clearance of pathogens secondary to deficient macrophage phagolysosomal function. It is important to be aware of this entity as malakoplakia mimics carcinoma gallbladder both clinically and on imaging. This poster describes a rare case of gallbladder malakoplakia in a 32-year-old immune-competent female. Case Report: A 32-year-old female presented with intermittent episodes of vague pain in the epigastrium and right hypochondrium of one year's duration. There was no associated gastro-oesophageal reflux, vomiting, fever, jaundice or weight loss. Ultrasonography revealed nodular circumferential gallbladder mural thickening associated with an impacted calculus in the gallbladder neck. Computerized tomography also revealed enhancing nodular mural thickening. A diagnosis of carcinoma gallbladder was suspected and the patient underwent a radical cholecystectomy. On gross examination, multiple yellowish-brown nodules were seen on the serosal surface of the gallbladder. Histopathology revealed transmural sheets of eosinophilic granular histiocytes (von Hansseman cells) along with multiple intra- and extra-cellular basophilic concentric Michelis-Gutmann bodies. On Perl's Prussian blue stain, there was prominent hemosiderin deposition inside the macrophages. Ziehl-Neelsen stain for acid-fast bacilli was negative. There were no signs of cellular atypia or malignancy. A diagnosis of Malakoplakia was thus made. The lady made an uneventful recovery without any evidence of recurrence. Conclusion: Gallbladder malakoplakia is a rare entity. The varied clinical and radiological manifestations present a diagnostic conundrum. Histopathology has a pivotal role in confirming the diagnosis and excluding other sinister diseases.

   PP133: Malakoplakia of gall bladder: An unexpected finding Top

Chandrakant Pawar, Anjali Kulkarni, Vijay Mulay, Anil Joshi

Government Medical College, Aurangabad, Maharashtra, India. E-mail: [email protected]

Introduction: Malakoplakia is a rare pathological condition with only a handful cases involving the gall bladder reported in the literature. Patients present with complaints mimicking cholecystitis or carcinoma gall bladder and is almost never diagnosed pre-surgically. Pathognomic feature of this lesion is presence of Michaelis-guttman bodies. Case Description: We here present a case of 58yrs male who presented with complains of pain in abdomen (on & off) since 1 year. Pre-operative USG was suggestive of acute cholecystitis with cholelithiasis and CECT suggested chronic calculus cholelithiasis. We received specimen of gall bladder of size 5.5x3x3 cm, brownish and irregular thickened, wall of gall bladder appeared thickened, mucosa sloughed off at places and a whitish firm area of size 0.5x0.5 cm was identified. Microscopic examination showed glandular mucosa lined by columnar cells having regular basal nuclei and underneath coats are thickened and shows infiltration by sheets of histiocytes with Michaelis-guttman bodies (PAS+ve), sparse lymphocytes along with congested blood vessels. Conclusion: Due to its close mimic being carcinoma of gall bladder, it may lead to intra-operative extensive surgical dissection.

   PP134: An unusual presentation of Hodgkin's lymphoma Top

Kusha Sharma, Anita Nangia, Kavita Gaur

Lady Hardinge Medical College, New Delhi, India. E-mail: [email protected]

Introduction: Hodgkin's lymphoma (HL) is a common lymphoma in lymph nodes which spreads in a contiguous fashion via lymphatics and typically presents with painless lymphadenopathy and associated B-symptoms. Liver infiltration by lymphoma cells has been reported in 15% of patients with HL usually in Stage III/IV disease. Jaundice as a presenting symptom is rare and occurs in 3-13% cases of HL. We present a rare case of Hodgkin's lymphoma in a 8 year female with jaundice and hepatomegaly as initial presentation. Case Report: A 8 year old female child, presented with febrile illness on-off over a year, loss of appetite and ascites for 3 months, and jaundice for 15 days. Physical examination revealed jaundice, pallor, hepatosplenomegaly (hard and nodular) with no lymphadenopathy. Hematological profile including peripheral smear was normal except for severe anaemia (Hb - 4.2 g/dL) for which patient had received transfusion previously. A liver biopsy was done and showed portal tract expansion and infiltration by highly pleomorphic cells, round to spindled having abundant eosinophilic to vacuolated cytoplasm, coarse clumped chromatin with single prominent eosinophilic nucleolus, surrounded by a reactive milieu comprising of lymphocytes, plasma cells and histiocytes. On immunohistochemistry, neoplastic cells were positive for PAX5, CD15, Vimentin and negative for LCA, CD20, MPO, S100, CD1a, EMA and Desmin. A diagnosis of Hodgkin's lymphoma was made. Conclusion: HL masquerading as primary liver pathology can rarely present as the initial symptom of the disease and should be considered in the differential diagnosis of hepatomegaly especially in a young child.

   PP135: Non cirrhotic portal hypertension-A clinicopathological analysis Top

Sonia Hasija, Rajeev Sen1, Nisha Marwah1, Shivani Kalhan, Shilpa Garg

Department of Pathology, SHKM GMC Nalhar Nuh, Gehbar,1Department of Pathology, PGIMS, Rohtak, Haryana, India. E-mail: [email protected]

Introduction: Non cirrhotic portal fibrosis (NCPF) is a rare clinicopathological disorder of unknown etiology consisting of intrahepatic portal hypertension in the absence of other identifiable intrinsic liver diseases and/or splanchnic vein thrombosis. An increasing number of patients are being reported, manifesting with triad of portal hypertension, splenomegaly and variceal bleed without underlying cirrhosis or portal vein thrombosis. Incidence of NCPF is reduced these days, but it still remains one of the commoner causes of NCPH in India. Materials and Methods: This is a prospective study where in liver biopsies of cases with clinical suspicion of NCPF were received over a period of 4 years. Data collected comprised of age, gender, clinical features, radiological findings and histological findings. Analysis of clinical and histopathological features associated with NCPF were studied and compared. Results: A sum total of 45 liver biopsies of cases suspected of NCPF were received. Patient's age ranged from 14 to 40 years & male:female ratio of 2.5:1. Most common presenting symptoms were long standing splenomegaly, esophageal varices & ascites. Liver function tests were deranged in 35.7% cases. Among the histological findings, the specific features like parenchymal aberrant vessel and phlebosclerosis were more common. Normal liver histology was found in 8 (17.8%) cases. Conclusion: NCPF can present with features of decompensation mimicking cirrhosis, but have relatively stable course. It is very important to recognise this entity and differentiate it from cirrhosis and hepatic and portal vein thrombosis in view of different connotation of therapeutic, management and prognostic purposes.

   PP136: Collision tumor of pancreas: A rare case presentation Top

Ritika Gupta, Prita Pradhan, Prajna Das, Mihir Kumar Mohapatra1, Ranjita Panigrahi, Urmila Senapati

Departments of Pathology and1Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: [email protected]

Introduction: A collision tumor is composed of two adjacent histological distinct neoplasms without the histological admixture of cell types in the same organ or tissue.It is rare in pancreas. Herein we report an unusual case of a mixed malignant neuroendocrine tumor (NET) and ductal adenocarcinoma of pancreas. Case Report: A 24 year old male, a known case of type 2 diabetes mellitus on insulin therapy and chronic alcoholism presented with history of dull aching pain in upper abdomen for 10 years. Serum CA-19.9 levels was markedly elevated. CECT abdomen showed a radioenhancing mass in body of pancreas. Radical distal pancreaticosplenectomy with end to side pancreaticojejunostomy was done. The specimen showed a grey white, solid growth measuring 2x2x1.2 cm in diameter . Multiple sections revealed a composite tumor consisting of ductal and neuroendocrine origin. The former showed tumor cells in acinar and cribriform pattern with surrounding desmoplasia and focal mucin pools. The latter constituting more than 30% showed cells arranged in nests having characteristic salt and pepper chromatin. Peripancreatic fat and perineural invasion was noted. Immunohistochemistry showed complementary staining; diffuse strong cytoplasmic positivity for CK7 in adenocarcinoma while diffuse strong chromogranin A positivity in NET areas confirming the diagnosis. Conclusion: Collision tumor of pancreas can only be diagnosed postoperatively by histopathology. From the small number of reported cases, collision tumors appear to have a poor prognosis. So accurate evaluation and correlation of radiological, histomorphological and immunohistochemical findings are essential for correct diagnosis.

   PP137: Histopathologically challenging findings in hepatic involvement in HELLP syndrome: A case report Top

Epsita Das, Amit K Yadav, Rashmi Arora

Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. E-mail: [email protected]

Introduction: HELLP syndrome is a rare liver related disorder associated with pregnancy ( Incidence- 0.6% of all pregnancies). It was first described by Weinstein in 1982 as a constellation of clinical and laboratory abnormalities in the third trimester. It is characterized by hemolysis, elevated liver enzymes and low platelet counts. The histopathological findings in liver maybe non specific leading to diagnostic challenge. Case Description: A 30 year G2P1L1 at 38 weeks of gestation presented with complaints of fatigue, headache, difficult in breathing. On examination, there was elevated blood pressure, pedal edema,with bilateral basal crepitations and cephalopelvic disproportion. Routine investigations showed anemia, thrombocytopenia and deranged liver function tests. Coagulation profile was normal. Ultrasound abdomen showed bright liver with multiple echogenic areas. Clinical differentials included HELLP syndrome with DIC, acute fatty liver of pregnancy and liver abscess. A liver biopsy was taken and sent for histopathological examination. Microscopic examination showed periportal intrasinusoidal fibrin deposition with areas of necrosis and inflammation. A final diagnosis of HELLP syndrome with associated DIC was made. In view of the clinical condition, termination of pregnancy was done. The baby delivered was healthy and postoperative course was uneventful. Conclusion: HELLP syndrome is a rare but serious disorder carrying significant perinatal and maternal morbidity/mortality. This case has been presented to highlight the histopathological changes seen in liver secondary to HELLP syndrome. The pathologists must be aware of these changes so as to not miss the diagnosis of this life threatening condition.

   PP138: Clear cell myomelanocytic tumor of ligamentum teres: A rare case with review of literature Top

Ariba Zaidi, Debajyoti Chatterjee, Ashim Das, Vikas Gupta

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]

Background: Clear cell myomelanocytic tumor (CCMMT) of the falciform ligament/ligamentum teres is a rare tumor of liver, and it is a variant of perivascular epithelioid cell tumor (PEComa) family. CCMMT is the rarest variant of hepatic PEComas. Only a very few cases of CCMMT have been reported in the English literature. Because of its rarity, less is known about its biological behaviour. Design - Case Report: We present a case of a 31-year-old female, who complained of pain abdomen, bilious vomiting and abdominal fullness of two months duration. Radiological impression was of focal nodular hyperplasia. Results and Discussion: Histological examination of the resection specimen revealed a well circumscribed tumor, arranged in fascicles, sheets and whirling pattern. The tumor cells were spindle to epithelioid shaped with abundant clear to pale eosinophilic cytoplasm. The tumor cells expressed both myoid (smooth muscle actin) and melanocytic (MelanA and HMB45) markers, while they were negative for hepatocytic and vascular markers. Review of literature was done and very few cases were found to be reported in past. Conclusion: Based on histology and immunohistochemistry, a diagnosis of CCMMT of ligamentum teres was made. This case presents the diagnostic challenges of CCMMT and discusses the differential diagnosis with review of literature.

   PP139: Tumor associated malakoplakia of gall bladder Top

Shweta Bhatoa

Department of Histopathology, PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: Malakoplakia is caused by the defect in the phagocytic function of histiocytes in response to the gram negative coliform, leading to chronic inflammation, followed by the deposition of iron and calcium intracellularly. Malakoplakia in association with tumor of the gall bladder is a rare entity. Case Discussion: We present a rare case of tumor associated malakoplakia of the gall bladder. 50 years female underwent extended cholecystectomy procedure for carcinoma of gall bladder. Histology showed Adenocarcinoma, infilterating upto the serosa. Coexisting features of malakoplakia were noted. Conclusion: Malakoplakia can mimic malignancy and can co exist with tumor. Pathologists should be aware of this entity to avoid mis-interpretation of nodules of malakoplakia as tumor and leading to overstaging.

   PP140: Clinicopathological spectrum of explant liver specimens in a tertiary care centre Top

Harish Kumar Kamboj, Amninder Singh, Neena Sood

Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: [email protected]

Introduction: Liver diseases are common cause of mortality in developing countries. Hepatic neoplasms particularly Hepatocellular carcinoma (HCC) is one of the commonest cancers in the world especially in countries like India where high incidence of Hepatitis B and C is being reported. Unfortunately, like many other cancers, liver cancer may go undetected until a late stage. Hepatectomy in early stages is associated with increase survival. Fatty liver diseases particularly both alcoholic & non alcoholic are increasing day by day in Punjab causing end stage liver disease at many instances and requires liver transplant. Explant liver specimen are performed only in few centres in India with high chances of cure for diseases confined to portion of liver. Aims and Objectives: To study the detailed clinicopathological spectrum of explant specimens in a tertiary care centre. Main aim is to analyze the clinicopathological spectrum of all explant specimen done in a tertiary care centre and to compare it with world wide data. Materials and Methods: During a 5 year of study total 13 explant specimens were analysed for underlying diseases. Conclusion: Explant specimens are usually done for chronic liver diseases particularly in cases of cirrhosis secondary to Hepatitis A, B & C, alcoholic liver diseases and others. Most common cause was found to be chronic liver disease followed by hepatic viruses.

   PP141: A retrospective analysis of pancreatic lesions in a tertiary referral centre Top

Kollabathula Arpitha

PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: A wide spectrum of benign and malignant diseases can present as pain abdomen and produce mass in pancreas. The important question is to understand whether it is malignant or benign and treat accordingly. Objective: To analyse the prevalence and incidence of pancreatic lesions in a tertiary referral centre like PGIMER. Methods: Retrospective four year (2015-2018) analysis of all pancreatic biopsies and resection specimens. Results: A total of 477 cases examined of which 62.3% are males and 37.7% are females. Non neoplastic are 60.5% and neoplastic are 39.5%. In neoplastic malignant are 63% and 37%are benign lesions. The most common condition of non malignant is chronic pancreatitis and most common malignant condition observed is adenocarcinoma. Conclusion: Chronic pancreatitis is the most common benign condition and the adenocarcinoma is the most common malignant condition observed in this analysis. Cystic neoplasms like serous cystadenoma and mucinous cystadenoma are seen most coomonly in females. IgG4 related disease seems to evolving and is commonly presenting as a pain abdomen and mass abdomen causing resection and leading to morbidity. Some interesting cases like paraganglioma and GIST metastasis also noted.

   PP142: Sigma metrics: A valuable tool for evaluating performance of internal quality control in laboratory Top

Akriti Kashyap, Sangeetha Sampath, Preeti Tripathi, Arijit Sen

Command Hospital Air Force, Bengaluru, Karnataka, India. E-mail: [email protected]

Background: Six sigma is a widely accepted quality management system that provides an objective assessment of analytical methods and instrumentation .Six Sigma scale typically runs from zero to six with sigma value above 6 being considered adequate and 3 sigma being considered the minimal acceptable performance for a process. Methodology: Sigma Metrics of 10 biochemistry parameters namely Glucose, triglycerides, HDL, Albumin, Direct Bilirubin, Alanine transaminase, Aspartate transaminase, Urea Nitrogen, Creatinine and Uric acid and Haematology paramenters like Hb ,TLC, PCV, MCV,MCH,MCHC and Platelet were calculated by analyzing IQC data of 06 months (Jan 2019-June 2019). Results: Sigma Value was found to be >6 for triglyceride , HDL Hb TLC and MCH signifying excellent results and no further modification with respect to IQC. Sigma value was between 3-6 for glucose, albumin, Creatinine, uric acid ,PCV and MCHC implying the requirement of improvement in QC processes. Sigma value of <3 was seen in AST, ALT, Direct bilirubin, Urea Nitrogen ,platelet and MCV signifying suboptimal performance. Discussion: Six sigma provides a more quantitative frame work for evaluating process performance with evidence for process improvement and describes how many sigmas fit within the tolerance limits. Thus for parameters with sigma value <3 , duplicate testing of sample along with 3 QC three times a day may be used along with stringent Westgaard rules for rejecting a run. Conclusion: Sigma metrics helps to assess analytical methodologies and augment laboratory performance.

   PP143: Bone marrow evaluation of pancytopenia in a rural tertiary care center Top

Sanyukta Goyal, Charu Batra Atreja, Ridhima Auplish, Vijay Nijhawan

MMIMSR, Mullana (Ambala), Haryana, India. E-mail: [email protected]

Background: Pancytopenia is often a diagnostic dilemma as a wide variety of etiologies are associated with the entity. In addition to a detailed clinical history, bone marrow aspiration and biopsy play an integral role in reaching an accurate diagnosis. The present study aimed at determining the causes of pancytopenia in patients presenting to a rural tertiary care hospital in Haryana. Design: This study was conducted in Maharishi Markandeshwar Institute of Medical Sciences and Research between January 2016 to September 2019 and included 91 patients presenting with pancytopenia. These patients were evaluated clinically and a detailed haematological investigation including, complete blood counts, peripheral blood smear examination, bone marrow aspiration and biopsy were done. Results and Discussion: . The average age of the patients was 36.9 (range 2-70 years) year with a male: female ratio of 1.1:1. Megaloblastic anemia was the commonest cause identified in 31.8% patients followed by hypoplastic marrow (18.6% ) and acute leukemia (17.5 %) . Other less prevalent causes included Myelodysplastic syndrome, Multiple myeloma and a few cases of Leishmaniasis and granulomatous infiltration of marrow. Conclusion: In subjects with pancytopenia in rural Indian settings, the megaloblastic anemia seems to be most important etiology. A detailed primary hematological investigation along with bone marrow aspiration and biopsy are helpful in revealing underlying cause in patients with pancytopenia.

   PP145: Role of hematological parameters in differentiating between iron deficiency anemia and thalassemia trait Top

Mudita Bhargava, Varsha Kumar, Vatsala Misra, Himansha Pandey, Vasudha Singh

M.L.N.M.C., Prayagraj, Uttar Pradesh, India. E-mail: [email protected]

Background: The two most common causes of microcytic hypochromic anemia are thalassemia trait and Iron deficiency which have a similar morphology but differ completely in terms of management and prognosis. Hemoglobin electrophoresis (HPLC) and Serum iron profile as confirmatory tests are not available at all health care centers. Blanket therapy of iron supplements is therefore give in all such cases which, when prolonged, may cause iron overload and related complications in thalassemia minor cases. Hence, easy to use and cost effective screening methods are desirable. This study evaluated 12 indices to find the most reliable index based on the diagnostic accuracy of each. Design: Routine samples from the hematology lab with Hb<13 gm/dl and MCV<80fl were screened. Out of total 1353 cases, 98 cases of thalassemia trait (HbA2>3.5 on HPLC) and 1102 cases of Iron deficiency anemia (Serum Ferritin <12 g/ml) were evaluated using discrimination indices. Diagnostic accuracy for each index was calculated. Results and Discussion: While few indices showed a sensitivity of 100%, their specificity was low which meant more number of false positive cases. Based on Youdens Index which measures the diagnostic test's ability to balance sensitivity and specificity, the best three indices in the decreasing order of their efficacy in our study were Ricerca index (RI), Green and King Index (GKI) and Mentzers Index (MI). Conclusion: MI is considered a reliable index by many clinicians since a long time, however RI and GKI were found to have a better diagnostic accuracy based on our study.

   PP146: Corelative study of RBC, WBC and platelet histograms with peripheral blood smear findings Top

Namrata Patro

Research Centre, D Y Patil Hospital, Pimpri, Pune, Maharashtra, India. E-mail: [email protected]

Background: The varying shapes and patterns of histograms produced by hematology analyzers are extremely useful in identifying the underlying pathology. The present study was undertaken to correlate RBC, WBC and Platelet histogram abnormalities with peripheral blood smear findings. Design: A descriptive cross sectional study was done on 500 cases showing abnormal histograms and/or abnormal peripheral smears. These histograms obtained from Benesphera H31 were compared with their respective peripheral smears stained by Leishman stain. Chi square test and unpaired t-test were used for statistical analysis. Results and Discussion: Of 500 cases, 85.2% showed RBC histogram defects (n=426), 4.2% had WBC histogram defects (n=21), and 3.6% showed platelet histogram defects (n=18). In RBC histogram defects, majority had a left shift (66.8%) followed by right shift (17.8%) and bimodal peak (0.6%) respectively. 21 WBC defects were found. These included WU defects (n=5), F1 defects (n=4), F3 defects (n=3), T1 defects (n=3), T2 defects (n=3) and F2 defect defects (n=1). Platelet graph showed a lower peak (PL, n=4), upper peak (PU, n=3) and multiple peak (MP, n=1). PBS abnormalities included RBC (n=420), WBC (n=171) and platelet (n=117). Correlation between RBC, WBC and platelet histogram defects with PBS was statistically significant (P value P<0.0001). But the number of pathological samples picked up by the automated analyzer were significantly less for WBC and platelet compared to RBC. Conclusion: Histograms should be used as a screening method to pick up pathological samples. These samples should then be followed by a peripheral blood smear examination for confirmatory diagnosis.

   PP147: Association of serum chemerin with hs-CRP in patients presenting with acute coronary syndrome with and without diabetes mellitus Top

Manoj Kumar, Anshul Singh, Vatsala Misra

Department of Pathology, M.L.N.M.C., Prayagraj, Uttar Pradesh, India. E-mail: [email protected]

Background: Chemerin is a novel proinflammatory adipokine whose role in Metabolic Syndrome and Insulin Resistance is well known. Recently few studies done abroad have shown that the S. Chemerin were found to be higher in patients of Coronary Artery Diseases( both Chronic as well as Acute) with a good prediction value for Acute coronary syndrome (ACS), similar to hs- CRP. In this study, we assessed the levels of S. Chemerin in patients of ACS with and without DM and also their relationship with hs-CRP. Design: We included 70 cases presenting with acute chest pain along with ECG changes / raised Trop- I and divided them into two subgroups of with DM (n=40) and without DM (n= 30) on the basis of RBS > 160 mg/ dl and <= 160 mg/dl respectively. We took 15 age and sex matched controls with no pre existing illness for comparison. Serum levels of chemerin were measured by an enzyme-linked immunosorbent assay (ELISA) and hs – CRP by turbidimetric. Results: Serum Chemerin level were significantly higher in patients with ACS than in controls, with their levels being significantly higher in the DM subgroup than in the NDM . Chemerin levels showed a significant positive correlation with C-reactive protein in ACS patients . Conclusion: Chemerin levels show a significant raise in patients of Acute Coronary Syndrome, moreso with co-existent DM with a significant positive correlation with hs-CRP which implies that they may carry the same predictive value as of hs –CRP for these patients.

   PP148: Risk of t-APL in a cancer survivor: A case report with very early occurrence Top

Juhi Rahatekar, Mayura Phulpagar, Amol Akhade, J S Pandya

Topiwala National Medical College and B.Y.L. Nair Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Objective: Acute Promyelocytic Leukemia (APL) is a rare disease comprising 5% of all newly diagnosed acute myeloid leukemia (AML). 1-5 % of all APL are found to be therapy-related (t-APL) often observed post hodgkins and colonic cancer treatment, however in one of the largest previous study, breast cancer was the primary antecedent cause in 57 % of all t-APL cases. It increases the risk of early mortality. We highlight a rare case of t-APL in a cured breast cancer patient resuming with a palpable lump in contralateral breast. Case Report: A 32year old female in 2016, underwent left sided Modified Radical Mastectomy. Diagnosed as Invasive Ductal Carcinoma (NOS) Stage T2N1M0, was treated with adjuvant chemotherapy and radiotherapy. She had normal sono-mammogram on regular follow up. A year after therapy, patient developed fever, generalized weakness and body ache. Purpuric spots were noted. Total WBC count was raised and peripheral smear showed acute promyelocytic leukemia (APL). Patient was successfully treated t-APL with conventional induction and subsequent consolidation therapy after confirming the PML/RARA rearrangement. Nine months later she noticed a lump in the contralateral breast while on regular surveillance. Conclusion: Anthracyclin and/or topoisomerase-inhibitor based chemotherapy in breast cancer does carry a small increased risk of APL as in our case. This unique case occurred as early as within 1 year of follow up. So patient should be diligently monitored and physicians be aware of delayed complication of radiotherapy and/or chemotherapy for primary breast cancer.

KEYWORDS: Breast cancer, secondary leukemia, therapy-related

   PP149: Granulocytic sarcoma: A rare case report Top

B N Sandhyalakshmi

ESICMC and PGIMSR, Bengaluru, Karnataka, India. E-mail: [email protected]

Introduction: Granulocytic sarcoma also known as Myeloid sarcoma (MS) or chloroma represents the tissue mass form of acute myeloid leukemia (AML), thus, the diagnosis is equivalent to a diagnosis of AML. Granulocytic sarcoma is an uncommon presentation of extramedullary tumor consisting of immature myeloid cells.Myeloid sarcoma may occur de novo, may precede or coincide with AML, or may represent a blastic transformation of a preceding chronic myeloproliferative neoplasm. Abstract: We present a case of 19 year old female presented to medical OPD with history of easy fatiguability since 3 months, abdominal bloating and reduced appetite since 1month and multiple swellings over the right thigh and anterior aspect of right leg since1week. On examination there was pallor and hepatosplenomegaly, multiple swellings in right thigh largest measuring 5x3 cms, non mobile, ill defined , tender swelling in the subcutaneous plane. Complete hemogram revealed Hb – 6.8g%, total WBC count- 5.8 lakhs/dl, plateletes – 2.7 lakhs/dl. Peripharal smear myeloblasts- 4%, promyelocytes- 9%, myelocytes – 21%, metamyelocytes- 18%, neutrophils- 26%, basophils – 4%. With the above findings diagnosis of Chronic myeloid leukemia – Chronic phase made. Bone marrow aspiration and biopsy showed similar findings, with grade 2 fibrosis.Aspirations from thigh swellings were hemorrhagic,showed highly cellular smears comprisingof immature myeloid precursors. Hence the diagnosis of granulocytic sarcoma was made. Conclusion: Intensive standard AML chemotherapy with or without radiotherapy is an effective treatment for granulocytic sarcoma. But patient survival is poor.Patients with isolated MS may have a better prognosis compared with AML patients without MS.

   PP150: Comparative study to assess the coagulation profile in breast malignancies Top

Seema Jathapi, R K Nigam, Rajni Choudhary

GMC, Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Malignant tumours are often associated with disturbed coagulative processes and thromboembolic episodes. Coagulation abnormalities play a major role in breast cancer patients. Design: This study included 50 cases of breast cancer and 50 control group were selected to compare the results. After processing of blood samples, various test like complete blood count, platelet count, PT, APTT, Fibrin degradation product, and D-Dimer were done. Results and Discussion: A total of 100 cases were evaluated in the study. Significant differences were noted in the coagulation parameters of both the groups. Malignant cases show abnormal coagulation parameters as compared to control group. Conclusion: Cancer is associated with a high risk of thrombotic complications. Altered coagulation parameters significantly correlate with malignant nature of tumour and also their spread. Preventing this complications is clinically relevant because they significantly contribute to morbidity and mortality of this patients.

   PP151: Abnormal semen parameters among males in infertile couples: A cross-sectional study from a tertiary care centre Top

Rachana Meena, Jyoti Garg, Shailaja Shukla, Sunita Sharma

Lady Hardinge Medical College, New Delhi, India. E-mail: [email protected]

Background: In India,the prevalence of primary infertility ranges from 3.9% to 16.8%. Male factor contributes 40-50% of this . Male factor infertility is indicated by decreased sperm concentration, reduced motility,vitality or abnormal sperm morphology.Semen analysis is single most important investigation to detect male factor infertility. The aim is to study prevalence of abnormal semen parameters among males in infertile couple and their association with contributing factors . Design: Cross-sectional hospital based study was carried out in the department of Pathology at Lady hardinge Medical College and Smt Sucheta Kriplani Hospital . A total of 400 cases were analyzed during a period of 6 months. Detailed history of the couple was taken.Semen Analysis was done using automated semen analyser (SQA-Vision) after 3 days of abstinence according to WHO 5th edition 2010 guidelines.The results were analysed using excel sheet and SPSS software Results and Discussion: In present study, 130 cases (32.5%) out of 400 cases had abnormal semen parameters. Most common abnormality was asthenozoospermia (25%) followed by oligozoospermia (14%),azoospermia (11%) and teratozoospermia( 10%) . There was significant association of alcohol intake,obesity and trauma with abnormal semen parameters. Conclusion: Asthenozoospermia was the most common abnormality noted in this study.Lifestyle modifications along with timely medical attention in male partners of infertile couples can address this issue.

