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Year : 2022  |  Volume : 65  |  Issue : 6  |  Page : 93-150
Poster abstracts

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Date of Web Publication28-Nov-2022

How to cite this article:
. Poster abstracts. Indian J Pathol Microbiol 2022;65, Suppl S2:93-150

How to cite this URL:
. Poster abstracts. Indian J Pathol Microbiol [serial online] 2022 [cited 2023 Feb 3];65, Suppl S2:93-150. Available from:

   AEP1 Top

   Autopsy Pathology Top

Autopsy in a case of severe malaria (Plasmodium falciparum) – Opening a Pandora's box of salient malarial pathophysiology!

Syed Sabina, Jyotsna Suri, Subash Bhardwaj, Syed Mehdi Ali, Kavita Rukwal, Palka Gouria

Government Medical College, Jammu, Jammu and Kashmir, India

Case Report: Malaria is a potentially lethal infectious disease caused by a unicellular protozoan parasite Plasmodium, transmitted by female Anopheles mosquito. Severe malaria by P. falciparum has a high mortality rate and is a major cause of death due to malaria. As complete pathological autopsies are scarce in India, findings of disseminated malaria are rarely well-documented. We report a 36 year-old male from a non-endemic area with workstation in Bihar, endemic for P. falciparum, who died of severe malaria with multiorgan dysfunction syndrome (MODS). Diagnosis was based on the history provided, eminent autopsy table findings, and classic histopathological examination findings. Discussion: According to WHO criteria, cerebral malaria as a cause of death should be based on presence of malarial pigment in the brain; which must be confirmed histologically. Our patient was admitted to GMC Jammu with high grade fever and fresh onset seizures, hematuria, coma and respiratory distress. He died during admission. For insurance claims, we did an autopsy and discovered a treasure trove of HPE findings of disseminated malaria. Conclusion: In our prodigious case, most criteria of WHO for severe classification of malaria were all in attendance. The cause of death was MODS caused by disseminated falciparum malaria infection. Our study, therefore, further reinforces histopathological examination as an indispensable requisite of a necropsy- rightly justifying the name of the discipline as 'Forensic Pathology'!

Keywords: Cerebral malaria, DIC in malaria, Plasmodium falciparum

   AEP2 Top

   Autopsy Pathology Top

Myocardial bridging of left circumflex coronary artery in young male: A case report

U R Kavya, Sonali Mishra, Sanjeev Kishore, Ravi Hari Phulware

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Case Report: A whole heart specimen from a 22 year old man's autopsy revealed myocardial banding in the course of left circumfelx coronary artery. This was an incidental finding during the autopsy oh heart in a 22 year old male expired in a road traffic accident with no known comorbidities. On histopathology the ventricular muscle wall demonstrated patchy areas of fibrosis suggesting ischaemic myocardial injury. Discussion: Myocardial bridging is commonly known to involve the proximal and middle portions of the left anterior descending artery. It is an abnormality present since birth that has been described to as a band of heart muscle overlying the course of coronary artery through the epicardium. This causes narrowing of the lumen during the systole compromising the blood flow. Conclusion: Myocardial bridging has been categorised as benign and pathological depending on the intra-myocardial length and depth. It is defined as pathological when the tunneled segment if 20-30 mm in length and 2-3 mm deep. There are reported cases of sudden death, myocardial iscahemia, arteriventricular rupture, heart failure reported. The prognosis of these patients is therefore not as benign as it was thought to be earlier.

Keywords: Chest pain, coronary vessel anamolies, coronary vessels, myocardial bridging

   AEP3 Top

   Autopsy Pathology Top

A myriad of flesh within a pot-fetal teratoma

R N J Vaishnavi, M R Amrutha, Dhruva Rajagopal1, H Shruthi

Department of Pathology, Sri Siddhartha Medical College, 1Vishwa Guru Scanning Center, Tumkur, Karnataka, India

Case Report: Case 1: Female fetus of 20 weeks gestation- Anomaly scan revealed-? Chordoma at sacrococcygeal region with unilateral CTEV. Gross: Grey-white to Grey-brown mass measuring 3.5x2.2 cm. Cut section: Solid and cystic with glistening white areas. Case 2: Female fetus of 33 weeks gestation- Growth scan revealed cervical neoplasm- ? Teratoma. Gross: Grey-white mass partly covered by skin 13x12 m. Cut section-Solid and cystic. Microscopy of both Case: 1 & Case: 2 - Tumor constitutes heterogenous collection of elements of three germ cell layers this includes cartilage, muscle bundle, adipose tissue and nerve tissue. Discussion: Teratomas are formed by pluripotent cells of all three germ layers. Teratoma cause high morbidity as they develop hydrops fetalis or premature delivery. In order to achieve best outcome for children with teratoma, it is important for multidisciplinary approach. Smaller tumors are treated by puncture of cystic lesions followed by EXIT or operation on placental support (OOPS) can be performed. Conclusion: Teratomas should be specifically assessed, aiming for a prenatal diagnosis, treatment and prognosis, that increases the chances for survival of the affected fetus.

Keywords: Cervical, congenital teratoma, mature teratoma

   AEP4 Top

   Autopsy Pathology Top

Binder's facies: Two case reports

Mansi Shah, Manasi Gosavi, Ashwini Ratnakar

Jawaharlal Nehru Medical College, Dr. Prabhakar Kore Hospital and MRC, KLE University, Belagavi, Karnataka, India

Case Report: 1) A 29-years female G2P1L1 with 19 weeks period of gestation. Anomaly scan revealed binder's facies with unilateral cleft palate. 2) A 19 years female primigravida with 20 weeks period of gestation. Anomaly scan revealed binder's facies. Both Patients were advised for medical termination of pregnancy (MTP). After consent, MTP was performed for both females. Their fetuses were sent for autopsy after taking consent from both of them. Autopsy findings of both fetuses suggested enlarged head, eyes swollen, flat midface-nasal bridge, short nose, protruding lower jaw. Infantogram of these babies also reveal maxillo-nasal hypoplasia. Discussion: Binder's syndrome is quiet rare which can be reason for lack of knowledge of its Etiology, inheritance pattern and real prevalence. Still mother's with autoimmune disease, lack of vitamin K, alcohol abuse, warfarin or phenytoin have higher risk of binder syndrome babies. Skeletal and dental anomalies are also seen. Conclusion: MTP is advised for binder's syndrome, genetic counselling should be done for patients to know inheritance pattern, birth defects for binder's and other congenital disorders also. Orthodontic treatment for malocclusion and surgical treatment for nose reconstruction is needed if baby survives.

Keywords: Anomaly scan, Binder's syndrome, medical termination of abortion

   AEP5 Top

   Autopsy Pathology Top

Semilobar holoprosencephaly – A rare congenital anomaly finding on autopsy

Aishwarya Raut, Manasi Gosavi

KLE'S Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Case Report: A 21 year old female G2P1L1 with 16 weeks 3 days period of gestation was admitted. An USG scan done revealed features of semilobar holoprosencephaly with facial dysmorphogenesis for which the patient opted for medical termination of pregnancy due to bad prognosis and with the informed consent fetus was sent for autopsy. Discussion: On receiving the fetus for autopsy infantogram done suggested features of absence of nasal bone with hypoplastic B/L orbit and holoprosencephaly. On gross examination cyclopia was evident and on brain dissection Holoprosencephaly was confirmed and microscopic examination did not reveal anything abnormal. Thus it was a case of Holoprosencephaly semilobar type. Conclusion: Holoprosencephaly semilobar variant accounts to moderate to severe holoprosencephaly where the mortality is seen in 50% cases, The fetus with cyclopia typically do not survive beyond one week after birth. Genetic counselling is important as the recurrence rate is variable ranging from 2%-50%. Early diagnosis and genetic counselling is necessary due to chance of its recurrence in subsequent pregnancy.

Keywords: Cyclopia, fetal autopsy, semilobar holoprosencephaly

   AEP6 Top

   Autopsy Pathology Top

An incidental finding of cutaneous B cell lymphoma in an autopsy case – A rare case report

R Raziabegam, Yogambal, K Swaminathan

Tirunelveli Medical College Hospital, Tirunelveli, Tamil Nadu, India

Case Report: 75 year old female was found unconscious at home and was declared dead. She had history of right arm cellulitis before 6 months for which fasciotomy was done. Autopsy was performed and there were no lymphadenopathy /organomegaly. We received portion of Brain, lung, liver, spleen, kidney, heart and a skin attached soft tissue fragment measuring 10x8x2.5 cm. Other organs were unremarkable grossly and microscopically. Grossly skin showed a grey white firm mass and microscopy showed a neoplasm in the dermis composed of tumor cells arranged in vague nodules and sheets. Individual cells are small having scant cytoplasm with hyperchromatic nuclei. Differential diagnosis of cutaneous lymphoma, merkle cell carcinoma and poorly differentiated carcinoma deposits were considered. IHC was performed and it was positive for CD45, CD20 and negative for CD3, pan CK and synaptophysin. Cutaneous B cell lymphoma was diagnosed. Discussion: CBCLs are most often indolent presenting as reddish rash, lump, or nodule in the skin without any lymphadenopathy or masses, as presented in our case. This case highlights discrepancies between clinical diagnosis and autopsy findings and the importance of insights on obscure presentation and appropriate timely medical intervention which could prolong the survival. Conclusion: Physicians need to consider lymphoma in the differential diagnosis, especially in patients with obscure clinical presentation. Autopsy remains a valuable tool for identifying the cause of death.

Keywords: Autopsy, lymphoma, valuable tool

   AEP7 Top

   Autopsy Pathology Top

Space occupying lesion in fetal heart: A rare benign cardiac lesion

Poonam Yadav, Deep Kumar Raman, Jeenu Varghese, Subramanyam, Manoj Pant, Natasha Dogra

Command Hospital Air Force, Bengaluru, Karnataka, India

Case Report: A 30-year-old female at 21 weeks of gestation presented with an anomaly scan showing growth in right and left ventricles, suspicious of an intraventricular lesion and MTP was performed. Following which fetal autopsy was conducted which revealed two well defined nodules arising from the ventricles and causing outlet obstruction. On histopathological examination the final diagnosis of Fetal Cardiac Rhabdomyoma was made. Discussion: Cardiac rhabdomyoma is a benign tumour of striated cardiac myocytes. They are usually detected in the ventricle and interventricular septal areas as multiple masses. Rhabdomyomas are an early manifestation of tuberous sclerosis and may be the only finding before other clinical manifestations appear. For this reason, the diagnosis of tuberous sclerosis should be considered in cases of cardiac rhabdomyomas. Conclusion: Fetal cardiac rhabdomyomas are often benign and have a tendency to regress, however the prognosis is guarded due to frequent association with arrythmias and tuberous sclerosis. Recognition of this benign entity is important due to its association with an autosomal dominant condition with variable penetrance like tuberous sclerosis and the need for couples to undergo genetic counselling for the same. This case is being presented for it's unusual involvement of both ventricles causing outlet obstruction and it's rarity.

Keywords: Fetal rhabdomyoma, tuberous sclerosis

   AEP8 Top

   Autopsy Pathology Top

Tetra-phocomelia – Twin pregnancy, first case in literature??

Gunica Potdukhe, Sunita Patil

Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Case Report: A 29 yr old primigravida of 15 weeks with monochorionic diamniotic twins, on ultrasonography first twin - cystic hygroma with phocomelia and second - blighted ovum. After termination we received fetus weighing 10 gm with placenta and umbilical cord. External examination showed absence of long bones in upper and lower limbs with poorly developed facial features, anal atresia, polydactyly. On dissection all organs were found in situ and umbilical cord showed only single umbilical artery. Discussion: Phocomelia term was first used in 1836 by Etienne Geoffroy Saint Hilaire. Use of drugs during pregnancy like thalidomide, substance abuse like alcohol, X ray radiation is considered to be the cause. In our case there was no drug history. Close observation at around 16 to 18 weeks can give us correct view about limb deformity. Conclusion: Tetra phocomelia is rare occurrence. Antenatal ultrasound remains hallmark for detecting all fetal anomalies including that of limbs.

Keywords: Phocomelia, tetra-phocomelia, twin pregnancy

   AEP9 Top

   Autopsy Pathology Top

Visible leukemic infiltration in heart

Sanjana, Waghmare, Tejas Patil, Tejaswini Waghmare, Pradeep Vaideeswar

Department of Pathology, SETH GSMC and KEM Hospital, Mumbai, Maharashtra, India

Case Report: We report three postmortem cases of acute leukemia with macroscopic cardiac infiltration- 1. 3 years, 6 months, Female; Presentation with left renal mass; Diagnosed as acute lymphoblastic leukemia (ALL). 2. 19 years, Male; Presentation as acute febrile illness with gum hypertrophy and moderate pericardial effusion; Diagnosed as acute myeloid leukemia (AML). 3. 52 years, Male; Operated case of suprasellar astrocytoma; Presented now as acute febrile illness with altered sensorium; Diagnosed as ALL. At autopsy, mass lesions with overlying thrombi were seen in the 2 cases of ALL, while a grossly visible pancarditic infiltration was seen in the patient with AML. Discussion: Cardiac involvement in acute leukemia is usually diagnosed at autopsy and is seen more frequently with ALL than AML. Several mechanisms have been suggested for the occurrence of cardiovascular disease during acute leukemia: leukemic thrombi or leukostasis in major arteries, leukemic infiltration into the myocardium or pericardium, and disorders of coagulation secondary to leukemia and antileukemic therapies. Conclusion: As new diagnostic technologies and improved survival of oncological patients may increase the incidence of metastatic cardiac tumors in the future, awareness to their existence and knowledge of their presentation are key factors in their timely recognition.

Keywords: Acute leukemia, cardiac infiltration, visible mass

   AEP10 Top

   Autopsy Pathology Top

Portal hypertensive vasculopathy reminiscent of NCPF in Neonate – A rare serendipitous postmortem observation

Pratima Kukreja, Nimisha Tiwari, Monika Yadav, Kavita Gaur, Kiran Agarwal

Lady Hardinge Medical College, New Delhi, India

Case Report: A full term female baby born by normal vaginal delivery with antepartum haemorrhage and abruptio placentae in mother, cried immediately after birth but developed respiratory distress within a few minutes. The baby went into cardiac arrest within 6 hours of birth and could not be revived. A detailed postmortem examination was done. The liver showed mottling on the external surface, the cut surface showed numerous dilated blood vessels. On microscopy, there was loss of normal architecture with porto-portal and porto-venous approximation. There was dilatation of sinusoids and rounding of portal tracts. Ectatic vascular channels and occasional fibrous spurs were also observed. While, all other organs showed unremarkable histology, sections from lung and spleen showed congestive changes. Discussion: The presence of features of vascular remodelling as observed in NCPF/EHPVO in neonatal liver might point towards pre-cirrhotic changes. Conclusion: Since the etiology of these changes remains unrecognized, it poses a challenge for pathologists in autopsy diagnosis and becomes an interesting topic to be studied further.

Keywords: Liver, NCPF, neonate, portal hypertensive vasculopathy

   AEP11 Top

   Autopsy Pathology Top

Lipoid pneumonia and secondary glomerulonephritis in machine oil poisoning – A deadly concoction

Gunjan Batra, Kavita Gaur, Kiran Agarwal, Rushali Saxena, Divya Jyoti

Lady Hardinge Medical College, New Delhi, India

Case Report: A seven year old boy came to emergency with a history of machine oil ingestion, supportive treatment was started. Unfortunately, the patient died during the course of treatment. We received the following specimens-whole brain, pieces of both lungs, kidneys, heart, liver and spleen. Significant histopathological findings observed in the lung showed alveolar spaces distended with histiocytes & occasional polymorphs were admixed with fibrin. In some foci, alveolar content appeared lipoidal. There was focal loss of type 1 & type 2 pneumocytes with complete destruction of alveolar walls with foci of necrotic debris and alveolar spaces were distended with edematous fluid. Sections from the kidneys showed glomeruli showing increased cellularity & mild increase in mesangial matrix. On ancillary stains, PAS & silver stain showed focal splitting of basement membrane, giving tram track appearance suggesting membranoproliferative glomerulonephritis. Section from the brain showed reactive gliosis & the spleen showed features of congestion. No significant pathology was noted in the heart or liver. Discussion: Machine oils have high volatility and low viscosity owing to their toxicity. Most common yet most lethal involvement seen in lungs. Conclusion: To the best of our knowledge, machine oil ingestion histology has not been reported in humans or animal models in the literature so far.

Keywords: Hydrocarbons, lipoid pneumonia, machine oil, membranoproliferative glomerulonephritis

   AEP12 Top

   Autopsy Pathology Top

Young hearts too die – An autopsy case series

K C Anjali, S R Niveditha

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: • 26-year male, heart weighing 667 gms with banana shaped left ventricular cavity and thickened mitral leaflets. Microscopically, massive myocardial hypertrophy and myofiber disarray noted.• 33-year male, heart weighs 722 gms with both dilated atria and thickened left ventricle. Microscopy showed diffuse subendocardial fibrosis involving the left ventricular wall, interventricular septum and papillary muscles.• 29-year male, heart weighs 299 gms with increased fat around pericardium. Microscopically, right atrial and ventricular thinning with sheets of adipocytes between cardiac myocytes with endomyocardial fibrosis. Masson's trichome stain highlighted decreased muscle mass and increased collagen. Discussion: EMF, characterized by fibrotic thickening of endocardium and myocardium of ventricle (Incidence 1-20%) has varied etiology. ARVC characterized by replacement of ventricles by fat or fibrous tissue is an AD disorder (risk of sudden death 2.5% per year). HOCM (1 in 500) is a common inherited cardiovascular disease frequently causing sudden death in young people. Conclusion: Identification of rare causes of sudden death aid in family workup.

Keywords: Arrhythmogenic right ventricular cardiomyopathy, endomyocardial fibrosis, hypertrophic obstructive cardiomyopathy, sudden cardiac death

   AEP13 Top

   Autopsy Pathology Top

Placental mesenchymal dysplasia (PMD): A classical presentation of rare vascular anomaly

Shushruta Mohanty, Kaustav Mohapatra, Sunitarani Senapati, Anjali Shinde, Swayamprava Pradhan

MKCG Medical College, Brahmapur, Odisha, India

Case Report: A 29 years old female gravida 2 and para 2, presented with full term pregnancy and delivered normal male fetus with placentomegaly. The placental tissue along with cord was sent for histopathology study to our department. Grossly placenta measured 24x18x8 cm with cord measuring 30 cm and weighed 1350 gms. Fetal surface of placental tissue showed multiple dilated blood vessels and few vesicular structures, which were filled with haemorrahgic and serous fluid respectively. Histosections from different sites of maternal and fetal surface of the placenta were given. Microscopy showed presence of term villi, hydropic villi with central cisterns and no trophoblastic proliferation. Based on gross and microscopic features diagnosis of PMD was rendered. Discussion: Pathologically PMD placentas are of large size, and show edema of stem villi with intact terminal villi and vascular anomalies like cirsoid chorionic vessels, thrombosis, vascular stenosis, villous chorangiosis, chorangioma and fetal thrombotic vasculopathy. Conclusion: Placental mesenchymal Dysplasia should always be considered as a differential diagnosis for molar pregnancy because of its gross, microscopic and ultrasonographic resemblance with molar pregnancy.

Keywords: Beckwith-Wiedemann syndrome, molar pregnancy, placental mesenchymal dysplasia

   AEP14 Top

   Autopsy Pathology Top

Limb body wall complex: A trio tale

Manasi Gosavi, Ashwini Ratnakar

Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka, India

Case Report: Case 1: Age of foetus- 19 week External anomalies- low set ears, anterior abdominal wall defect, herniation of liver, spleen, stomach, intestines, kyphoscoliosis, meningocoele. Case 2: Age of foetus: 16 weeks. External anomalies: Gastroschisis, scoliosis, amelia right upper limb, posterior wall defect, encephalocele. Case 3: Age of foetus: 17 weeks External anomalies: anterior wall defect with herniation of stomach, liver and parts of intestines, scoliosis with single lower Limb. Discussion: The three essential characteristic features of BSA include: 1. Encephalocele or exencephaly or facial clefts 2. Thoraco or abdominoschisis 3. Limb deformity. Considering all the above studies we classified our present three cases of as case 1- BSA Type IV and case 2 and 3 – BSA Type III Possible etiopathogenesis: Early rupture of amnion and embryonic mal-development. Conclusion: BSA though a rare anomaly with fatal outcome, an awareness about its diagnostic criteria and close differential must be made so it can be diagnosed at the earliest which is beneficial for both the expecting parents and the physician.

Keywords: Abdominal wall defect, body stalk anomaly, congenital

   AEP15 Top

   Autopsy Pathology Top

Needle in a haystack: Sickle cell disease in an adult at autopsy

Sunita Patil, Ganga S Pilli

J N Medical College, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India

Case Report: 26 year male was brought to casualty in an uncounscious state with history of severe abdominal pain, chest pain and fever. On examination, PR: 110/min (Carotid), Plasma glucose: 35 mg/dl, Blood pressure and SPO2 were not recordable. ECG showed no specific changes. Patient had cardiac arrest in 10 mins and succumbed to death. Since, he appeared apparently healthy, his family registered a case unnatural death. Hence a medico-legal autopsy was done. No significant findings at posr-mortem. The organs received in pathology (Heart, lungs, liver, spleen) showed no significant changes on gross except congestion. The microscopy of organs revealed packed sickle cells in blood vessels indicating vaso-occlusive crisis of SCD. Discussion: SCD presenting in adults is not rare though, presenting first with fatal crisis is extremely rare. This case showed no history suggestive of SCD and was never diagnosed till adulthood. Other than sickle cells at microscopy, there was evidence of SCD in this case. Conclusion: SCD can present with rarely with fatal crisis in adulthood. Patient with recurrent pains should be investigated for SCD.

Keywords: Autopsy, sickle cell disease

   AEP16 Top

   Autopsy Pathology Top

Rare complications of heart transplantation: Autopsy findings

Devika Gupta, Ankita Kumari, Sameer Kumar

Army Hospital (Research and Referral), New Delhi, India

Case Report: We had two patients who underwent heart transplantation for underlying idiopathic dilated cardiomyopathy. One patient had sudden, unexpected death after 08 months of transplant. The other patient, 03 months post transplant, was detected to have severe mixed antibody mediated (AMR) and cellular rejection on surveillance endomyocardial biopsy and was being treated for same. However, during the course of management, he developed sudden onset chest pain and imaging done was suggestive of massive aortic aneurysm. Emergency thoracotomy was done, but patient exsanguinated. Autopsy was performed in both the cases. Discussion: Post mortem of first case confirmed severe AMR (p AMR 3). In the second case post mortem revealed ruptured mycotic ascending aorta aneurysm with multiple necrotic blackish cavitatory lesions in both lungs. Conclusion: Heart transplant is a life-saving therapy that is associated with a risk of significant complications. Physicians should be prepared to deal with these risks by acting collaboratively to prevent, identify and treat complications as they arise. We want to highlight here two major complications, that if detected timely can prevent fatal consequences.

Keywords: Heart transplantation, mycotic aneurysm, rejection

   AEP17 Top

   Bone/Joints/Soft Tissue Pathology Top

Biphasic synovial sarcoma with squamous differentiation in the thigh – A case report

Akanksha Hegde, Sindhoor, Vijaya Mysorekar

M S Ramaiah Medical College, Bengaluru, Karnataka, India

Case Report: We are presenting a case of synovial sarcoma of left thigh in a 70-year-old lady. Grossly a resected soft tissue specimen was received. On cutting open hemorrhagic fluid oozed out. Noted a cyst measuring 12x11.5x11 cm. Multiple polypoidal growths seen, largest measuring 3x2.5x1 cm. Microscopy showed an invasive highly pleomorphic biphasic tumor. The spindle cell component was arranged in fascicles and whorled pattern, the epithelial component was arranged in solid diffuse sheets and nests composed of abundant pleomorphic cells. Epithelial component showed more than 50% squamous differentiation. 5-6 mitoses/HPF, abundant necrosis and desmoplastic stroma was noted. SMA, Vimentin, CD 99, CD68, Bcl-2 showed expression in spindle cell component and p63 showed nuclear expression in epithelial component. Molecular studies could not be done due to economic restraints. Discussion: Synovial sarcoma is a rare malignant tumor of soft tissue. They are encapsulated and most often in contact with bone. Malignant spread to surrounding nerves and vasculature is common. It can undergo biphasic differentiation. It mostly occurs in the large joints of the extremities. Squamous differentiation in synovial sarcoma is a rare entity. The aggressive behavior of synovial sarcoma makes the pathological and radiological diagnosis very important for staging and treatment. Undifferentiated tumors, necrosis, high histologic grades and increased mitoses are associated with worse prognosis. Local recurrence increases risk of metastasis and decreases survival. Conclusion: Immunohistochemistry plays a vital role in the definitive diagnosis of this tumor.

Keywords: Epithelial component, spindle cell component, squamous differentiation, Synovial sarcomas

   AEP18 Top

   Bone/Joints/Soft Tissue Pathology Top

A case series study of seven cases of rhabdomyosarcoma: Uncommon sites and varied histological subtypes

Lanka Kowsalya, Harika Mandava, Renuka Professor

NRI Medical College, Guntur, Andhra Pradesh, India

Case Report: 7 cases. In our study the age ranged from 4 months to 65 years with a male to female ratio of 1:2.5. The sites of presentation were retroperitoneum, head and neck, paratesticular, sacrococcygeal region, parotid region and uterus. The gross size of the tumor ranged from 3 to 18 cm. The histological variants were embryonal, alveolar, pleomorphic, spindle cell and mixed (alveolar and embryonal) types. The tumors were positive for IHC markers Desmin, Vimentin and Myo D1. Discussion: Our study showed a female preponderance and comprised predominantly of an adult population (71.4%). This is in contrast to studies done by Ahmed et al and Rekhi et al where RMS is predominantly a paediatric disease with male preponderance. Alveolar RMS is the most common type in our study which is similar to the study done by Rekhi et al. We encountered a few rare cases such as uterine alveolar RMS, paratesticular spindle cell RMS and sacrococcygeal mixed embryonal and alveolar RMS. Conclusion: We present these cases in view of the rarity of sites and mixed histological types.

Keywords: Alveolar, embryonal, IHC, rhabdomyosarcoma

   AEP19 Top

   Bone/Joints/Soft Tissue Pathology Top

Peripheral primitive neuroectodermal tumour – A rare case presentation

Rajashree Asokan, B H Ramesh, Purnima Poste, Tejeshwini Patil

Raichur Institute of Medical Sciences, Raichur, Karnataka, India

Case Report: An extremely rare case of small round cell tumour in 60 years old female with tumour involving extraskeletal soft tissue in right gluteal region, presented with pain while walking, numbness and tingling sensation for three years. CT showed features of Nerve sheath tumour. Biopsy sent for HPE, revealed fragments of grey brown tissue macroscopically. Microscopy revealed small round cell tumour consisting of pockets of tumour tissue arranged in solid nests and diffuse sheets separated by stromal tissue. Tumour cells were monotonous with small round nuclei and scant amount of clear to amphophilic cytoplasm. Mitosis 2-3/hpf. Adjacent areas showed fibroadipose tissue, nerve fibres and blood vessels with areas of haemorrhage and necrosis. IHC showed positivity for PAS stain, NSE, CD99, Ki-67 and S-100 protein which confirmed the diagnosis of p-PNET and molecular study showed EWSR1 gene rearrangement. Discussion: PNET, part of Ewing's Sarcoma family of tumours are small round cell tumours arising from embryonic neural crest cells, divided into central and peripheral PNET, occurring in 2nd and 3rd decade and rarely over 40 years age group. Immunohistochemically, PNETS are positive for CD99, NSE, Leu 7, S-100 and synaptophysin and negative for desmin and myogenin/ myoD1. Conclusion: p-PNET is a highly aggressive tumour with poor prognosis. We emphasize the need of histopathology and IHC for early diagnosis of such aggressive tumours to improve the prognosis of patient by providing timely management.

Keywords: HPE, IHC, PNET

   AEP20 Top

   Bone/Joints/Soft Tissue Pathology Top

Mucormycosis in COVID pandemic: A case series of 69 cases

Santhi Imandi, P Ramya, I V Renuka

NRI Academy of Medical Sciences, Guntur, Andhra Pradesh, India

Case Report: The study aims to analyze the age and sex incidence, sites, and microscopic features associated with mucormycosis in covid pandemic at our institute for a period of three years. A Total of 69 cases were included in the study, 3 being mixed fungal infection. The age range was 25-80 years with male preponderance. Diabetes was the most common risk factor seen in 53 patients followed by post covid status in 49. The most common site was paranasal sinuses seen in 58 patients followed by orbit in 8 and one each of lung and bone. Majority of cases showed necrosis and few granulomatous inflammation. Angioinvasion, bony invasion and perineural invasion were also seen. Discussion: In our study the mean age of presentation was 43 years with a male preponderance which was similar to other studies. The common underlying condition was Diabetes mellitus followed by Covid 19 with paranasal sinuses being the common site. In most of the other studies the common sites were Rhinoorbital and pulmonary. Very few studies showed bone and intestinal involvement. Conclusion: This study describes the phenomenal increase in mucormycosis in the covid pandemic with varied sites of presentation including rare sites like bone and intestine.

Keywords: Diabetes, histopathology, mucormycosis

   AEP21 Top

   Bone/Joints/Soft Tissue Pathology Top

Diagnostically challenging atypical epithelioid schwanomma in a young female – A dilemma set by morphology; resolved by immunohistochemistry – A case report with literature review

Rashmi Ravindran, K Amita, M Sanjay, H B Rakshita

Adichunchanagiri Institute of Medical Sciences, B G Nagara, Karnataka, India

Case Report: A 24 year female presented with a depressed lesion over left back since one year. On clinical and radiological examination, provisional diagnosis of vascular malformation was made. At histopathology, a well circumscribed tumour, characteristically oblong on scanner magnification, surrounded by perineurium like capsule was noted in deep dermis. The tumour cells were epithelioid in nature, arranged in sheets, nodules & trabecula. Individual tumour cells abundant eosinophilic cytoplasm, round nucleus with nuclear indentation, nucleomegaly & prominent single large nucleoli. Occasional atypical mitosis & hyalinization were noted. At immunohistochemistry, tumour showed strong positivity for S100 and negative for EMA, CD34, LCA, CK, and INI1. Ki67 was 7 to 8%. A final diagnosis of Atypical epithelioid schwannoma was made. Discussion: Epitheloid shwannomas are rare and challening soft tissue tumours. Atypical epitheloid shwannomas, 1st described by Taxi and Battifora in 1981, are rare. In the largest series of 58 cases of epitheloid shwannoma, 13 atypical variants were reported. The clincial outcome for atypical variants reported is good. Immunohistochemical studies also help in their differentiation. Conclusion: Atypical epithelioid schwannomas are rare but it is important to be aware of this variant to avoid misdiagnosis with other malignant epithelioid tumours. Apart from clinical & morphological features, immunohistochemistry aids in arriving at a decisive diagnosis. Perineurium like capsule, well circumscription, oblong shape of lesion, hyalinized blood vessels are pointers towards schwannomatous differentiation of the tumour.

Keywords: Atypical epithelioid schwannoma, epithelioid tumours, immunohistochemistry

   AEP22 Top

   Bone/Joints/Soft Tissue Pathology Top

Biphasic synovial sarcoma of Thenar region – A case report

Sananda Kumar, Neha Bhardwaj, Nandita Kakkar, Siddhant Khare

Postgraduate Institute of Medical Education and Research, Chandigarh, India

Case Report: We report a case of a 65-year-old male who was referred to our institute after undergoing excision of a recurrent swelling in the left thenar eminence diagnosed as moderately differentiated adenocarcinoma of adnexal origin. On local examination, a healed scar was seen over the left thenar region with multiple lobulated swellings over the scar region. Histopathology was reviewed in our institute and a biphasic tumor with epithelial and mesenchymal components and diffuse TLE-1 positivity was reported as synovial sarcoma. Fluorescent in situ hybridization (FISH) revealed t (X;18), thus confirming the diagnosis. Discussion: Synovial sarcomas occur in adolescents and adults between 15-40 years. Our patient developed the lesion initially at the age of 62 which recurred twice over 2 years. Due to rare location, most cases of synovial sarcoma of hand are treated by unplanned excision before referral to a specialist oncological centre. Local recurrence and/or metastatic disease are found in nearly 80% of patients as seen in this case. Conclusion: Synovial sarcoma must be considered as one of the differential diagnosis of a non-resolving and slow-growing mass in the palm. Complete excision is warranted to avoid local recurrence and metastasis.

Keywords: Soft tissue, synovial sarcoma, thenar

   AEP23 Top

   Bone/Joints/Soft Tissue Pathology Top

Clinical synovial chondromatosis with radiological and pathological correlation

Siddhi Dave, Arpana Chaudhari, Mubin Patel, Hemali Tailor

Government Medical College, Surat, Gujarat, India

Case Report: A 52 years old female patient presents with pain in right knee since 6 years had done MRI which suggests Right knee Synovial Chondromatosis and clinically suspects the same. Discussion: Primary synovial chondromatosis is a benign neoplastic process where radiographs reveal multiple intraarticular calcifications of similar size and shape, distributed throughout the joint, with typical ring and arc chondroid mineralization & it is treated by surgical synovectomy with removal of chondral fragments. Secondary synovial chondromatosis is associated with joint abnormalities that cause intraarticular chondral bodies where radiologically underlying articular disease and fewer variable size and shaped chondral bodies seen & concentric rings of growth seen pathologically. It is treated mainly by antiinflammatory drugs. Pathologically synovial chondromatosis can be confused with chondrosarcoma because of significant histologic atypia. So radiological correlation is required. Conclusion: Recognising the appearance of Synovial Chondromatosis with radiological and pathological findings is important to optimize patient management.

Keywords: Clinopathocorrelation, radiopatho correlation, synovial chondromatosis

   AEP24 Top

   Bone/Joints/Soft Tissue Pathology Top

Atypical presentation of undifferentiated small round cell sarcoma

C Suganya, K Swmainathan, Arasi Rajesh

Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Case Report: 22 year old male presented with fever, breathlessness and cough for 3 months. Imaging studies showed right massive pleural effusion with ill defined heterogeneously enhancing soft tissue lesion 11.4x6.1 cm with involvement of 5th rib with possibility of infectious etiology. With clinical suspicion of tuberculosis, Thoracotomy was done and multiple grey brown soft tissue fragments totally measuring 30 cc were received in Department of Pathology at TVMCH. Histopathological evaluation revealed sheets of malignant cells which are uniform small having moderate eosinophilic cytoplasm, pleomorphic nuclei with areas of hemorrhage and necrosis. Immunohistochemistry showed CD99 diffuse membrane positivity and NKX2.2 diffuse nuclear positivity. Discussion: Ewing sarcoma (ES) is one of the undifferentiated small round cell sarcomas of bone and soft tissue in adolescents. ES shows NKX2.2 diffuse nuclear positivity, CD99 diffuse membranous positivity and FLI 1 nuclear positivity. Prognosis has improved with multimodal therapy with 65-70% cure rate for localised disease. Metastasis and early relapsing tumours have poor prognosis. Conclusion: Here, clinical symptoms mimicked features of Tuberculosis. Immunohistochemically, NKX 2.2 becomes the valuable marker for Ewing sarcoma than CD99, with a sensitivity of 93% and a specificity of 89%, and aids in the differential diagnosis of small round cell tumors.

Keywords: Ewing sarcoma, NKX2.2, round cell sarcoma

   AEP25 Top

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Interesting cases of soft tissue tumors at different sites – Report of 5 cases

Shweta Selukar, Archana M Joshi, Kalpana A Bothale, Sabiha A Maimoon, Sadhana D Mahore

Department of Pathology, NKP Salve Institute of Medical Science and Research Centre, Nagpur, Maharashtra, India

Case Report: Medical records of 5 interesting cases of soft tissue tumors received at the Department of Pathology, NKP Salve Medical College were reviewed for patient demographics, clinical presentation, investigations, sites, histopathology and treatment modalities. Discussion: Soft tissue tumors (STT) are a highly heterogeneous group of tumors. Awareness of rare soft tissue tumors is of paramount importance as they may often be misdiagnosed with other common conditions. Conclusion: The above mentioned cases are rare and oftenly misdiagnosed with other common conditions.

Keywords: Dermatofibrosarcoma protuberance, desmoid tumor (fibromatosis), lipoma with chondroid and osseous metaplasia, myxofibrosarcoma, soft tissue sarcoma

   AEP26 Top

   Bone/Joints/Soft Tissue Pathology Top

A diagnostic conundrum: Nasal mass in a middle aged woman

P Anvitha, S Suchitha, T S Rekha

JSSAHER, Mysuru, Karnataka, India

Case Report: 49-year-old female patient came with complaints of nasal bleeding since two years. Computerised tomography showed well-defined heterogeneously enhancing mass in the nasal cavity with coarse calcifications. Endoscopic resection of the mass was done. Histopathology revealed sheets of spindle cells separated by hemangiopericytomatous vasculature with adipose tissue, grungy calcification and osteoid. A diagnosis of PMT was made. Post-operative alkaline phosphatase and phosphorus levels were elevated. Discussion: PMTs are rare neoplasms accounting for <0.01% of all soft tissue tumors. They affect mostly the middle aged adults. Clinical features include bone pain, muscle weakness, and multiple fractures due to increased secretion of fibroblast growth factor 23. Complete excision of the tumor is crucial due to resolution of clinical symptoms and laboratory abnormalities. Conclusion: The diagnosis is commonly delayed for years due to non-specific nature of the symptoms, lack of clinical suspicion, failure to include serum phosphorus levels in routine blood chemistry testing and difficulty in identifying the tumor. PMTs are often missed histologically because of their rarity and morphologic overlap with other mesenchymal neoplasms. A high index of suspicion is necessary for an accurate diagnosis and management, especially in clinically unsuspected cases as the present one.

Keywords: Histopathology, nasal cavity, Phosphaturic mesenchymal tumor

   AEP27 Top

   Bone/Joints/Soft Tissue Pathology Top

Papillary endothelial hyperplasia of right forearm

Ramya Kumari, Jayasree G Pawar, B N Divya Sree

PES Medical Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Case Report: A 79 year old male came with complaints of swelling in the right forearm. Clinically they thought as sebaceous cyst of right forearm. On histopathological examination the mass showed dilated vessels with organising thrombi. Intravascularly seen are anastomosing network of vessels lined by plump endothelial cells with collagenised core. Focally within the vessels cluster of hemosiderin layden macrophages are seen surrounding the vascular channels. Based on these features, the lesion diagnosed as papillary endothelial hyperplasia which is reactive in nature. Hence reactive vascular proliferation papillary endothelial hyperplasia - right foream diagnosis made, diagnosis purely based on histopathological features. Discussion: Intravascular papillary hyperplasia is a non-neoplastic reactive endothelial proliferation. These lesions account for approximately 2% of the vascular tumors of skin and soft tissue. The lesions are usually solitary in nature, but multiple lesions are occasionally reported. Intravascular papillary hyperplasia is a reactive process that occurs in the setting of unusual thrombus organisation. Conclusion: The intravascular papillary hyperplasia presents diagnostic challenge because of its rarity. Histopathology plays a key role in diagnosing this tumor. Correct diagnosis is essential to prevent aggressive treatment. Immunohistochemistry is confirmatory.

Keywords: Collagenised core, haemangioma, hyperplasia, intravascular endothelial papillary

   AEP28 Top

   Bone/Joints/Soft Tissue Pathology Top

Actinomycotic osteomyelitis of maxilla – A rare entity

Palak Arora, Sramana Mukhopadhyay, Jitendra Kumar, Pankaj Goel

All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Case Report: A 40 year old lady, reported to the Dental OPD with swelling and tooth mobility in the right upper jaw since 3 months. Orthopantomogram and CECT showed a radiolucent lesion in the maxilla suggestive of osteomyelitis. Patient was operated with a clinical suspicion of Mucormycosis. On histopathological examination predominantly necrotic cortical and cancellous bone were seen with intervening innumerable large colonies of intertwined filamentous bacilli that stained deep purple on gram stain and magenta with Periodic acid Schiff stain. Some of the colonies were bordered by eosinophilic Splendore Hoeppli material and neutrophilic aggregates. A diagnosis of Actinomycotic osteomyelitis of maxilla was rendered. Discussion: Actinomycotic infections in the cervicofacial region commonly involve soft tissue and the fascia. Bone involvement is unusual. Involvement of the maxilla is a rarity due to its abundant vascular supply and cancellous bony architecture accounting for only 0.5-9.0% cases in the head and neck. Histopathology forms the cornerstone of a diagnosis of actinomycotic osteomyelitis as few cases are cultured and clinically the differential diagnoses are usually aggressive fungal infection or a malignancy. Conclusion: Maxillary actinomycotic osteomyelitis is a rare entity and prompt diagnosis is warranted to prevent further morbidity and intracranial involvement.

Keywords: Actinomycosis, bacterial infection, maxilla, osteomyelitis

   AEP29 Top

   Bone/Joints/Soft Tissue Pathology Top

CD34 negative recurrent solitary fibrous tumor of the eye

Sayantani Sarkar, M Hemalata, Sruthi Prasad

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: A 32-year man presented with painless, progressive proptosis, and diminished vision in the right eye since 1 year. The patient had similar complains 3 yrs back for which he underwent excision after diagnosis of spindle cell hemangioma. CE-MRI orbit demonstrated an infiltrating T2 heterointense lesion in the medial aspect of right orbit. Right eye lateral orbitotomy was done and histopathological diagnosis of CD34 negative solitary fibrous tumour was given. Discussion: CD34 negative SFTs are rare and are more likely to arise in the head and neck area as recurrence or metastatic disease. A significantly higher percentage of CD34-negative SFT exhibit cytologic atypia, necrosis, mitoses 4/10 hpf, haemorrhage, tumor size >5 cm and microcystic change. Use of STAT6 immunohistochemistry may be prudent in CD34 negative soft tissue tumors lacking conventional histopathologic characteristics of SFT. Conclusion: The recognition of CD34 negative SFTs are important as they are known to be recurrent, aggressive projecting towards malignant behaviour. STAT 6 and CD34 expression is an important diagnostic marker favouring SFT. Wide surgical excision with adjuvant radiotherapy is the mainstay of treatment. Extended follow up is required as recurrence may appear long after excision.

Keywords: CD34 negative, orbital solitary fibrous tumor (SFTs)

   AEP30 Top

   Bone/Joints/Soft Tissue Pathology Top

A case report of extragastrointestinal stromal tumor in a tertiary care center

Mulukala Swetha, B Laxmi Narayana, G Vandana

Kakatiya Medical College, Kaloji Narayana Rao University, Warangal, Telangana, India

Case Report: A 65 year old male patient admitted with complaints of lower abdominal pain, abdominal distension since 1 year O/E: Generalised tenderness with abdominal distention and intra abdominal mass was palpable. CT scan: Large heterodense lesion m/s 8.6×7.8 cms noted in lower abdomen above urinary bladder with thickening of bowel wall superiorly Surgery - En bloc resection of mass, proximal jejunum, sigmoid colon and partly bladder wall Gross: Grey white to Grey brown irregular soft tissue mass with adherent small bowel loops m/s 10×10.5×6.5 cms. C/S: Irregular, lobulated, solid lesion grey white with few tiny yellowish areas. Discussion: Extragastrointestinal stromal tumors are uncommon. Discovery of mutation of KIT (CD117) in Gist proto-oncogene is fundamental to understand the genesis and classification of the tumor. Conclusion: Extra GIST are rare and their cell of origin is same as GIST from the interstitial cells of cajal. With CD117 immunostaining we can differentiate them from other soft tissue tumors.

Keywords: CD117, DOG1, GIST

   AEP31 Top

   Bone/Joints/Soft Tissue Pathology Top

Primary ovarian leiomyosarcoma

Sushreeta Swaymprabha, Rabia Parveen Siddiqui

Pt. J N M Medical College, Raipur, Chhattisgarh, India

Case Report: A 55 years female presented with mass and pain in right lower abdomen. Per-abdominal examination- revealed unilateral mass. Trucut biopsy showed intersecting fascicles with cellular spindle cells with mild to moderate nuclear pleomorphism and mitosis 2-3/10 HPF. No necrosis was seen. On Immunohistochemistry, it was positive for Desmin, SMA and H Caldesmon and negative for Inhibin, WT1, Ki-67 was 30%. A diagnosis of Atypical Leiomyosarcoma was made. TAH+BSO+Omenectomy+Pelvic lymph node resection was performed. Grossly, greyish-white lobulated mass 16x15x15 cm was seen. Cut section was solid with areas of necrosis. On microscopy-Intersecting bundles of spindle cells with moderate nuclear atypia with mitosis >15/10 HPF with areas of necrosis were seen. A diagnosis of Extrauterine Leiomyosarcoma was made. Sections from uterus, left ovary and both tubes were unremarkable. Right ovary was completely replaced by tumour. All the lymph nodes and omentum were free from tumour. Discussion: Primary Leiomyosarcoma of ovary is a very rare subtype of ovarian sarcomas with a poor prognosis with a very high metastatic rate. These tumours originate from hilar blood vessels or smooth muscles of ovarian stromal or thecal cells. Conclusion: Spindle cell variant of Leiomyosarcoma is difficult to assess on trucut biopsy alone. Bell and Colleagues criteria and Immunohistochemistry is of extreme importance to diagnose accurately.

Keywords: Immunohistochemistry, leiomyosarcoma, ovarian

   AEP32 Top

   Bone/Joints/Soft Tissue Pathology Top

Tubercular osteoarthrities in a HIV patient with an unusual presentation

Rashmi Nayak, Rabia Parveen Siddiqui, Riti Sharma

Pt. J N M Medical College, Raipur, Chhattisgarh, India

Case Report: A 30 years female presented with complaints of pain and swelling in her left elbow for the past 2-3 months. On examination - massive circumferential swelling around left elbow with tenderness and restricted movement. Patient was known case of pulmonary tuberculosis on DOTS for last 6 months and she was recently diagnosed for HIV and on antiretroviral treatment for last 2 months. X-Ray showed- soft tissue density around elbow with lysis of lower end of humerus. MRI showed- multilobulated mass in distal end of humerus extending upto olecranon humeral joint with involvement of soft tissue and biceps muscle with enlarged lymph nodes in cubital fossa, likely presenting neoplastic mass (? soft tissue sarcoma) Biopsy showed fibrous tissue and skeletal muscles with marked chronic inflammatory cell infiltrates along with epithelioid granulomas with langhan's giant cells and caseous necrosis. Ziehl-Neelsen staining for AFB was positive. Discussion: Tuberculosis is classified as pulmonary or extra-pulmonary. A thorough evaluation is recommended in any case of soft tissue swelling adjacent to a joint, to rule out extrapulmonary tuberculosis. Conclusion: Tubercular osteoarthritis of elbow is rare presentation. However, any swelling in an immunocompromised patient should be thoroughly evaluated to rule out possibility of extrapulmonary tuberculosis.