   PP152: A case report of renal osteodystrophy in chronic kidney disease Top

Jyoti Oberoi, Anita Tahlan, H N Pavithra, Sanjay D Cruz

GMCH, Chandigarh, India. E-mail: [email protected]

<p>&lt;p&gt;&lt;strong&gt;Introduction:&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;The majority of patients with chronic renal disease have some abnormality of bone structure. The manifestations are complex and include combinations of bone disease due to secondary hyperparathyroidism (80-90% of cases), osteomalacia and osteosclerosis. The most severe changes are seen in those patients with chronic renal disease who are maintained on dialysis.&lt;/p&gt; &lt;p&gt;&lt;strong&gt;Case description&lt;/strong&gt;&lt;/p&gt; &lt;p&gt;A 32 years old female presented with pain in abdomen and generalized weakness for last 6 months. On hemogram patient was found to have hemoglobin of 5.5 g/dl, total leucocyte count 6.2x109/L and platelets 232x109/L. RBCs were predominantly normocytic normochromic. Patient had deranged renal function tests and solitary kidney by birth which was small in size. Patients was diagnosed as chronic kidney disease and bone marrow examination was done in view of severe anemia not improving on medication.&lt;/p&gt; &lt;p&gt;Bone marrow aspirate was attempted but was a dry tap. Bone marrow trephine biopsy showed irregular thickening of the bony trabeculae with extensive remodeling.There was scalloping of trabeculae with tunneling of the fibrous tissue into the bony trabaculae and presence of osteoblasts lining the bony trabeculae. Some of the marrow spaces showed fibrosis while the preserved marrow spaces were&amp;nbsp; normocellular with adequate representation of all the three hematopoietic elements.&lt;/p&gt;</p>

   PP153: Philadelphia negative chronic myeloproliferative neoplasms with morphology as the yardstick of classification: A report of 5 cases Top

Monika Singh, Savita S Patil, Sharada R Rane, Leena A Nakate

BJGMC and SGH, Pune, Maharashtra, India. E-mail: [email protected]

Philadelphia chromosome negative or BCR-ABL negative myeloproliferative neoplasms(MPNs) include essential thrombocythemia(ET), polycythemia vera(PV), and primary myelofibrosis(PMF), chronic neutrophilic leukemia and chronic eosinophilic leukemia. They are uncommon clonal disorders. Incidence range from 0.5-3/1,00,000 persons. The new WHO classification of MPNs delivered a comprehensive and practically useful outline of diagnostic criteria for ET, PV and PMF. Special attention to morphology is required in order to distinguish ET from prefibrotic-PMF(pre-PMF) and JAK2 mutated ET from PV. Such details are prognostically significant. Materials and Methods: This study was conducted in department of pathology, BJGMC and SGH, Pune from January 1, 2019 to September 30, 2019. All cases fulfilling the criteria of non-CML MPN were included. Bone marrow examination was done in all the cases diagnosed as PV, ET and PMF. Results: 4 cases of non-CML were diagnosed during the study period. One case of Polycythemia vera, one of essential thrombocythemia, and two of primary myelofibrosis were diagnosed which were fulfillng the new WHO 2016 diagnostic criteria. 1 case of post PV myelofibrosis is also included. Conclusion: We recommend a bone marrow examination at the time of diagnosis and encourage repeating the procedure during follow-up, in the presence of signs of progression of disease

   PP154: Post transplant lymphoproliferative disease: Experience at a tertiary centre Top

Nidhi Rathi

Army Hospital Research and Referral, Delhi, India. E-mail: [email protected]

Objectives: Posttransplant Lymphoproliferative Disorders (PTLD) encompass a spectrum of lymphoid proliferations ranging from indolent, benign to malignant population of polyclonal to monoclonal cells. PTLD are defined as lymphomas arising in transplant recipients on immunosuppression. Recipients of both solid organ transplant (SOT) and Hematopoietic stem cell transplant(HSCT) have increased risk of developing lymphoproliferative disorders, mostly EBV related. We report here, the pattern of various categories of PTLDs in renal transplant cases, their diagnosis, treatment and outcome as observed at our centre. Methods: This was a retrospective analysis of 350 patients who underwent renal transplant at Army Hospital (Research &Referral) over a period of last 06 years (2014-2019). We identified 06 cases who developed lymphoproliferative disease after kidney transplant during this period. All our 06 cases were confirmed as PTLD on organ specific biopsy, supported by immunohistochemistry. Results: 06 cases were diagnosed with PTLDs out of a total of 350 renal transplant cases (1.7%). All our 06 cases suffered from monomorphic B cell Non-Hodgkin's lymphoma. 02 cases presented within two years of renal transplant (early onset) whereas other 4 had late onset disease. Organ involvement was primarily extranodal (05 cases). Only one patient had involvement of the allograft by lymphoma whereas two suffered from Primary CNS lymphoma. Conclusions: PTLDs are a major cause of increased mortality and morbidity in patients of solid organ transplant. PTLDs are rare diseases and hence a high index of suspicion on part of clinicians can help clinch the diagnosis in early stages and improve outcome.

   PP155: Reticulated platelets estimation by flowcytometry: Comparison and reproducibility of different methods Top

Shelly Singla, Vikrant Singh Bhar, Rachna Singh, Vineeta Raina

Artemis Hospitals, Gurgaon, Haryana, India. E-mail: [email protected]

Introduction: Reticulated platelets (RP) are young platelets released from bone marrow and can act as a marker of megakaryopoietic activity in the bone marrow. RP% can be estimated by flow cytometry following staining with thiazole orange(TO), a nucleic acid binding dye.Various gating strategies and staining protocols have been described in the past giving rise to variability of results. Aim: To establish easily reproducible protocol for enumeration of RP% with flow cytometry using TO staining and fluorochrome conjugated anti- GPIIb/IIIa (CD41/CD61) antibodies. Methods: A direct, whole-blood, dual-labelling flow cytometric method was used. The anti-CD 41 or anti-CD61 antibodies were used for platelet identification and TO for staining platelet mRNA. TO concentration, incubation and fixation method were determined to be 1 μg/ml,15 min and 1% formaldehyde respectively. Multiple gating strategies were used to determine RP fraction with threshold determined using normal control tube or unstained control tube. Results: Normal range was determined using thirty normal samples(Normal CBC parameters). The RP% varies between 1.92% to 8.24% with our protocol and mean RP% was 4.06% with SD of 1.65%. Different gating strategies and staining protocols were evaluated and compared on normal and thrombocytopenic samples. Conclusions: RP% estimation by flow cytometry is an economical, simple and useful test. The laboratory should establish in-house normal range according to the gating strategy and staining protocol used. Reporting results with respect to mean value of normal control samples can be used as a useful alternative reporting strategy to overcome effect of background fluorescence and batch to batch variability.

   PP156: Association of serum prolactin level with severity of diabetic retinopathy Top

Abhilasha Soni

VMMS and Safdarjung Hospital, New Delhi, India

Background: Diabetic Retinopathy(DR) is a major microvascular complication of diabetes.There is loss of pericytes and endothelial cells causing abnormally permeable retinal capillaries eventually resulting in hypoxia which stimulates the production of proangiogenic factors such as vascular endothelial growth factor. Neovasculariztion extends and bleeds into vitreous,causing detachment of retina leading to loss of vision. Prolactin is known to produce vasoinhibins which reduce vasodilation, prevents angiogenesis and decreases retinal vasopermeability. Thus, it may decrease the effects of DR and therefore prolactin therapy may represent a novel therapeutic approach against DR. Aim: To evaluate the level of serum prolactin in diabetic retinopathy cases and to correlate its level with severity of Diabetic Retinopathy. Design: The study included NDR(diabetes without retinopathy)n=10, NPDR(non proliferative diabetic retinopathy)n=16.The mean serum prolactin levels were compared between the two groups. Results and Discussion: Mean serum prolactin level was compared between the two groups. Mean serum prolactin in NDR group was 11.8ng/mL and in NPDR was 8.05ng/mL. Conclusion: Thus it was concluded that serum prolactin level does not play a significant role in Diabetic Retinopathy.

   PP157: Can LCA be used as a surrogate first line marker for diagnosis of high grade lymphomas: A series of 8 cases Top

Ritu Jangir, Anjali Sharma, Syeda Firdos Jamil, Amandeep Talwar

BMCHRC, Jaipur, Rajasthan, India. E-mail: [email protected]

Introduction: LCA is initial immunohistochemical marker to make diagnosis of Lymphoma. Some have ambiguous LCA expression. In this case series we studied Anaplastic Large cell & Plasmablastic lymphoma cases where LCA showed bimodal immunoexpression. ALCL & PBL are rare type of T & B-cell Lymphoma respectively. PBL has highest incidence in HIV positive, immunocompromised individuals and most common in oral cavity & mean age 50 year. ALCL and PBL both are predominant in males. ALCL are more common in nodes but can be extranodal with presence of B symptoms. Materials and Methods: We present eight cases of high grade lymphoma received in BMCHRC from January 2017 to august 2019. On the morphology Lymphoma was suspected and basic panel for IHC was done. Results: In eight cases of lymphoma, 2 were PBL & 6 were ALCL. Age is 45 & 54 years in 2 cases of PBL while 22 to 77 years in ALCL. In PBL male and female were equal while in ALCL 5 male & 1 female. one case nodal & one Extranodal (liver) in PBL whereas in ALCL 4 cases nodal & 2 Extranodal (vertebra and abdominal mass). On IHC PBL cases expressed LCA (1/2), CD38 (2/2), CD138 (2/2), MUM-1(2/2), CYCLNE D1 (1/2)(dim positive) and in ALCL cases expressed CD30 (6/6),EMA (3/6) & LCA(3/6). Conclusion: We conclude that extensive Lymphoma IHC panel should be applied for arriving at a definite diagnosis of high grade Lymphoproliferetive disorders and not be solely based on LCA expression.

   PP158: A rare cause of massive splenomegaly Top

J Thanka1,2, S Sri Gayathri1,2, S Rajendiran1,2, V Pavithra1,2, S Sankar1,2

Departments of1Pathology and2Surgical Gastroenterology, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Splenomegaly can be associated with a variety of clinical conditions and sometimes pose great diagnostic challenges. We are presenting one such rare cause of splenomegaly clinically presenting with pancytopenia. Case History: 50 year female known diabetic presented with pain abdomen for 6 months in the left upper outer quadrant with gradually increasing mass for 6 month. On examination large spleen measuring 25cm from left costal margin present. Blood parameters showed features of pancytopenia. Portal vein Doppler showed features of portal hypertension. A clinical diagnosis of non cirrhotic portal fibrosis with portal hypertension and hypersplenism was made and therapeutic splenectomy with protocol wedge biopsy of liver was done. Pathology: Grossly the spleen weighed 2.9kg. Microscopically H & E and immunohistochemistry from the liver biopsy and spleen showed features of Hepatosplenic T cell lymphoma. The patient was referred to the Department of Hemato oncology and is on chemotherapy. Conclusion: This case was a surprise to surgical gastroenterologist. we present this case for its rarity and to highlight the key features of diagnosis in Hematoxylin and Eosin sections and the role of immunohistochemistry in arriving at the final diagnosis of Hepato splenic T cell Lymphoma.

   PP159: Myriad of lymphomas Top

C B Likhitha

Kerala University of Health Sciences, Thrissur, Kerala, India. E-mail: [email protected]

Introduction: The NHLs are a heterogeneous group of lymphoproliferative malignancies with distinct causes and patterns of behavior. Here we are presenting three cases of NHL at two unusual sites presenting with distinctive symptoms. This study incorporates immunophenotypic findings while investigating the patient. Discussion and Conclusion: Anaplastic large cell lymphoma is a T-cell lymphoma consisting of lymphoid cells that are usually large and have abundant cytoplasm and pleomorphic ,often horseshoe-shaped nuclei, with a chromosomal translocation involving the ALK gene and expression of ALK protein and CD30 . ALK positive ALCL accounts for 3% of all NHL and has got two peaks of incidence .It involves both lymph nodes and extranodal sites. The most commonly involved extranodal sites include skin, bone, soft tissue, lungs and liver. ALCL is well-known for its extra nodal involvement and GIT involvement is extremely rare (<1%). This case report is presented to highlight that symptoms and signs of GIT lymphoma is variable and early diagnosis gives better prognosis. DLBCL-The clinical and neurological presentation of primary CNS lymphoma is often nonspecific and histopathological confirmation is necessary and if left untreated, leads to death within weeks or months .

   PP160: Intravascular large B-cell Lymphoma presenting with hepatosplenomegaly, pancytopenia, coagulopathy and hypoalbuminemia: A transjugular liver biopsy diagnosis Top

Debdeep Dey, Saurabh Jayant Bhave, Suvadip Chatterjee, Dayanand Lingegowda, Neeraj Arora, Mayur Parihar, Deepak Mishra, Mammen Chandy

Tata Medical Center, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Intravascular large B-cell lymphoma (IVLBCL) is a large B-cell lymphoma which poses a diagnostic challenge due to its rarity, presentation in extra nodal organs and unsuspecting clinical presentation. Design: We present a case of IVLBCL in Liver diagnosed in a patient of hepatosplenomegaly, coagulopathy with pancytopenia. Results and Discussion: A 74-year-old Asian lady presented with anasarca and intermittent fever for 5 months. Investigations revealed pancytopenia and hypoalbuminemia. CT scan showed hepato-splenomegaly and ascites. Gastroscopy was normal. PET-CT demonstrated massive splenomegaly with diffusely increased metabolic activity. Bone marrow examination showed no abnormal cells. Immuno-phenotyping showed mild degree of haemophagocytosis. Cytogenetic analysis confirmed complex karyotype abnormality. Standard liver biopsy or splenectomy could not be performed in view of thrombocytopenia and coagulopathy. Transjugular liver biopsy showed sinusoidal large lymphoid cells with pleomorphic nuclei and mitotic figures. Immunohistochemistry showed the large sinusoidal lymphoid cells are positive for CD20, bcl6, bcl2, MUM-1 and negative for CD30, Cyclin-D1. The Ki67 proliferation index was 70%. A diagnosis of IVLBCL was made. She was started on R-CVP protocol and she responded with increase in blood counts and albumin. Conclusion: IVLBCL is characterized by the presence of lymphoma cells within the lumen of small vessels. There are 2 major patterns of clinical presentation. Caucasian patients present with skin and neurological symptoms, whereas Asian patients exhibit involvement of the liver, bone marrow and spleen. This case highlights the benefits of doing transjugular liver biopsy in a patient of pancytopenia with hepatosplenomegaly and being aware of the diagnosis of IVLBCL.

   PP161: Intradural diffuse large B-cell lymphoma of spinal cord at L4-L5 and S1-S2: A rare case report Top

Arpita Dhal, P K Satpathy, Raghumani Mohanty, R C Mohanty, K M Panda, Sunil Agrawal, T Bhuyan, Swagatika Agarwal1

Hi-tech Medical College and Hospital,1Hi-tech Medical College, Utkal University, Bhubaneswar, Odisha, India. E-mail: [email protected]

Background: Intradural diffuse large B cell lymphoma(DLBCL) is an extremely rare entity which represent 0.12% of all non hodgkins lymphoma(NHL). It has a slight male predominance in older age groups. we report an unique case of intradural lymphoma in a young patient.

Design: A 15 yr old boy presented with lower backache and radiating pain to bilateral lower limb with urine retention. The patient was examined,CT/ MRI report revealed intradural solid mass lesion with spinal cord compression at L4-L5,S1-S2 level. The patient was operated and sample for biopsy was sent for histopathology. Results and Discussion: Grossly multiple bits of greyish white tissue all together measuring 3×2×1 cm.M/S: Bits of bony tissue and tumor tissue .The tumor consisting of lymphoid cells which are large cells with small membrane bound nucleoli with condensation of nuclear chromatin at the nuclear margin .The cells are monomorphic and arranged in sheets. Some mitotic figures are seen. There are a few necrotic areas.One section shows skeletal muscle tissue IHC: CD20+ve.CD3,bcl2,cyclinD1and CD5-ve. D/D:DLBCL,Mantle cell lymphoma, Follicular lymphoma, Chronic lymphocytic leukemia. Conclusion: This is a case of intradural DLBCL of spinal cord at L4-L5 and S1-S2 level.

   PP162: Diffuse large B-cell lymphoma of right parietal lobe of brain: A rare case report Top

P K Satpathy, Raghumani Mohanty, R C Mohanty, K M Panda, Sunil Agarwal, T Bhuyan, S Agarwal, Kamalesh Lenka

Hitech Medical College and Hospital, Bhubaneswar, Odisha, India. E-mail: [email protected]

DLBCL is the most common subtype of non-Hodgkin lymphoma accounting for 30%-40% of all cases. Primary diffuse large B-cell lymphoma (Bcl) of the central nervous system (CNS) is a rare tumour of the brain and spinal cord, which has been estimated to account for &le;1% of all lymphomas, 4&ndash;6% of all extra nodal lymphomas and ~1&ndash;3% of primary CNS tumours (1&ndash;3). Immunocompromised individuals are considered most at risk of the disease, however, the incidence of primary diffuse large Bcl of the CNS (PCNSL) is increasing in immunocompetent populations. Case Report: 36/m presented with left side hemiparesis since 2 months with inability to talk and comprehend.H/O fever . Known case of hypertension since 2 years .No h/o dm or asthma MRI MULTIPLE AREAS OF HYPERINTENSE AND ISOINTENSE IN RT PARIETAL LOBE AND AND RIGHT LOBE OF CEREBELLUM MICROSCOPY &ndash; sections from brain tissue bits show a small bit oof tissue showing normal glial component ,other bits show a tumor consisting of medium to large atypical lymphoid tissue with nuclei having clumped chromatin and uniform in size and arranged in sheets. Immunohistochemestry: Tumor cells were strongly positive for CD 20 and bcl 2and negative for CD 3 and Ki 67. DIAGNOSIS DIFFUSE LARGE B CELL LYMPHOMA OF BRAIN? DIFFERENTIAL DIAGNOSIS-? Burkitt lymphoma? Lymphoblastic lymphoma? Diffuse mixed lymphoma? Paraimmunoblastic SLL/CLL? Large cell transformation of SLL/CLL? Plasmablastic lymphoma. Disscusion: Sometimes associated with B symptoms&mdash;fever, weight loss, and night sweats.

   PP163: Immunomorphologic characteristics of diffuse large b cell lymphoma, NOS: A study from a tertiary care center in southern India Top

K R Aarthiprabha

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Diffuse large B- cell lymphoma (DLBCL) is the most common lymphoma worldwide. It has a broad age distribution with heterogenous immunomorphologic characteristics. There is marked diversity in its biologic behavior and response to treatment. This led to various researches in understanding the nature of this neoplasm. Design: To study the frequency, distribution and immunomorphologic characteristics of DLBCL, NOS. This was a retrospective study which included all patients with DLBCL diagnosed in our department between January 2018 to December 2018. Results: This study includes 129 patients diagnosed with DLBCL, NOS. The mean age was 57 years with male predominance ( M:F= 2:1). DLBCL involved both nodal (48%) and extranodal (52%) location equally. Centroblastic variant (71%) was the most common variant followed by anaplastic (19%) and immunoblastic (10%) variant. 43% had Germinal centre B-cell phenotype (GCB) and 57% had non-GCB phenotype. 37 cases were c-MYC positive, of which 14 cases showed either BCL2/ BCL6 overexpression and were reported as double expressors. 20 cases showed coexpression of c-MYC, BCL2 and BCL6, were reported as triple expressors. Conclusion: The diagnostic techniques to subclassify DLBCLs are ever expanding. Dramatic changes have been made in assessing the prognosis through techniques such as immuno-histochemistry and molecular studies. These studies will help us to better understand the disease to develop new treatment modalities thereby attaining longer remissions.

   PP164: Lesion common, location unusual: Two interesting cases Top

Sandhya Sundaram, Lawrence D'cruz, S Prasanna Kumar1, S Rajendiran, S Gouthaman2, Rithika Rajendran, K Krishnarathinam3

Departments of Pathology,1ENT and2Surgical Oncology, Sri Ramachandra Medical College Hospital, SRIHER,3Department of Haemato Oncologist, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Non-Hodgkin lymphoma is a diverse group of lymphoid neoplasms with wide variety of presentations. It also has a propensity to affect organs and tissue that does not physiologically contain lymphoid cells. Design: We describe two unique soft tissue like presentations of Non-Hodgkin's lymphoma at very rare sites. The first case is a 9 year old male child who presented with difficulty in swallowing .On ENT examination, a nodular lesion was seen at the base of the tongue. The lesion was excised and sent for histopathological examination. The second case was a 65 year old male who came with a nodular lesion in the base of the thumb on the dorsal aspect. A Tru-cut biopsy was done and sent for histopathology. Results and Discussion: The first case showed sheets of atypical lymphoid cells with brisk mitosis. Immnunohistochemistry revealed diffuse and strong positivity for CD45 and CD20. Hence a diagnosis diffuse large B cell lymphoma of base of tongue was rendered. The second case showed sheets of neoplastic cells with high N/C ratio and numerous mitotic and apoptotic figures. Cells were strongly positive for CD20 and Cyclin D1. A final diagnosis of Mantle cell lymphoma was given . Conclusion: Although NHL is disease of reticuloendothelial system , it can also involve rare sites. Both the cases discussed are rare sites with presentation as isolated small nodular firm mass. Careful evaluation of patient, proper investigations and high degree of suspicion is required to arrive at the correct diagnosis.

   PP165: Clinicopathologic analysis of diffuse large B cell lymphoma in a tertiary care centre Top

Mary Anelia Correya, S Rajendiran, N Priyathersini

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Diffuse Large B cell lymphoma (DLBCL) constitutes about 25-35% of all adult non-hodgkins lymphoma. The Hans algorithm classifies DLBCL into germinal center and non germinal center subtypes. Aim: This study was undertaken to study the clinical, histopathological and immunohistochemical characteristics of diffuse large B cell lymphoma. Materials and Methods: It is a retrospective study done for a period between January 2016 and September 2019. The various parameters of diffuse large B cell lymphoma were studied and analysed. Results and Observations: A total of 41 cases of DLBCL were studied. The age of presentation ranged from 22years to 84years. The male to female ratio was 2.34:1. Both nodal and extra nodal sites were involved , 55% of the cases involving the lymph nodes, 7.5% involving the central nervous system, 7.5% involving the tonsil and other sites involved were the maxillary sinus, oropharynx, mediastinum, liver, spleen, stomach, kidney and testis. Majority of the cases were of the type DLBCL, NOS, but however few cases of DLBCL anaplastic type, EBV associated DLBCL and T cell rich DLBCL were reported. Hans algorithm was applied wherever possible and majority of the cases were found to be of B cell, non germinal center type. Conclusion: Thus DLBCL was found to be more common in older age males. The most common site was in the lymph nodes, more commonly the cervical nodes and followed by extra nodal sites like tonsil and central nervous system. Applying Hans algorithm, non germinal center B cell type was most common.

   PP166: A rare primary ovarian tumour Top

Fayiqah Sadique, Febe R Suman, Sri Gayathri, Krishnarathinam, Jayalakshmi, Vinod Panicker

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Introduction: Burkitt lymphoma is a highly aggressive lymphoma that often presents in extranodal sites or as acute leukemia. The incidence of it occurring in abdominal organs is 21% but its occurrence as primary ovarian lymphoma is very rare. Discussion: A 39year old female presented with abdominal pain for 3 months. Fever and palpable lymph nodes were absent. USG and MRI showed an ovarian neoplasm. Hematologic work up was within normal range. As exploratory laparotomy revealed a right ovarian tumour without lymphadenopathy, total abdominal hysterectomy with bilateral salphingo-oopherectomy was performed. Grossly it was a solid tumour weighing 689 grams with bosselated surface. Histopathological examination revealed Non-Hodgkin lymphoma-Burkitt lymphoma. IHC for CD10, CD79a and BCL2 were positive.CD20, CD3 and BCL6 were negative. Two months later the patient visited for chemotherapy. CBC: haemoglobin 7.6gm%, leukocyte count 16,000/cu mm, platelet count 30,000/cu mm. Peripheral smear and bone marrow aspirate showed acute lymphoblastic leukemia with 85% blasts. Biopsy showed bone marrow infiltration with lymphoblasts positive for CD20, lambda and BCL2 and negative for CD5, CD138, kappa and Tdt. KI67 labelling index 75%. By flowcytometry the blasts were positive for CD19, CD20, CD10, CD38, CD58, CD123, HLA DR, cytoplasmic CD79a, CD13, CD33, CD11c, CD64 and negative for CD34, T cell and myeloid markers. The patient is being treated with adult acute B- lymphoblastic leukemia protocol and lost to follow up after 6 months. Conclusion: This case is presented for its rarity as primary ovarian Burkitt lymphoma with spill over.

KEYWORDS: B-lymphoblastic leukemia, burkitt lymphoma, ovarian neoplasm

   PP167: Cytology of a rare and unusual case of lymphoma Top

Riya Prakash Zambare, N M More, Abeer Mohd, L P Naik

Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Extranodal Non-Hodgkin's lymphomas account for 25% cases which can be primary or secondary i.e. secondary to widespread involvement. The incidence of primary extranodal lymphomas is rising and as it presents with swelling, pain or discomfort, it can mimic many neoplastic lesions. Hence, careful evaluation and proper investigations are necessary for correct diagnosis. Results and Discussion: We present a case of a 32 years old female with diffuse 8x8 cm, firm, non-mobile, non-tender, ill-defined swelling in upper part of left thigh on medial, extensor aspect. On USG local part, malignancy was suspected. FNAC showed a cellular smear with many intermediate sized lymphoid cells, histiocytes with eccentric nuclei, lymphoid cells with vacuolated cytoplasm and few atypical large cells in a blood mixed aspirate. The diagnosis of lymphoma was made on cytology. Histopathology of the same was followed up and confirmed to be T cell / histiocyte rich large B cell lymphoma (THRLBCL) on immunohistochemistry (CD20, PAX5 +). The patient has completed chemotherapy. THRLBCL is a rare variant (1-3%) of diffuse large B cell lymphoma (DLBCL) with common extranodal sites being bone marrow, skin, liver, spleen. In DLBCL, most common extranodal soft tissue site is thigh, but there is lack of data regarding THRLBCL in soft tissue thigh region. THRLBCL has a diffuse morphology with predominance of reactive T lymphocytes, histiocytes and scattered neoplastic large B cells (< 20-25% of cell population, even 1% ). Conclusion: THRLBCL is a rare variant and presentation as left sided thigh swelling is quite unusual.

   PP168: Histiocytoses and neoplasm of macrophage-dendritic cell lineages: A report of case series Top

Vandana Raphael, Yookarin Khonglah, Jaya Mishra, Evarisalin Marbaniang, Biswajit Dey, Darilin Shangpliang, Pakesh Baishya

Department of Pathology, NEIGRIHMS, Shillong, Meghalaya, India. E-mail: [email protected]

Introduction: The Histiocytoses are rare disorders characterized by the accumulation of macrophage, dendritic cell, or monocyte-derived cells in various tissues and organs of children and adults. WHO Revised classification 2016 classifies them in to 5 groups. Langerhans-related, cutaneous and mucocutaneous, malignant histiocytoses, Rosai-Dorfman disease and hemophagocytic lymphohistiocytosis . We hereby report the case series in the context of revised classification. Methods: We retrospectively analyzed all the histiocytic and dendritic neoplasm reported during last 7 years at NEIGRIHMS. Results: There were twenty cases with 10 cases of HLH, 4 cases of RDD, 2 cases each of Erdheim Chester Disease, and juvenile xanthogranuloma,1 each case of Langerhans cell histiocytosis and Malignant histiocytoses. RDD was diagnosed in cervical lymph nodes in two cases and one each in the soft tissue and the dura. Both the cases of ECD involved the soft tissue. Eight cases of HLH diagnosed in bone marrow and two in lymph nodes with three primary and 7 secondary. There were two cases of juvenile xanthogranuloma arising in the head & neck region. There was only 1 case of LCH in a patient with history of Alpha 1 antitrypsin deficiency. The sole case of malignant histiocytosis had an aggressive course in a 16- year- old boy and involved lymph nodes and bone marrow. IHC was done wherever required for confirmation of the diagnosis. Conclusion: Histiocytic and dendritic neoplasm are rare and can be diagnostically challenging. Timely diagnosis especially in conditions like HLH can be life saving.

   PP169: Carcinoma breast presenting as occult primary with bone marrow metastasis Top

Kranthi Kumar Jandrasupalli

AllMS, Rishikesh, Uttarakhand, India. E-mail: [email protected]

Introduction: Carcinoma breast is commonly known to metastasize to bone marrow, but its initial presentation as bone marrow metastasis with unknown primary is extremely rare.1 Occult primary breast cancer is diagnosed in the absence of any detectable tumor in the breast, along with histologically proven metastatic deposits elsewhere.2,3 The reported incidence of carcinoma breast presenting as an occult primary is 0.1-1%. 2,3. Case Report: An 84-year-old lady presented with severe pain in back and legs for 3 months. Routine blood and radiological investigations were normal. FDG PET scan revealed mixed lytic and sclerotic lesions involving multiple skeletal sites suggestive of multiple myeloma. Bone marrow aspirate was markedly diluted, however imprint smears showed clusters of atypical cells with moderate pleomorphism, coarse chromatin and abundant cytoplasm. Trephine biopsy revealed diffuse infiltration by sheets and acini of plasmacytoid cells, with intervening desmoplastic stroma. Her systemic examination as well as PET-CT did not detect any primary lesion. The patient gave a strong family history of breast cancer and hence the immunohistochemistry panel was selected accordingly. The tumor cells were positive for Cytokeratin, Mammaglobin, GCDFP-15 and ER, and negative for PR and HER2/neu. Conclusion: Carcinoma breast presenting as an occult primary with bone marrow metastasis is extremely rare. This case report highlights the importance of a detailed clinical history, careful bone marrow examination and selection of an accurate Immunohistochemistry panel in diagnosing even rare conditions like carcinoma breast presenting as occult primary with bone marrow metastasis.

   PP170: CD23 positive follicular lymphoma: A rare occurrence Top

Jasleen Kaur

Department of Pathology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: [email protected]

Introduction: Follicular lymphoma (FL) is a malignant lymphoma, derived from germinal centre B cells. Typical growth pattern is follicular but diffuse areas can be found. Tumor is composed of small to medium-sized cleaved centrocytes and centroblasts. Case Report: 59 year female with left inguinal lymph node swelling since 5 years , painless, no increase in size. Patient was a known diabetic with no family history of malignancy. On examination- swelling was 3x0.7 cm in size, firm, fixed and nontender. USG abdomen- multiple discrete and confluent lymph nodes varying in size. FNAC- monomorphic small sized atypical lymphoid cells having high N:C ratio, coarse chromatin, granular chromatin pattern, inconspicuous nucleoli and scanty cytoplasm. Findings consistent with Non Hodgkin's lymphoma- small cell type. Histopathology: soft tissue mass measuring 4x2x2 cm. Microscopy showed effaced nodal architecture with presence of sheets and follicles of atypical lymphoid cells. Individual cell had convoluted nuclei and scanty cytoplasm- centrocyte. Interspersed cells having round nuclei with 1-2 prominent nucleoli- centroblasts. Mitotic figures identified . On IHC- CD23 positive, CD10 positive, CD20 positive, LCA positive, Bcl-2 positive, Bcl-6 weakly positive. Conclusion: It was noted that expression of CD23 was more frequently detected in grade 1 FL(grade 1-37%; grade 2-18%; grade 3-23%) indicating FL of different grades could represent different stages. Expression of CD23 might be correlated with a better prognosis in DLBCL and indicate early germinal center origin.

   PP171: Monocytic myeloid sarcoma preceding acute myeloid leukemia: A case report Top

Manish Kumar

Department of Pathology, KGMU, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Background: Myeloid sarcoma (MS) is the extramedullary tumor of malignant myeloid precursor cells (also called nonleukemic granulocytic sarcoma). Common site involving are bone, periosteum, lymph node & less commonly orbit. MS can occur at any age, but appears more frequent in children and in older patients. In children, the rate of isolated myeloid sarcoma is ~ 1.3%, while the rate of isolated MS preceding acute myeloid leukemia (AML) is ~ 2.5%. Monocytic variant of MS are even rarer and poses difficulty in diagnosis. Case Report: A 3 yrs old male child presented with complaints of painless, progressively increasing swelling of right lower lid since 2½ months. Biochemical parameter and hematological parameters were normal. Biopsy of swelling and bone marrow aspiration was advised for further work up. Results: FNAC and biopsy from swelling showed medium to large sized cells with fine chromatin, occasional prominent nucleoli and moderate cytoplasm IHC showed positivity for LCA and CD68 while was negative for Desmin, CD20, CD3, MPO & CD117.Based on IHC finding a diagnosis of MS – Monocytic variant was made. Arepeat BMA after 2 month showed 26% monocytic blasts in the marrow which were positive for CD13, CD33 , CD38, CD64, HLADR & dim MPO on flow cytometry (FCM). FCM was reported as Acute monocytic leukemia. Conclusion: Monocytic variants of MS are difficult to diagnose as they are often negative for MPO and other marker. CD13,CD33, Myeloperoxidase (MPO), CD68 and CD163 markers help to identify the majority of MS types.

   PP172: A case report of Rosai – Dorfman disease with generalized lymphadenopathy and extranodal involvement Top

Sanchit Jain, Charanjeet Ahluwalia, Rashmi Arora

VMMC and Safdarjung Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Rosai–Dorfman disease (RDD) also known as sinus histiocytosis with massive lymphadenopathy usually present as bilateral massive painless lymph nodes in neck region. However, 1/4th cases have extra-nodal involvement. It occurs at any age, but mainly presents in 1st and 2nd decade of life. Etiology remains unknown, with possibility of viral/microbial infection. Case Description: A 25-year old male presented with bilateral cervical lymphadenopathy for 2 years, abdominal pain for 4 months along with history of fever and weight loss. FNAC performed from cervical lymph nodes, stated it to be lymphoproliferative disorder with possibility of Hodgkin's lymphoma. Ultrasound abdomen showed abdominal lymphadenopathy both pre and post diaphragmatic along with hypoechoic lesion in bilateral kidney. Findings were confirmed by CECT and PETCT. Clinical differential of lympho-proliferative disorder was kept. Biopsy from cervical lymph node was taken and sent for histopathological examination. Microscopic examination showed lymph node with intact capsule and variably sized lymphoid follicles. There was marked sinus dilatation and proliferation of histiocytes. Histiocytes had abundant pale cytoplasm, large vesicular nuclei and prominent nucleoli. Characteristic lymphophagocytosis was seen. There was presence of numerous plasma cells many of which showed eosinophilic inclusion within nucleus and cytoplasm. Histiocytes were positive for S100 and CD68. Diagnosis of Rosai–Dorfman disease was made. Conclusion: RDD is a rare, benign type of non-Langerhans cell histiocytosis, named after pathologists Juan Rosai and Ronald Dorfman. Imaging features of RDD are non-specific, possibly resembling lymphoproliferative diseases. This case has been presented to highlight importance of histological correlation in such cases.

   PP173: Multiclonal, panton-valentine leucocidin negative, staphylococcal cassette chromosome MEC type ii methicillin-resistant staphylococcus aureus isolates from health care workers Top

Chinmoy Sahu, Ujjala Ghoshal

Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Methicillin Resistant Staphylococcus aureus ( MRSA) carriage in health care workers is a major problem. Design: Nasal and hand swabs in duplicates were collected from the nursing personnels of various wards. The swabs were cultured on routine bacteriological media including mannitol salt agar. Staphylococcus aureus isolates were identified by phenotypic tests and confirmed by Polymerase Chain Reaction (PCR). MRSA isolates were identified by Cefoxitin disc method and confirmed by mecA gene detection. The mecA positive isolates were typed by Pulsed-Field Gel Electrophoresis (PFGE). SCCmec typing and PVL gene detection was also done in MRSA isolates by recommended methods. 2% mupirocin ointment was given to treat colonization 2 times a day for 5 days. Results: A total of 300 health-care workers were included in the study. 15 (28%) were confirmed to be MRSA by mecA gene detection out of which 8 (53%) were from nasal swabs and 7 (47%) were from hand swabs. Among the Nasal swab isolates (8), 7 were of SCCmec type II ( 87%) and 1 ( 13%) was of type III. No PVL gene was noted in this study. Pulse field gel electrophoresis analysis showed all the MRSA isolates were of different pulsotype. 6 ( 75%) nasal carriers were cleared off the MRSA. Conclusions: Unique feature of the isolates was that majority were of SCCmec type II isolates and all were PVL negative. Multiclonality of isolates suggest multiple sources and need for integrated approach for control.

   PP174: Isolation of bacteria from blood samples of patients of apex trauma center with special reference to methicillin resistant Staphylococcus aureus Top

Sangram Singh Patel, Ujjala Ghoshal, Chinmoy Sahu

Department of Microbiology, SGPGI, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Infections in trauma patients differ from other patients in many aspects. There are few data in India about bacterial antibiogram and Methicillin Resistant Staphylococcus aureus ( MRSA) and colistin resistant Enterobacteriaceae in trauma centers. Design: Blood samples from patients of suspected sepsis were sent to Microbiology Laboratory in Bactec aerobic and anaerobic vials. Bacterial isolates in the culture were detected by routine phenotypic methods and confirmed by Matrix-Assisted Laser Desorption Ionization Mass Spectrometry ( MALDI-TOF MS). Antibiotic sensitivity tests were done by Kirby-Bauer technique. MRSA were dectected by cefoxitin disc sensitivity method followed by mecA gene detection by Polymerase Chain Reaction ( PCR). mcr-1 for colistin resistance gene was detected by PCR. Results: One year blood samples positivity rate was 15%. The most common isolate was Klebsiella pneumoniae (37%) followed by MRSA (29%), E.coli( 15%) and Acinetobacter baumanii ( 11%).Prevalence of MRSA was more than that from routine samples. The most sensitive antibiotic for Gram negative bacilli was colistin ( 98%) followed by imipenem (47% ) and meropenem ( 38%).In 90% of colistin resistant strains mcr-1 was positive. For MRSA, the most sensitive antibiotic was teicoplanin (100%), vancomycin (100%) followed by clindamycin ( 65%). All the MRSA isolates were detected by cefoxitin disc method. 98% isolates were positive for mecA gene and only one ( 2%) was positive for mecC gene. Conclusions: Sepsis from trauma patients revealed different kind of antibiogram. In our isolates, all MRSA were detected by both phenotypic and genotypic methods.

   PP175: Epidemiological and demographic characteristics of dengue fever at a tertiary care centre in Haryana Top

Sarita Yadav, Sundeep Singh, Surinder Kumar

BPS GMC, Sonepat, Haryana, India. E-mail: [email protected]

Background: Dengue is a tropical and subtropical mosquito borne infection that can cause severe illness and death. As per the data from National Vector Borne Disease Control Programme (NVBDCP) and National Health Profile 2018, from less than 60,000 cases in 2009, dengue cases increased to 188,401 in 2017—more than a 300 per cent spike. The present study was designed to detect the epidemiological and demographic characteristics of dengue fever at a tertiary care centre in Haryana. These findings may be of help to the epidemiologists and dengue prevention and control measure authorities to plan out and implement various measures targeting the rural population. Design: The present study was conducted at Virology Research and Diagnostic Laboratory(VRDL),Department of Microbiology,BPS Govt. Medical College, Khanpur Kalan, Sonepat. A total of 2896 blood samples were collected during study period and serologically tested for dengue NS1 antigen and IgM antibody by capture ELISA testing. Results and Discussion: Out of 2896 tested samples,505 samples were found positive for dengue. Majority of positive cases were in the age group 21-30 years (30.29%) and 11-20 years (20.79%). The ratio of male cases (21.72%) was higher than female cases. Conclusion: Small surveys with a sufficient sample size would be useful to do at the state level,to capture geographical heterogeneity within a state. This study, in fact, has important public health implications on planning public health responses to dengue.

   PP176: Germline EPCAM mutation in colorectal adenocarcinoma: a rare case of Lynch syndrome Top

Vamshi Krishna Thamtam, Neeraj Arora, Biswajoy Pal, Pragya Gupta, Debdeep Dey, Paromita Roy, Angad Singh, Mohandas Mallath, Manas Roy, Joydeep Ghosh, Sandip Ganguly, Deepak Kumar Mishra

Tata Medical Center, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Lynch syndrome is an autosomal dominant disorder caused by germline mutation in one of several DNA mismatch repair genes (MMR), or due to deletion in the EPCAM gene. Deletions involving EPCAM gene are causative in 1% to 2.8% of families with Lynch syndrome. Herein we describe a rare case of colorectal adenocarcinoma showing an EPCAM germline pathogenic mutation. Design: A 51 years-old female presented with diarrhea, haematochezia, abdominal pain, and loss of appetite. There was no organomegaly, fever, vomiting or other symptoms. Family history revealed colon cancer in a cousin and unknown cancer in uncle. Sigmoidoscopy showed large tumor measuring more than 5 cm. She underwent laparoscopic anterior resection for a recto-sigmoidal growth. Histopathological examination revealed moderately differentiated mucinous adenocarinoma, with brisk lymphocytic infiltrate. The tumor was evaluated both by MSI-PCR and MMR protein expression by IHC. Peripheral blood mutation testing was done for commonly implicated genes with hereditary colon cancer by NGS, as recommended by the ACMG. Results: IHC revealed complete loss of MSH2 and a heterogeneous staining (intraglandular loss) of MSH6. MSI-PCR showed instability of all microsatellite markers (BAT-25, BAT-26, NR-21, NR-24 & MONO-27). Germline mutation analysis revealed a pathogenic heterozygous deletion mutation of exons 8-9 in the EPCAM gene. Conclusion: Worldwide, numerous EPCAM 3'-end deletions that differ in size and location are described. The risk of colorectal cancer in carriers of EPCAM deletions is comparable to that of MSH2 mutation carriers, and is in accordance with a high expression of EPCAM in colorectal cancer stem cells.

   PP178: Diagnosis of mutilocular cystic renal neoplasm of low malignant potential-A serendipity Top

Nekta Anand, Amruta Patil, Darshana Wakkar, V R Pawar

Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra, India. E-mail: [email protected]

Background: Multilocular cystic renal neoplasm of low malignant potential is a rare variant of clear cell carcinoma of kidney. It is recognized as a separate subtype of renal cell carcinoma in 2004 WHO classification of renal tumor. Design: Ours is a case of 73-year-old female who presented with symptoms of uterovesical prolapse. Incidentally a right renal mass was detected at her abdominal sonography and was suspected to be a conventional renal cell carcinoma with cystic change. Results & Discussion: On histopathology diagnosis of Multilocular cystic renal neoplasm of low malignant potential was given. The histopathological diagnosis was confirmed with immunopositivity for EMA, PAX-8, CK7 and immunonegative for ER, PR, AMACR. Multilocular cystic renal cell carcinoma is often unilateral, with no side predilection, and is slightly more often seen in men than in women (1.7:1). It is frequently misdiagnosed as a benign renal cyst. The differential diagnosis includes cystic nephroma, conventional renal cell carcinoma and tubulocystic carcinoma. It carries excellent prognosis following excision. Conclusion: This case is being highlighted for its rarity, accidental presentation and to avoid misdiagnosis of conventional renal cell carcinoma.

   PP179: Glomerular morphometry-A useful adjunct in the diagnosis of pediatric nephropathies Top

A W KASHIF, Nisha Verma, Ajay Malik, Dibyajyoti Bourah

Armed Forces Medical College, Pune, Maharashtra, India. E-mail: [email protected]

Background: Only few studies describe histopathological changes in the renal biopsies performed in pediatric patients. This study was conducted to

  1. To ascertain any difference in Bowmans capsule area (BCA), Glomerular capillary tuft area (GCTA) and Bowmans space area(BSA) with nephrotic and nephritic pediatric nephropathies
  2. To identify any association between BCA, GCT and BSA with different renal function parameters in pediatric nephropathies

Design: It is a retrospective crossectional study done over a period of 05 years and includes 28 cases of pediatric (age till 14 years) nephropathies. Diseases were divided into three groups – Nephrotic presentation (Podocytopathy group-MCD/FSGS), Nephritic presentation (HSP, IgA nephropathy, Lupus Nephritis, Alports disease) and Healthy controls (Renal tissue from age matched autopsy cases). Clinical profile of these patients included Hemoglbine, Serum Creatinine, Blood Urea, Urine Protein Creatinine ratio, Serum Cholesterol, Serum Total Protein, Serum Albumin and Liver function test. Glomerular morphometry was performed by semiautomatic procedure using Quantimet-600 image analysis system (Leica, Cambridge, UK). Atleast 5 glomeruli were studied and their mean was calculated for BCA, GCT and BSA; for the three groups respectively. Results and Discussion: Mean of BCA was higher in the Nephrotic group than the control group and Nephritic group. The mean GCTA was least in Nephritic group. Statistical significance was found between BCA, GCT and BSA with Renal function parameters in the disease group. Conclusion: Glomerular morphometry may contribute to the diagnosis of some glomerulopathies and the association between glomerular morphometric parameters and laboratory data may promote better understanding of the disease.

   PP180: Ewing sarcoma of kidney: A rare case Top

Vinaya Gore, Anitha Padmanabham, Nitin Gadgil, Leena Naik

Lokamanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Ewing sarcoma (ES) and Primitive neuroectodermal tumor (PNET) have been unified into a single category: The Ewing Sarcoma Family Tumor(ESFT). It is high grade malignant tumor and approximately 85-90% are associated with DNA translocation t(11,22)(q24,q12). Primary Renal ES/PNET is very rare with <100 cases have been reported in literature till date. Design: We present a case of 35-year-old male, who presented with complaints of left sided loin pain and haematuria since one week. CT scan was suggestive of large lobulated mass lesion in the left kidney replacing the almost entire kidney and bony metastatic lesions in multiple bones. Patient underwent left radical nephrectomy. Result and Discussion: On gross a 20×13×8cm bosselated tumor with diffuse infiltration of kidney parenchyma by fleshy mass having variegated appearance and focal areas of hemorrhages and cystic changes. Histopathology showed tumor composed of small round blue cells arranged in sheets with vacuolated cytoplasm and central nucleus with fine to slightly coarse chromatin. At places tumor cells arranged in peudorosette pattern. Adrenal gland was also involved by tumor. Immunohistochemistry showed membranous diffuse positivity for CD99, negative for synaptophysin, CD56 and chromogranin, hence confirming the diagnosis of Ewing Sarcoma (ES). On follow up within 2 month, patient developed altered sensorium and multiple palpable metastatic lesion in the skull and subsequently expired. Conclusion: Primary ES/PNET of the kidney is a rare tumor. Histopathology and immunohistochemistry are gold standard for diagnosis.

   PP181: Malformation and it's hidden misery Top

V Vidhya

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Horseshoe kidney is the most common congenital renal fusion anomaly seen in 1 in 400. Carcinoma arising in a horse shoe kidney is very less. The incidence of urothelial malignancy in a horseshoe kidney is very rare, much more is the rarity of occurrence of divergent differentiation of urothelial carcinoma. Case Details: 66 years old male, known case of horseshoe kidney presented with complaints of hematuria for 1 week. Baseline blood investigations were normal. Urine was reddish in colour with RBC > 409 cells/HPF. PET scan showed Horseshoe kidney with focal FDG avid lesion seen in isthmus extending to bilateral lower poles and right midpole possible of malignant etiology with right renal calculus without obstructive features. Right open nephrectomy was done, grossly single lesion extending up to upper pole was noticed in the horseshoe kidney. Microscopic examination showed malignant cells, in papillary pattern, adenoid pattern with squamous differentiation and classic urothelial carcinoma pattern. The tumor Islands were seen penetrating up the renal parenchyma. Immunohistochemistry stains were positive for p63, GATA3 thus confirming the urothelial carcinoma. The margins were involved. Patient was referred to Oncologist opinion. Conclusion: Common malignancies associated with horseshoe kidney are Wilms tumor and adenocarcinoma. Recognition of the variants are important as they have prognostic implication.

   PP182: Renal angiomyolipoma: A clinicopathological study in a tertiary care centre Top

T Annie Mary Prashanthy, Geeta Chacko, Santosh Kumar, Arun Jacob Philip George

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: [email protected]

Background: Angiomyolipoma(AML) is a relatively rare entity. It is however, the mostcommon benign mesenchymal neoplasm of the kidney.Though benign it can cause significant morbidity and mortality due its distinct clinicopathological characteristics.It is therefore of utmost importance that an accurate diagnosis of AML be made. Objectives: 1.To evaluate the prevalence and clinicopathological characteristics of renal AML. 2.To evaluate the association of renal AML with renal or other malignancies and with tuberous sclerosis complex(TSC). Methods: This retrospective descriptive study was carried out in the Department of General Pathology, Christian Medical College,Vellore during the period 2017-2019 on all the diagnosed cases of renal AML from 2001 to 2018. Demographic and clinical details were obtained from the electronic medical records and analyzed.The histopathological details of all cases were reviewed either from the archives or by examining the slides. Results and Discussion: There were a total of 88 cases in this study. AML was more common in females (female:male = 2.2:1) and the median age of presentation was 41±11.7 years.58% of patients were symptomatic.79 cases(90%) were classic AML, while 9cases(10%) were epithelioid AML. 10 cases of AML (11%) were associated with Tuberous sclerosis (TS) . Compared to sporadic cases those associated with TS differ in tumour size(P = 0.002)), and are more often bilateral (P=0.000) and multiple (P=0.003). Conclusion: This is a relatively large series of renal AMLs from a tertiary care centre in South India which highlights the clinicopathological features of this rare tumor.

   PP183: Russel viper venom induced thrombotic microangiopathy: A pathologist's view Top

Pranita Halge, Deepika Tamhankar, Anitha Padmanabhan, Nitin Gadgil, Leena Naik

Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Thrombotic microangiopathy as a cause of snake bite induced acute kidney injury is uncommon. Here we present russel viper venom induced thrombotic microangiopathy resulting in renal failure. Design: A 48 years male diabetic and hypertensive was transferred to our tertiary care centre from a general hospital after snake bite on right hand. He presented as cellulitis with swollen, discoloured hand. Later patient had thrombocytopenia , deranged clotting time, INR and raised serum creatinine. On admission he was treated with polyvalent ASV. During course with decreasing urinary output he developed anuria and underwent hemodialysis along with surgical debridment for cellulitis. Renal biopsy performed showed fibrin thrombi in glomerular capillaries, onion skinning of interstitial vessels and intimal hyperplasia and immunofluorescence test done for IgG, IgM, IgA, C3 and C1q were negative so the diagnosis was given as russel viper venom induced thrombotic microangiopathy. Result and Discussion: Snake bite induced acute kidney injury is an uncommon occurance. Viper venom is notoriously vasculotoxic leading to hemodynamic changes commonly affecting kidneys. Such kidneys show fibrin thrombi in the glomerular capillaries, mesangiolysis, vascular onion skinning and intimal hyperplasia which are suggestive of russel viper venom induced thrombotic microangiopathy. Conclusion: Thrombotic microangiopathy should be considered as a possible pathogenesis of acute kidney injury after snake bite as early identification can contribute to better prognosis.

   PP184: Multicystic nephroma: A rare case report Top

Apoorva Nigam, Apoorva Nigam, Amrinder Kaur, Ramesh Kumar Kundal, Harjinder Singh

GMC, Patiala, Punjab, India. E-mail: [email protected]

Background: Multilocular Cystic Nephroma represents a rare benign cystic lesion of the kidney which usually presents as unilateral renal mass without solid elements. The non specific clinical presentation and confusing radiological features create difficult pre-operative differentiation from malignant cystic renal neoplasm. Design: Case Report. Result and Discussion: The present case describes a case of 26 yr old Female who came to gynecology department with History of abortion. No flank pain or hematuria was reported. Usg/CT scan showed incidental well defined heterogeneous mass with cystic component at the lower pole of right kidney. Provisional diagnosis of cystic renal carcinoma was made. Nephrectomy was done. On gross examination, a well circumscribed tumor was seen at lower pole with cystic appearance , no solid component was identified. On extensive sectioning of the tumor, an impression of multicystic nephroma was based on histopathological findings. Conclusion: Cystic nephroma can present a diagnostic dilemma for radiologist preoperatively and pathologist post operatively because of rarity of lesion and overlapping morphological features between Cystic Partially differentiated nephroma and Multicystic Renal cell carcinoma. Definitive diagnosis made on extensive sections and lack of blastemal elements and clear cells. Even IHC cannot differentiate between RCC and MCN but still suggested for supporting evidence. Since treatment and prognosis is entirely different so making a correct diagnosis is impertinent.

   PP185: Immune complex associated glomerulonephritis in a patient with prefibrotic primary myelofibrosis: A case report Top

Tanya Sharma, Dr Mahendra Atlani1, Deepti Joshi, Dr Aman Kumar2

Departments of Pathology and Lab Medicine,1Nephrology and2Radiodiagnosis, All India Institute of Medical Sciences Bhopal, Madhya Pradesh, India. E-mail: [email protected]

Background: Renal involvement is reported to be uncommon in cases of Myeloproliferative Neoplasms (MPNs) and may occur in form of thrombosis of renal arteries, extramedullary hematopoiesis or leukemic infiltration in renal parenchyma causing obstructive uropathy and renal failure. The glomerular involvement in cases of MPNs has been described in various studies as 'MPN-related glomerulopathy' which include hypercellularity, segmental sclerosis, features of chronic thrombotic microangiopathy (TMA), and intracapillary hematopoietic cell infiltration. However, none of the cases have shown immune complex mediated glomerulonephritis. Case Report: A case of Prefibrotic Myelofibrosis with immune complex mediated Glomerulonephritis is presented. A 45 year female, with history of right subclavian and axillary vein thrombosis, presented with abdominal distension, facial puffiness and pedal edema. Evaluation revealed deranged renal functions with Nephrotic range proteinuria and Acute Kidney injury. JAK2 mutation evaluated in view of portal vein thrombosis and splenomegaly was positive. Renal biopsy revealed mesangioproliferative glomerulonephritis with full house immune complex deposition on Direct Immunofluorescence (DIF). The patient had no signs or symptoms of Systemic Lupus Erythematosus and serological markers for autoimmune or collagen vascular disease were negative. Discussion and Conclusion: Renal involvement in Myeloproliferative Neoplasms (MPNs) is uncommon and histological patterns of DIF negative mesangial proliferative glomerulonephritis, focal segmental glomerulosclerosis (FSGS) and IgA nephropathy have been reported. Renal involvement may occur early as well as late in the course of MPNs and immune complex associated glomerulopathy could be a manifestation of early occurrence of renal disease in this continuum.

   PP186: Renal tumour with pericytomatous pattern, a rare entity with diagnostic difficulty and unpredictable behaviour Top

Anuprita Satish Kulkarni, Rakesh Ajmera1, Somesh Nilkanth1, Hemant Kokandakar1, Anil Joshi

Government Medical College,1Government Medical College and Cancer Hospital, Aurangabad, Maharashtra, India. E-mail: [email protected]

Introduction: Renal pericytoma is a rare tumour of kidney. It is a soft tissue tumour which originates from the myopericytes which are transitional cells between pericytes and smooth muscle cells of arteries and veins. On microscopic examination, it shows spindle cells, foamy cells and thickening of vessel wall. Patient usually presents with hematuria and pain in abdomen in the 5th decade of life. Case Description: We here present a case of 52 years old male patient presenting with pain in abdomen. Preoperative imaging and USG guided FNAC were suggestive of Renal cell carcinoma. We received specimen of left radical nephrectomy, grossly showing brownish tan lesion of size 5x4.5x4.5cm at mid portion of kidney. Microscopic examination revealed a dual population of large cells with binucleated pleomorphic nuclei with abundant foamy cytoplasm, interspersed between these were bland spindle cells. IHC studies ruled out conventional and Sarcomatoid Renal Cell Carcinoma and Angiomyolipoma. CD34, CD68 and SMA positivity showing a possibility of pericytomatous tumour was considered. Conclusion: Pericytomatous tumours primarily involving kidney are extremely rare and this case proved the diagnosis to be difficult even on IHC studies. The differentials of hemangiopericytoma/myopericytoma/glomangiopericytoma were considered. Radical nephrectomy is the preferred treatment with variable outcome with close follow up because of the unpredictable behaviour.

   PP187: Clinicopathological spectrum of renal biopsies in glomerulonephritis Top

Aditi Sharma, Harpreet Kaur, Pavneet Kaur Selhi, Vikas Makkar1

Departments of Pathology and1Nephrology, DMCH, Ludhiana, Punjab, India. E-mail: [email protected]

Introduction: Glomerulonephritis is defined as glomerular injury due to inflammation and is characterized by increase in glomerular cellularity. These patients usually have hematuria with varying degrees of proteinuria. There are many forms of glomerular diseases presenting with varying patterns and pathogenesis. Aims: To study the histo-pathological spectrum of renal biopsies taking into account morphology and Immunofluorescence in glomerulonephritis and to correlate them with clinical profile and laboratory parameters. Materials and Methods: The study was conducted over a period of 1.5 years in the department of Pathology. Renal biopsies of patients presenting with hematuria with or without proteinuria were included in the study. These were analyzed in detail with reference to the light microscopic findings (H&E, PAS, Silver and MT stain) with immunofluorescence. Results: A total of 416 renal biopsies were received in the department of pathology, over the period of 1.5 years; of which 68 cases fulfilled the inclusion criteria and were included in the study. Age of these patients raged from 7 years to 92 years with slight female predominance (F:M-1.2:1). Most common histo-morphological pattern encountered was crescentic glomerulonephritis. IgA Nephropathy and Lupus Nephritis were the most frequent etiologies. Conclusion: Glomerulonephritis are clinically significant as they affect young people and have rapid progression to chronic kidney disease with associated morbidity and cost.

   PP188: Increasing relevance of electron microscopy in renal pathology Top

Oshan Saini, Ashwani Kumar, C S Rayat, A W Kashif, Gnanpriya, Raja Ramachandran, Vivek Kumar, Manish Rathi, H S Kohli, Ritambhra Nada

PGIMER, Chandigarh, India. E-mail: [email protected]

Background: Electron microscopic (EM) evaluation of renal biopsies is integral part of comprehensive diagnosis, though not available in many resource constraint laboratories. It is diagnostic in certain conditions where structural changes or evaluation of organised deposits are integral to the diagnosis. It may be complementary in certain conditions where it fine tunes the diagnosis established on light microscopy and immunofluorescence. This study was undertaken to stratify renal biopsies into these diagnostic groups with variable utility of EM to reinforce or undermine it's use in context of cost effectiveness in Indian scenario. Design: Retrospective study of renal biopsies with EM reports from 2008 to July 2019 (12years) subgrouped into a) diagnostic essential b)complementary c) not essential. Results: There were total of 12409 renal biospies in the mentioned period (Native-9735 , Allograft – 2674). EM was done in 11,175 cases (Native – 9500, Allograft – 1675). The diagnosis were as follows


1. Native

Podocytopathy 1236

MCD 565

FSGS 671




Other Glomerular Diseases

  • Dense Deposit Disease 64
  • C3 Glomerulonephritis 59

Alport's disease 40

Monoclonal conditions

  • MIDD 33
  • PGNMID 10
  • Tubulopathy 9

Organised Deposits

  • Cryoglobulinemia 12
  • Fibrillary 5
  • Collagenofibrotic 5
  • Immunotactoid 3
  • Cryofibrinogenemia 1

Fabry's Disease 6

2. Transplant biopsies

Glomerular Diseases

  • C3 Glomerulonephritis 8
  • Dense Deposit Disease 8

Podocytopathy 5

Anti Body Mediated Rejection

  • Peritubular capillaropathy 484
  • Transpalnt Glomerulopathy 202



MGN 976

Tubulopathy-crystalline/ non-crystalline 31


IGAN 952

TMA 453




AKI 375


Conclusion: Electron Microscopy was essential for diagnosis in 19.8% (2220/11175); 15.9% ( 1513/9500) of native biopsies and 42.2 % (707/1675) of transplant biopsies. In 15.8 % (1763/11175) it was complementary in improving precision of diagnosis. In 64.4 % (7192/11175) of biopsies it was not essential. Hence, with increase in diagnostic categories like C3 Glomerulopathy, Podocytopathy in setting of other glomerular diseases,PGNMID, tubulopathies, changed definition of transplant glomerulopathy, the utility of diagnostic biopsies has increased over the years, hence should still be considered essential for diagnostic renal biopsies.