Keywords: Elbow, HIV, osteoarthritis, tuberculosis

   AEP33 Top

   Bone/Joints/Soft Tissue Pathology Top

Giant cell tumor larynx: A rare case report

V L Vishnu, K R Anila, K Jayasree, Sindhu P Nair, Rari P Mony

Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Case Report: A 25 yr old male presented with change in voice for 1 month and neck swelling for 2 weeks. He was evaluated in local hospital with CT head and neck which showed a transglottic lesion measuring 3.9x3.5x3 cm. He was referred to our centre with a diagnosis of laryngeal chordoma. Here FNAC was done and reported as giant cell neoplasm. Excision biopsy was done. We received a specimen of thyroid cartilage with a grey white fleshy lobulated growth with friable areas. Histopathology showed a cellular neoplasm arising from thyroid cartilage composed of uniformly distributed osteoclastic like giant cells in a background of mononuclear spindle cells. Foci of reactive osteoid formation, increased mitotic activity and mature bony spicules at the periphery were noted. Tumour cells were positive for CD 68 and negative for S100. A final diagnosis of giant cell tumor larynx developing from secondary ossification of cartilage with reactive osteoid production and peripheral bone formation was made. Patient is currently on follow up. Discussion: Giant cell tumor of larynx are rare benign neoplasms, only a few well documented, histologically confirmed case reports in the literature and usually presenting in middle age male patient with obstructive symptoms. Conclusion: The tumor arises from the cartilages of larynx in areas of endochondral ossification with typical histology showing numerous giant cells. Conservative surgical excision is the treatment of choice and excellent long term prognosis without the development of recurrence or metastatic disease is the usual outcome.

Keywords: Conservative surgical excision, giant cell tumor of larynx, rare benign neoplasm

   AEP34 Top

   Bone/Joints/Soft Tissue Pathology Top

Bilateral orbital Rosai Dorfman disease – A rare sight!

Saral Madan, Sharada Rai, Nayana Rao

Kasturba Medical College, Manipal Institute of Higher Education, Mangalore, Karnataka, India

Case Report: • A 66-year-old man presented with swelling around the right eye since 2 months. • Ophthalmological examination- Total ophthalmoplegia, palpable mass at inferomedial aspect of right eye.• CT Scan- soft tissue thickening in B/L orbits, s/o mucocele with pseudotumour formation & fibrous dysplasia involving B/L maxillary, frontal, sphenoid and ethmoid sinus.• Right orbital mass biopsy- histiocytic proliferation with emperipolesis, with CD68 and S100 +ve and CD1a -ve. Histological and IHC features- consistent with Extranodal Rosai-Dorfman disease.• Complete resection done. On follow up: No complication/ recurrence. Discussion: • RDD- characterized by proliferation of histiocytes leading to sinus expansion, engulfment of lymphocytes by SHML cells (Emperipolesis) and presence of plasma cells.• Differentials: Sinus histiocytosis (no lymphophagocytosis, S100-ve), Langerhan cell histiocytosis (morphologically different from SHML cells, eosinophils +nt, necrosis +nt and CD1a+ve), Erdheim Chester disease (foamy histiocytes with surrounding fibrosis).• Generally self limiting. Conclusion: Extranodal RDD- rare presentation at orbit, with B/L cases being even rarer. Incisional/ excisional biopsy is gold standard to confirm the diagnosis. Hence, RDD needs to be considered as a differential diagnosis for any U/L or B/L ocular masses.

Keywords: Emperipolesis, orbital Rosai Dorfman disease, sinonasal mass

   AEP35 Top

   Bone/Joints/Soft Tissue Pathology Top

Wandering gastrointestinal stromal tumor (GIST) in the pelvic cavity: A case report at a rare location

Divvay Vishvam, Sufian Zaheer, Sunil Ranga

Vardhman Mahavir Medical College, New Delhi, India

Case Report: A 43-year-old female presented with abdominopelvic mass since past 1 month with pain and menstrual irregularities. Radiology revealed an isolated lobulated mass in right pelvic cavity abutting the fundal region of uterus. Based on clinico-radiological findings, total abdominal hysterectomy of the patient was done. Grossly, mass measured 21x13x4.5 cm. Intraoperative frozen section was suggestive of a uterine leiomyosarcoma. Microscopically, an encapsulated tumor consisting of mixed population of spindled cells arranged in fascicles alongwith nests of epithelioid cells seen. Mitotic activity brisk (5-7/50 hpf) with frequent atypical mitosis alongwith areas of necrosis. On immunohistochemistry tumour cells were positive for CD117, DOG1 and negative for SMA, vimentin, S-100 and HMB 45. Based on these findings' diagnosis of High grade GIST, epithelioid variant was made. Discussion: Preoperative diagnosis of GIST is uncommon due to their rarity and lack of specific radiological findings. Diagnosis of GIST is made on morphological and confirmed by immunohistochemistry. Extraintestinal GISTs usually have a better prognosis than their intestinal counterparts and previous case reports have showed no recurrence post chemotherapy. Conclusion: Pelvic cavity is a rare location for extraintestinal GIST and they can be mistakenly diagnosed as ovarian tumors.

Keywords: Extraintestinal, GIST, pelvic cavity

   AEP36 Top

   Bone/Joints/Soft Tissue Pathology Top

Lower limb soft tissue tumor – A diagnostic dilemma

Manoj Pant, Deep Kumar Raman, Jeenu Varghese, Gurpreet Kaur Walia, Natasha Dogra, Poonam Yadav

Command Hospital Air Force, Bengaluru, Karnataka, India

Case Report: A 35-year-old male presented with complaint of painless, gradually progressive swelling on right thigh since 8 months. Initial evaluation at other centre showed an intensely enhancing well-circumscribed mass in the subcutaneous plane of lateral aspect of right thigh on CEMRI and FNAC was opined as malignant spindle cell tumor suggestive of Rhabdomyosarcoma. Histopathological examination at our centre revealed features of Intermediate grade spindle cell malignancy. Immunohistochemistry showed positivity for CD34, INI1 & Vimentin and focal positivity for Desmin with Ki67 <5%. However, Pan CK, S-100, SMA, Myogenin, CD99, STAT6, Cyclin D1 and ALK-1 expressions were negative ruling out other pleomorphic soft tissue sarcomas. Final diagnosis of superficial CD34-positive fibroblastic tumor was made. Discussion: Superficial CD34-positive fibroblastic tumor is a rare entity with predilection to lower extremities, mostly occurring in middle age adults with male predominance. It presents as a slow-growing, painless mass of the superficial soft tissues, generally less than 5 cm in size. Conclusion: Superficial CD34-positive fibroblastic tumor has very low evidence of recurrence or malignant potential, however creating a difficulty to differentiate from other pleomorphic soft tissue tumors. Accurate diagnosis of this tumor will help in better understanding the disease occurrence, morphology, biological behaviour & differentiating it from other aggressive neoplasms with poor prognosis.

Keywords: CD34, fibroblastic, immunohistochemistry

   AEP37 Top

   Bone/Joints/Soft Tissue Pathology Top

An unusual case of mesenteric inflammatory myofibroblastic tumor

Sagar Soman, Sqn Ldr Jeenu Varghese, Col Deep Kumar Raman

Command Hospital Air Force, Bengaluru, Karnataka, India

Case Report: A 26-year-old male, presented with vague abdominal symptoms over umbilical region, hard stools and irritation while passing urine. On palpation a vague lump in umbilical, right hypochondrium and hypogastrium region. USG abdomen showed an echoic lesion causing locoregional pressure over bladder and colon. CECT revealed a large hypodense cystic lesion, with provisional clinicoradiological diagnosis of Mesenteric lymphangioma. Grossly a giant multi-cystic, capsulated mass, which on histopathological examination showed that the tumour composed of myofibroblastic spindle cells with an inflammatory infiltrate of plasma cells, lymphocytes and histiocytes in a predominantly myxoid stroma. Immunohistochemical staining indicated positive for SMA, vimentin and negative for ALK. A histological diagnosis of IMT was made. Discussion: The nature of IMTs has been controversial whether it represents a tumour or inflammation, and whether it is benign or malignant. This tumour most frequently involves the lungs and in extrapulmonary locations such as the mesentery, occasionally, they present as an abdominal mass with pressure symptoms. A definitive preoperative diagnosis of IMT is difficult, and can establish only after resection. Most are solitary tumours with range in size from 5-10 cm. Multiple nodules restricted to same anatomical location are uncommon. Inadequate surgical resection can lead to local recurrence. Conclusion: The preferred primary treatment is complete surgical excision, and close follow-up. Cases treated with complete surgical resection have a good prognosis.

Keywords: Extra pulmonary, inflammatory myofibroblastic tumour, mesentery

   AEP38 Top

   Bone/Joints/Soft Tissue Pathology Top

Desmoid tumor of anterior abdominal wall in a postpartum young female – A rare case report

Jinendrasinh Jadeja, Mandakini Patel, Pinkal Shah, Prashant Patel, R N Hathila

Government Medical College, Surat, Gujarat, India

Case Report: We present a case of anterior abdominal wall desmoid tumor in a postpartum 28 years old female patient with chief complaint of abdominal lump since 7 months. Discussion: Desmoid tumors are benign, deep, aggressive fibromatous tumor originating from fascia and muscle aponeurosis. On the basis of location they are classified into extra abdominal, intra abdominal and abdominal wall tumors. They usually present as painless, firm mass in abdominal region with radiology showing neoplastic abdominal lesion with well to poorly defined margins. Histologically tumor demonstrates long fascicles of spindle cells in collagenous stroma. IHC for spectrum of spindle cell tumors is required to reach confirmatory diagnosis. The mainstay of treatment is surgical resection. Conclusion: Abdominal wall desmoid tumor should be considered in young female presenting with abdominal mass especially during pregnancy and postpartum period. Appropriate use of IHC and correlation with clinical and radiological findings are crucial in establishment of correct diagnosis.

Keywords: Desmoid tumor, IHC, spindle cell tumors

   AEP39 Top

   Bone/Joints/Soft Tissue Pathology Top

Central giant cell granuloma

Suhit Naseri, Samarth Shukla, Sourya Acharya, Sunita Vagha, Preeti Mishra

Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Case Report: A 22-year-old female reported to the oral and maxillofacial surgery department with a 6-month history of localised swelling on the upper right jaw of her face. The swelling was gradual and insidious, with mild, progressive nasal obstruction, loosening of accompanying teeth, and various facial swelling affecting the facial skeleton, which revealed a multiloculated cystic appearance on C.T. involving the maxilla and mandible. The lesion was surgically resected. Grossly, soft tissue specimen was brown coloured, firm in consistency with size of 5.5 x 3 x 2 cm. Microscopically, large multinucleated cells were noted in a highly cellular stroma that comprised both spindle-shaped and round cells and was predominantly located in hemorrhagic and reactive bone areas. Ingested R.B.C.s and sparse collagen fibres were observed. These findings confirmed diagnosis of CGCG. Discussion: Giant cell granuloma and its associated lesions in the jaw are classified as a single entity, although their clinical behaviour varies from simple reactive to neoplasm, and can even emerge as threatening malignant neoplasm. The existence of giant cells in multiple bone diseases complicates differential diagnosis even further. Conclusion: Pathogenicity is still an enigma and must be distinguished from other similar lesions to devise appropriate therapy. Furthermore, in order to avoid mutilating procedures, CGCG must be distinguished from central giant cell tumour.

Keywords: Benign, giant cells, granuloma

   AEP40 Top

   Bone/Joints/Soft Tissue Pathology Top

Plexiform schwannoma of the great toe: A case report with review of literature

Swati Narute, Aradhana Mishra, Saranya Singaravel

Seth VC Gandhi and MA Vora Municipal General Hospital, Mumbai, Maharashtra, India

Case Report: 12 years female presented with slow growing soft tissue mass on plantar aspect of the great toe since 6 months. Ultrasonography showed a well-defined hypoechoic lesion measuring 9x3x6 mm. The lesion was surgically excised. Grossly, grey-white, solid, nodular tissue mass measuring 2x1.8x1 cm. Microscopic examination showed plexiform neoplasm in the dermis composed of multiple nodules of proliferating spindle cells with wavy nuclei. Areas of nuclear palisading forming Verocay bodies was noted. Tumor was strongly immuno-reactive for S-100 protein. Discussion: Schwannoma is extremely rare benign neurogenic tumor, affecting the head, neck and flexor surfaces of limbs. Our case presented with tumor on the plantar surface of the great toe which is unusual location. MRI can be helpful in the diagnosis. However, a definitive diagnosis requires histopathological studies. The histopathological differential diagnosis of PS includes plexiform neurofibroma and plexiform fibro-histiocytic tumor. PS consists of multiple intradermal and subcutaneous nodules composed primarily of cellular Antoni A regions with nuclear palisading and verocay bodies. But plexiform neurofibroma usually does not have these characteristics. PS is strongly immuno-reactive for S-100 protein. Conclusion: It is important to keep Plexiform Schwannoma in the diagnosis when dealing with soft tissue tumors of foot. Histopathological examination is essential to avoid misdiagnosis with other lesions.

Keywords: Benign peripheral nerve sheath tumor, foot, plexiform schwannoma, schwannoma

   AEP41 Top

   Bone/Joints/Soft Tissue Pathology Top

Pseudo gout – A case report

Eesha Nimmakayala, Kaumudi

NTRUHS, Vijayawada, Andhra Pradesh, India

Case Report: Female aged 73 yrs presented with severe osteoarthritis of left knee joint. TKR (Total Knee replacement) was done, The synovial tissue was sent for histopathological examination. Gross: Irregular grey and yellow mass of 8x5x5 cms, with surface villous projections and chalky white deposits. Wet Film preparation from chalky white material showed rhomboid shaped CPPD crystals of 0.5 – 5 micro meters. Microscopy showed synovial tissue and cartilage tissue with amorphous basophilic, refractile deposit. Hence, a diagnosis of Pseudo Gout was made. Discussion: Pseudo gout (CPPD Disease) can be diagnosed through joint fluid analysis which shows rhomboid shaped crystals. Its diagnosis is essential as it mimics Osteoarthritis and Rheumatoid arthritis clinically. Conclusion: CPPD deposition disease (Pseudo Gout) is rare and causes potentially severe arthropathy. The basis for crystal formation is not known. Therapy is supportive to minimize symptoms. There is no known treatment that prevents and slows crystal formation.

Keywords: Arthritis, CPPD crystals, pseudo gout

   AEP42 Top

   Breast Pathology Top

Ectopic breast tissue with features of lactating adenoma

Shraddha Bhoskar, Amit Kumar Chowhan, Dharmendra Dugar, Rakesh Kumar Gupta, Yashita Gupta, Babita Khangar, Ankita K Simon

AIIMS, Raipur, Chhattisgarh, India

Case Report: We reported a case of 22 year old PNC patient with 5 x 5 cm suprapubic mass for 7 months which was painless, non tender and gradually increasing in size. USG suggested large hemangioma/ AV malformation. FNAC suggested ectopic breast mass. Excision biopsy showed ectopic breast tissue with features of lactating adenoma. Discussion: Ectopic breast tissue can become apparent during puberty and pregnancy because of hormonal influences. Conclusion: We report this case to shed light on such a rare condition and to keep in mind that ectopic breast tissue can be found outside the milk line. Due to its rarity, diagnosis and treatment are often delayed, negatively affecting the prognosis. This case report illustrates the value of clinical, radiological and histological correlation in the approach of indeterminate soft tissue masses.

Keywords: Ectopic breast tissue, lactating adenoma

   AEP43 Top

   Breast Pathology Top

A retrospective study on trends of breast cancer in a tertiary care hospital catering an industrial area in Central India

Nadasha Kadeeja, Priya Sahu, Gurmeet Singh, Nily S Kujur, Manisha Kango, M Ravindranath

Department of Pathology, J L N H R C, Bhilai, Chhattisgarh, India

Case Report: Methods and materials: In this retrospective observational study, we retrieved 269 breast cases registered in the histopathology laboratory from September-2019 to August-2022. The specimens include core-biopsies, lumpectomies and mastectomies. The clinical data, histopathology and IHC reports were reviewed and evaluated for demography, histology, grade, stage and hormonal status. Discussion: Results: In this study, out of 269 cases, 101 (37.5%) showed breast cancers. Age of the patients ranged from 24-85 years with mean age of 59.87 years. Maximum incidence was seen in 6th decade (33.6%). Cancers show predominantly right breast (51.5%) and upper outer quadrant (35.8%) involvement. Histopathological subtypes show Invasive ductal carcinoma (NOS) 72 (71.2%) predominantly and remaining 29 (28.7%) includes lobular, medullary, mucinous, papillary, apocrine, angiosarcoma etc. Most patients presented with Grade III (46.5%) lesions. The T2 tumour stage (67.3%) observed predominantly. Nodal metastasis seen in 20 (39.2%) cases out of 51 mastectomies. On molecular profiling, luminal type (65.3%), her2-neu enriched (19.2%) and triple negative (15.38%) were observed. Conclusion: Breast cancer is highly prevalent in this studied industrial area. Increased awareness, early detection and prompt treatment with respect to hormonal status are crucial in decreasing morbidity and mortality. Histopathological examination provides an inexpensive tool for diagnosis, prognosis and management.

Keywords: Breast cancer, histopathology, hormonal status

   AEP44 Top

   Breast Pathology Top

Metaplastic carcinoma of breast

Rashi Dudeja, T S Anisha

Rajarajeswari Medical College and Hospital, Kambipura, Karnataka, India

Case Report: A 35 yr old female presented with c/o lump in the right breast and yellowish nipple discharge for one month. Examination revealed an irregular mobile tender lump of 3x3 cms in the upper outer quadrant of right breast. USG Mammogram showed a BIRADS IV Lesion. Aspiration cytology and trucut biopsy were reported as proliferative breast disease with atypia. Lumpectomy with wide local excision was done initially. Grossly it showed an irregular grey white mass measuring 4x3x1.5 cms gritty and firm in consistency. Microscopically, it showed breast tissue with large areas of chondroid matrix with cartilage and osteoid tissue along with neoplastic ductal elements. Discussion: Metaplastic breast cancer accounts for 0.2-5% of all invasive breast cancers. It is characterized by differentiation of the neoplastic epithelium into squamous cells and mesenchymal-looking elements. Owing to its rarity, MpBC has been treated as a variant of Invasive Duct Carcinoma (IDC). Conclusion: Metaplastic breast carcinoma is rare with no standard treatment guidelines. Surgery remains the mainstay of treatment. Regardless of the type of surgery, adjuvant radiation should be considered as a part of the treatment. The prognosis of patients in this rare sub group remains poor.

Keywords: Breast, carcinoma, metaplastic

   AEP45 Top

   Breast Pathology Top

A rare male breast malignancy – Case report

Sreeya Sathees, R Sujatha, Akshay Raju, Rufaida Shafiuddin, Y A Manjunatha

DR B R Ambedkar Medical College, Bengaluru, Karnataka, India

Case Report: A 60 yr old male with a lump in left breast since 1 year with on and off nipple discharge. On examination noted a solitary, nontender, lump measuring ∼2X1 cm in subareolar area of left breast. Excised specimen was sent for histopathological examination. GROSS: Received single fibrofatty mass of tissue measuring 5x2x1 cm. Cut surface revealed grey white cystic area measuring 1x0.7 cm with papillary excrescences. MICROSCOPY: Showed thick fibrous cyst wall with malignant neoplasm, the cells arranged in papillary and micropapillary pattern. These papillae show fibrovascular core lined by round to oval cells exhibiting high N/C ratio, vesicular nuclei, prominent nucleoli and moderate cytoplasm. Numerous psammoma bodies and atypical mitotic figures (2-3/hpf) were noted. IHC showed ER/PR: Positive, Her 2 neu: Negative and p63: Negative for myoepithelial cells at the periphery. Discussion: EPC is a rare subtype of breast cancer that despite a lack of distinct myoepithelial layer is considered in situ carcinoma unless associated with a frank invasive component. Absence of myoepithelial cell layer by IHC is significant for pathological diagnosis. Literature indicates that neoplastic cells are strongly ER positive and Her 2/neu negative. Conclusion: EPC in male breast is rare indolent subtype of breast cancer with good prognosis. Hence cystic lesion in men should be evaluated as potentially malignant lesion.

Keywords: Encapsulated papillary carcinoma

   AEP46 Top

   Breast Pathology Top

Invasive ductal carcinoma breast with micropapillary carcinoma component: A rare case report

Saumya Bindlish, Ruchi Agarwal, Kulwant Singh, Parveen Rana Kundu, Sunaina Hooda, Swaran Kaur

Bhagat Phool Singh Government Medical College for Women, Sonepat, Haryana, India

Case Report: A 40 years old female presented in surgery OPD with right breast lump since 6 months. On USG, well circumscribed heterogenous opacity seen in right breast central region measuring 38×36×36 mm. On FNAC, monomorphic cells which are round to oval with high N/C ratio and moderate amount of cytoplasm and interspersed with these cells numerous multinucleate giant cells also seen, suggestive of proliferative mammary lesion with atypia. Excised breast lump specimen was sent for histopathology. Grossly, specimen measures 5×4×3 cm. On cutting, grey brown firm mass identified measuring 3×2 cm. Microscopically, large areas of infarction with relatively preserved areas shows micropapillary structure lined by epithelial cells revealing round to oval cells, moderate nuclear pleomorphism and eosinophilic cytoplasm. Invasive nest and tubules of tumor cells identified in the surrounding breast parenchyma. Tumor cells shows inside out pattern with EMA immunostaining. Final diagnosis of invasive breast carcinoma with resemblance to invasive micropapillary carcinoma is given. Discussion: MPC is a rare variant of breast cancer. Accurate diagnoses of MPC would allow timely, albeit intensive, disease management. Conclusion: MPC is an aggressive and distinctive variant of breast cancer. These tumours have a characteristic histological appearance and have been associated with a high incidence of axillary lymph node metastases and a poor clinical outcome.

Keywords: Aggressive, ductal carcinoma, EMA, micropapillary breast carcinoma

   AEP47 Top

   Breast Pathology Top

Pseudoangiomatous stromal hyperplasia of the breast: A case report

Purnika Tongbram, G K Parvathidevi

Department of Pathology, Sri Siddhartha Medical College, Tumakuru, Karnataka, India

Case Report: A female aged 40 years presented with subareolar lump in right breast. Gross- Single ovoid mass of grey white to grey brown polypoid lobular mass measuring 1.5x1x0.5 cm. Cut section-grey white lobulated and yellowish area noted. Microscopically, section shows sclerosed stromal tissue with slit like spaces lined by spindle shaped cells. At places, tiny lobules of breast tissue and scattered tiny ducts are seen. No atypia is seen. IHC has been done for confirmation. Discussion: Pseudoangiomatous stromal hyperplasia is a benign proliferation of stromal myofibroblasts characterised by dense collagenous stroma forming pseudoangiomatous capillary like spaces lined by slender spindle cells. It is mostly found in the premenopausal and perimenopausal women. Although, the exact pathogenesis in unclear, it is considered that hormonal factors play an important role in the development of PASH. It may present as a palpable mass or as an incidental findings. PASH is not associated with increased risk of breast cancer and has a favourable prognosis. Conclusion: Pseudoangiomatous stromal hyperplasia is a rare breast entity with diverse clinical presesntation and non-specific radiological features. The definitive diagnosis is established on biopsy and histopathology.