   PP189: Paraganglioma of filum terminale: A rare case report Top

Venkata Sri Laxmi Chennupati

Prathima Institute of Medical Sciences, Nagunoor, Telangana, India. E-mail: [email protected]

Background: Paragangliomas are benign neoplasms originating from autonomic nervous system,generally found in adrenal & extra adrenal locations.Extra adrenal paragangliomas are rare and occur most commonly in carotid bodies and glomus.Primary spinal paragangliomas are extremely rare,most frequently involve cauda equina and filum terminale. Design: A 55yr old female presented to neurosurgery OPD with low back ache and sciatica.MRI spine was suggestive of L3-L4 lesion most probably Schwannoma. Results and Discussion: H&E stained sections showed fibrocollagenous capsule.Subcapsularly, tumor cells arranged in cords and lobules,forming perivascular pseudorosettes.Individual cells are round to oval with pale to clear cytoplasm and salt and pepper chromatin.IHC showed positivity with Synaptophysin and S100.Immunoprofile suggestive of neuroendocrine tumor, probablyPARAGANGLIOMA. Conclusion: In view of histomorphological and radiological similarities of various tumors,IHC plays an important role for confirmation and prognostic evaluation.Paragangliomas though rare need to be considered one of the differentials for tumors of cauda equina/filum terminale.These are benign slow growing tumors with gross surgical resection as first line treatment with nearly immediate improvement in symptoms.

   PP190: Solitary plasmacytoma with amyloid: An unusual dural based lesion Top

Pooja Kamlesh Gajaria, Ashvini Kolhe, Naina Goel, Asha Shenoy

Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Neoplasms affecting the dura, other than meningiomas are rare and include metastasis, solitary fibrous tumor/ hemangiopericytoma, melanoma or lymphoma. Solitary extraosseous plasmacytoma (SEP) affecting the dura is extremely rare with about 13 cases reported in literature of which 2 showed amyloid. Case Report: A 50 year old male complained of headache, right sided weakness, giddiness and vomiting since 2 months. Magnetic Resonance Imaging showed a 10x8.7x3.9cm homogeneously intensely enhancing dural based lesion in left fronto-parietal region suggestive of meningioma. He underwent left fronto-parietal craniotomy with excision of the tumour. Grossly, multiple grey brown, firm tissue bits were received along with thinned out membrane-like bit of calvarium measuring 8x6x0.1cm. H&E sections revealed plasma cell neoplasm with nodules of eosinophilic acellular material. Polarizing microscopy with congo-red stain demonstrated apple-green birefringence, confirming it as amyloid. Immunohistochemistry showed tumour cells to be positive for CD38, CD138 and kappa light chain restriction. Mib-1 proliferative index was 2-3%. Tumor was diagnosed as plasmacytoma. Serum electrophoresis showed M band (IgG Kappa). Bone marrow was not involved. Bence Jones proteins were negative. Positron Emission Tomography scan did not show active metabolic disease anywhere in the body, thus ruling out systemic myeloma disease. On follow-up, the patient is free of disease, 6 months post-surgery. Conclusion: Dural involvement in plasma cell neoplasms is usually seen as a part of multiple myeloma. SEP need to be reported with caution. These have a good overall prognosis. Follow-up is recommended to look for subsequent development of systemic myeloma.

   PP191: Vagus nerve schwannoma in parapharyngeal space: A case report Top

Nainshi Bhatt, Sheetal Sale, Vaibhav Mane

Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Sangli, Maharashtra, India. E-mail: [email protected]

Background: Parapharyngeal space tumors account for less than 0.5% of head and neck neoplasms.Vagus nerve schwannoma is a rare, slow growing neurogenic tumour but with good prognosis. Design: 31 year old female patient presented with complains of change in voice,muffled (Hot Potato) low pitch and hoarseness of voice for 1.5 years,difficulty in swallowing solids for 2 months.Clinical and radiological examination in the form of CT and MRI examination revealed a firm,left parapharyngeal mass with smooth surface measuring 62x55x42mm compressing the hypopharynx with absent gag reflex,on the basis of which a clinical diagnosis of Schwannoma or Pleomorphic adenoma was made.Transoral left parapharyngeal mass excision was done.The final histopathological diagnosis was Schwannoma of Vagus nerve. Result and Discussion: Parapharyngeal space tumours can be primary,metastatic or tumoral extensions.Primary neoplasms are either salivary gland tumors or neurogenic tumors.Benign Neurogenic tumors are the second most common and are schwannomas,neurofibromas and paragangliomas.Schwannoma of vagus nerve is uncommon ( 2-5%),slow-growing, asymptomatic benign nerve tumors which can occur at any age and is seen equally in both sex.It may cause secondary symptoms such as dysphagia,hoarseness and nasal obstruction.Hoarseness is the most common complication after surgery.IHC immunoreactivity for S-100,calretinin and CD56 is highly suggestive of schwannoma. Conclusion: Parapharyngeal space vagus nerve schwannoma is a rare,slow growing neoplasm.CT and MRI can be very useful for surgical planning and identifying the nerve of origin.Complete surgical excision is the treatment of choice and recurrence is rare.

   PP192: Lhermitte - duclos disease: A report of five cases Top

Shubhra Tayal, Naina Goel

Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: The Lhermitte-Duclos disease (LDD), also known as Dysplastic cerebellar gangliocytoma is a rare lesion characterized by variable enlargement of cerebellar folia. The pathologic basis of LDD has long been debated, as it has overlapping features of both neoplasm and hamartoma, although recurrence following initial surgery has been cited as evidence of neoplastic etiology. Association between adult-onset LDD and Cowden syndrome (CS) has been established based on the presence of PTEN germline mutation in both. Case Report: We present a series of five cases of LDD, of which, four were females and one male, with age distribution from 16 to 38 years. Commonest presenting complaints were headache and imbalance on walking of 1.5 months to 7 months duration. Two of the five cases were received for intra-operative assessment. Histo-morphology showed characteristic thickening and vacuolation of the molecular layer, loss of Purkinje cells, replacement of granular cell layer by large dysplastic ganglion cells which were arranged in nodules and clusters. There was focal calcification seen. Two cases also showed associated gliosis and inflammation. Conclusion: LDD is a rare entity, associated with Cowden syndrome in 80% of cases. Radiological correlation is necessary in tiny biopsies to avoid misinterpretation. Further clinical workup and close follow-up is required in the absence of the associated features of CS.

   PP193: Histopathological audit of nerve biopsies: Ten years data Top

R K Saran, Aditi Goyal, Arun Kaul1, Debashih Chaudhary1

G B Pant IPGMER,1Department of Neurology, G B Pant IPGMER, New Delhi, India. E-mail: [email protected]

Background: The decrease in nerve biopsy in the present day scenario is mainly attributed to improved electrophysiological diagnostics and genetic methods (PMP22 mutation). Nevertheless, nerve biopsies are helpful in certain diagnostic dilemmas specially in diagnosing the cause of mono-neuritis multiplex. In Indian scenario, cases of neuritic leprosy also play an important indication requiring nerve biopsy. Design: A retrospective audit of data of nerve biopsies received over a period of 10 years was done. Results and Discussion: Total of 463 nerve biopsies were received from August 2009 to July 2019. Apart from 99 cases which were non- diagnostic (inadequate, normal or end stage nerve), 363 cases showed morphological changes. 143 cases showed features of non-specific axonopathy, 44 cases showed features of demyelinating diseases and 32 cases of hereditary sensory motor neuropathy. Specific diagnosis could be made in 145 cases (31%) including vasculitis (68 cases), neuriticleprosy (64 cases) and rarer cases of diabetic neuropathy (5 cases), toxic neuropathy (3 cases), neuroma (4 cases) and amyloid (1 cases). Conclusion: Though the role of nerve biopsies has gradually decreased according to world literature, it is nearly the same over 10years in our resource limited setting and does provide a specific diagnosis in about one-third cases.

   PP194: Histomorphological and immunohistochemical study of medulloblastoma: A series of 9 cases Top

Surbhi Dahiya, Harendra Kumar, Chaitali Jain, R C Mishra

Sarojini Naidu Medical College, Agra, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Medulloblastoma is a malignant brain tumor (WHO grade IV) that is thought to arise from stem cells located in the subependymal matrix. It constitutes 20 % of cancer deaths among pediatric patients. Clinically, they fill the 4th ventricle and present insidiously with signs and symptoms of elevated intracranial pressure secondary to obstructive hydrocephalus. Methods: We hereby, report a series of 09 cases of posterior fossa tumors, which presented clinically with symptoms of raised intracranial pressure of insidious onset and were operated in the neurosurgery department. Results: The age of the patients ranged from 01 to 19 years with male predominance (07 males and 02 females). The biopsy samples revealed histomorphological features of medulloblastoma showing densely cellular small blue round tumor cells in a syncytial arrangement with frequent mitosis and occasional Homer- Wright rosettes. Out of 9 cases, 8 were of classic medulloblastoma and 1 case was of desmoplastic medulloblastoma. The diagnoses were confirmed using a panel of IHC markers- synaptophysin, chromogranin, INI-1, MIB- 1 and EMA. Synaptophysin was positive in all cases, chromogranin and INI-1 was positive in 08 cases. MIB-1 reactivity ranged from 50% to 80%. Conclusion: Medulloblastoma is the second most common brain tumor in children after pilocytic astrocytoma. Dissemination within CSF pathways is characteristically common and signifies a dismal prognosis. WHO classified medulloblastoma into four subgroups: WNT activated, SHH activated, group C and group D (non WNT and non SHH activated). All carry different prognostic significance and show specific IHC profiles. Thus, optimizing the treatment plans.

   PP195: Malignant peripheral nerve sheath tumor with neuroblastic differentiation in young child: Rare entity Top

Ashvini Pandit Mane, R J Ajmera, S P Nilkanth, H R Kokandakar

Government Medical College and cancer Hospital, Aurangabad, Maharashtra, India. E-mail: [email protected]

Introduction: Malignant peripheral nerve sheath tumors (MPNSTs) are rare tumors with a incidence of 1 per 10 lakh people per year. Most of MPNST occurs in the deep soft tissue, usually close to a nerve trunk. MPNSTs locate in the extremities and most of paraspinal MPNST is metastatic lesion, so primary paraspinal MPNST is very rare . Malignant peripheral nerve sheath tumour usually occurs between 20-50 years of age, comprising about 5-10% of soft tissue sarcomas. Only 1.7% of them have been reported to occur in children < 5 years of age.

Case Description: A two year female child had presented with swelling over back since birth. Swelling was increasing in size since last 2 months. MRI lumbar spine – abscess/ inflammatory cyst. USG local- ? Neurofibroma. Excision of paraspinal cyst had done. On histopathology examination- malignant undifferentiated tumor with morphological differential diagnosis were neuroblastoma, angioimmunoblastic meningioma. IHC findings are spindle cell component positive for S-100, neuroblastic component positive for synaptophysin which confirmed diagnosis of malignant peripheral nerve sheath tumor with neuroblastic differentiation. Same patient presented with recurrence of same swelling after 2 months of previous excision. Biopsy from suspected recurrent lesion show recurrent tumor infiltrating adjacent fibroadipose tissue.

Conclusion: Considering age and site of presentation this case is unusual and rare presentation of malignant peripheral nerve sheath tumor with neuroblastic differentiation. Differential diagnosis of malignant peripheral nerve sheath tumor kept in mind whenever paraspinal swelling evaluated. MPNST are usually high grade sarcoma and has potential differentiation of the primitive neuraloblastic component.

   PP196: A Rare case of multifocal pindborg tumour Top

Maymol P Varghese

Kerala University of Health Science, Thrissur, Kerala, India. E-mail: [email protected]

Background: A 23 year old female presented with pain and swelling in lower jaw since 3 months.On examination irregular,malaligned ,retained deciduous teeth with missing permanent molars and canine noted. X-ray showed multiple impacted teeth.Clinical diagnosis made was dentigerous cyst following which multiple cyst excision in maxilla and mandible was done. Specimen was received as multiple bits of pale brown firm to hard tissue aggregate measuring 3x2x1cm.Microscopy revealed a lesion composed of islands and strands of polyhedral epithelial cells with distinct outlines in a fibrous stroma .Deposits of amorphous eosinophilic material with degeneration of the epithelial cells seen.Concentric calcification which fused to form large calcified mass also noted.Congo red showed apple green birefringence.Diagnosed as Pindborg tumour [Calcifying Epithelial Odontogenic Tumour(CEOT)]. Discussion: Pindborg tumour or CEOT is a rare and benign entity accounting for less than 1% of odontogenic tumours.It occurs commonly in fourth or fifth decade as a slow growing painless unifocal tumour.It is locally aggressive and frequently affects mandibular premolar-molar area.Grossly it present as a solid lesion but cystic variety also seen.Multifocal CEOT are not typical but have been observed in conditions associated with known genetic mutations such as nevoid basal cell carcinoma syndrome. Conclusion: We present a multifocal variant of CEOT in a young female.To the best of our knowledge only two such case reports have been published suggesting the rarity of the lesion.

   PP197: An unusual metastatic site: Nose, sinuses and nasopharynx Top

Varun Kumar Singh, Mary Mathew1, Ranjini Kudva1, Kanthilatha Pai1, Arijit Bishnu2

Melaka Manipal Medical College, Manipal Campus, Manipal Academy of Higher Education,1Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka,2Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: [email protected]

Background: Metastases to the sinonasal region are rare and presents with features overlapping with various regional neoplastic/non-neoplastic lesions. This series aims to highlight the clinical presentations and diagnostic difficulties of sinonasal metastases. Design: A review of pertinent demographic and laboratory data for patients diagnosed with metastases to the sinonasal region, over a period of 6 years (2012- 2017) was done. Results and Discussion: Seven cases (males- 6, females-1) of sinonasal and nasopharyngeal metastases were identified. The age ranged from 41-72 years. The common clinical presentation were nasal obstruction, epistaxis and pain. Grossly tumours were irregular masses (mean size – 4.2cm) with maxillary sinus as the most common site. The histologic types included Squamous cell carcinoma (3cases), clear cell renal cell carcinoma (2cases), and one case each of infiltrating ductal carcinoma, and malignant eccrine spiradenoma. The site of primary tumour were larynx (2/7), kidney (2/7), breast (1/7), lung (1/7) and neck (1/7). The mean time interval between the primary tumour and metastasis was 4.5 months. Six patients underwent radical excision while one received palliative therapy. Metastatic breast and renal tumours comprise the bulk of reported cases in English literature. Metastasis from a lung carcinoma are rare and here we report the first case of a metastatic malignant eccrine spiradenoma to maxillary sinus. Conclusions: Owing to the overlapping clinical presentations, a high degree of suspicion is needed in patients with previous history of malignancy for early diagnosis. The current course of therapy is palliative for such patients and carries a grim prognosis.

   PP198: Tuberculosis at unusual sites: A case series from tertiary care center in central India Top

Jayanti Chandrakar, Renuka Gahine, Bhavana Thahur, Vanita Bhashkar, Varsha Pandey1

Pt JNM Medical College,1Pt IN Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Tuberculosis is the top 10 causes of death worldwide specially in developing countries . Pulmonary infection is the commonest form of the disease, though the bacteria can cause systemic infection in virtually any organ. Due to a very high incidence and prevalence of pulmonary TB in India, different forms of extrapulmonary TB are also relatively high. Extrapulmonary tuberculosis with the rarest and most unexpected localizations represents a significant proportion of all cases of tuberculosis and remains an important public health problem. It can present in many diverse ways at unusual sites, which can be confused with many treatable and nontreatable conditions. Cases: We are presenting a case series of 10 cases of extrapulmonary tuberculosis at unusual sites. One case was from gallbladder, presented with perforation of gallbladder. Another case was presented as bilateral nasal obstruction, having TB soft palate near uvula. One endometrial biopsy specimen for primary infertility had granulomatous lesion. One case was from nodular lesion in the tongue, mimicking to carcinoma was having tubercular lesion. Other cases are from glassoepiglottic fold ,breast ,skin and mandibular soft tissue swelling. Conclusion: The unusual localization of tuberculosis also highlight the possibility of extrapulmonary tuberculosis as a differential diagnosis in many common diseases. Hence, it is very important to have a high index of suspiciousness to rule out TB, as this disease is a curable disease. Late diagnosis or untreatable TB will lead to high morbidity and mortality.

   PP199: Cysticercosis presenting as ranula: A rare occurrence Top

Tanmay Patel, Neha Madan, Charanjeet Ahluwalia, Rashmi Arora

Vardhman Mahavir Medical College, New Delhi, India. E-mail: [email protected]

Background: Cysticercosis seldom involves oral cavity in humans. It results from extra-intestinal encystation of the larval form of Taenia solium. Although the precise incidence remains unknown, oral cysticercosis is considered a rare event and an exact clinical diagnosis is not generally established. Here we present a case of cysticercosis as the cause of a sublingual swelling in a young male. Case Report: A 20 year old male presented with a painless sublingual swelling. The swelling was cystic, globular with a diameter of 1cm. The cyst was filled with clear fluid. An excision biopsy was performed with a provisional diagnosis of mucus retention cyst (ranula). Microscopic examination revealed the presence of larval form of Cysticercus cellulosae surrounded by dense inflammation and granulomatous reaction. Discussion: Cysticercosis can present at rare sites. It is important to consider the diagnosis of cysticercosis in oral lesions which present as single nodules, especially in patients coming from endemic areas. Conclusion: Once the diagnosis of cysticercosis is established, treatment should be initiated promptly and a search for involvement of other sites should be undertaken to avoid complications.

   PP200: Intraoperative frozen section consultation: An audit of 110 cases in a tertiary care hospital Top

Pragya Sharma, P Arpitha, Arijit Sen, Shiv Kumar, P K Jaiswal, Angshuman Datta, B N Pathak, R Gangavatikar

Command Hospital Air Force, Bengaluru, Karnataka, India. E-mail: [email protected]

Background: Frozen section (FS) influences surgeon's decision and further management of patient by helping in intraoperative diagnosis of tumors, margins, lymphnode assessment and organ identification. Audits of the frozen section consultations help in identifying the pitfalls and carrying out preventive measures for its optimal usage. Design: A retrospective study of 256 specimens from 110 cases of FS consultations was performed. The FS reports and corrosponding formalin fixed tissue reports were analyzed. The results were categorized into concordant and discordant. Diagnostic accuracy, discordance, sensitivity and specificity were evaluated. Causes for discrepancy and limitations of FS were analyzed. Results and Discussion: The study included 71 (64.5%) females and 39(35.5% ) males.Majority of frozen sections were requested from Department of Obstetric and Gynaecology (43.6%). Ovarian mass was the commonest specimen received for evaluation. Most common indication for frozen section evaluation was for establishing nature of lesion i.e malignant versus benign. 105 (95.45%) cases were concordant and 05 (4.5%) were discordant with histopatholgical diagnosis. The diagnostic accuracy was 95.45% with sensitivity and specificity of 97.44% and 94.37 % respectively. Interpretative error was the main reason for discordance in 04 cases and sampling error in 01 case. Conclusions: FS diagnosis is highly accurate very useful but one needs to be aware of its indications and limitations. Avoiding technical errors and close cooperation with surgeon can avoid limitations and provide rapid reliable information necessary for patient care. The study turned out as a quality check and identified the areas requiring improvement to reduce the error rates.

   PP201: Neutrophil to lymphocyte ratio as a prognostic factor in oral squamous cell carcinoma: A single institution experience from developing country Top

Vigyan Mishra, Ranjana Giri, Urmila Senapati, Subhrat Kumar Sahu1

Departments of Pathology and1Surgical Oncology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: [email protected]

Background: Persistent inflammation promotes cell proliferation and may lead to oncogenic activation and tumor suppressor genes inactivation. It will result in genomic instability and promotes malignant transformation. NLR can provide an early and simple indicator for outcome compared with other prognostic factors that would be available only after surgical resection or require advanced laboratory techniques. In our study we explored the significance of the correlation between NLR and survival in our patients with SCC of oral cavity. Design: We retrospectively studied biopsy proven, non-metastatic OSCC treated in our centre between 2013-2015. NLR was calculated from pre-treatment absolute neutrophils and lymphocytes counts. Based on median NLR as a cut-off, patients were classified into high NLR and low NLR groups. NLR was compared among two groups and impact of NLR on overall survival (OS) and progression free survival (PFS) was investigated by uni and multivariate analysis. P < 0.05 considered statistically significant. Statistical analysis performed on IBM SPSS V 23 and R-Studio V 1.2.1335. Results: We identified 50 patients of OSCC with median age of 45 years. Median pre-treatment NLR ratio was 2.52. Elevated NLR (>2.52) was significantly associated with lymph node metastases (p = 0.011). Four-years OS and PFS for high and low NLR groups were (51.4% vs. 100%, p = 0.001) and (38.8% vs. 87.8%, p = 0.002), respectively. Conclusion: In our study pre-treatment NLR has been shown to be an independent prognostic factor in patients with OSCC. It provides a simple, cheap and early measurable indicator of outcome.

   PP202: Mature sacrococcygeal teratoma: A case report Top

Sudesna Debnath, Rajib Sarkar, Manikuntala De

Department of Pathology, Indira Gandhi Memorial Hospital, Agartala, Tripura, India. E-mailI: [email protected]

Background: Sacrococcygeal teratomas in newborn are congenital neoplasms that arise from coccyx and are comprised of tissues derived from all three germ layers. They are either benign (mature) or malignant (immature). Mature sacrococcygeal teratomas are more common in neonates (68%) and older children (73%), and has a good prognosis after surgical resection. Study Design: Here we report a case of neonate,2days of age,female,born with a growth measuring 4.5 cms in diameter, along with a tail-like projection,measuring 11 cms x 0.5 cm, skin covered, in the sacrococcygeal area.Excision of the sacrococcygeal mass was done. Gross examination revealed a firm skin covered mass. On cut-section, it was solid, brownish in colour with a central yellowish-white area. Representative sections were taken and processed. Microscopic evaluation revealed mature tissues of all three germ layers.No immature elements were seen. Result and Discussion: A diagnosis of mature sacrococcygeal teratoma was given in the final report. Prevalence of sacrococcygeal teratoma is 1 in 35,000 – 40,000 live births. Females are more affected than males. Female to male ratio being 3:1 to 4:1. 18% of these infants have additional congenital anomalies. Conclusion: The incidence of malignancy in sacro-coccygeal teratoma increase with age. Early complete excision and histopathological diagnosis of mature teratoma is associated with good prognosis. Recurrence is mostly associated with tumour spillage during excision.

   PP203: Extranodal rosai-dorfman disease involving head and neck region: A case series Top

Vishesha Vipul Adhvaryu, Neha Mittal, Swapnil Rane, Munita Bal, Asawari Patil

Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Rosai-Dorfman disease (RDD/Sinus histiocytosis with massive lymphadenopathy) is a rare, idiopathic, benign disorder which presents as massive, painless lymphadenopathy. Extranodal presentation involving head and neck is rare and worth reporting. Clinical appearance simulating malignancy necessitates a correct diagnosis for appropriate treatment. Design: We retrospectively reviewed cases of extranodal RDD diagnosed in our institute over last 10 years including medical records, H-E slides and immunohistochemistry. Results and Discussion: Three cases were identified, all were males aged 27, 46 and 72 years. Two cases involved the maxilla and one involved the nasal cavity with concomitant cervical lymphadenopathy in 2 cases. Two cases were referred from outside with a diagnosis of inflammatory myofibroblastic tumor on histology. On histology, all three lesions were rich in histiocytes, lymphocytes and plasma cells with histiocytes showing emperipolesis. Storiform fibrosis was noted in one case. Immunohistochemical profile showed expression of S100 protein, CD68 and CD163 in histiocytes. There was increase in IgG4 positive plasma cells in two cases, leading to suspicion of IgG4-related sclerosing disease and RDD overlap. However, other diagnostic criteria for IgG4-related disease were not fulfilled. Two cases were treated with steroids while one with disseminated disease required chemotherapy and radiotherapy. Conclusion: Diagnosis of extranodal RDD can be challenging, especially in a small biopsy. A high index of suspicion combined with characteristic histologic features can help to get accurate diagnosis. Increased IgG4 positive plasma cells may be seen in pure RDD, unrelated to IgG4-related disease.

   PP204: Schneiderian cancer? A rare tumor of confusing nomenclature Top

Neeraj Kumar Singh, Vatsala Kishore, Dhananjay S Kotasthane

Heritage Institute of Medical Sciences, Bhadawar, Uttar Pradesh, India. E-mail: [email protected]

Introduction: Malignant sinonasal carcinomas constitiute <1% of all cancers with annual incidence of 3.5 per ten thousand population and of these,15-20% are non-keratinizing with a male preponderance. Case Report: We report a case of 56 year male with history of nasal obstruction and discharge.CECT showed large ,expansile mass predominantly in left nasal cavity with destruction of adjacent sinuses.A biopsy was taken which revealed Non-keratinizing carcinoma(transitional type). Discussion: Non keratinizing carcinoma of sinonasal cavity is a rare malignancy of nose and paranasal sinuses.It has many synonyms according to WHO classification including transitional cell carcinoma, schneiderian cancer,cylindrical cell carcinoma,Ringertz carcinoma and respiratory epithelial carcinoma.This could be the reason for very few reported cases of these tumors in Indian literature.Grossly these tumors grow as exophytic masses with corrugated to smooth surface.most common sites are maxillary and ethmoid sinuses.Microscopic examinantion of these tumors shows cylindrical tumor cells with a tendency to form palisade arrangements perpendicular to basement membrane.Treatment of sinonasal carcinoma depends upon their stage,patient performance status,comorbidities and tumor types. Conclusion: Rarity of this case and multiple confusing nomenclatures prompted us to report this case.Caution should be taken while diagnosing a nasal polyp in an elderly with occupational exposure to wood,nickeland leather dust.Histopathological diagnosis is confirmatory.

   PP205: Potentially dangerous o group blood donors: A lab based assessment Top

Resmi T Mony

Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India. E-mail: [email protected]

Background: Usually ABO matched blood components are the choice for transfusion In certain circumstances out of group transfusions are required -due to non- availability of same group components, desperate requirement & unresolved ABO grouping. Occasionally these result in hemolytic transfusion reaction especially in infants, elderly & massive transfusion receiving patients. Hemolytic potential and / or high titre of anti-A & anti-B attributes to it & is regarded as dangerous O group. Aim - estimate anti-A & anti-B titre & hemolytic property. Methods: Hemolysin test & agglutination test were performed in plasma of 75 randomly selected O blood group donors. Anti-A & Anti-B titre was also determined in saline as well as Coomb's phase Titer cut off for anti-A & anti-B taken as 64. Result & Discussion: Significant hemolysis detected in 49.3% (both A & B -32%, A alone - 9.33% & B alone - 8 %) Significant titre levels detected in rapid spin is 21.2% (both A & B - 6.6 %, A alone - 9.3% & B alone -5.3 %) Significant titre levels detected in Coomb's Phase is 25.33% (both A & B -13.33%, A alone - 4% & B alone -8 %) 2.6 % had both significant hemolytic potential and high titers. Only 41.8 % of the samples with significant hemolytic potential had high titre. Conclusion: Hemolytic potential will not always co-relate with the titre of anti-A & anti-B & hence testing of one alone is inadequate. All institutions should implement a dangerous O group screening system.

   PP206: Peritoneal malignant mesothelioma, an incidental finding in a patient with bilateral hydrocele and RT inguinal hernia: A rare case presentation Top

Shamaila Nehal

Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: [email protected]

Introduction: Malignant mesothelioma is a highly aggressive primary neoplasm of the serosal lining of pleura,peritoneum,pericardium or tunica vaginalis. Though common in the pleura, peritoneal malignant mesothelioma (PMM) is a rare entity with an incidence of approximately 1 in 1 million. Case Report: 62 year male presented with a right sided inguinal hernia and bilateral hydrocele.After reduction of inguinal hernia there was persistent ascitis .Ultrasound revealed subdiaphragmatic echogenic tissue debris over liver- suggestive of peritoneal deposits.CECT revealed multiple omental,peritoneal and liver surface deposits with a diagnosis- ?metastatic carcinoma. Ascitic fluid examination showed no malignant cells .Diagnostic laparoscopy was done , ,tissue from deposits on ligamentum falciparum of liver was received for histopathological study.Microsections revealed tumor cells in tubulopapillary architecture in an abundant myxoid stroma, having abundant eosinophilic cytoplasm, round to oval nuclei, some with prominent nucleoli.Mitosis was sparse. Immunohistochemistry was advised for definitive diagnosis which showed strong cytoplasmic positivity in CK5/6 & strong membranous positivity for D2-40. Tumor cells were negative for CEA . Correlating with histomorphology and IHC, final diagnosis was peritoneal malignant mesothelioma. Conclusion: Mesothelioma occurs in pleura but PMM is very rare and can pose a diagnostic challenge in patients presenting as B/L hydrocele and inguinal hernia.

   PP207: Influence of histopathological parameters in predicting outcome in squamous cell carcinoma tongue-study from tertiary cancer centre in South India Top

Rebecca George, K R Anila, K Ramadas, Elizabeth Mathew Iype, K Jayasree

Regional Cancer Centre, Thiruvananthapuram, Kerala, India. E-mail: [email protected]

Background: Several histopathological parameters have been known to be associated with poor outcome in oral squamous cell carcinoma (SCC). Fascin, actin bundling protein is known to promote tumor progression by inducing cell motility. Aims and Objective: 1) To identify influence of histopathological parameters in predicting outcome in SCC of oral tongue 2) To analyse the role of fascin over-expression in progression and aggressiveness of SCC oral tongue. Design: A total of 78 cases of histologically proven oral tongue SCC (OSCC) of all clinical stages which were managed primarily with surgery and neck dissection in the year 2012 were included. Clinical data was retrieved from case records and follow up done till December 2018 and slides were reviewed for pathological data including recently recognized parameter worst pattern of invasion 5(WPOI 5). WPOI 5 was assessed only for T 1 and T 2 cases. All cases were studied for fascin expression. Results: In a total of 78 cases (55 males, 23 females) the median age at presentation was 55 (48-62) years. The 5-year overall survival was 83.9 % with median survival 74 months. Following histopathological parameters worst pattern of invasion 5, depth of invasion, perineural invasion and lympho vascular invasion were associated with poor survival in early stages of OSCC. 92.3 % cases showed over expression of fascin but did not show significant association with survival. Conclusion: Certain histopathological parameters have significant association with outcome in early stages of OSCC.

   PP208: Respiratory epithelial adenomatoid hamartoma: An important differential of sinonasal masses: A rare case report Top

A G Yadav, P S Murarkar, A V Gosavi, N A Ramteerthakar

Government Medical College, Miraj, Maharashtra, India. E-mail: [email protected]

Background: Respiratory epithelial adenomatoid hamartoma(REAH) is a rare benign acquired non-neoplastic overgrowth of indigenous glands of nasal cavity, paranasal sinuses and nasopharynx arising from surface epithelium. It predominantly affects men in third to ninth decades of life. Majority occur in posterior nasal septum, other sites are lateral nasal wall, middle meatus and inferior turbinate. REAH is a benign lesion, recognition of which is important as it can be easily confused with inflammatory polyp, inverted papilloma and threatening tumours like sinonasal carcinoma. Design: We present a case of bilateral nasal polyposis reported on histopathology as respiratory epithelial adenomatoid hamartoma. Results and Discussion: A 36 year old lady presented with bilateral nasal masses, recurrent episodes of upper respiratory tract infection and rhinorrhea since 1 year. Grossly received multiple irregular pieces of whitish tissue together weighing 10gm. Histopathological examination showed multiple polypoidal tissue fragments lined by respiratory epithelium. Core of the polyp showed many variably sized proliferating glands lined by respiratory epithelium, some of the glands were seen invaginating into the deeper tissue. The lumina contained eosinophilic secretion or mucin. The stroma was oedematous and showed diffuse infiltration by mononuclear cells and polymorphs. Conclusion: Regardless of its rarity, REAH should be included in the differential diagnosis of symptomatic nasal masses as unawareness of this lesion may lead to unnecessary aggressive surgical intervention. Conservative surgical resection is the treatment of choice.

   PP209: Polycystic spleen an unusual presentation in a case of autosomal dominant polycystic kidney disease Top

Kinalee Chothani

Department of Pathology, Gujarat Adani Institute of Medical Sciences, Bhuj, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Splenic cysts are unusual lesions and can be solitary or multiple. Cysts with an epithelial lining is primary (true) where as those without lining is secondary (false) cyst. Parasitic cyst of the spleen secondary to Echinococcus infestation is also described. Autosomal dominant polycystic kidney disease (ADPKD) is common hereditary disease exhibiting cyst formation in kidney. Extra renal involvement of ADPKD includes presence of splenic cyst in 7% patients. In this report, we describe polycystic spleen as the first clinical manifestation of ADPKD. Case Description: Female 63 years, presented with fullness in left upper quadrant of abdomen with dull aching pain since 3 years. Patient is a known case of hypertension since seven years. Clinically there was massive splenomegaly, CT scan of spleen showed well-defined cysts of varying sizes, having rim of calcification at periphery. Both kidneys were enlarged and showed numerous cysts. A provisional diagnosis of hydatid cyst was considered and splenectomy was performed. Spleen measured 28x16x9 cms. and weighted 1800 grams. The capsular surface of it showed nodularity. The cut surface was gritty and revealed numerous cysts, ranging from 0.5 to 3.5 cm in diameter. Microscopic examination showed replacement of splenic parenchyma by cysts which were lined by flat cells, cyst wall also showed calcification. Conclusions: Literature describes only one report of polycystic spleen presenting with massive splenomegaly. ADPKD usually present as hypertension or renal failure or intracranial hemorrhage. Our case represents an unusual presentation of ADPKD; presenting as splenomegaly.

   PP210: An interesting case of of salivary gland tumor Top

Neethika Menon, Bhavana Bharambe, Vikas Maindad, Purwa Patil

Department of Pathology, Grant Government Medical College and JJ Group of Hospitals, Mumbai, Maharashtra, India. E-mail: [email protected]

Mammary analogue secretory carcinoma is low grade salivary gland tumor hence named because of its morphological resemblance to secretary carcinoma of breast . Presence of chromosomal translocation of t(12;15)(p13;q25) producing ETV6 NTRK3 fusion gene is characteristic. Secretory carcinoma was first documented in salivary glands in 2010. These tumors affect all age groups. Most common site is parotid gland followed by oral cavity and submandibular gland and presents as a painless slow growing mass. Case Report: A 19 Year old male comes with complaints of right submandibular swelling since 1 year . On examination a gradually increasing right submandibular swelling measuring 2x2cm, firm, hyperemic , immobile, non fluctuant with scars of previous surgery. The mass along with the overlying skin was excised and sent for histopathology .Microscopy revealed a unencapsulated tumor arranged in lobulated nested and cribriform pattern with intervening fibrous stroma . Pseudoglandular, microcystic and tubular areas were also seen . Individual tumor cells show clear to eosinophilic cytoplasm round to oval nuclei, vesicular chromatin and inconspicuous nucleoli. Few foci of intracellular and extracellular secretions were evident. Intervening stroma showed chronic inflammatory infiltrate. IHC was positive for S100 and mammaglobin. Conclusion: These low grade malignant tumors have an overall good prognosis though they carry risk of local recurrence.

   PP212: A rare case report of mammary analogue secretory carcinoma of parotid gland Top

Aprajita Garg, Pooja Sharma, Ranjeev Bhagat, Shashikant A Pol

GMCH, Chandigarh, India. E-mail: [email protected]

Background: Mammary analogue secretory carcinoma (MASC) is a rare neoplasm of the salivary gland. This entity shares morphologic and inmmunohistochemical features with the secretory carcinoma of the breast. 70% of the cases are found to occur in major salivary glands. This tumor is considered a low-grade carcinoma, hoewever, has the potential for high grade transformation. IHC can support the diagnosis and confirmation is obtained by demonstration of ETV6-NTRK3 fusion gene. Case Report: A 47 years old female presented with the complaints of left post auricular swelling since last one month. Initially, small sized, it gradually increased to the current size measuring 4cm. CECT neck showed a 28 x 25mm heterogeneously enhancing mass in the superficial lobe of parotid gland without extraparotid extension. FNAC was done and showed a benign epithelial tumor with cystic change. Later the excision of swelling was done and histopathological examination of the excised swelling showed cystic tumor arranged in papillary to microcystic architecture and tumor cells are polygonal with eosinophilic granular cytoplasm and numerous intraluminal and intracellular basophilic secretions. On immunohistochemistry, these cells showed strong nucleo-cytoplasmic positivity for S-100 and were negative for SMA. Thus, a diagnosis of Mammary analogue secretory carcinoma was rendered. Conclusion: It is low grade tumor but recurrence and dissemination are not uncommon and mimics other salivary gland tumors, most commonly acinic cell carcinoma and adenocarcinoma, NOS. So, awareness of this entity is essential for an accurate diagnosis and thereby, formulate an appropriate treatment.

   PP213: Phlebolith in vascular malformation at anterior triangle of neck: A rare case report Top

Deepa Janghel, R Gahine, Shashikala Kosam, Mohd. Jafar Memon, Ruchi Verma

PT. JNM Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Vascular malformations and haemangiomas are one of the most frequently encountered angiomatous lesions of head and neck region that possess significant morbidity and even mortality in both children and young adults but association with phleboliths is an unusual entity. This case describes multiple phleboliths found in excised mass of haemangioma neck. Case Report: A 15 year old male patient presented with complaint of right sided neck swelling just above the clavicle since 2 years. CT Neck Angiography revealed multilobulated soft tissue mass approximately measuring 5.6 Cm X 4.3 Cm X 5.7 Cm with multiple foci of calcification in right anterior triangle of neck with provisional diagnosis of Hemangioma or Arteriovenous malformation. Fine Needle Aspiration Cytology smears showed only RBCs. Histopathology slides revealed calcified nodules as well as hyalinized nodule in the blood vessels surrounded by dilated vascular channels lined by single layer of endothelium separated by variable amount of stroma associated with hemorrhage. Final Diagnosis given was Vascular malformation with extensive calcification and hyalinisation. Conclusion: Phleboliths are unusual pathological finding characterized by calcified vascular thrombi formed due to stasis of blood. Haemangiomas and developmental vascular malformations of the head and neck region can reveal the presence of phleboliths within them rarely.

   PP214: Comparative study of intraoperative cytology, frozen sections, and histopathology of tumor and tumor-like lesions Top

Taiba Farooque, Amit Varma

Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India. E-mail: [email protected]

Background: Intraoperative consultation (IOC) methods are used to render a diagnosis that has impact on the immediate surgical/ therapeutic procedures being contemplated. Our study aims to find the diagnostic utility and accuracy of intra-operative cytology and frozen section taking paraffin-embedded histology as a gold standard for diagnosis of frequently encountered tumor and tumor-like lesions operated at our institute. Design: On receiving the unfixed specimen per operatively, imprint smears were prepared after gross examination. A few representative tissue sections were processed by frozen section. After smear and frozen section (FS) reporting, specimens were processed routinely for paraffin section evaluation. Observations of each method were categorized as inflammatory, benign, malignant or inconclusive, and accuracy was determined taking routine histopathology as the gold standard. Results: Of the 115 cases studied, with a 0% rate of deferral, suspicion of malignancy was the most common (72.2%) indication for consultation, followed by evaluation of resection margins and metastatic lymph nodes. Cytology offered sensitivity, specificity, PPV and NPV of 69%, 96%, 90% and 85% respectively. Frozen section performed exceedingly well with a sensitivity, specificity, PPV and NPV of 88%, 93.6%, 86% and 94.9% respectively. Concordance of 92.1% and discordance of 7.9% was derived. Kappa statistic for FS with relation to HPE was 0.834 which was inferred as near perfect agreement. Conclusion: Our study reaffirms that IOC, when warranted, is a very useful and highly accurate procedure. It endorses that the accuracy, sensitivity and specificity of intraoperative methods are high for investigating malignancy and are statistically significant.

   PP215: Uncommon sites of adenoid cystic carcinoma: A diganostic dilemma Top

Ariba Zaidi, Jaimanti Bakshi, Uma Nahar, B D Radotra

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: [email protected]

Background: The adenoid cystic carcinoma(ACC) is a rare epithelial tumor of major and minor salivary glands, amounting to about 1% of all malignant tumor of maxillofacial regions. The commonest age of presentation is in 5th and 6th decades of life. Most common sites of ACC include salivary glands and other parts of oral and nasal cavity. Rarely these tumors can present at less common locations such as orbit, liver and rarely brain and breast. Design: This is a retrospective study. Cases diagnosed as adenoid cystic carcinoma from uncommon sites were retrieved from Department of Histopathology, PGIMER, between 2015 to 2018. Results and Discussion: A total of 115 cases adenoid cystic carcinoma were found in our archives during the period of 4 years (2015-18) out of total 388 salivary gland tumors. There were 48 were males and 67 females with age ranged between 17years to 75 years, median 45 years. The sites involved were oral cavity with involvement of salivary glands, palate, base of tongue, maxilla and mandible. The rare site of presentation, included brain(4cases), orbit(4 cases), base of skull and infra-temporal fossa(2 cases), liver(1 case) and breast(1 case). Histologically varied morphology was noted commonly, cribriform, tubular and solid pattern. Conclusion: Adenoid cystic carcinoma is a malignant tumour with a deceptively benign morphology characterized by indolent, locally aggressive growth with metastasis.A high index of suspicion is required to diagnose these tumours at rare sites. Immunohistochemistry can be used as an useful adjunct with varied pattern

   PP216: A case report of myopericytoma of lower extremity Top

Sonu Bansal, Shikha Prakash, Rajni Bharti

S.N.M.C., Agra, Uttar Pradesh, India. E-mail: [email protected]

Background: Myopericytoma (MPC) is a recently proposed term to describe a group of tumors that originate from perivascular myoid cells. It is a rare, benign tumor forming from cells, surrounding the blood vessels. This tumor frequently affects the lower limbs; other affected areas include the head and neck region Individuals in their mid-adult phase are commonly affected. Most MPC tumors are asymptomatic and painless masses. Surgical treatment of the tumor is generally performed, through a complete excision. The prognosis of MPC is excellent. Case Report: A 26-year male incidentally noticed a hard area over medial aspect of left leg. On FNAC features were suggestive of benign spindle cell lesion. Total excision was performed, grossly tumor was grey-white measuring 2.4x2.0x1.0 cm with irregular surface. Cut surface was grey white with tiny hemorrhagic areas. Capsule was not appreciated. Microscopy, showed a circumscribed mass with focal areas of thin capsule. Plump ovoid to spindle cells with eosinophilic cytoplasm & indistinct cell boundaries were present in concentric fashion around thin walled stag horn vessels. Intervening stroma was occupied with fascicles of spindle cells. Foci of hemorrhage was seen. Mitosis, atypia and necrosis were not identified. Features were suggestive of benign vascular neoplasm favoring myopericytoma. On Immunohistochemistry- vimentin, h-caldesmon and smooth muscle actin positivity was seen in tumor cells. Conclusion: Findings indicate that the present case is a HPC- related tumor (myopericytoma).

   PP217: Splenic abscess in B-thalassemia major: A case report Top

Bhawana Sharma, Nidhi Shah, Jigna Dave, Mona Der, D N Lanjewar

Department of Pathology, Gujarat Adani Institute of Medical Sciences, Bhuj, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Splenic abscess is a rare entity with only 600 cases reported in the literature. It is more common in patients with endocarditis, and immunodeficiency disorders. Splenic abscess is caused by streptococcus species, staphylococcus species, mycobacterium, fungi and parasites. Patients of Beta-thalassemia major have an increased susceptibility to infection, which is attributable to a number of immune abnormalities. To the best of our knowledge, only two reports of splenic abscess in patients with thalassemia are described in the literature. In this report we describe one additional case of splenic abscess in a patient with beta-thalassemia major. Case Description: A 22 year old male was diagnosed thalassemia major at the age of 6 year. Patient presented with pain and swelling in left hypochondrium. The clinical examination showed enlarged spleen, USG confirmed splenomegaly with abscess in spleen, measuring 13x10x8 cms. CT scan also confirmed splenic abscess, and in addition showed infarction, and hemosiderosis of spleen. Grossly spleen was enlarged, it measured 27x16x12 cms. in size and weighed 1.6 kg. The anterosuperior border of spleen showed an abscess measuring 13x10x8 cms. in size, the adjoining spleen showed recent infarct and brownish color due to presence of hemosiderin pigment. Microscopic examination confirmed pyogenic splenic abscess, splenic infarct and hemosiderosis. Pus culture was negative for microorganisms. Conclusions: In hemoglobinopathies splenic infection is recognized complication of sickle cell disease and thalassemia. We suggest regular follow up for identification of infection and use of oral antibiotic prophylaxis in thalassemia.

   PP218: Malignant salivary gland neoplasms: A tertiary care experience Top

Parul Thombre

KMC, Manipal, Karnataka, India. E-mail: [email protected]

Background: Salivary gland neoplasms comprising less than 0.3 % of all cancers, with complex histomorphology and overlapping morphologic features are diagnostic challenges to the surgical pathologist. This study was done to study the relative frequency, histomorphology of malignant salivary gland neoplasms, and to correlate diagnosis given on fine needle aspiration cytology. Design: 45 cases of malignant salivary gland neoplasms received during the data collection period (January 2014 - December 2018) were retrieved from the electronic records. Histopathological slides along with the age, sex and presenting details were included. Correlation of diagnosis given on histopathology and cytology was done whenever cytology slides were available. Immunohistochemical findings were studied whenever available. All slides were independently evaluated by 2 observers. Results and Discussion: Malignant salivary gland neoplasms were most commonly seen in the 4th and 5th decade (31% each), with M: F=2:1 and Parotid gland was most commonly affected (64.44%). These findings were in concordance with other studies.1–7 Mucoepidermoid carcinoma(MEC) was the most common histologic type with 19 cases, in an age range of 38–76 yrs followed by adenoid cystic carcinoma with 8 cases in an age range of 36-76 yrs.8,9 Cytology was available in 29 cases, and type specific concordance was noted in 22cases(78.57%). In 6 cases with cytohistological discordance, 3 were rendered cytologically malignant. Thus, cytologically malignant diagnosis was rendered in (89.28%) cases which is in concordance with other studies.10–12. Conclusion: Malignant salivary gland neoplasms commonly occur in major glands, have a male predilection and MEC is most common histologic type.

   PP219: Salivary gland amyloidoma; an unusual cause of salivary gland neoplasm Top

Pushpanjali Behera, Arvind Ahuja, Minakshi Bhardwaj

Department of Pathology, ABVIMS, Dr. RML Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Localized deposition of amyloid presenting as mass lesion is very uncommon. Amyloidoma in salivary glands is among the extremely rare site. Amyloidoma usually presents as a slowly growing mass and mimics a neoplastic lesion clinically as well as radiologically. We report a case of amyloidoma presenting in right parotid region with clinical suspicion of salivary gland malignancy. To the best of our knowledge, this is the third case report of amyloidoma of the parotid gland. Case Description: A 66-year-old man presented with a localized painless mass in the right parotid gland since 6-7 months duration. On physical examination, there was a firm to hard mass in the right parotid region measuring 4 cm in its largest dimension with no intra-oral involvement. Patient underwent superficial parotidectomy, suspecting malignancy. However, on histopathological examination it turned out to be a case of amyloidoma. Monoclonality for kappa light chains was also established on immunohistochemistry. At 4 months follow up patient is doing well and there is no evidence of recurrence. However, as part of further investigation protocol, serum protein electrophoresis of the patient was done and which revealed presence of M band. Thereafter, patient was advised bone marrow examination. Conclusion: Salivary amyloidoma is extremely rare.Awareness about this rare entity, high index of suspicion accompanied by extensive tissue sampling and meticulous examination of all the sections is recommended for rendering this rare diagnosis. Complete workup of the patient is necessary to uncover underlying plasma cell dyscrasia and for definitive management of the patient.

   PP220: A mixed adeno-neuroendocrine carcinoma ex-pleomorphic adenoma of soft palate: A heretofore undescribed occurrence Top

Bharati Sitaram Hubale, Munita Bal, Asawari Patil, Neha Mittal, Swapnil Rane

Department of Pathology, Tata Memorial Centre, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Mixed Adeno-Neuroendocrine Carcinoma (MANEC) are extremely rare malignancies reported in the gastrointestinal tract (GIT). It consists of dual adenocarcinoma and neuroendocrine components, with each component representing at least 30% of tumor. Occurrence of MANEC outside the GIT is exceptionally rare. Herein, we report a hitherto undescribed case of Carcinoma ex-pleomorphic adenoma (CXPA) arising in a palate exhibiting a histology. Case Report: A 32-year old male presented with a mass in soft-palate since two years associated with snoring and left nasal obstruction. On examination, a lobulated soft tissue lesion arising from soft palate was identified. Following a biopsy report of carcinoma ex pleomorphic adenoma, a left palatectomy with left modified radical neck dissection was performed. Macroscopy revealed a grey-white tumor in soft palate measuring 4.8x3.7x3.5cm without maxilla involvement. Microscopy revealed invasive carcinoma arising in a background of benign pleomorphic adenoma (PA) comprising intimately admixed salivary duct carcinoma (CK7, Androgen receptor, GATA-3, cerbB2-score 3+ positive) forming 55% and small cell carcinoma (synaptophysin and chromogranin positive) forming 45% of tumor. A diagnosis of MANEC ex-PA was made. Mitotic rate was 50/10HPF; Ki-67 was 75%. Lymphovascular emboli were seen; perineural invasion was absent. Underlying bone and resection margins were uninvolved; level III lymph node showed metastasis. Patient is currently receiving adjuvant chemotherapy. Conclusions: MANEC ex-pleomorphic adenoma of minor salivary gland is an extremely rare malignancy, heretofore unreported in literature, to the best of our knowledge. This case adds MANEC to the histologic spectrum of CXPA. These are aggressive malignancies requiring multimodality treatment.

   PP221: A rare case report of sarcoma ex pleomorphic adenoma of parotid gland Top

Damleen Kaur, Tanupriya Bindal, Ranjeev Bhagat, Shashikant A Pol

GMCH, Chandigarh, India. E-mail: [email protected]

Background: Sarcoma Ex Pleomorphic Adenoma is very rare and aggressive tumor of salivary gland. Various types of non lymphoid sarcoma have been documented to arise primarily in the salivary gland, representing about 0.3 to 0.5% of all benign and malignant salivary gland tumors. We present a case of Sarcoma Ex PA on the basis of histopathological features and immunohistochemical analysis to illustrate the characteristics of the tumor. Case Report: A 55 years old male presented with the complaint of swelling in the oral cavity since 10 years which was gradually increasing in size. CECT head and neck showed a large heterogeneously enhancing soft tissue space occupying lesion in oral cavity extending from hard palate superiorly till epiglottis inferiorly and measuring 60x30mm. FNAC was done and Carcinoma Ex Pleomorphic Adenoma was diagnosed. Later excision of the oropharyneal mass (parotid gland), submandibular gland and level Ib-V lymphnodes were done and histopathological examination showed spindle shaped morphology of tumor cells. Lymphnodes showed metastatic tumor deposits. On immunohistochemistry, these cells showed strong cytoplasmic positivity for vimentin. Thus, a diagnosis of Sarcoma Ex Pleomorphic Adenoma was made. Conclusion: Sarcoma Ex Pleomorphic adenoma is a malignant tumor with high rate of recurrence and diagnosis is challenging. The number of such cases is extremely low in the literature and the treatment outcomes are varied. So, early diagnosis is helpful for planning management of patient.

   PP222: Metastases to parotid gland: A challenging scenario Top

Aanchal Kakkar

AIIMS, New Delhi, India. E-mail: [email protected]

Introduction: The presence of intra-parotid lymph nodes makes the parotid unique: it harbors metastases twenty times more often than other major salivary glands. Metastases account for 7-25% of all parotid tumors, and usually originate from head and neck malignancies. We aimed to identify cases of metastases to parotid gland to highlight the dilemmas faced in their diagnosis. Methods: Cases of parotid gland metastases diagnosed on histology or cytology were retrieved, and clinicopathological features were reviewed. Results: Forty-one samples of metastatic tumors were identified among 31 patients. Of these, 10 were aspirates, 5 were biopsies, and 26 were parotidectomies. Relevant previous history was available in 15 cases, 14 parotidectomies were performed with main tumor excision, and in 12 cases previous history was not provided. The most common primary tumors metastasizing to parotid was eyelid sebaceous carcinoma of eyelid (17 cases). In cases where history was not available, most cases were called poorly differentiated carcinoma or poorly differentiated malignant tumor. Conclusion: Intraparotid metastases may mimic primary salivary gland neoplasms, particularly on cytology and small biopsies. A precise diagnosis was made only in cases with history of prior non-parotid primary, while in cases without relevant history, the diagnosis could not be made. This highlights that limited experience with salivary gland neoplasms among general surgical pathologists and cytopathologists may lead to unfamiliarity, and metastases may not enter the initial differential diagnosis on evaluation of a parotid mass.

   PP223: Retroperitoneal teratoma in a 13 days old male neonate presenting on day 1 with complaint of abdominal swelling: A rare case study Top

Gopinath Barui, Anish Kumar Rakshit

R G Kar Medical College, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Teratomas are classified under germ cell tumours which are derived from totipotential cells of hensen&rsquo;s node(also called primitive knot),a remnant of the primitive streak.Mainly seen in neonates, infants and children younger than 4 years.Majority are found in the sacrococcygeal area ,gonads,mediastinum,head and neck and retroperitoneal areas. Design: A 1 day old male neonate developed abdominal swelling.On per abdominal examination,abdomen was distended and prominence of superficial veins. Bladder was palpable. On 5th postnatal day USG KUB was done which suggested a large cystic intraabdominal SOL measuring about 5.7x6.2 cm extending from epigastrium to pelvis causing right sided hydronephrosis. Result and Discussion: Explorative laparotomy was done.A cystic lesion adherent to transverse and ascending colon arising from pelvis and mass could not be dissected out from anterior surface of lumbo sacral region. Alpha fetoprotein level was 21183 ng/ml. On gross examination, multiple fragmented flattened greyish brown cystic tissue pieces measuring 11x11cm.Histopathological examination from cystic structure shows elements from all three germinal layers. Surface ectoderm Nonkeratinised Stratified Squamous epithelium,pilosebaceous unit Neuroectoderm neurofibrils,neuroglial cells Mesoderm connective tissue,striated muscle,adipose tissue,blood vessels Endoderm glands,gastrointestinal mucosa,urogenital tract. Conclusion: Overall clinicohistopathological,radiological and biochemical analysis strongly support diagnosis of Altman type IV SCT or retroperitoneal teratoma.

   PP224: An analysis of pediatric round cell tumors highlighting the spectrum of differential diagnosis Top

Bhagat Singh Lali, Ipsita Dhal, Shashikant C U Patne, Parul Tripathi, Zachariah Chowdhury1, Soumitra Saha1, Rakesh Mittal2

Departments of Pathology,1Pediatric Oncosurgery and2Pediatric Oncology, Homi Bhabha Cancer Hospital, Tata Memorial Centre, Varanasi, Uttar Pradesh, India. E-mail: [email protected]

Background: Pediatric round cell tumors (RCT) are group of malignancies with similar histology but diverse histogenesis. Definite diagnosis is challenging but equally important for therapeutic and prognostic implications. We aimed at analysing the pediatric round cell tumors to outline an approach towards accurate diagnosis and exclusion of the close differentials. Design: A retrospective study was performed wherein pediatric RCT from May 2018 to September 2019 were included. Demography, clinical presentation, radiology and PET scan details were retrieved from archives. The histology and immunohistochemistry slides were reviewed, and subtle features noted. Molecular analysis was done in 10 cases. Data was analysed by appropriate statistical methods. Results and Discussion: Total 154 pediatric solid neoplasms were encountered during this period and 84 (54.5%) of them were tumors with round-cell morphology. The mean age was 5.8 years and male preponderance (63.1%) was observed. Wilms tumor was the most common (32.1%) malignancy, followed by non-hodgkin lymphomas (16.7%), Ewing/PNET (14.3%) and rhabdomyosarcomas (10.7%). Neuroblastomas (7.1%), hepatoblastomas (6%), non-rhabdomyomatous sarcomas (4.8%), clear cell sarcomas (3.6%) and immature teratomas were other entities. Immunohistochemical markers which aided in diagnosis were CD45, CD3, CD20, CD30, MyoD1, Myogenin, WT1, Fli1, Alk1, Chromogranin, CD56, CD99 and Desmin. Metastasis was observed in 34.5% cases, lung metastasis being most frequent, and 8.3% cases were recurrent/relapsed tumors. Conclusion: Pediatric RCT are a diverse group of tumors warranting detailed analysis. Core biopsy specimens/metastatic site biopsies are more challenging. Meticulous histological examination, judicious choice of immunohistochemistry panel and its methodical interpretation are the key to accurate diagnosis.

   PP225: Undifferentiated embryonal sarcoma of liver: A case series Top

Lakshmi Ramabadran, Mukta Ramadwar, Girish Chinnaswami, Tushar Vora, Sajid Qureshi

Tata Memorial Centre, Mumbai, Maharashtra, India. E-mail: [email protected]

Introduction: Undifferentiated embryonal sarcoma of liver is a rare tumour of childhood. Objective: Objective of this study is to describe the histological features, differential diagnosis, clinicopathological correlation and the diagnosis of undifferentiated embryonal sarcoma of liver. Methods: A retrospective review of medical records, histology and immunohistochemistry of 6 children with undifferentiated embryonal sarcoma of liver was done. Results: In our study, median age was 10.5 years (7 to 14 years). Serum AFP levels were normal in all patients. Primary tumour was located in the liver in all cases with extrahepatic extension in 2 out of 6 cases. Histologically, the tumour was composed of spindle to stellate cells with high mitotic rate and necrosis. Multinucleated and bizarre cells were seen in two out of six cases. Differential diagnosis of rhabdomyosarcoma and pleomorphic hepatoblastoma was considered in all. IHCs showed focal positivity for desmin in two cases and SMA in one case; negative for myogenin in five out of six cases. All children underwent surgery followed by chemotherapy. Two out of six tumours showed large areas of necrosis. Five out of six patients are stable post treatment. One patient is on chemotherapy due to recurrence. Median follow up was 1 year and 6 months. Conclusion: Undifferentiated embryonal sarcoma of liver is difficult to diagnose due to its rarity and heterogenous morphology. There are no specific immunomarkers for this tumour and it remains a diagnosis of exclusion. All 6 children in our study responded well to chemotherapy and are alive.