Keywords: Mimic malignant lesion, myofibroblasts, pseudoangiomatous

   AEP48 Top

   Breast Pathology Top

Synchronous occurrence of breast myoepithelioma with fibroadenoma

A Ramy, G K Parvathidevi

Sri Siddhartha Medical College, Tumakuru, Karnataka, India

Case Report: 22-year-old female presented with lump in both breasts Gross: Specimen 1-Single piece of grey-brown lobulated tissue measuring 6x4x2 cms. Cut section-grey-white to grey-brown areas noted with gelatinous grey-white leaf like areas Specimen 2-Two pieces of grey-white to grey-brown tissue, larger measuring 1.5x0.5 cms, smaller measuring 1x0.5x0.2 cms. Cut section-grey-white lobulated areas noted. Microscopy: Sections from right breast showed features of myoepithelioma. Sections from left breast showed features of fibroadenoma. IHC confirmation is awaited. Discussion: Myoepithelial neoplasm of the breast is a rare condition and often presents a diagnostic challenge. Benign version will always show a dual cell population; myoepithelial and epithelial cells found in the lining. No necrosis or mitoses is seen. There may be mild-moderate nuclear pleomorphism, but most have regular, oval nuclei. The background cytoplasm is usually clear, sometimes may contain occasional intranuclear cytoplasmic vacuole and fibrillary, metachromatic, myxoid material. Fibroadenomas are common, benign tumours made up of both glandular and stromal tissue. Conclusion: The benign character of myoepithelioma in conjunction with its slow progression could delay its detection and diagnosis. It can undergo malignant transformation, especially in long standing tumors with multiple recurrences. The recommended treatment is complete surgical excision. Fibroadenomas need surgical removal if it is massive and continues to grow in size, otherwise it is left untreated.

Keywords: Breast, fibroadenoma, myoepithelioma, synchronous

   AEP49 Top

   Breast Pathology Top

Metaplastic carcinoma: A rare entity with brief literature review

Vats Mehta, Amit Kumar Chowhan, Yashita Gupta, Debjyoti Mohanty, Ramchandani, Manish Agrawal, Aishwarya John, Ankita Simon

All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Case Report: We report a case of a 48 year female, who presented with lump in lower inner quadrant of right breast since one and half month, gradually increasing in size. USG- Heterogenous solid nodule of size 2.5x2.3 cm in right breast- s/o- Hematoma. FNAC from right breast mass -consistent with malignant neoplasm-? Sarcoma, ?carcinoma. Trucut biopsy was reported as Fibromatosis of breast. Excisional biopsy showed features consistent with Fibromatosis like metaplastic carcinoma. Discussion: Metaplastic carcinoma breast is a rare, aggressive, chemo-refractory entity, having poor outcome. On imaging it is difficult to differentiate it from benign counterparts. Histologically it is characterized by presence of 2 or more cellular components, comprising of epithelial and mesenchymal components. On immunoprofiling, these carcinomas are TNBC. The findings are in concordance with the above literature in our case. Conclusion: Metaplastic breast carcinoma has varied morphology; likely to be missed in FNAC and trucut biopsy, which needs to be kept in mind by pathologists and clinician alike. Extensive grossing should be performed in order to not miss any components of metaplastic carcinoma as this entity carries poor prognosis and lower response to conventional chemotherapy.

Keywords: Breast neoplasm, fibromatosis, triple negative breast neoplasm

   AEP50 Top

   Breast Pathology Top

Atypical fibroxanthoma of breast (a malignant mimicker)

Suprasidha Mohanty, Priyadarshini Biswal, Subhasish Mishra, Kalpalata Tripathy, Lity Mohanty

SCB Medical College, Cuttack, Odisha, India

Case Report: A 24 year old lactating female presented with a left breast lump measuring 3 cmx2 cmx 2 cm. Mammography showed a heterogeneous, hypoechoic solid lesion with mild cystic changes (BIRADS 4). The FNAC revealed pleomorphic, spindle cells along with mitosis. Histopathology revealed an encapsulated tumor with pleomorphic cells, mostly spindeloid cells along with multinucleated giant cells and several mitotic figures and few atypical forms. Immunohistochemistry showed negative for CD10, CD34, SMA, S-100, Desmin and Pan CK. Discussion: Cytological and histopathologic findings suggested a sarcoma of breast, but immunohistochemistry helped in confirming the diagnosis of AFX. Conclusion: Hence, despite the cytological and histopathological pictures the diagnosis of AFX should be confirmed after immunohistochemistry, to exclude the possibility of other breast sarcomas.

Keywords: Atypical fibroxanthoma, atypical mitosis, sarcoma

   AEP51 Top

   Breast Pathology Top

Primary B-lymphoblastic lymphoma of breast – A case report

Harsha Kumar, Chaithra Gowthuvalli Venkataramana, Kudurugundi Basavaraju Vatsala

Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Case Report: A 38 year old woman presented with painless, right breast lump since two weeks. Histopathological examination of core needle biopsy identified atypical lymphoid cells diffusely infiltrating into the breast parenchyma. Immunohistochemical evaluation revealed these atypical lymphoid cells to be positive for CD45, CD79a and Tdt. A diagnosis of B cell-lymphoblastic lymphoma was offered. Discussion: Wiseman and Liao first defined clinical criteria for the classification of PBL, which includes adequate pathologic evaluation, Mammary tissue in close association with lymphomatous infiltrate, no evidence of disseminated lymphoma other than simultaneous ipsilateral lymph node involvement, and no prior diagnosis of lymphoma. The management of Primary Non-Hodgkin's lymphoma of breast is based on histologic grade. Reports have recommended that surgery should be ordered for diagnosis only and that minimally invasive surgery is the more appropriate option because extensive surgery may carry a high risk of morbidity. Conclusion: We have described a rare case report of extranodal non hodgkin lymphoma arising in the breast. The prevalence of PLB is increasing and the available outcome data is limited. A joint approach by clinicians, radiologists and pathologists is essential to benefit the patients and their survival.

Keywords: B-lymphoblastic lymphoma, breast, lymphoma, Non-Hodgkin lymphoma, primary

   AEP52 Top

   Breast Pathology Top

Primary sarcoma of breast: A case report

Sapna Singla, Shilpa Bairwa, Sonia Hasija, Shilpa Garg, Puja

Shaheed Hasan Khan Mewati Government Medical College, Nalhar, Haryana, India

Case Report: A 62 year old female presented to surgery OPD with a lump measuring 12x8 cm in right breast. Overlying skin showed a large fungating lesion with presence of active bleeding since 15 days. FNAC of the lesion was performed. On Cytology smears were positive for malignancy. The patient was subjected to total mastectomy and the sample was submitted for histopathology in Histopathology department. On morphology tumor was diagnosed as malignant mesenchymal tumor and later on performing immunohistochemistry tumor cells were positive for Vimentin and negative for ER, PR, and EMA. The diagnosis of Primary Sarcoma of breast was made. Discussion: Sarcomas of breast are rare but constitute a specific clinicopathologic entity with a different clinical course and treatment protocol and so they should be differentiated from cystosarcoma phyllodes and metaplastic carcinoma. Conclusion: Sarcomas of breast are rare but constitute a specific clinicopathologic entity with a different clinical course and treatment protocol and so they should be differentiated from cystosarcoma phyllodes and metaplastic carcinoma.

Keywords: Breast pathology, cystosarcoma phyllode, sarcoma

   AEP53 Top

   Breast Pathology Top

Cystic neutrophilic granulomatous mastitis – Two case reports

Prasad CSBR, Vamsi Krishna1, Prashanth Murthy2

Vindhya Clinic and Diagnostic Center, 1Department of Surgery, Sri Sathya Sai Sarla Memorial Hospital, 2Murthy Nursing Home, Bengaluru, Karnataka, India

Case Report: Case-1: Thirty year old non-lactating female presented with a 9 month history of painful lump in the left breast which was not responding to many courses of antibiotics including ATT. Lesion was given as BIRADS 4. Patient underwent simple mastectomy. Gross examination showed an irregular grey white area measuring 12 cm across. Case-2: Thirty five year old non-lactating female presented with a 7 month history of painful left breast lump with skin ulceration. Patient underwent mastectomy with axillary clearance. Gross examination showed a 6 cm grey white irregular area ulcerating the overlying skin. In both the cases histopathological examination showed epithelioid granulomas, centered on neutrophils rimmed lipid vacuole. ZN stain and PAS stain were negative for acid fast bacilli and fungus respectively. Gram stain revealed Gram positive bacilli in the empty lipid vacuoles. Axillary lymphnodes in the second case showed reactive changes. Discussion: Both the cases satisfied the criteria required for the diagnosis of CNGM. This occurs in young patients between 30 and 40 years of age as are our cases. Gram stain showed Gram positive bacilli in the lipid spaces in both the biopsies. In our cases both ZN stain and PAS stain were negative excluding the Mycobacterial and fungal infections. Conclusion: Awareness of this recently described CNGM and doing Gram stain on all breast cytology and biopsy specimens that are showing granulomas, helps in providing specific treatment and avoids aggressive surgery.

Keywords: Corynebacterium, cystic, granulomatous, mastitis, neutrophilic

   AEP54 Top

   Cytopathology Top

Cytologic diagnosis of langerhans cell histiocytosis with cutaneous involvement

Suman Kumari, Ruchi Khajuria

GMC, Jammu, Jammu and Kashmir, India

Case Report: We present a case of 8 year old male child who presented with soft to cystic tender swelling in right frontal region. CT scan was showing soft tissue density lesion with heterogeneity along right frontal convexity causing erosion of underlying calvarial bone. Discussion: FNA was done from lesion and cytologic smears show features characteristic of Langerhans cell histiocytosis. These include dispersed cell population of histiocytes having eccentric nucleus and abundant pale blue cytoplasm. The nuclei showed characteristic intranuclear pseudoinclusions, prominent nuclear indentation and grooves. Binucleated and multinucleated histiocytic cells, numerous eosinophils, neutrophils and lymphocytes were seen in hemorrhagic background. On the basis of clinical and cytological findings, a diagnosis of LCH was suggested. The diagnosis was confirmed on histology and subsequently on immunohistochemistry. Conclusion: FNA procedure is quick and safe and may help in early diagnosis of LCH patients so that appropriate therapeutic measures are instituted. A high index of suspicion, awareness of characteristic cytological features of LCH and its differential diagnosis is necessary. This can obviate the need of biopsy and electron microscopy. IHC, if available can be performed on cytology smear and cell block.

Keywords: Cytology, FNA, langerhans cell histiocytosis

   AEP55 Top

   Cytopathology Top

Multifocal nodular oncocytic hyperplasia of the parotid gland

Prakriti Mishra, P S Srilatha

Departmnet of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Case Report: A 56 year old female presented to the ENT outpatient department with a 6 cm firm, non-tender swelling in the right parotid region. She noticed it 4 years back, and it increased gradually to the present size. MRI neck showed diffuse bulky right parotid gland and suggested the possibility of granulomatous parotiditis. FNAC revealed a cellular smear composed of sheets of oncocytic epithelial cells. Possibility of oncocytoma/ Warthin tumor was given. Total parotidectomy was performed. On gross, ill-circumscribed gray tan areas were identified. Histopathology showed multiple unencapsulated circumscribed nodules and lobules of oncocytes. The cells had abundant eosinophilic granular cytoplasm, mild anisonucleosis, nuclei with fine dispersed chromatin, and few with prominent nucleoli. Normal salivary acini and ducts are seen interspersed between the oncocytic nodules. Discussion: WHO classification of salivary gland neoplasms recognizes three oncocytic entities: oncocytosis, oncocytoma and oncocytic carcinoma. Differential diagnosis of MNOH include Warthin tumour, oncocytoma, papillary oncocytic cystadenoma /cystadenocarcinoma, salivary duct carcinoma, acinic cell carcinoma, mammary analog secretory carcinoma, oncocytic carcinoma and oncocytic mucoepidermoid carcinoma. MNOH is an extremely rare lesion with very few reported cases. Conclusion: Oncocytic lesions of salivary gland can pose considerable difficulty to the cytopathologist, and a histopathological examination often remains the cornerstone of diagnosis.

Keywords: Multifocal nodular oncocytic hyperplasia, oncocytic lesion, oncocytosis, parotid gland

   AEP56 Top

   Cytopathology Top

Cutaneous metastasis; An unusual metastatic presentation of carcinoma pyriform fossa

Shivangi Mittal, Sujata Kumbhar, Ramnik Singh, Nidhi Goswami

Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Case Report: We report a case of 54-year-old male diagnosed as carcinoma of pyriform fossa who was on radiotherapy and chemotherapy when he developed cutaneous metastases over chest wall which initially presented as small nodule and later progressed into a proliferative lesion. Discussion: Cutaneous metastasis present as nodules and can easily be confused with infection which are usually painless and can be solitary or multiple. Cutaneous metastasis are thought to develop from hematogenous spread if they appear distally and via dermal lymphatic spread if they occur in close proximity to primary tumor. The occurrence of cutaneous metastasis is associated with a very poor prognosis. Conclusion: Cutaneous metastasis in hypopharyngeal cancers is extremely rare and is accompanied with poor outcome with an average survival of 3 months after developing skin metastasis which demonstrates the aggressive nature of the disease.

Keywords: Chest wall metastasis, prognosis, pyriform fossa

   AEP57 Top

   Cytopathology Top

EUS FNA diagnosis of solid pseudopapillary neoplasm – A rare case report

Aneeta Mutgi, Aditya Agnihotri, Anita Javalgi, Basavaraj Yamakanamardi, Vidisha Athanikar

SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

Case Report: A 15-year-old female presented with pain abdomen and vomiting on and off for 2 years. On examination, abdomen was soft and non-tender with no organomegaly. CT Abdomen and Endosonography revealed a heterogenous, solid and cystic pancreatic head lesion measuring 5.1x4.9 cm. EUS (Endoscopic Ultrasound) guided FNA cytology study showed tumor cells arranged in delicate branching papillary fronds with fibrovascular cores lined by 1-2 layers of tumor cells, sheets, acini and single cells having eccentric bland round to oval nucleus and finely granular eosinophilic cytoplasm, consistent with SPN. Patient underwent Whipple's procedure following which the histopathological study confirmed the EUS-FNA cytological diagnosis of Solid pseudopapillary neoplasm of head of pancreas. Discussion: SPN was earlier known as Franzt's tumor or Hamoudi tumor until WHO labelled it as Solid pseudopapillary neoplasm in 1996. This tumor has low malignant potential and inert biological behaviour and excellent prognosis on complete resection. Conclusion: EUS guided FNA is a minimally invasive, safe and reliable method for diagnosing SPN by providing characteristic cytologic specimen and a definitive preoperative diagnosis leading to appropriate surgical management of these patients.

Keywords: Frantz's tumor, solid pseudopapillary neoplasm, Whipples procedure

   AEP58 Top

   Cytopathology Top

Metastatic malignant melanoma in 1 year child – A rare case report

Shreyanka Kale, Ashwin P Khageshan, M D Mateen Ahmed, Rajashree J Ingin

Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Case Report: 1 year old female was brought to OPD with complaint of swelling in left inguinal region since 2 months. On examination the swelling measured 3 cmx2 cm, firm, mobile and non tender with blackish discoloration. Multiple brown to black colored macules and patches involving whole of left lower limb was seen. FNAC of the swelling yielded blackish aspirate. Microscopy: Cellular aspirate showed cells with marked pleomorphism, high N:C ratio, vesicular chromatin and prominent nucleolus; scattered singly and in small clusters. Cytoplasm contained multiple coarse black pigmented granules. The background showed lymphoid cells. A diagnosis of metastatic malignant melanoma of inguinal lymphnode was made. Discussion: Malignant melanoma is commonly seen in adult population and in children commonly presents between 15-19 years. Children of 1-5 year old usually develop melanoma within congenital nevi. Very few such cases in children are reported in the world. Two similar cases from literature are (i) A newborn boy with multiple large congenital nevi on trunk died of meningeal malignant melanoma. (ii) A 5-year-old girl with elevated nodular malignant melanoma of left upper back. Conclusion: Maliganant melanoma is very rare in children below 5 years. Melanoma in <10 year old with nodal metastasis has poor prognosis. Hence the above case is presented because of its rarity.

Keywords: Congenital nevi, metastatic malignant melanoma, paediatric age

   AEP59 Top

   Cytopathology Top

Hepatocellular carcinoma presenting as a chest wall mass – An unusual case diagnosed on cytology

Avanika, Ankita Asthana, Mona Agnihotri, Pragati Sathe, Kanchan Kothari

Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India

Case Report: An 82-year-old diabetic male presented with edema feet, weight loss & a firm, well defined 3 x3 cm swelling on the left chest wall. Investigations: Hb-8.0 g/dl, Serum Creatinine-2.46 mg/dl, AST- 267 U/L, ALT-148 U/L, Total Protein-6.77 g/dl, Albumin-2.9 g/dl. Ultrasonography showed a soft tissue mass measuring 4.3x2.8x2.4 cm involving the anterior chest wall with adjacent rib erosion. Serum electrophoresis - increased beta2 microglobulin. Clinical diagnosis was multiple myeloma. Fine needle aspiration cytology (FNAC) from the mass showed loosely cohesive clusters with traversing blood vessels. Cells showed abundant vacuolated cytoplasm, round nuclei with prominent nucleoli and intranuclear cytoplasmic inclusions. A differential of metastatic HCC and renal cell carcinoma was considered. Subsequent imaging showed a 11 cm mass in the liver. Metastatic lesions were also found in bilateral scapulae and 1st rib. Biopsy with IHC (Hep Par1) from chest wall mass confirmed diagnosis. Discussion: Lungs and lymph nodes are the commonest sites for metastatic HCC; presentation as chest wall metastasis is rarely reported. Recent studies have shown that Beta2 microglobulin is a promising biomarker for early diagnosis of HCC in patients with chronic liver disease. One year survival in patients with metastasis is 24.9%. Conclusion: FNAC can play an invaluable role in the early diagnosis of metastatic HCC.

Keywords: Chest wall, cytology, hepatocellular carcinoma, metastasis

   AEP60 Top

   Cytopathology Top

The thyroid gland – TB or not TB?

Avani Pandey, Balaji Baste, Mona Agnihotri, Kanchan Kothari

Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India

Case Report: A 16-year-old female presented with a progressively enlarging neck swelling for 20 days and dry cough and fever since 7 days. On examination, a tender 8 x 3 cm swelling which moved with deglutition was noted. Thyroid profile showed evidence of hyperthyroidism. USG neck was suggestive of acute suppurative thyroiditis. CT chest and abdomen was unremarkable. Aspirate from the thyroid showed colloid, thick necrosis, neutrophils & epithelioid granulomas and was suspicious of mycobacterial etiology. AFB was negative however GeneXpert (CBNAAT) detected MTB and the patient was put on Category I AKT. She responded well to treatment and the swelling resolved. Discussion: Although not immune, as once propounded by Virchow and Rokitansky, thyroid is involved in just 0.1-0.4% of cases. The proposed reasons for this resistance are bactericidal properties of colloid, rich vascularity, and high levels of iodine. Most patients are euthyroid. Diagnosis is difficult as it is clinically unsuspected and radiology is non-specific. Presence of characteristic necrosis helps differentiate from other granulomatous inflammations on FNAC. Antituberculous therapy with surgical drainage if required is the treatment. Conclusion: FNAC plays an invaluable role in diagnosis and aids appropriate management. Use of multiple ancillary tests (AFB, CBNAAT etc) improves diagnostic accuracy.

Keywords: Extrapulmonary, thyroid, tuberculosis

   AEP61 Top

   Cytopathology Top

FNAC diagnosis of seminoma metastasis in cervical lymph node: A rare case report

Meenal Chidri, B M Soumya, Seema Bijjaragi

JJM Medical College, Davangere, Karnataka, India

Case Report: A 19 year male patient presented with hoarseness of voice, breathlessness since 1 month and swelling in left cervical region since 7 days. On examination, level II cervical lymphnode enlarged, measuring 2x2 cm. Fine needle aspiration performed revealed Cellular smears with predominance of dyscohesive large cells that are monotonous in appearance, round to irregular nuclei, vesicular nucleus, prominent nucleoli and abundant fragile vacuolated cytoplasm. Background shows frothy bubbly lace like tigroid appearance. CT Chest revealed well defined soft tissue dense in anterior mediastinum, suggestive of mediastinal mass. A diagnosis of Metastatic deposits to left cervical region lymphnode (probably from Mediastinal seminoma) was given. Patient was put on chemotherapy and radiotherapy. Discussion: Germ cell tumors comprises only 1-4% of all mediastinum tumors. Extragonadal seminoma are more common in mediastinum and retroperitoneum. Nearly 8% of patients present with metastasis in head and neck region. Tigroid background, characterized by the presence of a relatively granular, reticulated material that is foamy, lazy, tiger-striped or astrakhan. Primary mediastinal germ cell tumor can metastasize to cervical and abdominal lymphnode. Recommended treatment is chemotherapy and radiotherapy. Conclusion: Keen observation of pathognomic cytomorphological findings in conjuction with supportive imaging studies can be helpful in diagnosis of metastasis to cervival lymphnodes from mediastinal germ cell tumors.

Keywords: Mediastinal seminoma, tigroid background

   AEP62 Top

   Cytopathology Top

Metastatic rhabdomyosarcoma of breast: A rare presentation

Reetika Devashwar, Niharika Mishra, Smriti Gupta

Army Hospital R and R, Delhi Cantt, New Delhi, India

Case Report: A 17-year-old girl known case of primary embryonal rhabdomyosarcoma of right maxillary antrum diagnosed two years back and administered NACT-CCRT. Later she developed right breast lump; which on FNAC of the lump showed characteristic features of metastatic rhabdomyosarcoma, thus avoided surgical intervention of lumpectomy or mastectomy. The patient received adjuvant chemotherapy followed by radiotherapy & is doing well. Discussion: Metastasis of RMS to breast in adolescent girl is related to expression of IGF in tumor cells. Increased vascularity is another reason also. Conclusion: The aim of the present case is to assess the safer, faster role of fine needle aspiration cytology in the diagnosis of breast RMS. It is also recommended to include ultrasound/mammography of breast as a protocol in metastatic workup of RMS for adolescent females.

Keywords: Breast, fine needle aspiration cytology (FNAC), IGF (insulin like growth factor), metastasis, rhabdomyosarcoma

   AEP63 Top

   Cytopathology Top

FNAC of pleomorphic adenoma with squamous metaplasia and keratinous cyst: A case report

Ishita Agrawal, Manisha Y Tambekar, Shilpi Sahu, Ujwala Maheshwari, Priyanka Jadhav, Neha Jadhav, Vrutika Shah

MGM Medical College, Navi Mumbai, Maharashtra, India

Case Report: A 36-year-old female patient came with complaint of slow growing, painless swelling in left submandibular region since 5 years which gradually increased to present size. USG & CT Neck were s/o neoplastic etiology. On FNAC, a diagnosis of PA with squamous metaplasia and keratinous cyst was offered. We received encapsulated soft tissue mass measuring 3.5x2.5x1.5 cm, c/s – single, firm, grey-white, myxoid mass, with cyst containing keratinous material. Cytological diagnosis was confirmed on histopathological examination. Discussion: Squamous metaplasia is a common feature of non-neoplastic or neoplastic conditions of salivary glands but extensive metaplasia can be easily misdiagnosed as squamous cell carcinoma, especially on FNAC and incisional biopsies due to the limited and selective sampling. This case represents a rare variant of a common pathology that we need to recognize as misdiagnosis may lead to aggressive surgical management and/or radiation therapy. Conclusion: FNAC is a simple, reliable and highly accurate tool for the diagnosis of pleomorphic adenoma, the diagnosis of PA with squamous metaplasia can be challenging and can cause diagnostic pitfalls. Awareness towards the cytological variations, is important to avoid diagnostic errors.