   PP226: Immunohistochemical analysis of mutational changes in sporadic colorectal cancer of childhood: A series of three cases Top

Priyanka Maity, Aniket Halder1, Ranajoy Ghosh1, Uttara Chatterjee, Shibsankar Barman2, Avijit Mitra2

Departments of Pathology,1GI Pathology and2Paediatric Surgery, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Colorectal cancer (CRC) is rare in children with incidence of 1 in 10 million patients under 20 years of age. There is sparse literature describing CRC in paediatric age group along with their mutational changes. Here we elucidate three cases of sporadic CRC of childhood and analyse their underlying molecular signatures using immunohistochemistry. Case Summary: We present three cases of sporadic CRC in a 7 year, 10 year and 12 year old child affecting the rectosigmoid (n=2) and ileocaecal (n=1) regions. None of the cases had any family history of CRC. Morphologically, all the three cases were adenocarcinomas, of which one was of mucinous subtype. We had performed IHC for BRAF, p53 and β-catenin alongwith markers of microsatellite instability (MSI)—MLH-1, MSH-2, MSH-6 & PMS-2 in all the cases. All the three cases showed diffuse strong cytoplasmic BRAF positivity. There was focal p53 positivity in two cases while one case showed strong β-catenin staining. All the three cases were microsatellite stable. Conclusion: Childhood CRCs frequently present in advanced stages leading to poorer outcomes. Sporadic CRCs in children are a cumulative effect of multiple mutations, of which BRAF mutation is significant, as shown in some previous studies. As BRAF inhibitors are available, detection of BRAF mutation in CRC is critical for targeted therapy and prognosis prediction. Immunohistochemistry can be used as a surrogate marker for the underlying molecular derangements in CRC.

   PP227: Childhood rhabdomyosarcoma with anaplastic (pleomorphic) features and its correlation with histological subtypes Top

Reena Tomar, Shruti Thakur, Varuna Mallya, Shramana Manadal, Nita Khurana, Y K Sarin

Maulana Azad Medical College, New Delhi, India. E-mail: [email protected]

Background: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. Anapalsia is a rare phenomenon seen in childhood RMS. The most common histologic subtype was Embryonal followed by Alveolar and Spindle subtype. Design: A total of 14 cases of pediatric RMS were selected from January 2017 to June 2019 presenting at various sites. Out of 14 cases 10 were further diagnosed as Embryonal ,2 as Alveolar and 2 as Spindle subtype based on morphology. All cases were positive for Desmin. The presence of cells with lobated, hyperchromatic nuclei at least three times larger than the tumor cell (anaplastic cells) were selected as the main criterion to diagnose Anaplasia. Results: Anaplasia was seen in 9/14 (64%) cases,in which 6 cases showed Focal Anaplasia (FA) (43%) and 3 cases showed Diffuse Anaplasia (DA)(21%). 11/14 cases were <5 years and 8 showed anaplasia(57%) , out of which 6 cases showed FA and 2 cases showed DA. 3/14 cases were >5 years, only 1 case showed DA(7%). Out of 10 Embryonal RMS, 7 showed anaplasia(50%) , out of which 5 cases showed FA and 2 cases showed DA. Out of 2 Spindle RMS, both showed anaplasia (16%)(1-FA, 1-DA). Both Alveolar RMS showed no features of anaplasia. Conclusion: Incidence of Anaplasia is higher in pediatric RMS (<5 years ), (Focal>Diffuse) and showed increased association with Embryonal subtype. Anaplasia is often under reported in pediatric RMS and Pathologist should be more aware of this rare phenomenon.

   PP228: Immature gastric teratoma arising from lesser curvature: A rare entity with review of literature Top

Chaitali Vinchu, Pragati Sathe, Mona Agnihotri, Swati Shinde, Asha Shenoy, Roopali Manudhane

SETH GS Medical Collage and KEM Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Teratoma is usually extragonadal in infancy and early childhood. The common sites are sacrococcygeal region and mediastinum. Gastric teratoma is a rare entity having an incidence of less than 1% among teratomas. Males are largely affected.The usual location is greater curvature and posterior wall. Lesser curvature is a very rare site. Most of the gastric teratomas are mature. There are only 14 reported cases of immature gastric teratomas arising from lesser curvature of stomach. Design: A seven-month-old male child presented with vomiting, palpable abdominal mass and progressive distension of abdomen since 10 days. Examination revealed a firm to hard mass in the epigastric region measuring 10x10 cm. Serum Alfa Fetoprotein level was 6257ng/ml (N-0.89-8.78ng/ml). Computed Tomography showed a well defined heterogenous lesion arising exophytically from lesser curvature of stomach. Excised tumor was capsulated and showed predominantly solid areas with few tiny cysts filled with mucin and glistening areas. Results: Microscopy showed mature tissues derived from all three germ layers along with immature neuroglial tissue and rosettes. Histopathology diagnosis was given as immature gastric teratoma(Grade 3). Conclusion: Teratoma is rare in stomach and immature teratoma is rarer. We are adding one more case to the 14 cases of immature gastric teratomas arising from lesser curvature of stomach, reported in literature.

   PP229: Histomorphological spectrum of pediatric liver tumors: An experience in a tertiary care centre Top

P S Amritha, Dimple Chaudhary, Varuna Mallya, Shramana Mandal, Reena Tomar, Nita Khurana, Y K Sarin1

Departments of Pathology and1Pediatrics, Maulana Azad Medical College, New Delhi, India. E-mail: [email protected]

Background: Liver tumors are an important cause of morbidity and mortality in children. This account for 4% of all pediatric neoplasms Most common liver tumor in the pediatric age is hepatoblastoma, unlike adults where in the most common tumor is hepatocellular carcinoma. Design: All the hepatic tumors of childhood (under 18 years) from September 2017 to August 2019 were retrieved from the archives and the slides were reviewed and analyzed. Results and Discussion: A total of 14 pediatric liver tumors were detected in 3 years. The average age of presentation was 3.4 years. Male to female ratio was 3:1.Hepatoblastoma was the most common liver tumor in this group accounting for 10 cases. One case each of Mesenchymal hamartoma, Focal Nodular Hyperplasia, Infantile hemangioendothelioma and Embryonal Rhabdomyosarcoma were identified. The commonest type of hepatoblastoma noted was the fetal type. Most of these cases presented with abdominal swelling. The average duration of symptoms was 5 months. Serum AFP levels were raised in all cases of Hepatoblastoma and were normal in the other lesions. Conclusion: Hepatoblastoma is the commonest pediatric liver tumor, a proper histological diagnosis of pediatric liver tumors is imperative to plan further treatment and determine prognosis.

   PP230: Histopathologic spectrum of head and neck malignancies in pediatric age group in a teritiary care hospital Top

Pooja Sharma

GMCH, Chandigarh, India. E-mail: [email protected]

Background: Head and neck tumors account for 5% of all childhood cancers, however, majority are benign in nature. The majority of pediatric head and neck malignancies include Hodgkin lymphomas, non-Hodgkin lymphomas, rhabdomyosarcomas, thyroid malignancies, nasopharyngeal carcinomas, salivary gland malignancies, and olfactory neuroblastomas. Design: The present work was a retrospective study conducted in the Department of Pathology, of a tertiary care hospital over a period of 5 years from January 2014 to December 2018. Excision biopsy specimens and small biopsies sent for histopathological evaluation were studied by light microscopy after hematoxylin and eosin staining and immunohistochemistry. Results and Discussion: 24 cases were diagnosed with head and neck malignancies. The most common age group affected was 11-15years followed by 0-5years They showed an overall male preponderance and male to female ratio was 3:1. On histopathological examination, 17 cases were diagnosed as small round cell tumors, 3 were nasopharyngeal carcinomas, 2 were papillary thyroid carcinoma, 1 was mucoepidermoid carcinoma and 1 was diagnosed as metastatic osteosarcoma. On IHC, out of 17 diagnosed cases of small round cell tumors, lymphomas were the most common (41.2%), followed by retinoblastoma (29.4%), rhabdomyosarcoma (17.6%), Ewing family of tumors (5.8%), and olfactory neuroblastoma (5.8%). Conclusion: The aim of this study is to evaluate detailing cumulative incidences of various histologic types and differential diagnosis of the head and neck malignancies including age and gender distribution as well as organ-speci?c localization in children.

   PP231: Pleuropulmonary blastoma: Case report Top

Sonali Jakkulwar, Ashwini Tangde, Anjali Kulkarni, V M Mulay

Government Medical College, Aurangabad, Maharashtra, India. E-mail: [email protected]

Introduction: Pleuropulmonary blastoma is a rare and highly aggressive intrathoracic malignancy in childhood and less than 100 cases have been reported in the literature.It occurs mainly in children aged less than five to six years. It has poor prognosis with three different subtypes: cystic [type I], combined cystic and solid [type II] and solid [type III]. Case Description: A 3 year old girl presented with respiratory distress and fever. she had a 20-day history of persistent cough and low fever Chest X-ray showed an opacity on right side with heterodense cystic lesion and pleural effusion leading to mediastinal shift to the opposite side. Computerized Tomography (CT) of thorax revealed a large extraparenchyamal cystic lesion on right hemithorax. later on chest tube insertion revealed hemorrhagic effusion. Gross: We received multiple browinish soft to firm irregular tissue pieces collectively of size 7x7x1cm. Microscopic Slides Revealed Three distinct patterns: 1) Dominant is a loose network of spindle cells, moderate nuclear pleomorphism and hyperchromasia. 2) Sheets and nests of undifferentiated (blastomatous) cells, hyperchromatic nuclei, some with nucleoli. 3) clear large cells having clear vacuolated cytoplasm and centrally placed nuclei. Conclusion: PPB is an aggressive tumor having poor outcome and it usually occurs in young children. It needs a multimodal therapy regimen including aggressive surgery and chemotherapy. Though radiotherapy is an alternative treatment modality, especially in cases with high risk of recurrence, it causes severe morbidity, especially in younger children.

   PP232: Role of cyclin D1 and BCOR immunohistochemistry in differentiating clear cell sarcoma of kidney from its mimics Top

Vikram Singh, Kirti Gupta, Amita Trehan1, Nitin J Peters2

Departments of Histopathology,1Paediatric Haemat-Oncology and2Paediatric Surgery, PGIMER, Chandigarh, India. E-mail: [email protected]

Background and Aim: Clear cell sarcoma of kidney (CCSK) is the second most common paediatric renal malignancy, constituting approximately 3% of renal tumours. Due to its morphological diversity, the diagnosis of CCSK is often challenging. Recent studies, have identified internal tandem duplication (ITD) of the BCOR gene in CCSKs which coupled with cyclin D1 immunoreactivity is helpful in differentiating it from its mimics particularly blastema-rich Wilms tumour (WT), malignant rhabdoid tumour (MRT) andcongenital mesoblastic nephroma (CMN). We aimed to evaluate the utility of cyclin D1 and BCOR immunohistochemistry in differentiating CCSK from its morphologic mimics. Materials and Methods: Our cohort comprised of 38 paediatric renal tumors which included CCSK (n=18), WT (n=10),MRT (n=5) and CMN(n=5) cases. A detailed clinico-pathological analysis was performed and tissue microarray were constructed for CCSK and WT, while MRT and CMN tumours were individually stained. Results: Age ranged from 2 months to 4 years with M:F ratio of 3:1. Strong, diffuse nuclear immunoreactivity for cyclin D1 and BCOR was noted in 61% (n=11/18) and 83% (n=15/18) of CCSK while it was significantly less in WT (n=3/10 for cyclin D1) (n=2/10 for BCOR). None of MRT and CMN examples demonstrated any immunoreactivity. Interestingly, the blastemal component of most WTs showed distinct, rare positive nuclear immunoreactivity for BCOR in two cases which can be a diagnostic pitfall. The epithelial and stromal components were negative. Conclusions: Our results provide evidence both cyclin D1 and BCOR immunohistochemistry are helpful indistinguishing CCSK from its morphologic mimics.

   PP233: A rare case report of accessory spleen within the scrotum Top

Smriti Tiwari Pandey

Government Medical College, Ratlam, Madhya Pradesh, India. E-mail: [email protected]

Background: Presence of Accessory spleen in scrotum sac is an extremely rare condition. It was first reported in 1913 by Sneath and they introduced splenogonadal fusion, where spleen is abnormally attached to a gonad. Design: A reddish brown tissue mass of size 4x2.5 cm was excised from left scroatal area with preservance of testicle; Histological examination was done of tissue removed. Correlation was done with ultrasonographic findings. Results: Tissue submitted for histopathogical examination shows normal spleenic tissue reveals white pulp with central arteriole and red pulp with interspersed sinusoids. Outer most capsules are also seen with intervening trabeculae. Discussion: We are discussing an unusual case of accessory spleen in left scrotum in a 10 years old boy. Although Accessory spleen is not a rare occurrence in medical literature, but it's incidence varying from 2 to 35 %. Usually, accessory spleen present in close vicinity of spleen, in the hilum or in adjacent ligaments. The wall of jejunum, the mesentery and pelvis are very unusual sites of accessory spleen. Scrotal sac is a extremely rare site of this entity. Preoperative diagnosis of this entity is difficult, as radiology is not of much benefit. Clinicaly it's differential diagnosis ranging from some benign pathologies to certain testicular tumor, so the treatment. Conclusion: Presence of accessory splenic tissue in scrotal area is a very rare finding. It can be easily mistaken with some other pathologies and testicular malignancy. Awareness of this clinical entity could avoid unnecessary orchidectomies.

   PP234: Epitheloid inflammatory myofibroblastic tumor: The youngest case reported Top

Sajida Batool, Arvind Ahuja, D S Chauhan, Minakshi Bhardwaj, Ankita Yadav

Department of Pathology, ABVIMS and Dr RML Hospital, New Delhi, India. E-mail: [email protected]

Background: Epitheloid inflammatory myofibroblastic tumor (EIMT) is a rare variant of inflammatory myofibroblastic tumor. It has aggressive course and high chance of recurrence. We are reporting a case of 4 month old infant with epitheloid inflammatory myofibroblastic tumor which will be the youngest case reported so far, as per the literature. Case Report: A 4 month old female patient presented with the complaint of rapidly growing lump in abdomen. On CECT large hypodense lesion was present in right side of abdomen. Child was operated and an encapsulated mass (12x11x7cm) with attached segment of small bowl was received for HPE. External surface of the mass was shiny & lobulated. Cut section was greyish white and glistening with myxoid areas. HPE showed tumor consisting of spindle to epitheloid cells loosely arranged in myxoid background with numerous blood vessels and lymphoplasmacytic inflammatory infiltrate. Tumor cells had moderate eosinophilic cytoplasm, oval to elongated nuclei and inconspicuous nucleoli. Variable mitosis (4-5/10hpf) was noted. Various IHC were applied and tumor showed positivity for desmin, CD68 , ALK and focal positivity for SMA & CD30. A final diagnosis of epitheloid inflammatory myofibroblastic tumor was given. Conclusion: Epitheloid IMT is a rare and distict variant of IMT with very few cases reported in the literature. We report the youngest case of an EIMT arising in the mesentery of small bowl.

   PP235: Fetus-in-fetu a diagnostic dilemma: Case report and review of literature Top

Neha Yadav, Amit K Yadav, Rashmi Mathur, Manju Kumari

VMMC and Safdarjung Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Fetus in fetu (FIF) is a rare congenital anomaly with an incidence of 1:5,00,000 live births. It is characterized by the presence of one or more partially developed fetuses growing within the body of an otherwise normal fetus .The most common site is retroperitoneum. It typically presents in infancy or early childhood and can often go unnoticed as an abdominal mass. Case Report: A four days old male presented to the department of pediatric surgery with a history of retroperitoneal mass since birth. Contrast enhanced computed tomography was suggestive of fetus-in-fetu. The neonate underwent surgery and the excised mass was sent for histopathological examination. Grossly, a grey-brown lobulated soft tissue mass measuring 12x8x6 cm was received. On cut it was multiloculated filled with sero-sanguinous fluid along with grey-white solid as well as cartilaginous areas. On microscopic examination glial tissue, primitive neuroepithelium, choroid plexus, cartilage, skin appendages, adipose tissue and fibro-collagenous tissue were identified. Based on histopathological and clinicoradiological findings a final diagnosis of fetus in fetu was given. Discussion and Conclusion: Although rare Fetus in fetu should always be considered in differentials of an abdominal swelling which is present since birth. It needs to be differentiated from teratoma because of the small risk of malignancy in the latter. FIF shows presence of the vertebral column often with appropriate arrangement of organs or limbs around it which is not seen in teratoma. Correlation of histological and radiological findings is essential to reach a final diagnosis.

   PP236: Hepatoid variant of primary adenocarcinoma lung: A series of four cases with review of literature Top

Amandeep Talwar, Anjali Sharma, Syeda Firdos Jamil, Ritu Jangir

BMCHRC, Jaipur, Rajasthan, India. E-mail: [email protected]

Rationale: Hepatoid adenocarcinoma is an extremely rare malignant entity of lung tumors that resembles histologically hepatocellular carcinoma (HCC). Till date this entity has not been highlighted in the pulmonary literature very often. Hepatoid adenocarcinoma usually presents as solitary mass in the upper lobe; there is male predominance with history of smoking. Serum alpha-feto protein is very high in these patients. Nodal and distant metastasis are usually common at initial presentation. Immunohistochemistry is used as a tool to distinguish Hepatoid adenocarcinoma and hepatocellular carcinoma specially when patient has both lung and liver masses. Objective: Presenting a formal assessment of Hepatoid adenocarcinoma cases including relevant clinical details and difficulty in histopathological diagnosis. Materials/Methods and Results: Herein, we present four cases of pulmonary hepatoid adenocarcinoma received in BMCHRC from January 2019 to August 2019. All 3/4 cases showed advanced stages of metastatic disease. Biopsy site in one of the case was right lower lobe, in two cases supraclavicular lymph node and in the fourth case was acromion process of left scapula. On immunohistochemistry, these cases expressed CK7 (4/4), HepPar1 (4/4), cytoplasmic TTFI (2/4), Napsin (2/4) (dim focal), AFP (4/4), CK19 (2/3) and did not express CK20 & P40. Conclusion: Hepatoid adenocarcinoma is a rare entity, resembles morphologically Hepatocellular carcinoma. Its distinction from Hepatocellular carcinoma is difficult when the patient presents with both lung and liver lesions/biopsy is done from metastatic site. Extended panel of IHC is needful in these scenarios.

   PP237: Cardiac pleomorphic leiomyosarcoma: A rare case report Top

Monika Panda, Prajna Das, Prita Pradhan, Kanaklata Dash, Urmila Senapati, Chandan Kumar Ray Mohapatra1, Bana Bihari Mishra1

Departments of Pathology and1CTVS, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: [email protected]

Introduction: Primary cardiac sarcoma is a rare tumor with an incidence of 0.001 to 0.03%. Incidence of pleomorphic leiomyosarcoma is <0.25%. Left atrium is the common site. Case Report: A known case of RHD, presented with dyspnoea on exertion and cough. Trans- esophageal echocardiography showed severe MS, myxomatous multiple sessile structures over mitral valve extending into Lt Atrium. The clinical diagnosis was myxoma. Grossly we received a part of Lt arterial wall, mitral valvular apparatus with attached tumor together measuring 3x3x0.5 cm. Histopathology showed tumor cells arranged in fascicles and in storiform pattern. The cells were highly pleomorphic having high N/C ratio and hyperchromatic nuclei. Stroma showed focal myxoid change, areas of coagulative necrosis with increased mitotic count (29/10HPF) and vascularity. Immunohistochemistry showed strong positivity for Vimentin, SMA with high Ki67 index & negativity of CD68, CD34 and S100 of tumor cells. Correlating with histopathological and Immunohistochemical study a final diagnosis of cardiac pleomorphic leiomyosarcoma(Grade-III) was done. Conclusion: Cardiac pleomorphic leiomyosarcoma is a very rare tumor representing a challenge for diagnosis as well as therapeutic approach. Both histopatholohical and IHC are essential for correct diagnosis.

   PP238: Correlation of EGFR mutation status and histological subtype of lung adenocarcinoma: An institutional study Top

Sandhra Papparath Usman, Sreeja Raju, M C Savithri, Joy Augustine

Amala Institute of Medical Sciences, Thrissur, Kerala, India. E-mail: [email protected]

Background: Lung cancer is the most common cause of cancer death worldwide, with adenocarcinoma being the predominant histological subtype. Adenocarcinomas show heterogeneity in their presentation; clinical, radiological,histological,surgical outcome and molecular biology. The identification of EGFR mutation has facilitated the inclusion of Tyrosine kinase Inhibitors into the therapeutic armamentarium. A joint working group of the International Association for the Study of Lung Cancer, American Thoracic Society and European Respiratory Society(IASLC/ATS/ERS), in 2011, introduced a new histological classification for lung adenocarcinoma. This study correlates the EGFR mutation status in adenocarcinoma to its histological subtype. Design: This is a descriptive study where trucut biopsies of lung adenocarcinomas diagnosed over a period of 18months(October2017-March2019) were analysed. EGFR mutation studies were conducted in 50 cases, using ARMS-Real Time PCR. Results and Discussion: EGFR mutations were identified in 12 cases(24%). The mean age of presentation was 63 years with a male preponderance(66%). Most of these patients were non-smokers (83%). 8 cases(66%) presented with clinically advanced-Stage IV disease. The most common mutation was Exon19 deletion (75%). Although the predominant histological subtype in both EGFR-mutant(41%) and EGFR-wild type(71%) was acinar pattern; EGFR mutant cases showed a significantly higher proportion of lepidic(25%) and papillary(25%) growth patterns with a p value of 0.048. Conclusion: The most common EGFR mutation in lung adenocarcinoma according to our study was Exon19 deletion. A significant proportion of EGFR mutant cases showed lepidic and papillary histology when compared to the wild type EGFR.

   PP239: Epithelioid type of pleural malignant mesothelioma mimicking adenocarcinoma: An unusual report Top

Sulagna Sahoo, Prita Pradhan, Jayasree Rath, Ranjita Panigrahi, Urmila Senapati, K P Tripathy

Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: [email protected]

Introduction: Malignant mesothelioma of pleura is a rare diagnosis with only 15 cases reported in a 25 year period study in South India. Case Report: A 76 year old male presented with cough for 4 months, breathlessness and left sided chest pain for 1 month. Further examination revealed left sided pleural effusion. Fluid cytology showed 3-dimensional clusters of cells with a central eosinophilic matrix. Cell block showed similar findings. Immunohistochemistry showed diffuse nuclear positivity for WT-1 and diffuse strong cytoplasmic membranous positivity for D2-40 and negative for CEA and TTF-1. In view of 3-dimentional clusters, central collagenous matrix material, positivity for WT-1 and D2-40, the diagnosis of Epithelioid type of Malignant Mesothelioma was made. Conclusion: Malignant Mesothelioma of the pleura is very rare and can mimic adenocarcinoma, so detailed clinico-radiological workup, cytopathological evaluation, special staining and immunohistochemical analysis is required for accurate diagnosis.

   PP240: Lepidic pattern of adenocarcinoma of lung: A case report Top

Juthika Baishya

Assam Medical College and Hospital, Dibrugarh, Assam, India. E-mailI: [email protected]

Background: Adenocarcinoma of the lung is now the most common form of lung carcinoma in women and in many studies, in men as well. It is marked by mutations in multiple genes encoding receptor tyrosine kinases, including EGFR, ALK, ROS, HET, RET. Design: A 56 year old male patient presented with one and a half year old history of dry irritable cough, gradual weight and appetite loss over 6 months, recently developing respiratory distress and mild chest pain. On radiological examination, massive pleural effusion along with non homogeneous opacities in bilateral lung fields was noted. Bronchoalveolar lavage was done and small bits of tissue from the lung were sent for histopathological examination. Results: section from the small bits of tissue showed the picture of Adenocarcinoma of lung, lepidic pattern. Conclusion: The overall 5 year survival rate is 52% for cases detected when the disease is still localised, 22% when there is regional metastasis and only 4% with distant metastasis. As Adenocarcinoma tend to remain localised longer and have better prognosis than undifferentiated cancers. Targeted treatment of patients with Adenocarcinoma and activating mutations in EGFR or in other tyrosine kinase with specific inhibitors of mutated kinases prolong survival.

   PP241: Clinicopathological correlation of the lung resection specimens in a tertiary care centre Top

T R Praveen Paul, Gokul Kripesh, M Susruthan

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Lung resection is a procedure by which an entire lung or a part of it is removed. It is a major procedure and has a mortality rate of 16.4%. Lung resection is indicated for the treatment of pulmonary malignancy or metastasis infection, and trauma. Design: This is a retrospective, analytical study undertaken in a tertiary care centre from January 2014 to September 2019. The clinical data was retrieved from the medical records department of the hospital and the pathology slides and reports were retrieved from the department archives. Results and discussion: 41 cases of pneumonectomy and lobectomy specimen for neoplastic and non-neoplastic cases were studied in a 6-year timeframe. The mean age of the patients being 45 years. 66% of the patients were males. 26 cases were malignant of which 4 were metastatic deposits and 22 were primary. Of the 22, 12 were epithelial, 9 were neuroendocrine and 1 was mesenchymal. Fungal infection was the most common cause in benign aetiology. A relationship between post Tb sequelae followed by fungal infection was identified where 77.7% cases of fungal infection were post TB status. All the metastatic lesions were seen to involve the lower lobe and infective causes were seen to involve the upper lobe. The patients were followed up post-surgery and only one patient expired due to post-surgery complications. Conclusion: This study helps to establish the various associated dissease conditions seen in specimens of lung resection and to identify the causes of underlying lung pathology.

   PP242: Role of immunohistochemistry in the diagnosis and classification of primary lung carcinomas: Experience at a tertiary care cancer center Top

Swathi C Prabhu, Anitha Mathews, Sindhu Nair, K Jayasree

Department of Pathology, Regional Cancer Center, Thiruvananthapuram, Kerala, India. E-mail: [email protected]

Background: Standard morphology cannot specifically subtype all cases of lung carcinomas. Immunohistochemistry is a valuable tool for accurately subtyping lung carcinomas. The aim of the study is to categorize lung carcinomas on histopathology with minimal immunohistochemistry (IHC) and discuss the role of immunohistochemistry for accurate subtyping. Design: Present study included 264 cases of lung carcinomas received in our department from Jan 2019 to June 2019. Histopathological typing was based on WHO 2015 classification of lung tumors, in to small cell and non-small cell categories (squamous cell carcinoma, adenocarcinoma and poorly differentiated). Immunohistochemistry panel was then applied comprising of TTF1, Napsin A, p40, p63, chromogranin, synaptophysin, CK (AE1/AE3), CK7. Results and Discussion:

Conclusion: IHC panel comprising of TTF1, Napsin A, p40, p63, synaptophysin, chromogranin, CK (AE1/AE3), CK7 has a diagnostic value in accurately subtyping primary lung carcinomas

   PP243: Primary pulmonary glomus tumor: A case report Top

R Kalaharaghini, S Mehta, R Mavania, P Trivedi

Department of Oncopathology, GCRI, Ahmedabad, Gujarat, India. E-mail: [email protected]

Background: Glomus tumor are mesenchymal neoplasms composed of cells resembling modified smooth muscle cells of the normal glomus body. Occurrence is predominantly observed in distal extremities and subungal regions, although rare cases have been reported in deep connective tissue and viscera. Glomus tumor in lung is a rare presentation and was reported in our institute. Case Report: A 51year old male with clinical signs of obstructive pneumonia, soft tissue density 3.8x3cm in right middle lobe on CT scan underwent bronchoscopic biopsy followed by pneumonectomy. Gross examination revealed polyploid tumor involving the right middle lobe near bronchus. On microscopic examination and Immuhistochemical staining it was diagnosed as, primary pulmonary glomus tumor. It is essential, to distinguish glomus tumor from other primary lung tumors (hemangiopericytoma, neuroendocrine tumors, pulmonary sclerosing pneumocytoma, PNET) and Immunohistocmistry markers were used for the same. Grading of glomus tumors was performed according to recent WHO guidelines and was reported Glomus tumor of uncertain malignant potential. Conclusion: In pathology it's a common saying “rare entities to be diagnosed in the last” but, we should always remember these rare entities. In current case, pneumonectomy was justified for the diagnosis of glomus tumor of uncertain malignant potential. Knowledge of rare entities is equally important for the right patient management.

KEYWORDS: Glomus tumor

   PP244: Anaplastic embryonal rhabdomyosarcoma testis in a young adult: A rare case Top

Ranjan Agrawal, Cheena Garg, Vibhuti Goyal, Mithila Bisht, Arjun Agrawal1, Jagdamba Sharan1

Departments of Pathology and1Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Rhabdomyosarcoma of testis, epididymis and spermaticcord isa rare malignant neoplasm and occurs sporadically. The incidence reported less than 1 per 20 million males annually. A 14-year-oldboy presented with pain and swelling in the right lower abdomen. O/E there was a swelling in the right iliac fossa measuring 3 x 3 cm, which was firm in consistency and slightly mobile. The right testis was tender. USG whole abdomen showed right testicular tumour, which they suggested to be seminoma; minimal ascites in the flank, right sided hydronephrosis, para-aortic enlarged lymph nodes. CECTshowed a large lobulated mass with deposits along the spermatic cord, extensive peritoneal deposits, and retroperitoneal lymphadenopathy causing vascular encasement, thrombosis of IVC and lung metastases. The clinical diagnosis of seminoma was considered.

FNAC revealed dispersed population of atypical cells.The Rt testis with the spermatic cord was excised and subjected to histopathology. Microscopy showed perivascular arrangement of primitive cells, surroundings myxoid matrix. Rhabdomyoblastswith cross-striations were appreciated. Multinucleated tumour giant cells were present. The tumour cells were replacing the entire testis.Spermatic cord was also involved by the tumour cells.IHCwas strongly positive for Desmin, whereas CD30 was negative. The final diagnosis of anaplastic variety of embryonalrhabdomyosarcoma was given.Post-surgery the patient is on chemotherapy and doing well after 6 months.

Spindle cell variant is the commonest subtype. Pleomorphic or anaplastic type is the rarest of all subtypes occuring mainly in adults.Thus, the present case is very rare and unusual.