Keywords: Keratinous cyst, pleomorphic adenoma, salivary gland, squamous metaplasia

   AEP64 Top

   Cytopathology Top

Incidental detection of breast filariasis masquerading as malignancy: A rare case report

Jatin Godara, Mukul Singh, Sushma Bharti, Sunil Ranga

VMMC and SJH, New Delhi, India

Case Report: REPORT: A 66 yr old, resident of Bihar presented with complains of painful swelling of the left breast over a period of 2 months. The swelling was 0.8x0.5 cm in size. No axillary lymph node is palpable. Ultrasound revealed prominent ducts in retro-areolar region of left breast with soft hypoechoic lesion measuring 13 x 8 mm seen within the duct lumen at 9o'clock (Birads IV). The patient was sent for fine needle aspiration cytology to confirm the diagnosis. Giemsa stained smears and imprint cytology revealed microfilariae along with many cystic macrophages, ductal cells with apocrine change and myoepithelial cells. A final impression of microfilaria infestation of the breast was made. Discussion: Extranodal filariasis is rare and breast is an uncommon site for filariasis. Despite the high prevalence rate, it is rare to find microfilariae in cytology smears and body fluids. Here, we present a case of microfilaria in the breast detected by fine needle aspiration cytology. Conclusion: Filarial breast nodule is rare, and it often mimics a neoplastic breast lesion. FNAC is a very effective diagnostic tool in the diagnosis of filarial breast lesion and it helps avoid unnecessary surgical procedure.[3] It should be considered as a differential diagnosis for short-lasting nodular breast lump, especially in countries like India, where filariasis is an endemic disease.

Keywords: Breast, cytology, filariasis

   AEP65 Top

   Cytopathology Top

Sebaceous carcinoma of eyelid metastatizing to lung and lymph node – Report of a rare case

Soumargha Mitra, Palash Kumar Mandal, Rena Guha, Tushar Kanti Das, Anjali Bandyopadhyay, Payel Bandyopadhyay

R G Kar Medical College and Hospital, Kolkata, West Bengal, India

Case Report: A 46 year old male patient, presented to the Chest OPD of our hospital with complaints of shortness of breath. His CT scan and MRI revealed a mass in right upper lobe of lung and right cervical lymph node enlargement. FNAC was done from right lung SOL (CT guided) and from the right cervical lymph node. Microscopically, the smears from both lung and lymph node showed clusters and occasionally discrete malignant epithelial cells having abundant vacuolated cytoplasm and centrally placed pleomorphic nuclei with prominent nucleoli. Cytomorphological features were of metastasis of sebaceous carcinoma. He had past history of operation of a lower eyelid mass reported as sebaceous carcinoma, immunohistochemistry was positive for Pan-cytokeratin and EMA and negative for S100. Discussion: Sebaceous carcinoma may simulate many inflammatory and neoplastic conditions. It needs to be differentiated from its mimickers with help of proper cytology, histopathology and immunohistochemistry. Our case presented with lung and lymph node metastases with recurrence of primary tumor in spite of complete resection. Timely, post-operative chemotherapy may have helped to prevent metastases in our case. Conclusion: Sebaceous carcinoma is rare, aggressive tumor. Early diagnosis and proper management with current protocol is necessary to prevent progression and metastasis.

Keywords: Cytology, eyelid, sebaceous carcinoma

   AEP66 Top

   Cytopathology Top

Spectrum of cytomorphological features of idiopathic granulomatous mastitis: Experience of All India Institute of Medical Sciences, Gorakhpur

Brijnandan Gupta, Divya Singh, Vikas Shrivastava, Priyanka Gautam, Anshi Singh, Mukul Singh, Gaurav Gupta

AIIMS, Gorakhpur, Uttar Pradesh, India

Case Report: Eight adult females with cytological diagnosis of granulomatous mastitis were included in this case series. Ultrasonography suggested an inflammatory pathology in most of the cases. Trunat and Ziehl-Neelsen stain was performed in all eight cases. Discussion: Clinical examination revealed lump in breast with episodes of intense itching along with pus discharge in two patients. Microscopy showed diverse cytomorphological features, ranging from epithelioid cell granuloma, vague collection of histiocytes, neutrophils, multinucleated giant cells, plasma cells, few lymphocytes. In one of the case there was prominent emperipolesis of neutrophils. Based on cytomorphological features and after excluding infective pathology, a diagnosis of granulomatous mastitis was made. In addition, cytological diagnosis rests on finding histiocytes with neutrophils, giant cells, epithelioid cell granulomas with or without necrosis and excluding other common differential diagnoses like Tuberculosis, fungal infections and Rosai-Dorfman disease. Conclusion: It is important to keep a possibility of granulomatous mastitis in women presenting with painful nodular breast lump. Aggressive management of other specific etiological causes of granulomatous mastitis can be avoided with accurate cytological diagnosis of idiopathic granulomatous mastitis.

Keywords: Emperipolesis, granuloma, idiopathic granulomatous mastitis, neutrophils, Rosai-Dorfman disease

   AEP67 Top

   Cytopathology Top

Paratesticular desmoplastic small round cell tumour masquerading as rhabdomyosarcoma: A cytological approach with histologic confirmation

Aasma Nalwa, Rashim Sharma, Meenakshi Rao, Sudeep Khera, T Balamurugan, Taruna Yadav

All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Case Report: 25-year male presented with right-sided scrotal swelling & umbilical nodule. Radiology showed heteroechoic mass arising from right scrotal wall & paratesticular rhabdomyosarcoma was suggested. FNA from umbilical nodule showed loosely cohesive tumour cell sheets with round cell morphology, nuclear molding, grooving and bizarre cells in dense fibrocollagenous background. Right inguinal orchidectomy showed hydrocele sac with multiple whitish firm nodules attached to testicular wall. Light microscopy showed multifocal tumours arranged in anastomosing trabeculae & sheets separated by thick fibrous septa showing round nuclei & nuclear grooving. No rhabdoid/strap cells seen. Strong diffuse pancytokeratin &dot-like Desmin seen on IHC. Final diagnosis of Desmoplastic small round cell tumour was rendered. Discussion: Two most common features of DSRCT are round blue cells and desmoplastic stroma. Cytology shows cohesive clusters and pseudorosettes, nuclear molding and grooves. Histology has variable morphological patterns exhibiting, nests, tubules, trabeculae, zellballen and single-cell pattern in a desmoplastic stroma. IHC shows co-expression of epithelial and mesenchymal markers;CK and perinuclear dot-likedesmin. Conclusion: DSRCT has high metastatic potential. Awareness about cytological features helps in early non-invasive diagnosis of this rare entity with small round blue cell morphology.

Keywords: Cytology, desmoplastic round cell, small blue cell tumour

   AEP68 Top

   Cytopathology Top

Primary cutaneous nocardiosis, an infrequent encounter in a routine FNA slide tray….

Thejasvi Krishnamurthy, H B Shobha, H P Shruthi

Padmashree Diagnostics, Bengaluru, Karnataka, India

Case Report: A 45 yrs male presented with the history of swelling on left side of the upper lip. Fine needle aspiration (FNA) slides showed many neutrophils, granulomas and multinucleated giant cells. With these findings steroid induced granulomatous reaction was the first impression. Ziehl Neelsen stain (ZN) and Grams stain highlighted the thin, elongated filamentous, branching, acid fast bacilli in singles and groups. Discussion: Primary cutaneous nocardiosis, a rare infectious disease may present as pustules, erythematous nodules, abscesses, ulceration or pyoderma. The various species of Nocardia are pathogenic with low virulence, hence clinically significant infection occurs as an opportunistic infection in those with weak immune system. The diagnosis is by identification of Nocardia species from the site of infection. Superficial smears, tissue samples, and abscess aspiration are the most common methods of detection. The characteristic histologic appearance is an irregularly-shaped, filamentous, branching organism surrounded by neutrophils visualized by ZN, Grams, Gomori methenamine silver or modified Kinyoun acid-fast staining. Conclusion: Primary cutaneous Nocardiosis is indeed a diagnostic challenge especially on FNA smears, correlation with clinical history and positive special stains with typical morphology of the organisms facilitates diagnosis.

Keywords: Cutaneous, FNAC, nocardiosis

   AEP69 Top

   Dermatopathology Top

Combined skin adnexal tumors with Syndromic association – A case report

Ulagarasi Rajendran, Sandhya Sundaram, Deyonna Fernandes, Leena Dennis Joseph, B Archana, Janavi Sridhar

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Case Report: A 59 year old female patient complained of many painless nodules on her face, scalp and upper back since she was 16 years old, which had gotten worse during the period of last 5 years. The patient was hospitalised for a painful infected ulcerative lesion on posterior aspect of auricular region, right side that also had maggots and hematoma. Excision of these lesions were done and sent for histopathological examination which revealed multiple nodules of closely packed larger and smaller basophilic tumor cells enclosing eosinophilic basement membrane like material demonstrating cylindromas and areas resembling eccrine spiradenoma. Trichoepitheliomatous area with dystrophic calcification also noted. Discussion: CYLD cutaneous syndromes includes the conditions called Brooke spiegeler syndrome, multiple familial trichoepithelioma and familial cylindromatosis. Usually manifests in second or third decade with female predominance. These tumors usually arises from skin appendages like hair follicles. But affected individuals may develop tumors in other sites like salivary glands. Large tumors may become ulcers and they are prone for infections. Rarely tumors can develop in airways which leads to respiratory insufficiency. Conclusion: In this case, in view of multiple combination of skin adnexal tumors, a syndromic association such as Brooke spiegeler syndrome to be considered. To prove that, genomic study of CYLD gene is mandatory.

Keywords: Brooke spiegeler syndrome, cylindromas, spiradenomas, trichoepithelioma

   AEP70 Top

   Dermatopathology Top

Orofacial histoplasmosis in a patient with HIV/AIDS – A case report

Shweta Patel, Nikita Modh, D N Lanjewar

Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India

Case Report: A 19-years-old HIV infected male presented with multiple, well defined erythematous nodular umbilicated lesions in the soft palate, face and lips. Biopsy from soft palate and face showed proliferation of histiocytes which contained small intracellular round to oval bluish organisms with clear space around them. These organisms were positive with PAS and GMS stain. A diagnosis of histoplasmosis was made and subsequently patient was treated with HAART and Itraconazole. The oral and facial lesions of the patient completely disappeared within 20 days of treatment. Discussion: In India, the first case of histoplasmosis was reported in 1954, since than sporadic cases are reported. Since the beginning of AIDS epidemic in India, only 12 reports of AIDS associated histoplasmosis are described in the Indian literature, of these 6 cases are from Karnataka state, 2 are described from Maharashtra state and one case each from Manipur, Delhi, Punjab and Assam. The present report is the first case of AIDS associated histoplasmosis from the Kutch district of Gujarat state. Conclusion: Even though prevalence of histoplasmosis is less in India, it should be considered in the differential diagnosis of oral and cutaneous lesions in patient with AIDS. The pathologist plays an important role in definitive diagnosis which has implication on management of the patients with HIV/AIDS.

Keywords: AIDS, histoplasmosis, orofacial

   AEP71 Top

   Dermatopathology Top

Primary cutaneous T-cell lymphoma-granulomatous mycosis fungoides: A rare case report with review of literature

Krishna Nair, Surekha Bhalekar, Divya Shetty, S Sudhamani, Rajiv Rao

D Y Patil School of Medicine, Navi Mumbai, Maharashtra, India

Case Report: An 82-year-old man, came to the dermatology opd with complaints of itchy lesions over the scalp, face, forearms, trunk and bilateral lower limbs for six months. Lesion was gradually increasing in size. A superficial biopsy from the right forearm was sent for histopathology. Histopathology revealed skin with focally ulcerated and atrophied epidermis. The dermis and the subcutaneous tissue showed multiple foci of well-formed granulomas. Many Reed-Sternberg like cells were noted. Immunohistochemically, these atypical lymphocytes expressed CD3, CD4, CD5, CD8 but lacked CD20 expression. Hence, the diagnosis of CD8-positive GMF was given. Discussion: GMF is an epidermotrophic primary CTCL, rare histopathological variant of MF and accounts for 4% of MF. The diagnosis of GMF depends exclusively on histopathological findings, as it lacks distinctive clinical feature. To the best of our knowledge, CD8-positive GMF is extremely rare and to date, only five cases have been reported. Conclusion: In conclusion, this report describes CD8-positive GMF. Our findings and a review of literature suggest that it affects elderly females and presents at a later stage (nodule) and typically lacks abnormal pigmentation. The characteristic histomorphological features are presence of non-necrotizing granulomas with a lack of elastic fibers, and elastophagocytosis, not associated with adverse prognosis.

Keywords: CD 8 positive, granulomatous mycosis fungoides, mycosis fungoides

   AEP72 Top

   Dermatopathology Top

Proliferating pilomatrixoma masquerading as an infected sebaceous cyst – A case report

Vidhya Dhari, D Shobhitha, C A Arathi

PESIMSR, Kuppam, Andhra Pradesh, India

Case Report: A 58 year old female presented with progressive swelling on left side of the cheek since 3 months. On examination an ulcerated swelling of size 2x2 cm was noted over the left cheek and was clinically diagnosed as a Sebaceous cyst. Ultrasonography features were suspicious of malignancy. Fine needle aspiration revealed features of an Infected Sebaceous cyst with a few atypical cells. The swelling was locally excised and sent for Histopathology. Multiple sections studied showed a tumour in the dermis composed of aggregates of basaloid cells, few of which had prominent nucleoli. Large lobules of ghost cells & few focal areas of basaloid cells with progression of maturation were seen. Areas of necrosis within the nest of tumor cells, inflammatory cell debris and foci of squamoid cells showing mild pleomorphism were also evident. Based on these findings a diagnosis of Proliferating Pilomatrixoma was rendered. Discussion: Pilomatrixoma with mild atypical features not sufficient to warrant a frank diagnosis of Malignant Pilomatrixoma are rare and hence there is a lack of a well defined gold standard of management. Conclusion: A high rate of local recurrence seen in cases of Malignant Pilomatrixoma mandates a close follow up of such atypical lesions.

Keywords: Necrosis, pilomatrix carcinoma, proliferating pilomatrixoma

   AEP73 Top

   Dermatopathology Top

Ochronosis: The dark side of skin lightening agent

Priyanka Dhakare, Prachi Gholap, Vaibhav Bari

Rajiv Gandhi Medical College, Thane, Maharashtra, India

Case Report: A 43 years, non-pregnant, housewife presented with hyperpigmented blackish macules over both cheeks since 6 months. There is no history of oral contraceptive pill use. There is past history of application of some cosmetic bleaching cream for 2 years. There is no history of joint pain or a patchy pigmentation of sclerae. Microscopy: Revealed presence of ochre coloured (yellowish brown) pigment present within homogenized and swollen collagen bundles in the upper dermis. At places the collagen bundles were broken with ragged edges and formed irregular “banana- shaped” clumps. There was no increase in pigment either in basal layer or other layers of epidermis. On urine examination, urine did not turn dark on standing or adding sodium hydroxide. Based on the clinical and histopathological findings, a diagnosis of exogenous ochronosis was considered. Discussion: Ochronosis can occur in two forms: exogenous and endogenous. Endogenous ochronosis (alkaptonuria) is an autosomal recessive disease caused by absence of homogentisic acid oxidase. Exogenous ochronosis occurs due to hydroquinone therapy given for melasma. It can also develop secondary to phenol, resorcinol, mercury, picric acid and antimalarials. Conclusion: We are presenting this case of Exogenous ochronosis because of its rarity and to underline the importance of biopsy in any hyperpigmented skin lesions. This case also emphasizes the judicious use of hydroquinone in treatment.

Keywords: Hydroquinone, hyperpigmentation, ochronosis

   AEP74 Top

   Dermatopathology Top

Periorbital Chondroid Syringoma: A rare tumour at rare site

Pooja Katre, Anuja Yadav, Vaibhav Bari

Rajiv Gandhi Medical College, Thane, Maharashtra, India

Case Report: A 34 years old female presented with nodular lesion below right eyebrow for 2-3 years which was excised totally. Grossly, a single nodular mass without overlying skin was received measuring 1.2 x 0.6 x 0.4 cm. Externally, it was capsulated and firm. On cut surface, solid grey white lesion was seen reaching the resected margins. On microscopy, biphasic tumour showed epithelial component with ducts lined by double layered epithelium; inner cuboidal and outer flattened. The myoepithelial component showed scattered and clusters of spindled to plasmacytoid cells intermingled with fibromyxoid and chondromyxoid stroma. The stroma also showed few lobules of mature adipocytes. There is no evidence of surface epidermal lining. Hence, diagnosis of chondroid syringoma with lipomatous differentiation was rendered. Discussion: Chondroid syringoma is an adnexal tumour arising from sweat glands – apocrine or eccrine, commonly affecting middle to old aged men. This case is being reported for its rarity, its occurrence in female patient and involvement of rare site (periorbital). Histologically, follicular, sebaceous, lipomatous, osteoid and cartilaginous differentiation are described. Our case showed lipomatous differentiation. Conclusion: This tumour though benign, if capsule is ruptured, it may become locally invasive and incomplete excision can lead to recurrence or malignant transformation.

Keywords: Chondroid syringoma, periorbital

   AEP75 Top

   Dermatopathology Top

Epidermodysplasia verruciformis – An uncommon case

Gayathri Raj, T G Nisha

MES Medical College, Angadipuram, Kerala, India

Case Report: 10 yr old male. Multiple hyperpigmented warts all over the body involving palm, soles, scalp. Few taenia versicolor lesions noted. Started developing from 3rd day of life. Sometimes pink – reddish brown papules with scaly surface develops which ruptures and bleeds. Has recurrent episodes of bronchopneumonia (6-7 times/year). Fully immunized. Non consanguineous marriage. Epidermis shows parakeratosis, acanthosis with swollen keratinocytes, blue grey cytoplasm and abundant keratohyalin granules. Large, round and empty nucleus seen. Perivascular and periappendageal inflammatory cells noted. Discussion: EV is due to mutation in EVER1/TMC6 or EVER2/TMC8 (at 17q25). Suspectable to HPV strains which leads development of disseminated wart like lesion. Some patient show pityriasis versicolor like lesion. Two forms: HPV 1&3, presents as verrucae planae, no malignant changes, regression present. HPV 5&8, presents as plane warts, macules, seborrheic dermatitis, X- linked recessive, 20-25% malignant changes. EM- Viral particles in semicrystalline pattern in nuclei in stratum corneum. Conclusion: EV is a very rare genodermatosis, associated with generalized HPV infection. Stringent sun protection and life-long observation is necessary for prevention as well as detection of early development of malignant/premalignant lesions.

Keywords: Epidermodysplasia verruciformis, genodermatosis

   AEP76 Top

   Dermatopathology Top

Metastatic malignant melanoma involving the mediastinum

Saswati Das, Kalpalata Tripathy, Pragyan Lisha Panda, Lity Mohanty

SCB Medical College and Hospital, Cuttack, Odisha, India

Case Report: A 61 year old male presented with progressive chest pain and dyspnea for two months, cough for 20 days. Routine and radiological investigations were done. Radiography revealed large anterior mediastinal mass over right hilum. The patient was a treated case of cutaneous melanoma of sole ten years back. The patient underwent thoracotomy through median sternotomy and biopsy was done. Two irregular greyish black masses altogether measuring 10 x 6 x 5 cm and one lymph node measuring 1 cm in diameter were received. Discussion: Histopathological examination revealed large pleomorphic cells with hyperchromatic nuclei and prominent nucleoli with extracellular and intracytoplasmic melanin pigment. Immunohistochemistry study showed positive for S100 and HMB45. Hence the case was diagnosed to be metastatic malignant melanoma. Conclusion: This case adds to our collective knowledge of the unusual way in which metastatic melanoma can present. The pathogenesis of large mediastinal mass is probably due to lymphatic spread from lymph node. Due to aggressive nature of mediastinal melanoma and potential for invasion of mediastinal structures, urgent treatment of patient is required.

Keywords: HMB45, melanin, S100

   AEP77 Top

   Dermatopathology Top

Histomorphological spectrum of adnexal tumor with rippled pattern, an unusual variant: Report of 3 cases

Akriti Patel, Deepika Rana, Shramana Mandal, Nita Khurana, Pawaninder Lal

Maulana Azad Medical College, New Delhi, India

Case Report: Case 1: A 48 yr old male presented with slow growing swelling since 06 months on occipital region of size measuring 5x3x2 cm. Microscopy shows feature of Trichoblastoma with rippled pattern. Case 2: A 60 yr old male presented with swelling over left side of scalp since 7 years. Microscopy show feature of Cylindroma with rippled pattern. Case 3: A 61 yr old female presented with swelling of left ala of nose measuring 3x2x2 cm. Microscopy showed tumour arranged in lobules, separated by fibrous stroma infiltrating into the deep dermis also arranged in palisading pattern, resembles rippled pattern. This diagnosed as Sebaceous carcinoma with rippled pattern. Discussion: Rippled pattern is unique term first described by Hashimoto et al in 1989. The etiology is still unknown but may be due the overexpressions of laminin and phospholipids leading to cell to cell adhesion. Conclusion: The cases are being presented for its rarity and to make the pathologist aware to make unique histopathological pattern.

Keywords: Cylindroma, sebaceous carcinoma, trichoblastoma

   AEP78 Top

   Dermatopathology Top

Squamoid eccrine duct carcinoma (SEDC): A mimicker of squamous cell carcinoma (SCC)

Deepika Mishra, Swetambari Acharya, Chaitali Patnaik, Shushruta Mohanty, Lipika Behera, Swayamprava Pradhan

M K C G Medical College and Hospital, Berhampur, Odisha, India

Case Report: A twenty year female presented with a plaque lesion on scalp, gradually increasing in size over a period of 6 months, was excised and sent for histopathology. Grossly, skin lined irregular piece of hairy tissue. Cut section - solid, homogenous, gray white apperance. Microscopically, tumor was located in the dermis with connection to epidermis. The superficial part had squamous differentiation and deeper part showed ductal differentiation. The squamoid portion had pleomorphic cells arranged in solid sheets with peripheral clefting. Individual cells had moderate eosinophilic cytoplasm and hyperchromatic nucleus. Ducts in deeper portion had double lining of cuboidal cells. IHC- EMA, CEA, P-63 positive Ki-67- 18% and P-53 -65%. Discussion: This is a rare entity with very few case reports. The differentials include Squamous cell carcinoma, Microcystic Adnexal Carcinoma and Metastatic adenocarcinoma but presence of ductal component, absence of dense fibrous stroma and positivity for P-63 rules out these diagnoses. Conclusion: SEDC has got metastatic potential along with perineural and perivascular invasion. Limited information is available in literature about this tumor because of it's rarity. Hence further experience and close follow up is required.

Keywords: Adnexal tumor, squamous cell carcinoma, squamoid eccrine duct carcinoma

   AEP79 Top

   Dermatopathology Top

A rare case of langerhans cell histiocytosis

A Sabitha, Leena Dennis Joseph, G Barathi, Julius Xavier Scott1, Dharani1

Departments of Pathology and 1Pediatric Haemato Oncology, SRMC, Chennai, Tamil Nadu, India

Case Report: A 6-month-old male baby presented with light colored lesions over trunk and scalp with minimal scaling. It was associated with fever and red lesions over palms. On examination there were scattered papules over scalp with minimal scaling. Hypopigmented macules were present over back, abdomen. Bilateral palms had purpura. Patient also had hepatosplenomegaly. On histopathological examination, the dermis had diffuse infiltrate of cells with moderate eosinophilic cytoplasm. The nuclei had grooves and occasional multinucleation. IHC was positive for Langerin, CD1a, S100 and CD68 thus confirming the diagnosis of LCH. Discussion: LCH occurs in 3 forms namely Letterer-Siwe disease, Hand-Schuller-Christian disease and eosinophilic granuloma. Pulmonary form of LCH may have association with smoking. A rare multifocal form called Langerhans cell sarcoma can also occur in the which cytological atypia will be present. Most patients harbor BRAFV600E mutations. Electron microscopy will show tennis racquet shaped Birbeck granules. Conclusion: LCH is primarily a disease of childhood which can be unifocal or multifocal. Prognosis mainly depends on the number of organ systems involved. Multisystem involvement will have a poor prognosis.