   PP245: Evaluation of role of Trichomonas vaginalis,Chlamydia trachomatis and Candida spp. in cervical dysplasia and neoplasia Top

Ishita Ghosh

Institute of serology Government of India, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Genital infections by Trichomonas vaginalis(TV), Chlamydia trachomatis(CT) and Candida spp. might cause cervico-vaginal epithelial disintegration, protein degradation, immune modulation, genetic damage, promoting access of Human papilloma virus (HPV), the principal causative agent of cervical dysplasia to basal epithelial layer and acceleration of dysplastic process. We aimed to understand importance of TV, CT, Candida spp. in development of cervical dysplasia and neoplasia. Design: Cervical tissues from 483 women were examined microscopically for cervical intraepithelial neoplasia (CIN) and cancer. Laboratory tests performed from cervical swab specimens were i) Rapid immunochromatographic test for CT antigen detection ii) Candida spp. identification on Sabouraud-dextrose agar and speciation using Hi-chrome agar iii) TV detection using Kupferberg media iv) Microscopy of cervical tissues for HPV infection. Molecular tests were conducted in selected cases for confirmation. Results and Discussion: On multivariate analysis, age and menopausal status were found to significantly affect coinfection status (p < 0.001). CT or Candida spp. infection did not modify the estimated risk of cervical neoplasia. In cases of CIN, highest age and menopause adjusted relative risk was observed in case of coinfection with HPV and TV with or without Candida spp. infection. There was overall significant rise of HPV and TV coinfection with increasing histopathological grades of neoplasia (p < 0.001). Risk of invasive cervical cancer in HPV positive women was higher in presence of co-infection with TV though not statistically significant (p for heterogeneity = 0.53). Conclusion: Association of Trichomonas vaginalis infection with cervical intraepithelial neoplasia was found.

   PP246: Squamous cell carcinoma of cervix presenting as bilateral ovarian metastasis: A rare case report Top

Monika Gathwal, Ruchi Agarwal, Kulwant Singh, Parveen Rana, Deepti Agarwal, Swarn Kaur Saluja1, Chiranjeev Gathwal2

BPS Government Medical College for Women, Departments of1Pathology and2Radiology, BPS GMC for Women, Sonepat, Haryana, India. E-mail: [email protected]

Background: Cervical cancers rarely metastasize to the ovaries. The proportion of cases presenting with ovarian metastases at the time of surgery ranges from 0.6 to 1.5%.Ovarian metastasis was identified in 0.5% patient with squamous cell carcinoma of cervix while incidence of metastasis was 1.7% in cases of adenocarcinoma of cervix in a study of 1000 cases of cervical cancer. Case Report: A 66 year's female presented with pain abdomen and abdominal distension since one month. On per abdomen examination, firm masses in both right and left adenexa were palpable. CECT lower abdomen show bilateral ovarian cystic multilocular mass lesions with intervening septa of varying thickness. Serum levels of CA 125 was 202.1 U/ml, CEA was 26ng/ml and CA 19.9 was 138.5 u/ml. Clinical diagnosisof bilateral ovarian neoplasm was made and patient underwent trans-abdominal total hysterectomy with bilateral salpingo-oophrectomy and omentectomy. Grossly, endomyometrium was unremarkable, posterior lip of cervix showedan irregular grey white area measuring 1.5 cm in length. Right ovarian mass measured14x11x8 cm, left ovarian mass measured14x11x7 cm, outer surface of both masses were multinodular and on cut showed predominantly solid areas with few cysts. On histopathology, diagnosis of primary Squamous cell carcinoma of cervix with lymphovascular emboli in the myometrium and bilateral ovarian and omental deposits was made. Conclusion: In cases of bilateral ovarian squamous cell carcinoma, metastasis should be suspected than primary malignancy. Careful gross and microscopic examination of cervix and vagina should be performed to rule outoccult primary neoplasm.

   PP247: Carcinosarcoma of ovary: A rare case report Top

Chetana Pradhan

Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India. E-mail: [email protected]

Background: Malignant mixed mullerian tumours(carcinosarcoma) of ovary are very rare neoplasms. Incidence is less than 1%. Case Report: A 25 year old lady presented to gynaecology OPD with generalised weakness and gradual swelling of abdomen since 1 month.The patient was on lactational amenorrhea stage.On P/V examination-a large mass was felt throughout the fornix.Serum CA125 and serum ßhCG was increased. CT scan revealed a malignant left ovarian mass with omental caking and ascites.The mass is compressing the left ureter causing left side hydronephrosis. The patient underwent surgery and the left ovarian mass was received for histopathological examination. Results and Discussion: Grossly a nodular greyish brown mass m 25×20.5×9 cm.The cut section shows multiple nodules with some cystic areas. Microscopic examinations show a tumour exhibiting biphasic pattern.The epithelial components of tumour cells are arrnaged in irregular glandular pattern and some epithelial components showing clear cell changes.The stroma shows sarcomatoid change with both homologous and heterologous components.The histochemical stain for PAS shows positivity in few of the clear cells. MVI found.IHC for EMA and vimentin are diffusely positive.The differential diagnosis are malignant teratoma,ovarian adenosarcoma. Conclusion: Carcinosarcoma shows aggressive clinical course.The predisposing factors are chronic estrogen stimulation,nulliparity,obesity.The 5 year disease free survival rate is very poor with most patients developing extrapelvic spread.Early diagnosis and treatment is important to improve the survival.

   PP248: Periductal stromal tumor of vulva: An extremely rare entity Top

Vaishali Yadav, Anita Nangia, Neha Suman, Shaji Thomas1

Departments of Pathology and1Surgery, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E-mail: [email protected]

Introduction: Ectopic breast tissue on vulva is extremely rare and can give rise to both benign and malignant lesions. We hereby describe one such case of periductal stromal tumor (PDST) in accessory breast tissue in vulva in an adult female.The number of reported cases of PDST in breast is limited. After extensive search of literature, no case of PDST in vulva has been reported till now. Case Report: A 40 year old female presented with complaints of gradually progressive soft tissue swelling of right vulva since 1 year. On examination, the swelling was 10x9x4 cm, firm and non-tender. Fine needle aspiration suggested possibility of accessory breast tissue which was confirmed on trucut biopsy. Due to the progressively increasing size of swelling excision was done and specimen sent for histopathological examination. It was a skin covered 10x9x4cm specimen. On serial section, a partly circumscribed lesion was identified measuring 10x8.5x3.8 cm, firm and fleshy in appearance. Microscopic examination showed stratified squamous keratinised epithelium with underlying subepithelial tissue with non-circumscribed proliferation of spindle cells localised around the benign epithelial ducts. There was stromal hypercellularity along with focal areas of myxoid changes. Immunohistochemistry showed that the tumor cells were positive for CD34 and Ki-67 was<2%. The tumor was negative for CD117. The final diagnosis of PDST (ectopic breast) was made. Conclusion: Vulval breasts can undergo many physiological and pathologic changes that occur in the normally situated breast. PDST is a rare tumor in the differential diagnosis for women presenting with a vulvar mass.

   PP249: Paratesticular fibrous pseudotumour presenting as scrotal swelling Top

Leena Dennis Joseph, Mohana Priya1, Balaji Singh1, G Barathi2, Seelam Mounika

Sri Ramachandra Institute of Higher Education and Research, Departments of1Surgery and2Pathology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India. E-mail: [email protected]

Background: Paratesticular tumors are rare intrascrotal masses that grow mainly in structures containing connective tissue around the testis, epididymis, or spermatic cord.Fibrous pseudotumor is a rare benign lesion that arises from testicular tunics and, less commonly, grows into the epididymis and spermatic cord. This lesion is a consequence of a reactive proliferation of inflammatory and fibrous tissue. The initial stimulus of this reactive process may be a prior infection or trauma. Clinical Details: A 40 year old male patient,presented with swelling in the right scrotum,accompanied by a dull aching pain.On examination, the globular swelling was 10 cms in greatest dimension,with well defined borders.The swelling had a smooth surface and was hard in consistency.Ultrasonogram scrotum showed right paratesticular mass and right mild chronic paratesticular hydrocoele.Patient underwent orchidectomy and the specimen was sent for histopathology.Gross examination revealed a grey white cut surface,which was whorled with focal blackish areas.The adjacent normal testis was also noted.Microscopy showed a hypocellular spindle cell lesion,admixed with hyalinised eosinophilic material.Very few mitosis were noted.By Immunohistochemistry the tumor cells were positive for SMA and there was a cytoplasmic positivity for beta catenin.They were negative for desmin,S100 and CD 34. A diagnosis of paratesticular benign fibrous pseudotumor was given and the patient was discharged .A benign diagnosis is a big relief to the patient and recognition of this entity is important for both the clinician and pathologists.

   PP250: Phospho S6 ribosomal protein expression in endometrial hyperplasia and carcinoma Top

Sunakshi Yadav, Vinod K Arora, Preeti Diwaker

UCMS, GTB Hospital, Delhi, India. E-mail: [email protected]

Introduction: Endometrial carcinoma is one of the most common malignancy in females. Type I endometrial carcinoma is the most common type, arising in the setting of excess estrogen unopposed by progesterone. Type II carcinoma are more aggressive with no association to excess estrogen. Recently, molecular pathways have been implicated in pathogenesis of endometrial hyperplasia and carcinoma, of which mTOR phosphorylation is most important pathway whose substrate is the pS6 protein. Materials and Methods: study was conducted in UCMS, Immunohistochemistry for pS6 protein was applied on 20 cases of endometrial carcinoma and 20 cases of endometrial hyperplasia. The results were compared with the pS6 expression in 20 age matched normal endometrium. Observation: pS6 showed cytoplasmic positivity. H-score was calculated for each case. H score of hyperplastic endometrium was 96.1±42.01 which was significantly more than that of normal endometrium (42.35±25.32). H score of endometrial hyperplasia was significantly lower as compared to carcinoma cases (143±66.3). The difference in H score was statistically significant for endometrial carcinoma and normal endometrium (P value <0.05). Conclusion: Our findings in the study suggest that the pS6 expression, a marker of mTOR pathway is significantly increased in endometrial carcinoma suggesting that mTOR pathway hyperphosphorylation plays a crucial role in endometrial carcinogenesis.

   PP251: Mucormycosis involving uterus in an immunocompetent host presenting as irregular bleeding per vagina in 44 year female: A rare case report Top

Anish Kumar Rakshit

R G Kar M C, Kolkata, West Bengal, India. E-mail: [email protected]

Background: Mucormycosis,an uncommon opportunistic fungal infection which is caused by mucorales containing the genera rhizopus,mucor and rhizomucor.It usually affects immunocompromised persons.Most important risk factors include uncontrolled diabetes mellitus,haematologic disorder,haematopoietic or solid organ stem cell transplantation,surgery/trauma,corticosteroid therapy etc.Death rate from mucormycosis is less common than invasive candida or aspergillus infections.Literature has very limited cases of mucormycosis involving the uterus. Design: A 44 years old woman came to emergency with complaints of abdominal pain and fever for last 3 months and irregular bleeding per vagina for 3 years.She was known diabetic for 12 years.Physical examination revealed pallor with rise in temperature.Per vaginally pouch of douglas was bulging and tender. Ultrasonography revealed 30 ml fluid collection in POD and thickened peritoneal covering over posterior aspect of uterus.Fluid was taken out for cytological study which showed inflammatory cells with predominance of lymphocytes.Broad spectrum antibiotics were of no benefit.Finally, decision of hysterectomy was taken. Results and Discussion: Grossly,uterus measured 9.5x6x4.5cm3.Outer surface was blackish with variegated appearance.Tissue taken from blackish area sent for histopathological examination.Microscopically fungal elements (hyphae)were found in myometrium,mainly in the serosal layer on H and E stain.No granuloma was detected. Methanamine silver stain(Grocott) showed broad,aseptate,right angle branching,ribbon like hyphae of mucormycosis.Culture on sabouraud dextrose agar showed fluffy white growth and organism was identified as Rhizopus oryzae(R.arrhizus). Conclusion: Overall clinical,cytological,histopathological examination which was again confirmed by microbiological culture strongly support the diagnosis of mucormycosis involving the myometrium of the uterus.

   PP252: A rare case report of adenocarcinoma admixed with neuroendocrine carcinoma of uterine cervix Top

Anantha Sahitya Kolli

Prathima Institute of Medical Sciences, Nagunoor, Telangana, India. E-mail: sahityacapricorn.00[email protected]

Background: Small cell neuroendocrine tumours comprises approximately 2% of all cervical cancers and only 4% of tumours are associated with adenocarcinoma. Adenocarcinoma admixed with neuroendocrine differentiation (small cell differentiation) are more common than large cell variant. Design: Here we report a case of 33years old woman who presented with postcoital bleeding, dyspareunia and irregular menstrual bleeding. Cervical punch biopsy relieved mild dysplasia of cervix. Subsequent hysterectomy specimen relieved a small growth on cervix measuring 2 x 2cm. Results and Discussion: With conventional microscopic findings tumour tissue arranged in sheets and clusters, at places in acinar pattern. These neoplastic cells are small, round with scanty cytoplasm. nucleus is pleomorphic showing hyperchromasia with fine granular chromatin and inconspicuous nucleoli and ancillary studies like immunohistochemistry with carcinoembryonic antigen, P16, Chromogranin synaptophysin, MIB1 favours small cell neuroendocrine carcinoma and adenocarcinoma of cervix. Conclusion: Small cell neuroendocrine carcinoma of uterine cervix is a rare tumour with highly aggressive clinical course and poor prognosis due to high frequency of lymph node involvement at an early stage. Poor prognosis of small cell neuroendocrine carcinoma include advance stage, size of the tumour, small cell histology and increased rate of extra pelvic recurrences.

   PP253: Heterologous elements masquerading as mucinous cystadenocarcinoma in sertoli -leydig cell tumor of ovary: A rare case report Top

Toshi Agarwal, Satish Arakeri, Surekha U Arakeri, Mahesh H Karigoudar

Shri B.M Patil Medical College, Vijayapura, Karnataka, India. E-mail: [email protected]

Background: Sertoli–Leydig cell tumor (SLCT) comprises less than 0.1% of ovarian neoplasms. This tumor is usually associated with heterologous elements like gastrointestinal epithelium, cartilage etc. Case Report: A 27 year old female patient presented with infertility in OBG department. On examination, the patient had features of virilization, breast atrophy and hirsutism. USG and CT scan of abdomen & pelvis showed Large, predominantly cystic with solid component in the left adnexa measures 14x12x10cm, suggested, ovarian neoplasm ? benign cystadenoma. Patient underwent total abdominal hysterectomy with bilateral salphingo-opheretectomy. Grossly ovary showed solid & cystic areas. Microscopy showed features of sertoli- leydig cell tumor with heterologous elements (mucinous type of gastrointestinal epithelium). IHC confirmed the diagnosis. Discussion: The presence of heterologous elements misleads the diagnosis of SLCTs. In our case, the presence of mucinous type of gastrointestinal epithelium in addition to sertoli leydig cells misleads the pathologist in making a proper diagnosis. In such cases, a detailed clinical history of the patient should be taken as SLCT are hormone producing tumors. SLCT is usually seen in young age and having features of virilization and other hormone related changes. On the other hand, mucinous cystadenoma/ carcinoma presents in late middle age with no features of hormone related changes. Conclusion: Detailed clinical history, thorough gross examinantion and aid of IHC helps in arriving the diagnosis of rare ovarian neoplasms like SLCTs.

   PP254: Lepromatous leprosy with primary testicular involvement: A rare presentation Top

Reshma Rani Satapathy

MKCG MCH, Berhampur, Odisha, India. E-mail: [email protected]

Background: Leprosy is a chronic granulomatous infection caused by Mycobacterium Leprae that predominantly affects the skin and peripheral nerves.It presents with clinicopathological manifestation across the spectrum of tuberculoid(TT) to lepromatous(LL) leprosy.It has the propensity to involve lymphnode,spleen,bonemarrow,eyes and testis. Case: A 61yr Male presented with scrotal swelling and inguinal lymphadenopathy associated with severe pain for 6 months. clinical diagnosis of testicular tumour was given.we received biopsy of high inguinal orchidectomy specimen along with inguinal lymphnode for histopathological analysis. Histopathological study revealed aggregates of foamy macrophages in testis and inguinal lymphnode which in modified ZN stain showed globi of acid fast lepra bacilli. Conclusion: Herewith we report a case of lepromatous leprosy with an unusual presentation that was diagnosed from testis and inguinal lymphnode biopsy.

   PP255: Schaumann bodies in tuberculous granulomas of female genital tract: A rare case report Top

Swatismita Sahoo, P K Das

M.K.C.G Medical College, Berhampur, Odisha, India. E-mail: [email protected]

Background: Schaumann bodies are commonly observed and described in Sarcoidosis.They are very rarely seen in tuberculous granulomas. Case Report: A 50 year old female patient presented with pain abdomen and whitish discharge per vaginam.The hysterectomy specimen from the patient showed tuberculoid granulomas.The giant cells showed schaumann bodies in the form of concentric calcifications. Conclusion: Though,Schaumann bodies are commonly seen in sarcoid granulomas but can be rarely seen in granulomas due to other causes,especially tuberculosis.

   PP256: Granulomatous prostatitis: A clinicopathological series of 27 cases Top

Pooja Suteri, Arvind Ahuja, Minakshi Bhardwaj, Purnima Malhotra, D S Chauhan, Hemant Goel1

Departments of Pathology and1Urology, ABVIMS, Dr RML Hospital, Delhi, India. E-mail: [email protected]

Background: Granulomatous prostatitis is a rare, benign lesion of the prostate. It is important to diagnose it because it can present as prostate cancer clinically and radiologically along with elevated serum PSA levels. Design: A retrospective analysis of histopathological records of 1773 prostatic specimens received in the pathology department was done over a period of 07 years (2013 to 2019). All histologically proven cases of granulomatous prostatitis were retrieved, and relevant clinical data were collected from patients records and the lesions categorised accordingly. Results and Discussion: Out of 1773 cases, 27 cases of granulomatous prostatitis were identified. The age range of these patients was between 50- 89 years. Among these, nonspecific granulomatous prostatitis was the most common followed by tubercular prostatitis and xanthogranulomatous prostatitis. Three cases were associated with malignancy. Serum prostate-specific antigen(PSA) levels ranged between 0.8 ng/mL -20.94 ng/mL. 5 cases had presented with lower urinary tract symptoms, hard and fixed nodules were observed on digital rectal examination(DRE) in 7 cases. The diagnosis was made by histopathological examination of trucut biopsy, transuretheral resection of prostate chips, prostatectomy and cystoprostatectomy specimen. Conclusion: These patients usually presented as hard nodules on DRE alongwith raised serum PSA levels. A clinical diagnosis of carcinoma or benign prostatic hyperplasia was kept as the clinical diagnosis in these cases . Granulomatous prostatitis is made on histopathological examination only. Meticulous histomorphological assessment is therefore required to reach a definitive diagnosis of granulomatous prostatitis.

   PP257: Immature teratoma ovary: A rare case report Top

Deepika Wadhera, Deepika Wadhera, Mohanvir Kaur, Ramesh Kumar Kundal, Najinder Preet Kaur, Arshiya Bansal, Karan Garg

GMC, Patiala, Punjab, India

Background: Immature Teratoma is a rare germ cell neoplasm accounting for <1% of ovarian teratomas .It is characterized by the presence of immature tissue and amount of immature neuroepithelium component present correlates with the tumour grade and prognosis of tumor .It is malignant in nature .This study is conducted to evaluate pathological presentation of immature teratoma. Design: A case of 36 year female with complaint of pain in inguinal region radiating to thigh since 6 month.MRI was suggestive of Teratoma . Patient taken up for exploratory laparotomy . Hysterectomy specimen along with adnexal mass was received for histopathological examination. Tissues were fixed in 10% formalin for processing. Sections were processed routinely with paraffin embedding and stained with hematoxylin and eosin. Results and Discussion: According to WHO, the definition of immature teratoma is a teratoma containing a variable amount of immature embryonal type, predominantly the neuroectodermal tissues.In the present case on Histopathology, diagnosis of Immature Teratoma Ovary -Grade 2 was made. Conclusion: Immature teratoma of the ovary has complex morphological spectrum and offers diagnostic challenges. Although it is reported often but the case is reported because of its rarity.

   PP258: Accuracy of frozen section in analysis of ovarian tumors Top

Samrudhi Samant, Pragya Sharma, Arijit Sen

Command Hospital Air Force, Bengaluru, Karnataka, India. E-mail: [email protected]

Introduction: Tumours of the Ovary are a heterogeneous group of tumours which includes surface epithelial tumours, germ cell tumours, and sex cord stromal tumours. The preoperative diagnosis of the malignant potential of ovarian tumours based only on imaging techniques and tumour markers remains unreliable, and intra-operative pathological examination using Frozen section is irreplaceable. Materials and Methods: Retrospective study was over a span of three years between January 2017 and August 2019. Patients' demographic and clinical data, operative details, Frozen Section and final HPE report were reviewed from the medical records. Slides from incomparable cases were retrieved and re-evaluated Results: A total of 30 patients were evaluated with the mean age of the patients ranging from 42.30±10.88 yrs. The overall accuracy to determine Benign as well as borderline tumours was 93.3% while that of malignant tumours was 96.7%. Sensitivity of the test was highest in the benign group at 92.3% and lowest in the malignant groups at 75%. The specificity was 100% for benign, 93.3% for borderline and 96.3% for malignant. There were two false negative and one misdiagnosis in frozen section examination. Conclusion: A periodic review of the correlation between frozen section diagnosis and final diagnosis is useful to identify the potential causes of errors and thus measures can be implemented to help prevent similar occurrences.

   PP260: Does MELF pattern of myoinvasion in endometrioid endometrial adenocarcinoma signal worse outcomes? Top

Varuna Mallya, Navpreet Kaur, P S Amritha, Shramana Mandal, Nita Khurana, Deepti Goswami1

Departments of Pathology and1Obstetrics and Gynecology, Maulana Azad Medical College, New Delhi, India. E-mail: [email protected]

Background: Various patterns of myoinvasion are known to occur in Endometrioid Endometrial Adenocarcinoma (EEA). MELF ( Microcystic Elongated Fragmented glands)pattern of myoinvasion has been shown to indicate poorer outcomes.We conducted this study to find the prevalence of MELF pattern in a contemporary cohort of Indian patients who underwent hysterectomy and examined the correlation between MELF pattern and adverse pathologic outcomes. Design: This is a retrospective study of patients who underwent hysterectomy for endometrial carcinoma at a tertiary care teaching institution,between September 2017 and August 2019. Baseline demographics and clinical characteristics were noted. Histopathologic characteristics studied included pattern and depth (> 50 % or < 50%) of myoinvasion, Lymphovascular Invasion (LVI), Lymph nodal involvement (LNI, cervical stroma involvement (CSI) and grade of malignancy.Correlation between presence of MELF pattern of myoinvasion and adverse pathologic indicators was examined using statistical analysis. Results and Discussion: 33 hysterectomies for endometrial malignancy were performed during this period,of which 29 were EEA. Of these 12 (41%) patients were MELF pattern positive.Baseline characteristics(Age and Hypertension) did not correlate with presence of MELF (p =0.1 and 0.18 respectively) . The MELF pattern correlated with depth of myoinvasion (p=0.008) and cervical stroma involvement (p=0.001). LNI (p=0.08), LVI (p=0.05) and grade of malignancy (p=0.6) were not found to statistically correlate with presence of MELF pattern. Conclusion: Identification of MELF pattern of invasion is an indicator to predict adverse pathologic outcomes. Further studies looking at clinical outcomes like cancer free survival and overall survival in patients with MELF pattern invasion will be useful.

   PP261: Looking deeper: Reporting rare cases of primary ovarian carcinoid tumor in mature cystic teratomas Top

Akankshya S Kashyap

Assam Medical College, Dibrugarh, Assam, India. E-mail: [email protected]

Background: Primary ovarian carcinoids are rare and have been scarcely documented. Stewart et al reported the first case of carcinoid tumor arising in an ovarian teratoma in 1939. Carcinoid tumors constitute only 0.3% of all ovarian neoplasms. Design: Two post operative specimens of total abdominal hysterectomy with bilateral salpingo-oopherectomy, in middle aged women with a similar history of lower abdominal pain and radiologically diagnosed as mature cystic teratomas (dermoid cyst) were received few months apart in the Department of Pathology. The specimens were extensively sectioned and subjected to thorough histopathological examination. Result and Discussion: On gross examination, the first patient had an ovarian cyst of size 3x2.5x2cm arising from the right ovary and the second patient had an ovarian cyst of size 13x11x5cm arising from the right ovary. Hair and sebaceous material were seen on cut section on both the cysts. On histopathological examinations the ovarian mass of the first specimen showed a picture consistent with strumal carcinoid and the second specimen showed a picture consistent with insular carcinoid. Other sections from the ovarian masses of both the specimens showed a picture consistent with dermoid cyst. Conclusion: Primary carcinoid tumor of ovary arising from dermoid cysts requires thorough sectioning and detailed examination of the tissue for accurate diagnosis and reporting.

   PP262: Nephrogenic adenoma: Innocent until proven guilty! Top

Ashish Shah, Santosh Menon, Ganesh Bakshi, Gagan Prakash, Mahendra Pal, Sangeeta Desai

Tata Memorial Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]

Background: Nephrogenic adenoma(NA) is an uncommon benign lesion of the urinary tract with histological polymorphism masquerading as a malignant tumor. Design: Thirty seven patients with histopathologic diagnosis of NA (2010-2019) were included in this study. Clinical details were obtained from electronic medical records. Histopathologic slides of 39 reported cases (including 2 cases with residual lesion) were retrieved for histological and immunohistochemical(IHC) review. Results and Discussion: The median age of diagnosis was 63years(14-81years) with male:female ratio of 3:1. Majority of lesions were localized to urinary bladder(92.3%) followed by urethra(5.1%) and ureter(2.5%). Thirty patients(81%) had a prior history of bladder cancer treated with intravesical BCG(n=28) and mitomycin-C(n=17). Urine cytology in 3 cases(13%) was reported as atypical/suspicious for urothelial carcinoma. Cystoscopy(30 cases) showed flat erythematous(60%) or papillary(40%) lesions raising a suspicion of recurrence of urothelial carcinoma. Two referral cases were reported outside as signet ring cell adenocarcinoma and urothelial carcinoma. Histology showed tubular, papillary and microcystic growth pattern with minimal cytological atypia. The lesional cells were flat, cuboidal to low columnar with eosinophilic cytoplasm. Hobnail, signet ring-like and clear cell changes were identified in a subset of cases. IHC was performed on 27cases. PAX-8(n=22) and CK7(n=21) expression was seen in 100% of the cases. AMACR was positive in 89.4%cases(n=17/19). None of the cases had recurrence however, 2 cases had residual NA. Conclusions: Nephrogenic Adenoma is a benign lesion of urothelial tract which is often misdiagnosed clinically and histologically as a malignancy. Meticulous histological evaluation along with careful selection of IHC panel is critical for correct diagnosis.

   PP263: Melanosis of uterine cervix: A rare case report Top

P S Patil, Y A Momin, A V Gosavi, N A Ramteerthakar

Government Medical College, Miraj, Maharashtra, India. E-mail: [email protected]

Background: Melanosis of uterine cervix is a rare pigmented lesion characterised by melanocytic hyperpigmentation in basal layer of squamous mucosa. Though uncommon, these lesions carry clinical and pathologic significance. The spectrum of pigmented lesions of cervix is quite broad and includes melanosis, blue nevus, lentigo, and melanoma. Predisposing factors for the appearance of melanocytes in cervix include chronic irritation or trauma such as uterine prolapse and cryotherapy causing metaplastic change in cervical squamous epithelium. Design: We present a case of pigmented lesion of the cervix reported on histopathology as melanosis. Results and Discussion: A 60 year old postmenopausal lady underwent hysterectomy for third degree uterovaginal prolapse. Grossly, cervix showed a dark brown to black area measuring 3.5x1 cm. Uterine corpus was unremarkable. On microscopy the ectocervix was lined by hyperkeratotic, acanthotic stratified squamous epithelium with surface ulceration. The basal layer showed abundant intracytoplasmic melanin pigment. The subepithelium showed infiltration by mononuclear cells. The endometrium was atrophic and myometrium showed no specific lesion. Conclusion: Cervical melanosis is an extremely rare nonneoplastic melanocytic lesion, which needs to be differentiated from benign melanocytic proliferations like blue nevus and malignant melanoma which requires aggressive therapy and carries a poor prognosis.

   PP264: Sarcomatoid carcinoma of the penis: A rare tumor in rare age group Top

Sanjeet Kumar Singh, Ashish Ranjan Singh, Kshiti Atreya

Department of Pathology, IGIMS, Patna, Bihar, India. E-mail: [email protected]

Background: Spindle cell carcinoma (SpCC) or sarcomatoid carcinoma is a highly malignant variant of squamous cell carcinoma. These are biphasic tumors, which can occur at any site in the human body. Very few cases have been reported in the literature as arising from penis. Design: A 37 year gentleman presented with a history of a fleshy growth on the glans penis since 2 months. The growth was bleeding for the last week. Clinical examination revealed a 2.5x2.0x1.0 cm ulcero-proliferative growth involving glans penis, the shaft was not involved by the tumour. Histopathological examination of the biopsy from penile tissue was done by routine H&E stain followed by IHC. Result and Discussion: Histopathological examination of the tissue showed sarcomatoid carcinoma of the penis, which was confirmed on IHC. The rarity of this entity makes it a clinicopathologic curiosity The incidence of penile cancer in Indian subcontinent is 1.8/100,000 population. Almost 95% of these tumors are squamous cell carcinomas. An uncommon variant is sarcomatoid carcinoma, which is also called as spindle cell carcinoma, metaplastic carcinoma, or biphasic squamous cell carcinoma. Most pathologists today accept that carcinosarcoma is a tumor which originates from an epithelial cell. These tumors express both epithelial as well as mesenchymal antigens, when tested by immunohistochemistry. Conclusion: Although Spcc of penis are rare, this case highlights the need to consider it in the differential diagnosis of penile cancers. This case also illustrates that age is no bar for any tumor and rare tumors too occurs at early age groups.