Keywords: LCH, multisystem, unifocal

   AEP80 Top

   Dermatopathology Top

Pearl on the ear – A rare presentation of molluscum contagiosum

Nandini Hasilkar, P Shashikala, Manjunath Hulmani

S S Institute of Medical Sciences, Davangere, Karnataka, India

Case Report: An elderly male presented to Department of Dermatology with a solitary nodule and crusting noted near the helix of left ear since 25 days. Incisional biopsy was done and sent to Department of Pathology. Following differential diagnosis were proposed by the dermatologist. 1. Angiolymphoid hyperplasia with eosinophilia 2. Basal cell carcinoma 3. B cell lymphoma 4. Keratocanthoma 5. Dermoid lupus erythematosus. On further microscopic evaluation, sections studied showed hyperplastic epidermis. Dermis showed islands of squamous cells with hyperkeratosis, parakeratosis and basal cells vacuolar degeneration. Focal areas showed dyskeratotic and parakeratotic cells along with dense infiltration of neutrophils, lymphocytes, plasma cells and eosinophils. Deeper cuts showed islands of squamous cells with presence of groups of homogeneous purplish pink inclusion bodies resembling Henderson-patterson bodies (Viral inclusions) of Molluscum contagiosum. Histopathological diagnosis of infected molluscum contagiosum – Helix was made. Discussion: Although molluscum contagiosum is a benign, a misdiagnosis might lead to inappropriate treatment or repeat biopsy resulting in transmission of this infection. Clinically atypical cases require a correct pathological diagnosis. Conclusion: Because it's a rare site of occurrence and wide range of differential diagnosis, the case is being reported.

Keywords: Helix of ear, Henderson-patterson bodies, molluscum contagiosum, rare site

   AEP81 Top

   Dermatopathology Top

Dwindling and reappearing crops: The tale of lymphomatoid papulosis

V Harsha, Sruthi Prasad, M Chethana, S R Niveditha

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: 47-year-old lady presented with crops of papulonodular skin lesions over face and back for 2 weeks. History of self-regression with atrophic scars and development of fresh crops elsewhere. The lesions showed ulceration with central umbilication and few showed pus discharge. Microscopy showed collections of neutrophils amongst which were seen singly scattered large atypical cells. These cells are positive for T-cell markers and showed characteristic membranous and cytoplasmic dot positivity for CD 30. A diagnosis of CD 30 positive primary cutaneous lymphoproliferative disorders, favouring lymphomatoid papulosis was rendered. Discussion: Lymphomatoid papulosis is largely regarded as a low-grade cutaneous T-cell lymphoma, a part of the spectrum of primary cutaneous CD30 positive anaplastic large cell lymphoma. It is categorized into 5 histological types, some of which may show a mixed inflammatory infiltrate with only a few scattered atypical cells. The entity is likely to be confused for a reactive process. Conclusion: A multi-disciplinary approach with clinical, histological and immunohistochemical features is essential for an accurate diagnosis of lymphomatoid papulosis.

Keywords: CD30, cutaneous lymphoma, lymphomatoid papulosis

   AEP82 Top

   Dermatopathology Top

Nevoid basal cell carcinoma syndrome: A case report

M Lubina, Geethu G Nair, P M Shini, N K Supriya, K Devi

Government Medical College, Kozhikode, Kerala, India

Case Report: A 65-year-old male presented with multiple blackish and skin-colored lesions of 10 year duration. None of his family members were similarly affected. On examination, multiple discrete and few confluent hyper pigmented papules, plaques and nodules noted over face, trunk and limbs. Multiple discrete palmar pits were also present. Histological examination of 2 of the skin lesions from face showed Basal cell carcinoma. Patient was evaluated for the presence of genetic syndromes. Orthopantomogram showed unilocular lytic cystic lesion over ramus of left mandible. Chest X ray revealed bilateral bifid ribs. X ray and CT head showed bilamellar calcification of falx cerebri. Patient was diagnosed as a case of nevoid basal cell carcinoma syndrome (Gorlin Goltz syndrome) as the clinicoradiological features were satisfying 4 of the major diagnostic criteria. He was referred to higher centre for photodynamic therapy. Discussion: Nevoid Basal Cell Carcinoma syndrome is a rare hereditary multisystem disorder characterized by developmental anomalies and predisposition to basal cell carcinomas. It is caused mainly by mutations in PTCH 1 gene, inherited as autosomal dominant pattern with high level of penetrance and variable expressivity. It was first described by Gorlin and Goltz. Main clinical manifestations include multiple basal cell carcinomas, odontogenic keratocysts, palmar pits, intracranial ectopic calcifications and various skeletal deformities. Conclusion: Phenotypic variability of this syndrome may lead to a delayed diagnosis. All patients with suspected skin lesions should be evaluated for nevoid basal cell carcinoma syndrome. Multidisciplinary approach is crucial for early diagnosis and management of such patients.

Keywords: Basal cell carcinoma, Gorlin Goltz syndrome, nevoid basal cell carcinoma syndrome, PTCH

   AEP83 Top

   Dermatopathology Top

Ocular squamous cell neoplasm in a young Indian female

Ajay Joseph, Charanjeet Ahluwalia, Sunil Ranga

VMMC and Safdarjung Hospital, New Delhi, India

Case Report: A 21-year-old female patient presented to the OPD with a clinical history of multiple hyperpigmented macules and plaques with interspersed hypopigmented macules seen over face, forearms, and upper trunk and history of redness, burning sensation, and peeling of skin on exposure to sunlight since childhood. The presenting complaint was a swelling over the medial canthus of left eye with foul-smelling discharge. She underwent excision of the swelling. H&E-sections from the swelling showed features suggestive of moderately differentiated squamous cell carcinoma. Discussion: OSSN is quite rare in a young patient, albeit invasive SCC warrants a thorough clinical workup to figure out the secondary causes. In our case the clinical history was suggestive of XP, but the patient was lost to follow up for genetic analysis. XP is a rare disorder with autosomal recessive inheritance. OSSN is the most common ocular surface malignancy in XP. Conclusion: OSSN warrants a thorough clinical workup especially in young patients, where it is mostly secondary to systemic causes.

Keywords: Xeroderma pigmentosum

   AEP84 Top

   Dermatopathology Top

A case of trichofolliculoma of face – A rare case report

Varatha Rajan, Kulwant Singh, Sunaina Hooda, Monika Gathwal, Parveen Rana, Swaran Kaur

BPS GMC, Sonepat, Haryana, India

Case Report: A 65-year-old female patient presented with 4-year history of nodule below the left side eye. Discussion: The nodule was progressively increasing in size because of constant irritation of spectacles and gets infected, surgical excision was done and sent for histomorphology examination. Microscopic examination showed histomorphology of trichofolliculoma. Conclusion: Benign skin adnexal tumors are uncommon. Trichofolliculoma is a rare benign skin adnexal tumor. It should be distinguished from trichoepitheliomas, basal cell carcinoma, trichoblastoma which are its close differential diagnosis.

Keywords: Trichofolliculoma

   AEP85 Top

   Dermatopathology Top

Trichilemmal cyst in the perianal region: A rare case report

Shashank Mishra, C N Anushree, Y A Manjunatha

DR B R Ambedkar Medical College - Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Case Report: A 30 years old female presented with perianal nodule of approximately 5x3 cm. Patient underwent surgical excision and the mass was sent for histopathological examination. GROSS: Received a nodular cyst like structure measuring 5x3x2 cm. Cut surface shows cheesy lamellated contents. MICROSCOPY: Showed skin with epidermis and dermis. The epidermis is lined by keratinized stratified squamous epithelium. The dermis shows a cyst wall lined by squamous epithelium lacking granular cell layer and shows abrupt keratinization into solid eosinophilic staining keratin. Also noted foci of calcification. Discussion: A benign neoplasm arising from the external epithelial sheath of the hair follicle is histologically characterized by trichilemmal keratinization, which corresponds to the abrupt transition from nucleated epithelial cells to anucleated keratinized cells. Conclusion: The development of trichilemmal cyst in the perianal region is an exceptional occurrence, and when it occurs surgical treatment should be indicated because of the risk of malignant degeneration to form epidermoid carcinoma.

Keywords: Epidermoid carcinoma, trichilemmal cyst – perianal region

   AEP86 Top

   Dermatopathology Top

Amelanotic melanoma of sole

Vivek Kaushik, Rabia Parveen Siddiqui, Vanita Bhaskar Adile

Pt. J N M Medical College, Raipur, Chhattisgarh, India

Case Report: A 45-years male presented in surgery department with a cauliflower like growth on right sole over calcaneal area since 4 years. Clinical diagnosis made was Squamous Cell Carcinoma. Wedge biopsy from the edge was done and sent for Histopathogical examination to pathology laboratory. Grossly it was greyish white firm soft tissue piece measuring 0.8 cm in maximum diamension. On Histopathology- section showed tumour tissue arranged in sheets and nests. Individual tumour cells were large polygonal to spindle having eosinophilic cytoplasm, pleomorphic vesicular nuclei with prominent large nucleoli, with few tumour giant cells. On the basis of nuclear features suspicion of Melanoma was made. Immunohistochemistry (IHC) showed S100-Positive, HMB-45- Positive, Vimentin-Positive, EMA-Negative. On the basis of morphology and IHC, final diagnosis of Amelanotic Melanoma was made. Discussion: As AMs appear in acral sites, it becomes more likely to confuse with other skin lesions such as diabetic foot ulcer, tinea, wart, pyogenic granuloma, basal cell carcinoma, vascular lesions, or benign nevi. Delayed diagnosis can lead to increased mortality and morbidity. Treatment of AM is the same as for pigmented melanoma; extensive excision of the lesion with appropriate safety margins. Conclusion: Accurate and early diagnosis can be made by proper IHC markers. So that early surgical intervention can improve prognosis and reduce mortality.

Keywords: Amelanotic, histopathological examination (HPE), immunohistochemistry (IHC), melanin, melanoma

   AEP87 Top

   Dermatopathology Top

Diagnostic challenges to evaluate the etiology of maculopapular exanthems

Priya Yadav, Sonal Sharma, Sambit Nath Bhattacharya, Preeti Diwakar

University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Case Report: Materials and Methods: This was a descriptive pilot study on skin biopsies of MPE with total 35 cases including 10 cases each of clinically confirmed drug- and viral- induced exanthems and 15 cases with blinded clinical etiology. Biopsies were evaluated on histopathology (HP), direct immunofluorescence (DIF) and immunohistochemistry (IHC) for Interleukin-5 (IL-5) & Perforin. Findings of both types of clinically confirmed MPE cases were compared and correlated to categorise clinically blinded cases into either of the two etiologies. Concordance of clinical diagnosis with pathological diagnosis was noted for the clinically blinded cases. Discussion: Results: Skin biopsies of total 35 cases of MPE were evaluated. On histopathology, features such as spongiosis, necrotic keratinocytes, acanthosis, inflammatory infiltrate, basal cell degeneration, RBC extravasation, were more frequent and of increased severity in drug exanthems. Upon DIF, findings were not significant to compare between the two etiological groups. IHC expression for IL-5 & Perforin supported drug exanthems. Taking in view of all histopathological and IHC parameters, 8/15 clinically blinded cases were considered probably DIE and 7/15 cases as probably VIE. Concordance was 87.5% for DIE and 71.4% for VIE. Conclusion: Histopathology and IHC for IL-5 & Perforin can help differentiate the two exanthems.

Keywords: Basal cell degeneration, direct immunofluorescence, exanthems, interleukin-5, perforin

   AEP88 Top

   Dermatopathology Top

Benign fibrous histiocytoma with 'Monster cells'

Manoj Madakshira, Mandeep Kaur, Manas Patnaik

Command Hospital, Lucknow, Uttar Pradesh, India

Case Report: A 19-year-old lady presented with a lump over her left arm for 3 years. The lump was mobile, firm and non-tender on palpation measuring about 3.5 cm in largest dimension. The lump appeared to be in the subcutaneous plane. The lump was shelled out during the excision biopsy. On gross, the lump was 3.5x2.5x1.5 cm globular mass, having a white, firm homogenous cut surface. Microscopy showed a well circumscribed moderately cellular lesion composed of plump spindle cells dispersed in loose short intersecting fascicles with entrapped collagen bundles and interspersed thin delicate capillaries. Few dispersed large cells with foamy cytoplasm are seen. The tumor cells show have moderate to marked aniso-nucleolosis with many 'Monster forms' having bizarre nuclear forms. Mitosis and necrosis are absent. Immunohistochemistry showed the tumor cells to be positive for Vimentin (diffuse and cytoplasmic), and CD34 (patchy and membranous). The fomay cells are positive for CD68 (patchy, granular and cytoplasmic) and S100p (cytoplasmic). Ki67 proliferative index is less than 1%. A diagnosis of benign fibrous histiocytoma with monster cells was offered. Discussion: Benign fibrous histiocytoma is a well demarcated mesenchymal tumor made up of a combination of histiocytes and fibroblasts arranged in fascicles or sheets having an admixture of foamy and/or hemosiderin laden macrophages and variable number of inflammatory cells. Presence of bizarre pleomorphic cells is a rare occurrence and is considered as a degenerative change, in the absence of mitosis. A differential diagnosis include:- nodular fascitis, leiomyoma, dermatofibrosarcoma protruberans and pleomorphic sarcoma. The differentiators include the immunophenotype of patchy CD34, strong factor XIIIa with scattered CD68 positive histiocytes and absence of mitosis. Conclusion: Benign fibrous histiocytoma with monster cells is a rare variant, whose knowledge is vital to differentiate it from more sinister tumors.

Keywords: Benign fibrous histiocytoma, monster cell, soft tissue

   AEP89 Top

   Digital Pathology Top

Pathology and cost-effective use of technology – Feasible?

Anin Prakash, Anil K Reddy, Savitri M Nerune

Shri B M Patil Medical College, Bijapur, Karnataka, India

Case Report: Transformation into automation using low-cost 3D printed parts with ultra-low cost IoT's, valves, and pumps which have acted as brains and muscles of the automated stainer device which is portable and performs Leishman and Giemsa stain. This device can be upgraded to perform all stains and scalable capacity. Using 3D modeling we have created a Tri-smear Cytospin funnel which create three smears at a time. Modified FNAC gun and grossing finger guard helped us in easing grossing while offering optimized performance and safety. Machine learning assisted malarial parasite screening model using no-code image classification has helped us in achieving good performance and this model can be ported to any computer. Discussion: The initial learning curve was the only hindrance to the application of these technologies for better utilization of this knowledge in creating new-age tools and devices. Conclusion: Amalgamating these new-age technologies will help us in creating cost-effective solutions for different aspects of pathology.

Keywords: 3D printing, IoT, Machine learning

   AEP90 Top

   Endocrine Pathology Top

Neuroendocrine tumor of pancreas – A case report

Amrutha Shankar, D Clement Wilfred

M S Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India

Case Report: 61 year old male complains of recurrent episodes of loss of consciousness, sweating, confusion, tremor and double vision from past 3 years. PETCT scan showed a focal lesion of 2.1X1.6 cm in proximal body of pancreas compressing pancreatic duct with distal dilatation. Also, 1 cm of segment IV - A, liver showed increase SRS uptake consistent with metastasis. Gross findings - Cut surface of distal pancreatectomy specimen showed a well circumscribed grey-white firm mass measuring 2 X 1.8 X 1 cm. Microscopy - Showed an infiltrating tumor consistent with pNETs. Also, liver parenchyma showed deposits of tumor. W.H.O Grade - I, TNM STAGE - IV. Immunohistochemical studies revealed neoplastic cells were strongly positive for the neuroendocrine markers synaptophysin and chromogranin. Discussion: Insulinoma is detected throughout the pancreas including head, body and tail. Approximately 60% of functioning pNETs are insulinomas. Most insulinomas are under 2 cm in size solitary and benign. Malignant insulinoma is rare with locoregional and / or distant metastasis. Clinical symptoms, histopathological findings and IHC markers established a diagnosis of neuroendocrine tumors of pancreas - Malignant Insulinoma. The goal of treatment is to excise the primary and distant metastasis. Conclusion: A combination of increased clinician awareness, imaging, pathological grading and immunohistochemical studies help in early diagnosis and increase survival rate of patients suffering with pNETs and improve quality of life.

Keywords: Malignant insulinoma, pancreatic neuroendocrine tumors

   AEP91 Top

   Endocrine Pathology Top

A rare case of unilateral krukenberg tumor in a 33 years old patient

Varsha Srivastava, Seema Awasthi, Faiyaz Ahmed, Ankita Mittal

Teerthankar Mahavir Medical College and Research Centre, Moradabad, Uttar Pradesh, India

Case Report: A 33 Y/F presented with the initial complaint of abdominal fulness and on examination and initial work up found to have U/L ovarian mass to the Obst & Gynae department of TMMC & RC, Moradabad. Patient underwent a laproscopic surgery aiming at excision of the ovarian tumor. Specimen were taken and sent to Histopathological laboratory for further investigation. Discussion: ON GROSS: Ovaries are enlarged, globular measuring 12.0*10.0*8.0 cm. External surface was bosselated. On cutting open, the cut surface was solid with areas of mucinous changes seen. ON MICROSCOPY: Shows cells in variable sized nests /and cords with scattered tubules. Individual cells are highly pleomorphic, with hyperchromatic nuclei and contains cytoplasmic mucin globules. Some intermittent polygonal cells have eosinophilc cytoplasm with eccentric nuclei are also present in some areas. Stroma is abundant and hyper cellular, focally oedematous have coarse chromatin with conspicuous to in -conspicuous nuclei. Bizarre cells seen. Conclusion: Histomorphology shows features of metastatic tumor- Ovary.

Keywords: Bosselated, Krukenberg tumor

   AEP92 Top

   Endocrine Pathology Top

A rare case of adenoid cystic carcinoma of lacrimal gland-presenting with orbital mass and thyroid enlargement

S Gayathri, I Sandhya, G Prithal, Priyanka Shetty

A J Institute of Medical Sciences and Research Center, Mangalore, Karnataka, India

Case Report: A male aged 60 years was referred to our hospital for the evaluation of swelling in the front of the neck and over the right periorbital region with intermittent pain since 6 months. Swelling in the neck was initially asymptomatic and gradually increased in size. USG showed right lobe of the thyroid with cystic nodules and fine calcification, internal vascularity-TIRADS 4 and a soft tissue lesion over the right supraorbital ridge with vascularity displacing the right eye ball, radiologist suggested it to be metastasis. Imprint cytology of the Core Biopsy from orbital mass showed uniform blue cells and histopathological examination of Orbital mass showed infiltrating aggressive tumor in cribriform pattern and nest with high N:C ratio confirming the diagnosis of ACC. Thyroid biopsy showed only colloid goitre. Discussion: ACC is a rare epithelial tumor characterised as slow growing mass with perineural invasion, recurrence and metastasis. Histopathologically ACC presents as 3 patterns-cribriform, tubular, solid with classic feature of tumor cells arranged in nest having sieve-like configuration. Conclusion: In view of a diagnosis of ACC of the lacrimal gland, Surgical resection with postoperative radiation was given. Present case highlights the need for awareness of unusual location and presentations.

Keywords: Adenoid cystic carcinoma, lacrimal gland, orbital mass

   AEP93 Top

   Endocrine Pathology Top

Adrenal myelolipoma: A rare case report

Hirina Jairath, Surekha Bhalekar, Divya Shetty, Rajiv Rao

Dr. DY Patil School of Medicine, Navi Mumbai, Maharashtra, India

Case Report: A 66 year old male came to surgery opd with complaint of abdominal pain in right hypochondrial region since 3 months. Initially took medicines for pain relief, came with complaint of similar episode of pain. The pain was intermittent in nature, occasionally radiated to back. Routine investigations such as hematological parameters were within normal limits. Ultrasonography showed the presence of a large hyperechoic mass occupying right hypochondrium and right lumbar region reaching upto the umbilicus. Discussion: Myelolipomas are small, asymptomatic and non-functional tumors. Occasionally there are clinical symptoms such as abdominal pain or flank pain as in our patient. The size of adrenal myelolipoma ranges from millimeters to greater than 10 cm. These are called giant adrenal myelolipoma as in our case. Histological examination -Hematopoietic component shows normal trilineage hematopoiesis along with increased number of megakaryocytes and adipocytes. Recurrence - free survival rate is upto 12 years. Conclusion: We conclude that adrenal myelolipomas are rare tumours and may present with complication of spontaneous retroperitoneal haemorrhage. Symptomatic lesions must be treated with minimally invasive surgery, laparoscopic adrenalectomy has shown a considerable decrease in morbidity and convalescence.

Keywords: Non functional, rare, trilineage hematopoeisis

   AEP94 Top

   Endocrine Pathology Top

Papillary thyroid carcinoma metastasizing to the skull bone: A case report

Juhi Shishodia, Surekha Bhalekar, Kritika Singh, Rajiv Rao

Dr. D Y Patil School of Medicine, Navi Mumbai, Maharashtra, India

Case Report: A 67-year-old female presented with swelling over right fronto-temporal region and headache since 6 months. MRI brain revealed 4.8 x 4.7 x 4.1 cm sized lesion, suggestive of neoplastic etiology. Clinical diagnosis of meningioma was made. Histopathological evaluation of excised mass revealed features suggestive of metastases of PTC (likely Follicular Variant). Further, FNAC of thyroid was performed which was suggestive of PTC (Bethesda Category V). Patient underwent total thyroidectomy. Histopathology confirmed the diagnosis of FV-PTC. Discussion: Skull metastasis from PTC usually occurs years after primary cancer diagnosis. Our case is unique as it first presented as skull metastases, where histopathology paved way in detection of PTC. Only 2 similar cases have been reported. Due to its rarity, PTC metastasis to skull can be mistaken for osteosarcoma, multiple myeloma, or metastasis from renal cell cancer. Amongst reported cases, mean age was 60.1 years, ranging from 25 to 76 years, with female predominance. Conclusion: By illustrating this rare case report, we conclude that histopathological diagnosis, with multidisciplinary approach, is essential for effective treatment. Skull metastases should be considered in clinical course of PTC.

Keywords: Metastases, papillary thyroid carcinoma, skull, thyroid carcinoma.

   AEP95 Top

   Endocrine Pathology Top

Papillary carcinoma thyroid in branchial cleft cyst: A snake in the grass

Nimisha Shrivastava, Amit Kumar Chowhan

AIIMS, Raipur, Chhattisgarh, India

Case Report: We received blocks for review of a 32-year-old female with an excised right branchial cleft cyst which was reported outside as “Metastatic deposits of PCT in a lymph node”, though all the radiological and cytological evidences were in favour of a benign cystic pathology. Further there was no visible lesion in thyroid both clinically as well as radiologically. We report the case as “PCT developing in branchial cyst.” Discussion: In a case like this, three possibilities can be considered, first cystic degeneration of metastasized PCT in lymph node, metastasis of missed primary PCT in BCC or PCT arising in ectopic thyroid tissue in a BCC. Sidhu's criteria for the PCT in BCC was suggested to distinguish between the three. This case fulfilled all the criteria and hence considered as PCT arising in BCC. Conclusion: Branchial remnants can give rise to papillary carcinoma, with no lesion in the thyroid. Therefore, the clinicians and pathologists alike should keep this in mind while dealing with any case of BCCs.