   PP265: Hemangioma of uterus: Report of two cases Top

Arohi Parekh

Department of Pathology, Gujarat Adani Institute of Medical Sciences, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Uterine hemangioma is a rare benign tumour, and can be congenital or acquired. Acquired is associated with i) physical changes such as tissue injury, hypoxia, endometrial curettage, and increased blood volume during pregnancy and ii) hormonal alterations such as menarche, pregnancy and maternal ingestion of diethylstilbestrol. Uterine hemangiomas may present with bleeding P/V, or remain asymptomatic and usually are found incidentally. USG is inconclusive; however it can be diagnosed by pelvic angiography, CT scan and MRI. In this report we describe two cases of uterine hemangioma which were found incidentally. Case Description: Case 1: Female, 40 years G6P3L3A3, presented with bleeding P/V since 8 months. Case 2: Female 37 years G4P4L4A0, presented with bleeding P/V since 12 months. Hysterectomy specimens in both patients showed similar features. The serosal surface of uterus had slightly bluish tinge and the outer one third of myometrium had blackish brown appearance and contained sieve like spaces while the inner two third of myometrium had greyish white appearance. Microscopic examination of outer one third of uterus in both the cases showed proliferation of cavernous vascular spaces which were containing RBCs and were lined by endothelial cells. Conclusions: Literature describes only 50 cases of uterine hemangioma, which include three cases described in Indian literature. Identification of these lesions has clinical relevance, in patients with uterine hemangioma, vaginal delivery is preferred owing to the possibility of incising the lesion during cesarean delivery. If cesarean delivery is required, a vertical incision should be performed.

   PP266: Papillary serous adenocarcinoma of the endometrium: A rare case report Top

Saba Naaz, Charanjeet Ahluwalia, Amit K Yadav, Rashmi Arora

VMMC and Safdarjung Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Papillary serous adenocarcinoma of the female genital tract is a well known tumor that is characterised by papillary projections and contains psammoma bodies that may calcify. Most papillary serous adenocarcinoma are located in ovary, much less frequently is detected in endometrium. Case Description: A 30 year old female presented with complaints of intermenstrual bleeding and haematuria with weight loss from last 6 months. No other reports available with patient. A biopsy was taken from the growth involving the cervix. Histopathological examination showed tumor cells arranged in papillary pattern along with many psammoma bodies. Atypical mitosis also seen. The tumor cells were positive for CK, vimentin, ER and focally positive for PR but negative for p16. Conclusion: Papillary serous type of carcinoma is known to be a rare type of endometrial tumor that comprises only 5-10% of endometrial carcinoma, out of which only one- third shows psammoma bodies. Morphologically it mimics the ovarian papillary serous adenocarcinoma of the ovary, thus it has to be differentiated from metastatic ovarian cancer. This case is being presented because of its rarity and to raise clinicopathological awareness.

   PP267: Non-peutz-jeghers syndrome-associated malignant ovarian sex cord tumor with annular tubules in a young female: A rare case report Top

Shruti Gupta, Manish Rohilla, Arvind Rajwanshi, G R V Prasad1

Departments of Cytology and1Obstetric and Gynaecology, PGIMER, Chandigarh, India. E-mail: [email protected]

Background: Sex cord tumor with annular tubules (SCTATs) are rare tumors, comprising < 1% of sex cord-stromal tumors. The usual age of presentation is 20-40 years. The majority of SCTATs associated with PJ Syndrome are considered to be benign. In contrast, malignant behaviour with metastases is seen in at least 20% of non-PJS associated SCTATs. Results and Discussion: A 15-year-old premenarchal female with normal secondary sexual characteristics presented with complaints of abdominal distension and sharp pain localised to the left side of the abdomen for one month. An abdominal MRI scan revealed a large complex mass in the pelvis extending into the suprapubic area arising from left adnexa. The patient did not show any endocrine manifestations, lymphadenopathy or omental deposits. Left salpingo-oophorectomy was done and on gross examination, ovary measured 13 x 12 x 8 cm, with a predominantly solid gray-yellow cut surface. Microscopy revealed classical morphology comprised of simple and complex annular tubules of varying size with interspersed eosinophilic hyaline material. Tubules typically lacked lumens, and the nuclei of the lining cell had an antipodal arrangement. The tumor cells were immunopositive for Inhibin and calretinin. Extensive lympho-vascular invasion was noted; thus, the diagnosis of malignant sex cord stromal tumor with annular tubules was made. Conclusion: SCTAT's is a morphological diagnosis, and in cases without a history of PJ Syndrome, meticulous search for evidence of malignant potential is mandatory. The malignant SCTATs have bad prognosis with chances of recurrence and distant metastasis. These patients require adjuvant chemotherapy and close follow-up.

   PP268: Histopathological changes in placenta of HIV at tertiary care hosphital Top

Manisha Badne

Department of Pathology, GGMC and Sir JJ Group of Hospital, Mumbai, Maharashtra, India. E-mail: [email protected]


  • To describe the histopathological findings in placenta of mothers with HIV.
  • To identify the most frequent findings in the placenta with HIV.

Background: The placentas from HIV-infected mothers shows no specific histological changes that could be attributed to HIV contamination. These pathological changes are differ from other congenital transplacental viral infections. chorioamnionitis is most common finding occur in majority of cases. Deciduitis, low fetal:placental weight ratio are other nonspecific findings. Chorionic villitis is extremely rare. Methods: We conducted one year prospective study on histopathological changes of placentas from HIV infected mothers at department of pathology of tertiary care hospital. Placentas were collected and examinations performed according to the standard procedures of department. Data regarding demographic information, placental macroscopic and microscopic findings were reported according to a standard proforma. Results: We enrolled total 22 HIV placenta studied over one year period. Histopathological finding are chorioamnionitis (68%), deciduitis (18%), villitis (9%) and calcification (4.5%). Mean foetal birth weight in these cases is 1.68 g. We observed that, there is low fetal:placental weight ratio. Conclusion: Various histological lesions were observed in our study. Most common histological lesion observed was chorioamnionitis (68%) followed by deciduitis (18%).

KEYWORDS: Chorioamnionitis, deciduitis, HIV, placenta, villitis

   PP269: Serous carcinoma of fallopian tube: A case report Top

Akriti Dubey, R Gahine, J Chandrakar, Bhavana Thakur, Vanita Bhaskar

Pt. JNM Medical College, Raipur, Chhattisgarh, India. E-mail: [email protected]

Background: Primary fallopian tube carcinoma (PTFC) is uncommon tumour accounting for approximately 0.14-1.8% of female genital malignancies. It is a rare tumour that histologically and clinically resembles epithelial ovarian cancer. Here we report a case of high grade serous carcinoma of fimbrial end of fallopian tube. Case Report: A 60 years female presented with complaints of white discharge since 6 months and lower abdomen pain since 3 months. USG report was suggestive of left tubo-ovarian mass. CT scan findings revealed neoplastic mass at fimbrial end of left fallopian tube measuring approximately 3.3x2.9cm with mild proximal hydrosalpinx. On MRI abdomen and pelvis , asymmetrical circumferential mass lesion arising from fimbria of left fallopian tube was noted measuring 3.1x(AP)x2.6(TR)x2.6(CC)cm, suggesting tubal malignancy at fimbrial end. Total abdominal hysterectomy and bilateral salpingo-ophorectomy was performed. Histopathological diagnosis of high grade serous carcinoma of fimbrial end of fallopian tube was rendered (TNM Staging : T1a N0 M0). Tumour was confined within the lumen of fallopian tube, limited to the mucosa and not penetrating the tubal wall. Conclusion: Fallopian tube carcinoma is a rare tumour accounting for < 1% of all female genital tract cancers. It is rarely considered preoperatively and is usually first appreciated at the time of microscopic examination by a pathologist.

   PP270: An unsual case of placental tumor: A diagnostic and clinical challenge Top

Pooja Srivastava, Manju Yadav, Amit Yadav, Rashmi Arora

VMMC and Safdarjung Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Placental tumors are rare with majority being Chorangioma. Placental teratoma is an extremely rare non trophoblastic germ cell tumor composed of elements derived from two or more germ cell layers. Til date, less than 30 cases have been described in English literature. The first case was reported in 1925 by Morville. Here we report a unusual rare case of placental teratoma in a 30 years old female. Case Report: Afullterm 30 years primigravida female presented in obstretics and gynecology department with breech presentation. On antenatal ultrasonography she had fatures of complex cystic hypoechoic lesion along the fetal surface of placenta which was progressively increasing in size.

   PP271: Histopathological profile of urinary bladder tumors at tertiary care center in a northern state of India: A cross sectional study Top

Aarti Dhatwalia

Indira Gandhi Medical College, Shimla, Himachal Pradesh, India. E-mail: [email protected]

Background: Urothelial carcinoma of urinary bladder cancer is the fourth most common cancer in men and eighth most common malignancy in women in the Western world. It is three times more common in men than in women and 90% of the bladder tumors are transitional cell carcinoma (TCC). Cystoscopic examination has a limited role in staging process for which transurethral resection (TURBT) of visible tumor down to the base is required which can accurately assess depth of tumor invasion. Design: This record based cross sectional study was carried out in the department of Pathology, Indira Gandhi Medical College, Shimla over a period of one year from January to December 2018. Data was collected using a structured clinical Performa which included various sociodemographic and clinical variables. WHO (2016)/ISUP classification was used to classify bladder tumours. Result and Discussion: The mean age of presentation was 60 years with male female ratio 3.8:1. Majority (94.5%) of the malignancies were papillary urothelial carcinoma with equal proportion of high and low grade. Muscle invasion was significantly higher in high grade (78%) as compared to low grade papillary urothelial carcinoma (1.6%). These parameters were comparable to other studies. Conclusion: Among Urothelial tumors the most common bladder tumors, primary epithelial malignancies are more common. High grade urothelial carcinomas are usually associated with muscle invasion supporting correlation of histologic grade with aggressiveness. These findings were also seen in various other studies in literature.

   PP272: Xanthogranulomatous salpingo-oophoritis: A case report Top

Keval Patel, D N Lanjewar, Dixit Riti

Department of Pathology, Gujarat Adani Institute of Medical Sciences, Kachchh, Gujarat, India. E-mail: [email protected]

Introduction: Xanthogranulomatous inflammation of ovary and fallopian tube is an uncommon form of chronic inflammation and can be confused with ovarian tumour. Clinically patient presents with fever and pain in lower abdomen. The risk factors include endometriosis, pelvic inflammatory disease (PID), and in situ intrauterine contraceptive devices (IUCD). The involved ovary shows a well circumscribed solid, yellowish mass, the histology of which is characterised by proliferation of foamy macrophages and infiltration by plasma cells, lymphocytes and neutrophils. The etiologic agents are; Bacteroides fragilis, Escherichia coli, staphylococcus aureus and salmonella typhi. The differential diagnosis of this condition is tuberculosis, fungal infections, malakoplakia, and xanthelasma. In this report we describe a case of Xanthogranulomatous salpingo-oophoritis. Case Description: Female 25 years, having in situ IUCD, presented with left sided lower abdominal pain. Her USG and MRI showed hypoechoic solid tuboovarian mass measuring 7.1X 5.2 cms.in size. The gross examination of resected mass revealed yellowish appearance. Microscopy showed dense infiltration of the ovary and fallopian tube by foamy macrophages, plasma cells, lymphocytes and neutrophils. Special stains for tubercle bacilli and fungal infection were negative. Foamy macrophages showed diffuse positivity for CD 68. Conclusions: Literature search describes 47 cases of Xanthogranulomatous salpingo-oophoritis (38 of isolated oophoritis, and 9 of salpingo-oophoritis), which are comprised of 16 (34%) reports from developed countries and 29 (62%) reports from lndia, and one each report from Pakistan and Sri Lanka. PID, endometriosis and IUCD are major risk factors for xanthogranulomatous oophoritis in Asian females.

   PP273: Spectrum of placental changes in toxaemia of pregnancy and its comparison with normal pregnancy Top

Shilpa Garg, Shipra Misra1, Puja2, Shivani Kalhan2, Sonia Hasija2

Departments of Pathology and1Gynaecology, SHKM GMC,2SHKM GMC, Gehbar, Haryana, India. E-mail: [email protected]

Background: Toxaemia of pregnancy is the leading cause of maternal mortality and is an important factor in fetal wastage. The incidence is high in developing countries with malnutrition, hypoproteinemia and poor obstretic facilities. The intrauterine existence of fetus is dependant on one vital organ 'the placenta'. The placenta reflects the status of maternal hypertension as it is the mirror of maternal and fetal health.The hypertensive disorders complicate 5-10% of all pregnancies. Aim of the Study: To study the various morphological changes of placenta in pregnancy induced hypertension and compared them with normal pregnancies. Methods: Gross and microscopic examination was conducted on 100 placentas. These include 50 normal placentas and 50 placentas from patients suffering from pregnancy induced hypertension. Results: On gross examination placenta from eclampsia patients showed areas of infarction(19 %), haematoma formation(15.2%) and calcification(43.4%). Mean placental weight was 415 gm and mean placental diameter was 16.3cm. Microscopic findings were areas of calcification(43.4%),fibrinoid necrosis(21.7%), increased syncytial knotting(13.04%) and hemorrhagic areas (26.08%) in patients suffering from eclampsia. Conclusions: Maternal disorders affects the placental histology and can be detected by morphological examinations of such placentae. The placenta from hypertension pregnant women show significant morphological changes as compared to control, which may alter the perinatal outcome.

   PP274: Histomorphological changes of placenta in normal and pregnancy induced hypertension Top

Harendra Kumar, Garima Dundy, Yogendra Singh Lambey, Shikha Singh1, Chandrakanta

Departments of Pathology and1OBG, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India. E-mail: harendra/[email protected]

Background: The development of hypertension, accompanied by proteinuria & edema in the 3rd trimester of pregnancy, is referred to as pre-eclampsia, which occurs in 5-10% of pregnancies particularly in 1st pregnancy in women older than 35 years of age. Design: This study was done to find out morphological changes of placentas on 100 placentas; 50 cases of PIH (study group) & comparison with 50 cases of normal placentas (control) from January 18 to June 19. Results and Discussion: In the control group, most cases (64%) were in 20-24 years age group, as compared to 44% cases in 25-29 yrs in study group (PIH cases). Out of 50 cases of PIH, 20 were of mild PIH & 30 were of severe PIH. Average placental weight was

   PP275: Synchronous primaries with pre-malignant lesions of female genital tract in a 58 year female: A rare occurrence Top

Shreekant Bharti, Iffat Jamal

AIIMS, Patna, Bihar, India. E-mail: [email protected]

Introduction: Synchronous tumors of female genital tract are rare, accounting for approximately 1-2% of all gynecological malignancies having simultaneous independent primary malignancies. Synchronous tumors in ovary and endometrium are the commonest combination. We present an interesting case of multiple primary malignancies and pre-malignant lesions in the wertheims hysterectomy specimen of a postmenopausal lady. Case Report: A 58 year old postmenopausal female presented with bleeding per vaginum for one and a half months without any prior menstrual complaints. Ultrasonography revealed uterus of size 11x 9x8 cm with a mass of size 8x7 cm replacing entire uterine cavity with cystic space in between. CECT showed a heterogenous enhancing multilobated mass involving uterus and upeer part of cervix with internal necrosis and minimal fluid collection, suggestive of endometrial carcinoma. Bilateral ovaries were not visualised separately. Wertheim's hysterectomy specimen was sent for histopathology where a diagnosis of synchronous primary carcinosarcoma of uterine corpus and Serous cystadenocarcinoma, left ovary and left fallopian tube was made with carcinoma in-situ, cervix and adenocarcinoma in situ of right fallopian tube. Discussion: Synchronous tumours are diagnosed on the basis of histological dissimilarity of the tumours as highlighted in our case. It is essential to avoid their misinterpretation as a combination of primary and metastatic tumors since their management and prognostic implications are entirely different. However, the risk factors, molecular genetic profile and prognosis is almost similar to High grade Endometrioid carcinoma. B ad prognostic factors include Depth of myometrial invasion, serous or clear cell elements, heterologous elements and rhabdomyosarcomatous component.

   PP276: Correlation of inflammatory status of hyperplastic prostate gland with neutrophil lymphocyte ratio and prostate specific antigen Top

Navpreet Kaur, Shreya Shekhar Nigam, Shramana Mandal, Prerna Arora, Nita Khurana, Anurag Mishra

Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India. E-mail: [email protected]

Introduction: Prostate Specific Antigen (PSA) levels help asses status of prostate and have prognostic significance in management of Benign Prostatic Hyperplasia (BPH). Rise in PSA can also be due to associated inflammatory damage. Neutrophil Lymphocyte Ratio (NLR) is a potential biomarker to assess inflammation and predict outcome in cancer. Inflammatory status of prostate and its correlation with NLR and PSA was assessed here. Methods: We evaluated 25 newly diagnosed patients with BPH. NLR was calculated from the peripheral blood sample (ANC/ALC). Patients' total PSA was recorded. The biopsy specimens were examined by routine microscopy and inflammatory status was classified into 6 morphological patterns (segregated glandular, periglandular, diffuse stromal, acute necrotizing, focal granulomatous, isolated stromal lymphoid nodules) and extent of inflammation (mild, moderate, severe) was noted. Results: The mean age of the patients was 63.04±9.48 years. The range of NLR was 1.08-6.5 and the mean PSA levels ranged from 2.07-23.82 ng/mL. 21 patients had significant inflammation as observed by microscopy. A positive correlation was found between grade of inflammatory status and PSA level (p =0.007, r = 0.896) and NLR levels (p = 0.004, r = 0.715). A correlation was also found between NLR and PSA levels (p=0.032 , r= 0.574). Conclusion: We found a positive correlation between histopathological pattern of inflammation of the prostate gland with both NLR and PSA levels of the patient . As the grade of inflammation increases, the PSA and NLR also increase, hence making these suitable biomarker candidates.

   PP277: Small cell carcinoma of the ovary: Clinicopathologic analysis of 8 cases of an extremely rare malignancy Top

Parikshaa Gupta, Gargi Kapatia1, Nalini Gupta2, Pranab Dey2, Radhika Srinivasan2, Manish Rohilla, Arvind Rajwanshi2, Vanita Suri3, Parikshaa Gupta

Departments of Cytology and Gynecologic Pathology,1Pathology,2Cytology and Gynec Pathology and3Obstetrics and Gynecology, PGIMER, Chandigarh, India. E-mail: [email protected]

Background: Small cell carcinoma of ovary (SCCO) is an extremely rare malignancy. Establishing an accurate diagnosis,though challenging,is essential as the management differs,compared to its histopathologic mimics.Owing to its rarity,there is paucity of data regarding the distinctive histopathologic and immunohistochemical features.The present study was conducted to describe the clinicopathological and immunohistochemical characteristics of SCCO. Design: This was a retrospective study conducted over a period of 5years.All cases reported as SCCO on histopathology were retrieved.All the available clinical details along with histopathological and immunohistochemical features were studied in detail. Results and Discussion: A total of 8 cases of SCCO were diagnosed during the study period.The median age was 47.8years(9-65years).There were 4cases each of hypercalcemic(SCCOHT) and pulmonary type(SCCOPT).Among the SCCOHT cases, only 1/4 had associated hypercalcemia. Two cases had bilateral ovarian involvement.Of these, one showed coexistent uterine endometrioid adenocarcinoma and one showed cervical metastasis.Microscopy revealed sheets of small hyperchromatic cells with brisk mitosis in SCCOPT,while all the cases of SCCOHT, additionally, demonstrated the presence of scattered 'rhabdoid' tumor cells.On IHC, the most consistently expressed markers in SCCOPT were chromogranin,EMA and vimentin.In SCCOHT, chromogranin was negative, with variable positivity for EMA and vimentin,INI1 was lost in 1/4 cases.1/4 cases showed diffuse nuclear positivity for FLI1.Ki-67 index was more than 90% in all 8 cases. Conclusions: SCCO is an extremely uncommon ovarian malignancy with worse prognosis. Knowledge about its characteristic features is important for establishing an early and accurate tissue diagnosis which is quintessential for better patient outcome.

   PP278: Mixed germ cell tumor in a 50-year-old post gastric mucosa associated lymphoid tissue lymphoma: A chance association or chemotherapy induced? Top

Saumya Sahu, Mayur Parkhi, Uma Nahar Saikia, Bishan Dass Radotra

PGIMER, Chandigarh, India. E-mail: [email protected]

Introduction: Mixed germ cell tumours (GCTs) account for majority of non-seminomatous tumors, regardless of presence or absence of a seminoma component. The synchronous or metachronous association of germ cell tumor with Non-Hodgkin Lymphoma (NHL) is known but mixed germ cell tumor in a treated case of mucosa associated lymphoid tissue lymphoma (MALToma) is untold and not been described in the literature to the best of our knowledge. Case: A 55 year-old-male patient presented with painless right testicular mass, hard in consistency and gradually progressive in nature over last 3 months. The patient was diagnosed as gastric MALToma on gastric biopsy 4 years back and treated for the same (CHOP regime; 6 cycles). Elevated levels of alpha fetoprotein (AFP), lactate dehydrogenase (LDH) and b-HCG were found in the serum. The CECT imaging revealed multiple nodules and masses in lungs (bilateral) along with conglomerate lymph node in retroperitoneum and inferior vena cava (IVC) thrombus with possibility of metastasis. The patient underwent right inguinal orchiectomy which revealed mixed germ cell tumor (GCT) on histopathology. The immunohistochemistry panel (CD117, PLAP, CD30, OCT3/4, AFP, Glypican 3 and b-HCG) showed tumor comprised of more than two components in form of embryonal carcinoma (predominant), seminoma, yolk sac tumor and choriocarcinoma. Conclusion: Mixed germ cell tumors at 55 years are rare and its association with gastric MALToma post treatment is unknown. A possibility of chemotherapy inducing germ cell tumor or a specific genetic abnormalities need to be contemplated.

   PP279: Histopathological spectrum of ovarian lesion in a tertiary care hospital over a period of five years Top

Mohammad Jaseem Hassan, Nehal Ahmad, Sabina Khan, Zeeba Shamim Jairajpuri, Sujata Jetley

Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India. E-mail: [email protected]

Introduction: Ovarian lesions are commonly encountered lesions of diverse morphological spectrum that may develop from neonatal period to post-menopause. They are amongst the most frequent cause of hospitalization and surgery in gynaecological practice. Distinguishing non-neoplastic lesion from a neoplastic lesion on the basis of clinical, radiological or gross characteristics alone is a challenge clinically, so histopathological examination is must as it is important in guiding therapy. Objectives: This study was undertaken to study the various histopathological patterns of ovarian lesions, their classification and relative distribution of these lesions. Materials and Methods: This is a retrospective study of ovarian lesion specimen that was received in the Histopathology section of our department over a period of 5 years from January 2013 to December 2017. Results: A total of 190 cases of ovarian lesions were reported during the study period. Age ranged from 14 years to 75 years. Among all the lesions 106 were non-neoplastic and 84 were neoplastic. Out of 84 neoplastic lesions, 74 were benign, 3 Borderline and 7 were diagnosed as malignant tumors. Functional cyst including Corpus luteal cyst was the commonest non-neoplastic lesion while Serous cystadenoma was the commonest benign lesion and Serous carcinoma was the most common malignancy in our study. Conclusions: Ovarian lesions comprises of wide spectrum of lesions and their presenting clinical, radiological and gross features are very similar. Hence Histopathology forms the mainstay of definitive diagnosis and categorization of these lesions.

   PP280: Immunoexpression of PD-L1 and PD-1 in urinary bladder tumour Top

Utpal Kumar, Rishabh Sahai, Michael L Anthony, Prashant Durgapal, Sanjeev Kishore, Ankur Mittal

AIIMS, Rishikesh, Uttarakhand, India. E-mail: [email protected]

Introduction: PD-1/PD-L1 signaling pathway is one of the crucial mechanisms by which tumor cells evade the immune system. PD-L1 is a ligand of PD-1 which limits T cell-mediated immune response. PD-L1 expression is shown to be associated with aggressive tumor behavior in different studies. Immunoexpression of these markers needs to be studied in various geographical regions to show variation if any along with its role in predicting prognosis and therapeutics. Methods: All tissues of TURBT sent between June 2018 to February 2019 were examined retrospectively for this study. Routine H&E sections were examined along with immunohistochemistry for PD-1 and PD-L1. PD-1 was evaluated in tumor-infiltrating lymphocytes and PD-L1 was evaluated in both tumor-infiltrating lymphocytes and tumor cells. Results: Invasive Carcinoma as defined by lamina invasion showed a higher frequency of positivity of both PD-L1 and PD-1 expression (56%, 70% and 33 % vs. 28%, 44%, and 23%). Histopathological high-grade carcinomas also showed a higher frequency of PD-L1 and PD-1 expression (72%, 78% and 42 % vs. 20%, 46%, and 20%). Conclusion: High-grade urinary carcinoma expresses both PD-1 and PD-L1 in higher frequency and similarly PD-L1 expression is more frequent in invasive carcinoma. The expression of PD-1 did not show any statistical difference between invasive and noninvasive carcinoma although they had higher expression in invasive carcinoma. Our study shows that these markers may show tumor aggression as defined by grade and invasion however further study with follow-up data should be done to comment conclusively upon their role in prognostication.

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    PP128: Goblet ce...
    PP129: PD-L1 exp...
    PP130: De-nov...
    PP131: Clear cel...
    PP132: The cance...
    PP133: Malakopla...
    PP134: An unusua...
    PP135: Non cirrh...
    PP136: Collision...
    PP137: Histopath...
    PP138: Clear cel...
    PP139: Tumor ass...
    PP140: Clinicopa...
    PP141: A retrosp...
    PP142: Sigma met...
    PP143: Bone marr...
    PP145: Role of h...
    PP146: Corelativ...
    PP147: Associati...
    PP148: Risk of t...
    PP149: Granulocy...
    PP150: Comparati...
    PP151: Abnormal ...
    PP152: A case re...
    PP153: Philadelp...
    PP154: Post tran...
    PP155: Reticulat...
    PP156: Associati...
    PP157: Can LCA b...
    PP158: A rare ca...
    PP159: Myriad of...
    PP160: Intravasc...
    PP161: Intradura...
    PP162: Diffuse l...
    PP163: Immunomor...
    PP164: Lesion co...
    PP165: Clinicopa...
    PP166: A rare pr...
    PP167: Cytology ...
    PP168: Histiocyt...
    PP169: Carcinoma...
    PP170: CD23 posi...
    PP171: Monocytic...
    PP172: A case re...
    PP173: Multiclon...
    PP174: Isolation...
    PP175: Epidemiol...
    PP176: Germline ...
    PP178: Diagnosis...
    PP179: Glomerula...
    PP180: Ewing sar...
    PP181: Malformat...
    PP182: Renal ang...
    PP183: Russel vi...
    PP184: Multicyst...
    PP185: Immune co...
    PP186: Renal tum...
    PP187: Clinicopa...
    PP188: Increasin...
    PP189: Paragangl...
    PP190: Solitary ...
    PP191: Vagus ner...
    PP192: Lhermitte...
    PP193: Histopath...
    PP194: Histomorp...
    PP195: Malignant...
    PP196: A Rare ca...
    PP197: An unusua...
    PP198: Tuberculo...
    PP199: Cysticerc...
    PP200: Intraoper...
    PP201: Neutrophi...
    PP202: Mature sa...
    PP203: Extranoda...
    PP204: Schneider...
    PP205: Potential...
    PP206: Peritonea...
    PP207: Influence...
    PP208: Respirato...
    PP209: Polycysti...
    PP210: An intere...
    PP212: A rare ca...
    PP213: Phlebolit...
    PP214: Comparati...
    PP215: Uncommon ...
    PP216: A case re...
    PP217: Splenic a...
    PP218: Malignant...
    PP219: Salivary ...
    PP220: A mixed a...
    PP221: A rare ca...
    PP222: Metastase...
    PP223: Retroperi...
    PP224: An analys...
    PP225: Undiffere...
    PP226: Immunohis...
    PP227: Childhood...
    PP228: Immature ...
    PP229: Histomorp...
    PP230: Histopath...
    PP231: Pleuropul...
    PP232: Role of c...
    PP233: A rare ca...
    PP234: Epitheloi...
    PP235: Fetus-in-...
    PP236: Hepatoid ...
    PP237: Cardiac p...
    PP238: Correlati...
    PP239: Epithelio...
    PP240: Lepidic p...
    PP241: Clinicopa...
    PP242: Role of i...
    PP243: Primary p...
    PP244: Anaplasti...
    PP245: Evaluatio...
    PP246: Squamous ...
    PP247: Carcinosa...
    PP248: Periducta...
    PP249: Paratesti...
    PP250: Phospho S...
    PP251: Mucormyco...
    PP252: A rare ca...
    PP253: Heterolog...
    PP254: Lepromato...
    PP255: Schaumann...
    PP256: Granuloma...
    PP257: Immature ...
    PP258: Accuracy ...
    PP260: Does MELF...
    PP261: Looking d...
    PP262: Nephrogen...
    PP263: Melanosis...
    PP264: Sarcomato...
    PP265: Hemangiom...
    PP266: Papillary...
    PP267: Non-peutz...
    PP268: Histopath...
    PP269: Serous ca...
    PP270: An unsual...
    PP271: Histopath...
    PP272: Xanthogra...
    PP273: Spectrum ...
    PP274: Histomorp...
    PP275: Synchrono...
    PP276: Correlati...
    PP277: Small cel...
    PP278: Mixed ger...
    PP279: Histopath...
    PP280: Immunoexp...

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