Keywords: Branchial cleft cyst, branchioma, ectopic thyroid, neoplasms, primary, thyroid cancer papillary

   AEP96 Top

   Endocrine Pathology Top

A rare case of intrathyroidal parathyroid adenoma

Aparna Mohanlal, Krishna Balachandran, Limi Mohandas

Sree Gokulam Medical College, Venjarammoodu, Kerala, India

Case Report: 56 year old female known case of Diabetes mellitus and hypertension presented with swelling in the neck since one year duration associated with gradual increase in size was clinically and radiologically (USG) diagnosed as multinodular goitre but on HPE shows an encapsulated neoplasm with classical histological features of neuroendocrine cells and these cells are positive for GATA 3 and negative for TTF1 and calcitonin. Discussion: During the time of development, parathyroid glands can become misaligned and the displaced parathyroid glands are found more in the inferior gland (90%). Ultrasonography, contrast-enhanced CT, and MIBI scintigram are useful for the localization of parathyroid tumors. Conclusion: A Functional scan can help in the diagnosis, especially in cases of normal serum calcium level, but it is not done routinely. In such situations, the diagnosis is made only in resected specimen with histological and immunohistochemical examination.

Keywords: Ectopic parathyroid, intrathyroidal parathyroid adenoma, parathyroid adenoma

   AEP97 Top

   Endocrine Pathology Top

Papillary thyroid carcinoma-insular variant – A rare case presentation

GeethaSushma Siriki, Rajashree J Ingin, K Rajeshwari

Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India

Case Report: A 65 year male presented with rapidly progressive anterior neck mass since 4 months. USG Neck – bulky thyroid right lobe with well defined isoechoic lesion measuring 9x6.5 cm, cystic degeneration, internal septations, specs of calcifications. FNAC yielded few clusters of atypical cells suspicious for malignancy. Patient underwent right lobectomy. Gross- Grey brown cystic lesion measuring 10x7 cm. C/S cystic areas with peripheral solid areas and calcifications. Microscopy- confirmed Insular variant of PTC. Discussion: Thyroid cancer incidence is 1.2% among men with estimated death rate of 0.5 per 1 lakh/year. Insular variant is one among several variants of PTC which is rare accounting for only 5% of all thyroid tumors. Some studies classify it as aggressive subtype of well differentiated cancer and less aggressive form of poorly differentiated thyroid cancer in other studies. Clinical features are similar to any other thyroid disease. Calcification with or without osseous metaplasia in stroma occurs in 23% of insular cases indicating chronic disease. Conclusion: Insular variant of PTC is a rare tumor diagnosed mainly by histology, treated by thyroidectomy with lymph node resection in majority of cases. Requires early diagnosis and treatment in order to have better outcome. The presence of predominant insular component is associated with poor prognosis in terms of ongoing disease.

Keywords: Insular variant, male, papillary thyroid carcinoma

   AEP98 Top

   Endocrine Pathology Top

Hyalinizing trabecular tumor of the thyroid (HTT) – A rare case report

S Anusha, Seema Bijjeragi, H R Chandrashekar, Veerendra Swamy

JJMMC, Davanagere, Karnataka, India

Case Report: A 46 y old male patient came with complaint of swelling in front of neck more towards left side since 3 months. FNAC reported as follicular lesion of undetermined significance -Bethesda category III. Gross-Hemithyroidectomy specimen was received. C/S-well circumscribed grey white solid tumour with areas of hemorrhage. Microscopy showed a well capsulated tumour arranged in trabecular and nested pattern, nuclei oval to elongated with nuclear grooves and intranuclear inclusions with hyaline seen in intra-trabecular and Inter-trabecular area. IHC markers TTF1, thyroglobulin positive and Ki67 membrane staining positive. Discussion: World Health Organization (WHO) defines HTT as “a rare tumour of follicular origin with a trabecular pattern of growth and marked intra-trabecular hyalinization”. 80% of HTT nodules were cytologically misdiagnosed as PTC due to the overlapping nuclear features with classic PTC. However, HTT has to be differentiated from PTC or any other tumour as it is a benign neoplasm and management also varies accordingly. Conclusion: Concerning the biologic and clinical behavior, HTT should be considered as a benign neoplasm or at most a neoplasm of extremely low malignant potential. This case is presented for its rarity.

Keywords: Hyaline, hyalinizing trabecular tumour, papillary thyroid carcinoma

   AEP99 Top

   Endocrine Pathology Top

Papillary carcinoma in a thyroglossal duct cyst in childhood – A case report

Jaiminkumar Patel, Jigna Upadhyay, D N Lanjewar

Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India

Case Report: A 11-year-old girl presented with submental midline neck swelling since 2 years. The swelling moved with deglutination. A contrast enhanced CT scan of neck revealed solid cystic lesion measuring 3.1x3x2.8 cm in size. A clinical diagnosis of thyroglossal duct cyst with tumour was made and it was surgically resected. The specimen measured 3.5x3x2.5 cm., and the cut section of it revealed greyish white tumour with papillary configuration. The histopathology showed small to large cyst and papillae lined by single layer of cuboidal to low columnar cells having nuclear clearing, grooving, prominent nucleoli and presence of psammoma bodies. Immunohistochemistry showed positivity for TTF1, PAX8 and Thyroglobulin. The histological features and IHC confirmed the diagnosis of Papillary carcinoma of thyroid in thyroglossal cyst. Discussion: Thyroglossal duct cyst papillary carcinoma is a rare condition in children with only 11 documented cases in the English literature. Only one case of thyroglossal duct cyst papillary carcinoma in a child is described in Orissa, our case represents the second documented case in India. Conclusion: Malignancy within a thyroglossal duct cyst is very rare. Thyroglossal duct cyst papillary carcinoma should be included in the differential diagnosis of neck mass.

Keywords: Childhood, papillary carcinoma, thyroglossal duct cyst

   AEP100 Top

   Endocrine Pathology Top

Primary follicular lymphoma of the thyroid: A rare entity

Shruthi Pavithran, Lincy Joseph

Jubilee Mission Medical College, Thrissur, Kerala, India

Case Report: Here, we report a case of a 62-year-old female, who presented with swelling in the front of her neck of one month duration. The clinical diagnosis was a multinodular goitre. Fine needle aspiration cytology was done and reported as nodular colloid goitre with lymphocytic thyroiditis. Systemic examination was unremarkable. Histopathological assessments of the right hemithyroidectomy specimen revealed effacement of thyroid architecture by abnormal and extensive lymphoid follicles. Immunohistochemistry revealed CD20, CD10, BCL2, and BCL6 positivity in the lymphoid follicles. FDG-PT CT scan showed no evidence of lymphoma elsewhere. So, the final diagnosis was primary follicular lymphoma of the thyroid. Discussion: The thyroid gland contains no native lymphoid tissue. Intrathyroid lymphoid tissue is accrued in various pathological conditions, but more evidently in the course of autoimmune thyroid disease. Primary MALT lymphoma and DLBCL of thyroid are most common. Conclusion: Owing to the rarity and low prevalence of primary follicular lymphoma of the thyroid and the difficulty to differentiate it from Hashimoto's thyroiditis with dense lymphoplasmacytic infiltration forming lymphoid follicles, the histopathologic diagnosis should be confirmed by an immunohistochemistry study.

Keywords: Extranodal lymphoma, follicular lymphoma thyroid, primary thyroid lymphoma

   AEP101 Top

   Endocrine Pathology Top

Analysis of follicular thyroid lesions based on WHO 2022 criteria with emphasis of grey-zone lesions

Aanchal Khosla, Sunayana Misra, Seema Rao, Shashi Dhawan, Sonia Badwal

Sir Gangaram Hospital, New Delhi, India

Case Report: 71 cases were included with age range of 18-78 years; male-female ratio of 1: 4. Cytology-histology correlation was seen in 86% cases. Follicular nodular disease, Non-invasive follicular thyroid neoplasm with papillary-like nuclear features and encapsulated follicular variant of PTC were most commonly encountered benign, borderline and malignant entities. HBME1 and galectin-3 were positive in most malignant nodules while CK19 and CD56 were negative. Discussion: Proposed WHO 2022 has classified thyroid tumors into new categories allowing clearer understanding of cell of origin, pathologic features, molecular characteristics and biological behavior. On applying the new diagnostic criteria, 16% cases were reclassified. Accurate categorisation of morphologically similar lesions is vital to reduce over-diagnosis and over-treatment of indolent nodules. Conclusion: Using WHO 2022 criteria, we were able to re-classify follicular thyroid lesions with greater confidence. Use of IHC aids in categorizing challenging cases.

Keywords: Follicular thyroid lesions, thyroid nodules, WHO 2022 criteria

   AEP102 Top

   Endocrine Pathology Top

Adrenocortical carcinoma – Clinicopathological study at a tertiary care centre

Chethanababu Udupa, Karthik S Udupa

Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Case Report: We analysed clinico-pathological data of adult ACC between 2017 and 2020. A total of 6 cases of ACC were studied which included 5 females and 1 male patient. 4 cases presented with metastatic disease and 2 with localised disease, one of which later progressed to have distant metastases. The average age of patients was 44.83 years. All 5 female patients presented with functioning tumour manifesting as Cushing syndrome of which 2 presented with virilising features. The histopathological examination revealed the modified Weiss score of >4 in 3 cases and >6 in 3 cases, with immunopositivity for Vimentin, Inhibin and Calretinin. Ki 67 index ranging from 10-70%. One patient with non metastatic ACC underwent surgical resection and is on follow up. Out of 5 metastatic ACC, 2 did not receive treatment due to poor general condition and remaining 3 received Palliative chemotherapy with poor prognosis. Discussion: In our study, female predilection was noted. Mean age at diagnosis was 44.83 years, comparable to previous studies. Most cases were functional tumours with Cushing syndrome as presenting manifestation. Conclusion: ACC is a rare endocrine malignancy with aggressive behaviour. Surgical expertise in resection and proper pathological evaluation are important to improve outcome. Prognosis remains poor with currently available treatments. Newer agents are needed.

Keywords: Adrenocortical carcinoma, endocrine malignancy, Weiss scoring system

   AEP103 Top

   GastroIntestinal Pathology Top

Dissecting the pathology of E-GIST-histocytological correlation: A case report

Arundhati Vaid, Subhash Bhardwaj

Department of Pathology, GMC, Jammu, Jammu and Kashmir, India

Case Report: Here we report a case of malignant E-GIST in the liver in a 68 year old woman who presented with diffuse lump in the hypochondrium region. Discussion: Palpation revealed a diffuse mass in the hypochondrium. USG showed a heterogenous solid mass lesion with cystic/necrotic areas in close relation to left lobe of liver. CECT study revealed findings suggestive of mitotic pathology (? malignant GIST). FNAC depicted features of Benign spindle cell lesion (?GIST). Exploratory laparotomy was performed and multiple biopsies were taken and sent for histopathological examination. Microscopic examination of sections from liver biopsy and biopsy from growth revealed metastatic deposits of malignant GIST. Sections from falciform ligament and omentum were free from tumor. Further IHC markers CD117 and DOG1 confirmed the diagnosis. Conclusion: E-GISTs are very rare tumors that account for 1.5% of total GISTs. They possess a higher malignant potential and the risk of recurrance is quite high as compared with the conventional GISTs. The CT findings such as size, localisation of tumor and the presence of metastasis play a crucial role in the choice of treatment.

Keywords: E-GIST, liver, malignant

   AEP104 Top

   GastroIntestinal Pathology Top

An unusual presentation of gastrointestinal stromal tumor

Rachana Karajagi, Sneha Jawalkar, Surekha Arakeri

Shri BM Patil Medical College (BLDE) Hospital and Research Centre, Vijapur, Karnataka, India

Case Report: A 70 year old female presented with acute pain abdomen with previous history of constipation and difficulty in micturition since six months. CT scan of abdomen-pelvis revealed a large cystic mass with multiple septations compressing the adjacent structures suggesting ovarian cystadenoma. CA-125 was normal. On surgical exploration, the cystic mass was ruptured and was found adherent to uterus and ileum. Left adnexa were not visualized. The resected specimen grossly showed a ruptured cystic mass measuring 20X 9.5X 7 cm. It was adherent to one sided adnexa and intestinal segment. Histopathological diagnosis of Gastrointestinal stromal tumours (GISTs) arising from ileum was made on H and E stain. Further immunohistochemistry evaluation was done for confirmation and risk stratification. Discussion: Small bowel GISTs present as an incidental findings on abdominal imaging which commonly presents with ulceration, bleeding along with pain, weight loss, perforation. Conclusion: A clinical differential diagnosis of GIST has to be considered in abdomino-pelvic tumors that are adherent to various organs and mimics ovarian tumour on imaging.

Keywords: Abdomino-pelvic tumours, gastrointestinal stromal tumour, ovarian cystadenoma

   AEP105 Top

   GastroIntestinal Pathology Top

Retroperitoneal desmoid tumor masquerading as malignancy

P P Archana, Sneha Jawalkar, Surekha Arakeri

Shri BM Patil Medical College (BLDEU) Hospital and Reasearch Centre, Vijapura, Karnataka, India

Case Report: A 35 year old female patient came with complaints of mass per abdomen since two months and pain abdomen since one and half months. CT abdomen pelvis revealed a large mass in right retroperitoneal region abutting surrounding organs suggesting a possibility of soft tissue sarcoma. USG guided FNAC of mass was done and was reported as soft tissue neoplasm of benign to borderline malignant potential. The tumor was excised and sent for histopathology study. Grossly it was an encapsulated globular solid mass measuring 15x12x10 cm. On histopathology study it was reported as desmoid tumor which was confirmed on IHC with positivity for beta-catenin, cyclin D1 and smooth muscle actin. Discussion: Desmoid tumors are locally aggressive fibroblastic proliferations with variable presentation and high recurrence rate. For symptomatic desmoid tumors surgical resection with wide margin is treatment of choice. Conclusion: Although desmoid tumor is benign it has to be differentiated from other malignant retroperitoneal tumors such as pleomorphic sarcoma, leiomyosarcoma and lymphomas.

Keywords: Desmoid tumor, retroperitoneal mass, sarcoma

   AEP106 Top

   GastroIntestinal Pathology Top

A bud that could dig your graveyard

M P Priyanka, J P Geetha

Department of Pathology, Sri Siddhartha Medical College, Tumakuru, Karnataka, India

Case Report: 44 year old lady presented with acute abdominal pain. CT showed interval dilatation of bowel loops suggesting intestinal obstruction but course was not identified. Bowel was resected and grossly, entangled dilated bowel loop with mucosal nodules with ulceration measuring 1.2x1 cm noted. 8 lymphnodes were isolated. Histopathology showed tumor cells in nests with peripheral palisading and psudoglandular pattern and round to oval nuclei and fine granular chromatin are seen infiltrating upto subserosal fat. Atypical mitosis seen about 2-3/10 hpf. 6 Lymph nodes showed tumor deposits. Immunohistochemistry showed positivity for synaptophysin, chromogranin, ki67 index 8 -10%. Considering ki67 index and mitotic activity diagnosis of NEC grade 2 was made. Discussion: Majority of jejunoilleal NET are located in distal illeum with only 11% of jejunal origin. Tumors of small intestine are discovered after resection of bowel for obstruction or during exploration of small intestine in search of primary tumor after distant metastases. Nonlocalized lesions in NETs of small intestine is approximately 70% and 5 year survival is approximately 50%. Conclusion: Late presentation of symptoms make NEC of small intestine difficult to diagnose. So Morphology, mitotis and ki67 determine grade of tumor and aid in management.

Keywords: Grading, neuroendocrine tumors, small intestine

   AEP107 Top

   GastroIntestinal Pathology Top

Enteric?, Gastric?, combined duplication – A diagnostic dilemma?

Pratibha Bhooshan, Sunitha Vernekar, S M Choukimath, Purushotham Reddy

Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India

Case Report: 10 year old female presented with pain abdomen and vomiting. Xray showed air under the diaphragm. On USG there were thick loops with ascitis. Exploratory laparotomy was done and a segment of intestine was removed and sent for HPR. Grossly the specimen showed two lumens. On microscopy, one lumen showed hyperplastic gastric mucosa and other showed mucosa of small intestine. Diagnosis of Gastro-enteric duplication - Tubular type was made. Discussion: Enteric duplications (ED) are rare surgical anomalies. While the exact cause is unknown, some theories have been put forward like 1) split notochord theory (widely accepted) 2) incomplete twinning 3) phylogenetic reversal 4) persistent embryonic diverticula 5) dysvacuolation. Lipsett et al hypothesised that nests of trapped endodermal cells of the developing gut or persistent epithelial buds within the wall may be a cause of ED. ED maybe cystic, tubular, complex mixed (rare). Conclusion: Duplications with single segment have been reported earlier but this case was a rare occurrence wherein there was presence of duplicated enteric and gastric segment.

Keywords: Duplication, enteric, gastric

   AEP108 Top

   GastroIntestinal Pathology Top

A tale of lost gauze in abdomen – Gauzoma, a case report

J Thulasi, Ayesha Bhavikatti, Vijaya V Mysorekar

MS Ramaiah Medical College, Bengaluru, Karnataka, India

Case Report: 39-year-old female complains of difficulty in passing stools since 2 years and pain in lower abdomen since 1 year. Previous history of LSCS. The patient's daughter had undergone treatment for colonic GIST (Gastro-intestinal Stromal Tumour). On per abdominal examination noted a hard palpable mass of 6X6 cm in peri-umbilical region. USG and CECT abdomen and pelvis showed a well delineated exophytic mass arising from the wall of jejunum at the peri-umbilical region, to consider the possibility of GIST. Resection and anastomosis of small bowel loop was done. Gross – Noted a single cyst adjacent to serosa measuring 12.5X7X5 cm. Cut surface showed impacted degenerated surgical gauze material in the cyst. Microscopy – showed foreign body giant cells, foamy histiocytes and chronic inflammatory cell infiltrate around foreign body material. Discussion: Gauzomas are reported 1 in 1000–15000 intra-abdominal operations. The risk factors are emergency surgery, high body mass index and unplanned changes in procedure. In our case a family history of GIST and CECT abdomen findings directed the surgeons to put GIST as initial diagnosis and hence, radical surgery was done. Conclusion: This report proves that gauzoma can mimic neoplastic diseases, hence it should be considered in the differential diagnosis when the patient has a previous procedure or surgery.

Keywords: Gauze, gauzoma, GIST (gastro-intestinal stromal tumor)

   AEP109 Top

   GastroIntestinal Pathology Top

Systemic amyloidosis involving liver and duodenum – A case report

Madhusmita Mangaraj, Madhusmita Mohanty, Nageswar Sahu, Urmila Senapati, Preetam Nath

KIMS, Bhubaneswar, Odisha, India

Case Report: A 51 years old male, presented with watery diarrhea, pain abdomen and loss of appetite since 15 days. Biochemical analysis showed markedly elevated serum ALP and GGT with marginal increase in conjugated bilirubin and transaminases. UGI endoscopy revealed duodenal erosion. Endoscopic biopsy from duodenum and trucut biopsy from liver were taken. Duodenal biopsy revealed glassy homogeneous eosinophilic material deposits in lamina propria and around blood vessels. Liver biopsy revealed similar deposits in perisinusoidal spaces leading to focal destruction of hepatocytes and reticulin collapse. Congo red stain of both biopsies revealed salmon red stained deposits under light microscopy and apple green birefringence under polarized light. Duodenal and hepatic amyloidosis were confirmed. Discussion: Systemic amyloidosis is a group of disease characterized by deposition of amyloid fibrils in extracellular matrix and vessel walls in kidney (46%), heart (30%), liver (9%), spleen (5-10%), and gastrointestinal tract (7%). Diagnosis is usually delayed due to non-specific clinical and imaging presentations. Conclusion: Definite diagnosis of amyloidosis is based on histopathologic examination followed by Congo red stain. Hepatic involvement is associated with poor survival. Early diagnosis and appropriate treatment is crucial to improve the prognosis.

Keywords: Duodenum, liver, systemic amyloidosis

   AEP110 Top

   GastroIntestinal Pathology Top

Clinicians dilemma; pathologist pride – Story of masquerading bowel mass

J Aaslesha, H L Kishan Prasad, Jayaprakash Shetty, Sruthi, Aureen D'Cunha

KS Hegde Medical Academy, Ullal, Karnataka, India

Case Report: A 16 year old male presented with complaints of pain abdomen which is progressive. He had history of fever, vomiting's. PET-CT revealed circumferential, asymmetrical small bowel wall thickening up to 16 mm associated with mesenteric fat stranding with multiple enlarged lymph nodes giving differential diagnosis as lymphoma/GIST. Child underwent laparotomy and resection of small bowel, sigmoid colon and sent for HPE which revealed Angio invasive mucormycosis with necrotizing suppurative granulomatous jejunitis, and mesenteric lymphadenitis which is secondary to Angio invasive mucormycosis. Discussion: Diagnosis of GI mucormycosis is often delayed because of non-specific presentation as abdominal pain, vomiting's which are most common presenting symptoms. Infections may present as abdominal mass mistaken for tumours. The pathologic hallmark of mucormycosis is infarction of host tissue resulting from angioinvasion by hyphae, this gives rise to necrotic ulcers which results in acute pain abdomen, perforation and peritonitis. Conclusion: This case highlights the unusual presentation of a rare case of jejunal mucormycosis mimicking as tumor in an immunocompetent patient with the absence of any risk factors. The diagnosis mainly relies on careful histopathological examination. With global increase in patients at risk of developing mucormycosis, clinicians need to maintain high index of suspicion and evaluate appropriately to improve patient outcome. Early diagnosis and treatment with systemic amphotericin B were known for improving the prognosis.

Keywords: Jejunum, masquerading bowel mass, mucormycosis

   AEP111 Top

   GastroIntestinal Pathology Top

Goblet cell adenocarcinoma of appendix presenting as acute appendicitis – An incidental finding and a diagnostic challenge

Keertthana Premkumar, V Pavithra, Leena Dennis Joseph, Sandhya Sundaram

Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Case Report: We report a case of a 42 year old male patient who came to the emergency department with right lower quadrant abdominal pain that had migrated from the periumblical region. Appendicectomy was done and the specimen was sent for histopathology. The biopsy revealed appendix with small groups of cohesive goblet-like cells scattered circumferentially in the muscularis propria without eliciting a stromal reaction with mild nuclear atypia. The mucosa of the appendix appeared unremarkable. Immunohistochemistry was done and the goblet-like cells were positive for CK20, CEA and CK7. The H&E and IHC findings were favourable for a diagnosis of goblet cell adenocarcinoma of appendix. Discussion: Goblet cell adenocarcinoma was previously known as Goblet cell carcinoid or adenocarcinoid as it has features of both adenocarcinoma and neuroendocrine tumor. It is an amphicrine tumour composed of goblet-like mucinous cells and variable number of endocrine cells and Paneth-like cells. Staging of goblet cell adenocarcinoma is similar to other colorectal adenocarcinomas due to their more aggressive nature than neuroendocrine tumours. The appendix may be grossly normal or thickened and the tumour is easily overlooked macroscopically. Conclusion: Recognition of this entity plays a crucial role in evaluating the need for right hemicolectomy due to their aggressive nature and propensity to metastasize.

Keywords: Acute appendicitis, goblet cell adenocarcinoma, goblet cell carcinoid, right hemicolectomy

   AEP112 Top

   GastroIntestinal Pathology Top

Poorly cohesive carcinoma of gall bladder: Case report of a rare histological variant of primary gall bladder carcinoma

Payel Bandyopadhyay, Palash Kumar Mandal, Samindranath Basak, Soumargha Mitra

R G Kar Medical College and Hospital, Kolkata, West Bengal, India

Case Report: A 39 years old female patient was admitted in Surgery ward with complaint of right upper abdominal pain. CECT abdomen revealed a growth with irregular thickening of gall bladder wall with adjacent liver bed infiltration. Extended cholecystectomy was done. Grossly, gall bladder measured 9x4x3.4 cm, with congested serosa and multiple stones. Attached liver bed measured 4.4x2x1 cm. Cut section of gall bladder revealed a greyish white mass measuring 2.5x1.5x1 cm. Microscopic examination revealed poorly cohesive cells arranged discretely and in cord like pattern forming diffuse infiltrative growth invading the adjacent liver tissue with >50% signet ring cells. No lymph node was identified. Pathological stage- pT3Nx. Periodic acid Schiff stain showed presence of intracellular acid mucin in signet ring cells. Upon follow up, patient was on chemotherapy. Discussion: Poorly cohesive carcinoma can simulate several inflammatory and neoplastic conditions. Therefore, it needs to be differentiated from its mimickers by histopathological examination. Our patient presented at an early age and the tumour also progressed beyond gall bladder indicating poor prognosis. Conclusion: Early diagnosis and proper management with radical surgery and chemotherapy are necessary as 5 years survival of poorly cohesive carcinoma is only 5%.

Keywords: Gall bladder, poorly cohesive carcinoma, signet ring cells

   AEP113 Top

   GastroIntestinal Pathology Top

Fibromatosis of the jejunum

Yogeeta Tanty, S R Niveditha, C P Manjula

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: A 32 year old male presented with passing of black colored stools since 10 days. CECT scan showed well defined intraluminal lesion in the distal jejunum suggesting leiomyoma/ gastrointestinal stromal tumor (GIST). Resection and anastomosis was done. A segment of jejunum with well circumscribed, grey white homogenous mass in the wall was sent for histopathological examination. Microscopically, seen is a spindle cell neoplasm comprising of cells arranged in long fascicles with intervening collagen bundles and thin walled vessels. A Diagnosis of Fibromatosis was rendered as β catenin was positive while CD 117, Dog 1, SMA, S-100, STAT 6 were negative. Discussion: Fibromatosis is a benign neoplasm of fibroblast-myofibroblast origin. It either arises de novo or secondary to trauma or hormonal stimulation. It may present as an isolated lesion or as part of Gardener syndrome or Familial adenomatous polyposis. It should be differentiated from GIST. Conclusion: Intra-abdominal spindle cell neoplasms are difficult to differentiate through radiology and histomorphology alone, therfore immunohistochemical staining is must for diagnosis.

Keywords: Fibromatosis, jejunum, β catenin

   AEP114 Top

   GastroIntestinal Pathology Top

A dreadful complication in a case of post renal transplant

T Ruvanthika, K Swaminathan, G Gayathri

Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Case Report: A 32 year male with post renal transplant (POD-45 days) presented with fever and abdominal pain. On imaging colonic perforation seen. Right hemicolectomy done. Received specimen of distal ileum, caecum and portion of ascending colon, appendix. Grossly, perforation of size 3.5x2 cm noted in the anterior surface of ascending colon. External surface- surrounded by exudates. Microscopically, section studied from perforation site shows normal colonic mucosa with lamina propria having congestion and edema with chronic inflammatory infiltrates. Subserosa shows disruption covered by exudate with acute inflammatory cells, karryorhectic debris and many multinucleated giant cells. Few vague fungal hyphae, vague granuloma seen. In view of Suppurative inflammatory pathology with necrosis and multinucleated giant cells, possibility of mixed bacterial and fungal infectious etiology was considered. PAS and GMS stain revealed fungal hyphal elements and AFB shows negative for mycobacteria which confirms the fungal etiology. Discussion: Incidence of colon perforation is 1-2% in kidney transplantation patients. Most fungal infection occurs within six months of transplantation. Invasive fungal infection in colon is a life threatening complication in patients of organ transplantation. Conclusion: Gastrointestinal fungal infection is a rare presentation in patients of post renal transplantation and has increased mortality.

Keywords: Fungal infection, immunosuppression, renal transplantation

   AEP115 Top

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CD4 and CD8 expression in lymphocytic esophagitis and its clinico-pathological correlation

Sarah Khan, Arvind Ahuja

ABVIMS and Dr RML Hospital, New Delhi, India

Case Report: Our study was a cross sectional observational study and was conducted for one and half year's duration in Departments of Pathology and Gastroenterology, ABVIMS and Dr RML hospital, New Delhi. In this study 30 patients were taken. Clinical details and endoscopic findings were noted. Detailed histomorphological and immunohistochemical examination was done. Discussion: In our study, maximum number of patients belonged to the age group <= 40 years, and male to female ratio was 1:1.14. Chief complaint was dysphagia; esophageal ulcer was the most common endoscopic finding. Major pattern of lymphocytic infiltration was peripapillary (mild) consisting of 19 (63.3%) patients with CD8+ T cell predominance. GERD was the most common diagnosis. Common pattern of lymphocytic infiltration associated with GERD was diffuse and CD8 T cells were predominant in patients with GERD. Conclusion: LE is a manifestation of various diseases such as GERD and it has variable clinical manifestations and endoscopic features. CD8 T cell are the predominant intraepithelial lymphocytes in cases of GERD. Awareness of this newer entity by pathologists and gastroenterologists is necessary to consider LE in differential diagnosis, when evaluating patients of dysphagia.

Keywords: Immunohistochemistry, intraepithelial lymphocytes, lymphocytic esophagitis

   AEP116 Top

   GastroIntestinal Pathology Top

A cyst can be GIST too

Kalyani Chandramohan, S R Niveditha, C P Manjula

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: 46 year male presented with jaundice and pain abdomen. Radiologically diagnosed as mucinous cystadenoma of pancreas. FNAC reported as malignant spindle cell neoplasm. Whipple's procedure done. Head of pancreas showed two cystic masses, larger measuring 5X3 cms and smaller measuring 4X3 cms, cut surface - partly solid, grey white with central hemorrhagic cyst. Histopathology showed a well circumscribed tumor arising from the duodenal wall extending into the pancreatic head. Tumor comprised of spindle cells arranged in interlacing fascicles, whorls and in sheets. Cells have moderate amount of cytoplasm, round to oval nuclei with mild pleomorphism. Mitotic count <5/50 hpf. IHC positive for CD117, DOG 1 and Ki67 and diagnosed as GIST. Discussion: GISTs are common intestinal neoplasms, presenting as abdominal pain, discomfort, mass and bleeding. Extra gastrointestinal tumors are either metastases or detached mass from GIT. GISTs show strong CD117 positive. 50% of CD117 negative GISTs are positive for DOG1. Cystic GIST are rare and is difficult to diagnose preoperatively. It should be considered in the differential diagnosis of cystic lesions of pancreas, liver, mesentry, omentum and retroperitoneum. Conclusion: Cystic GISTs though rare, possibility of these should be considered when investigating cystic lesions in association with GIT.

Keywords: CD117, Cystic GIST, pancreas

   AEP117 Top

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Giant filiform polyposis: A rare entity in a patient of ulcerative colitis

Subhasis Sasmal, Rashmi Pattnaik

Hitech Medical College and Hospital, Bhubaneswar, Odisha, India

Case Report: A 43/m with per rectal bleeding, no family history of colon cancer or inflammatory bowel disease (IBD). He received treatment for more than 4 months on clinical basis and with AYUSH treatment but remained symptomatic. Later with multiple colonic biopsies revealed chronic active colitis possibility of IBD, the patient underwent colectomy. Discussion: FP typically presents as one to hundreds of uniform, slender, arborizing, vermiform projection in bowel mucosa in normal and inflamed mucosa. The polyps are thin, straight shaped. In rare case like our case When these polyps form tumour -like mass, they are called giant Filiform Polyposis (GFP). Microscopically these polypoidal structure are lined by epithelium, with no evidence of dysplasia or invasions, adjacent mucosa showing chronic inflammation as in IBD. Conclusion: Giant Filiform Polyposis can grossly mimic adenomatous polyp or colorectal carcinoma. It should be considered in differential diagnosis of Polyposis in IBD patients and a thorough sampling of the specimen required to exclude dysplasia or invasions.

Keywords: Filiform polyposis (FP), giant filiform polyposis (GFP), inflammatory bowel disease (IBD), ulcerative colitis (UC)

   AEP118 Top

   GastroIntestinal Pathology Top

Gastric leiomyosarcoma – Case report of a rare entity

Azfar Jamal, Pinki Pandey, Savita Agarwal, Geeta Maurya, Roopak Aggarwal, Dhruv Mahajan

UPUMS, Etawah, Uttar Pradesh, India

Case Report: Here, we present a case of 60-year-old female who presented with pain and swelling in left lumbar region. Patient was diagnosed with a lesser sac mass on ultrasonography. She underwent wedge gastrectomy with splenectomy with excision of mass. Histopathology and immunohistochemistry was carried out which revealed SMA positive Leiomyosarcoma. Discussion: Histopathological examination findings are in favour of Spindle Cell Neoplasm (Possibility of Gastro Intestinal Stromal Tumor is suspected). Whereas on applying Immunohistochemistry panel (DOG-1, CD-117, CD-34, SMA, Desmin) SMA was found to be positive and DOG-1, CD-117 were negative which led to diagnosis of Leiomyosarcoma. Conclusion: Surgical resection is the standard treatment for gastric leiomyosarcoma. The diagnosis of this tumor mainly depends on histopathological examination. This case may suggest the aggressive behavior and poor prognosis of this tumor.

Keywords: Leiomyosarcoma, lesser sac mass, spindle cell neoplasm

   AEP119 Top

   GastroIntestinal Pathology Top

Unsuspected invasive colonic mucormycosis in an immunocompetent patient: A rare clinical phenomenon and case report

K Gokul, Sangeeta Kini, Rima N Kamat, J S Pandya

Topiwala National Medical College and B Y L Nair Charitable Hospital, Mumbai, Maharashtra, India

Case Report: A 36-year-old female, with no known co-morbidities presented with pain in lower abdomen, vomiting, fever, generalised weakness & anasarca of 5 days duration. On examination, there was tenderness and guarding in right iliac fossa. CECT showed irregular circumferential wall thickening of terminal ileum & colon suggestive of inflammatory pathology. Covid test (RT-PCR) was negative. On exploratory laparotomy there was gangrene of large bowel with a single perforation. Gross examination of the resected colonic specimen revealed features of gangrene and histopathological examination showed features of ischemic enteritis with transmural gangrene and presence of angioinvasive broad aseptate hyphae of mucor, confirmed on special stains. Discussion: Primary intestinal mucormycosis in immunocompetent individuals can cause delay in clinical diagnosis due to lack of clinical suspicion & specific radiological findings. Thus, definitive diagnosis lies on histopathological demonstration of mucor in affected tissues. Conclusion: The present case highlights the need for a high degree of suspicion for mucormycosis in resected specimens of intestinal gangrene with or without perforation and inflammatory bowel disease thus facilitating a prompt treatment modality considering its high mortality.

Keywords: Angioinvasive, colon, immunocompetent, mucormycosis

   AEP120 Top

   GastroIntestinal Pathology Top

A synchronous adenocarcinoma of the jejunum in elderly patient: A rare case

Pothader Jayanth, Sqn Ldr Jeenu Varghese, Col Deep Kumar Raman, LT Col Arun Ravi John

Command Hospital Air Force, Bengaluru, Karnataka, India

Case Report: A 74 year old male presented with fatigue, detected with anemia. The patients was diagnosed with internal hemorrhoids & sigmoid colon ulcer from another hospital, HPE report showed high grade dysplasia. However repeat biopsy & review of the same was reported as well differentiated adenocarcinoma in the descending colon. Abdominal PET scan showed incidental metabolically active lesion also in the proximal jejunum and appendiceal mass along with the sigmoid colon ulcer. Left hemicolectomy & segmental jejunal resection HPE showed well differentiated adenocarcinoma (pT3No) along with lymphovascular invasion of proximal jejunum & well adenocarcinoma of sigmoid colon (pT2No).3rd pathology of appendicular mass was reported as mucocele of appendix. Discussion: Adenocarcinoma of jejunum is extremely rare tumor. Because of its rarity, nonspecific symptoms and diagnostic difficulty small bowel tumors are often diagnosed in the later on stage as in this case. Conclusion: Small bowel adeno carcinoma is one of the extremely rare adenocarcinomas of GI system, in this case it makes more rarer due to synchronous carcinoma diagnosed in GIT system along with mucocele of appendix. Hence this case is presented for its extreme rarity.

Keywords: Adenocarcinoma jejunum

   AEP121 Top

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Intestinal mucormycosis in a patient with COVID-19: A case report

Deepika Gupta, Purnima Paliwal, Seema Rahar, Anjnee Sharma, Arvind Ahuja, Devender Singh Chauhan

Dr. B C Roy Multispeciality Hospital and Research Centre, IIT Kharagpur, West Bengal, India

Case Report: We hereby describe a case of mucormycosis in a 17 year old COVID-19 positive female with no known comorbidities presenting with abdominal pain and distention and ultimately developing intestinal perforation. Discussion: COVID-19 may be associated with immune dysregulation, which might act as a risk factor for developing invasive fungal infections, such as candidiasis, invasive aspergillosis, and Pneumocystis jiroveci infection. However, only one case of mucormycosis associated with COVID-19 in a 78-year-old man with primary gastric mucormycosis has been reported to date. Conclusion: Early identication of the symptoms is essential to make a correct and early diagnosis to prevent complications

Keywords: Coronavirus, fungal co-infections, intestinal perforation, mucormycosis.

   AEP122 Top

   GastroIntestinal Pathology Top

Axillary soft tissue metastasis of occult pancreatic adenocarcinoma – A rare case report

Geeta Maurya, Sanjeev Kumar Singh, Sanjay Kannaujiya, Rashmi, Shiv Prasad Yadav, Pinki Pandey

Uttar Pradesh University of Medical Sciences, Saifai, Uttar Pradesh, India

Case Report: A small soft tissue mass of 80 year old male patient was received in pathology department labelled as excisional biopsy of left axillary lymph node. On gross examination resected mass was 2.5x1.5x1.0 cm., skin covered and cut surface show solid white areas. On histopathological examination (H&E) it was diagnosed as metastatic adenocarcinoma with unknown primary. On immunohistochemistry (IHC) tumour cells were positive for CK7, EMA, MUC-1, which confirm the diagnosis of Metastatic Adenocarcinoma. After this clinico-radiological evaluation had been done. CT findings of abdomen revealed heterogeneously enhancing mass lesion involving uncinate process and head of the pancreas. Final histopathological diagnosis (after IHC and CT findings) was “Soft tissue metastatic pancreatic adenocarcinoma of axillary region”. Discussion: Common metastatic sites of Pancreatic carcinoma are liver, lung and bone. Pancreatic carcinoma rarely metastasise to soft tissue and has very poor prognosis. IHC markers like CK7, EMA, MUC-1 along with radiological findings are very helpful in diagnosing metastatic pancreatic adenocarcinoma. Conclusion: clinician and histopathologist should always keep in mind this fact that pancreatic adenocarcinoma can present as metastatic soft tissue lesion. So the patient can get early treatment. IHC has a very important role in these type of lesions.

Keywords: Pancreatic adenocarcinoma, metastasis, soft tissue

   AEP123 Top

   GastroIntestinal Pathology Top

Lymphoepithelioma like carcinoma with sarcomatoid carcinoma of gall bladder – An extremely rare presentation

Shivani Kalhan, Paridhi, Madhuvan Gupta, Bhuvan Adlakha, Shalini Bahadur

Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India

Case Report: 50 year old female patient presented with history of pain in right hypochondrium since 1 week. The pain was not associated with jaundice, nausea or vomiting. The gall bladder wall was thickened approximately 8 mm. No lymphadenopathy was noted. Liver and intrahepatic vascular biliary radicals were normal. Discussion: LELC is described as a mass consisting of epithelial cells in a syncytial pattern with poorly delimited cytoplasm, infiltrated by numerous lymphocytes. Sarcomatoid carcinomas have have a pleomorphic morphology including giant cells. These tumours may also show heterologous differentiation. Carcinomas of gallbladder with dual morphology are extremely rare and only few such cases have been reported in the literature. Carcinomas of gallbladder with dual morphology are extremely rare and only few such cases have been reported in the literature like LELC with mucinous differentiation and LELC with adenocarcinoma of gall bladder. Conclusion: To the best of our knowledge, this is the first reported case with dual morphology of LELC and sarcomatoid carcinoma of gall bladder. Long term follow up of the patient and screening at regular intervals will aid in tracking the prognosis and observing the biological behaviour of this unusual variant.

Keywords: LELC, sarcomatoid carcinoma, undifferentiated carcinoma

   AEP124 Top

   GastroIntestinal Pathology Top

A 5 year presentation and follow-up of a case of familial adenomatous polyposis coli

B R Vani, Anvita Nilekani, Vishwas, B Deepak Kumar, V Srinivasa Murthy

ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India

Case Report: A 47 year old male patient presented with a history of bleeding per rectum since 22 years. Present resected surgical specimen of transverse colon and descending colon showed multiple adenomatous polyps with tubular and tubulovillous morphology exhibiting high grade dysplasia. HPE of colonic biopsy done on August 2018 was diagnosed as moderately differentiated adenocarcinoma and patient was treated with 28 cycles of chemotherapy. In February 2019 surgical resection of descending colon and rectum was done. Histomorphology showed numerous polyps exhibiting features of tubular adenoma with focal mucosal adenocarcinoma. Discussion: FAP was first described by Chargelaigne in 1859. Males and females are equally affected. 1/3 of cases have no family history of FAP and new germ line mutations is thought off. 80% of people with FAP have associated CHRPE. The index case exhibited CHRPE on fundoscopy. Mutational analysis of APC gene showed heterozygous dominant mutation in the patient. Conclusion: Patients with persistent per rectal bleeding, or with strong family history of FAP should undergo annual endoscopic assessment beginning at 10 to 12 years of age. Genetic test enables early detection of the FAP predisposition even before the appearance of polyps.

Keywords: Adenomatous polyposis coli, APC gene, colorectal neoplasms

   AEP125 Top

   GastroIntestinal Pathology Top

Synchronous tumours of ileum-invasive inflammatory fibroid polyp and gastrointestinal stromal tumour – A rare case report

G K Parvathidvei, K G Siddalingeshwar

Sri Siddhartha Medical College, Vinayaka Hospital, Tumkur, Karnataka, India

Case Report: A 62-year old male patient presented with pain abdomen since 1 month. USG examination showed a necrotic bowel mass in left lower abdomen with infiltration to adjacent fat planes and enlarged adjacent mesenteric lymphnodes. CT of abdomen showed similar findings. A provisional diagnosis of GIST,?malignant was done and specimen was excised and sent for histopathological examination which showed two different lesions ;invasive inflammatory fibroid polyp invading upto serosa and adjacent fatty tissue and adjacent lymph nodes and appendix. GIST also was noticed in submucosa. IHC has been done for confirmation. Discussion: IFPs often harbour PDGFRA (Platelet Dervied Growth Factor Alpha) mutation. Due to this finding these growth have been considered neoplastic lesions rather than reactive lesion. GIST can occur anywhere in GIT, are submucosal, size varies from 1-40 cms, more in males, more in 5th-6th decade of life. Radiologically plays important role in diagnosis. These were CD117 and CD34 positive. Targeted molecular therapy with imatinib is helpful in management of these patients. Mutational analysis and testing is an evolving concept. Radical surgical resection is the gold standard for localized primary GIST. Conclusion: Synchronous occurrence of invasive IFP and GIST is rare. Successful outcome requires a multidisciplinary approach; post-operative targeted molecular therapy in intermediate and high risk patients and continued surveillance.

Keywords: GIST, ileum, invasive IFP, synchronous tumors

   AEP126 Top

   GastroIntestinal Pathology Top

Prognostic significance of tumor infiltrating lymphocytes, tumor budding, tumor border configuration and tumor stroma ratio in colorectal carcinoma

Mukta Pujani, Kanika Singh, Charu Agarwal, Varsha Chauhan, Sneha Prasad, Mitasha Singh1

Departments of Pathology and 1Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India

Case Report: Material and Methods This cross-sectional observational study was conducted on hematoxylin and eosin (H&E) stained slides of 65 primary CRC cases. Stromal TIL was categorized into 3 groups: low (0 to 10%), intermediate (15 to 50%), and high (55 to 100%). Tumor budding was counted in 10 HPFs and graded as: 0–4 buds—low TB, 5–9 buds—intermediate TB and 10 or more buds—high TB. TBC was labelled as either pushing or infiltrative. TSR was scored into two groups as high TSR (low stroma as ≤ 50%) and low TSR (high stroma > 50%). A novel CRS was constructed based on TBC, TB and TSR: Infiltrating TBC, TB score > 5 (median) and low TSR was categorized as risk items. Final categories were: low risk-tumors with ≤ 1 risk item and high risk-tumors with > 1 risk items. Discussion: Results: TIL showed a significant correlation with histological tumor type, TB was significantly associated with tumor location, grade, T stage and perineural invasion while TBC significantly correlated with tumor location only. TSR showed significant association with tumor location and perineural invasion qwhile the combined risk score significantly correlated with tumor location and grade. Conclusion: Tumor border configuration, tumor budding, tumor stroma ratio and the newly formed combined risk score are simple, cost effective, potential markers in colorectal cancer patients, suggesting that their incorporation in the routine histopathological evaluation could be useful in determining the prognosis of colorectal cancer cases.

Keywords: Colorectal carcinoma, tumor border configuration, tumor budding, tumor infiltrating lymphocytes, tumor stroma ratio

   AEP127 Top

   GastroIntestinal Pathology Top

Fulminant necrotizing amebic colitis – A vanishing pathology

Rushita Makadia, Nikita Modh, D N Lanjewar

Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat, India

Case Report: A 65 year-male presented with abdominal pain and diarrhoea of 15 days duration. Patient had intermittent pain and diarrhoea since 4 year. The clinical examination confirmed perforation of colon. USG findings indicated a possibility of colonic tumour. Excised specimen of caecum and colon showed small to large round to oval mucosal ulcers showing yellowish slough at the base, and perforations. Histology of colonic ulcers showed numerous trophozoites and cyst forms of Entamoeba histolytica invading mucosa, sub mucosa, muscle coat and serosa. Histology also showed sickled RBCs cells in the vascular lumen. Discussion: In India, prevalence of amoebiasis, range from 0.6-11%. Autopsy reports before 1970s have shown mortality due to intestinal amoebiasis in 7.2% patients. Metronidazole has changed the picture of this illness in such a way that there are hardly any patients of complicated intestinal amoebiasis. In last 10 years, this is first case of fulminant amoebiasis found in our surgical pathology specimen. Amoebiasis can increase morbidity and mortality in patients with sickle cell disease as amoebic dysentery may contribute to dehydration which accelerates the sickling of RBCs that can result in ischemia of bowel wall and promote bowel perforation. Conclusion: Acute necrotizing fulminant amoebic colitis has a poor outcome when misdiagnosed. Early diagnosis treatment reduces mortality.

Keywords: Entamoeba histolytica, fulminant necrotising amoebic colitis, sickle cell disease

   AEP128 Top

   Hematopathology Top

Pure red cell aplasia-chronic type – A case report

Tanvi Chaubey, Ramesh Chavan

Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Case Report: 8 years female child, suffering from quadriplegia since birth presented with repeated convulsions. She was put on anticonvulsant (sodium valproate). After few years of treatment, she presented with pallor, generalised weakness, breathlessness and growth retardation. Based on the investigations she was diagnosed with pure red cell aplasia of chronic type and other causes were ruled out. The drug of treatment (sodium valproate) was replaced with other drug. The result was increased hemoglobin and improvement in red cell count. Discussion: Pure red aplasia can be congenital (Diamond Blackfan syndrome) or acquired. Congenital is sporadic and autosomal dominant. In Acquired causes include autoimmune diseases, leukemias, lymphoproliferative disorders, tumors, infections, drug induced. It involves mainly elderly. In children acquired type is less common includes infections followed by drugs and autoimmune causes. Anticonvulsant Sodium valproate acts by inhibition of sodium channels, increases GABA production and decrease its metabolism. Other side effects include nausea, vomiting, tremor, edema, liver toxicity, etc. Conclusion: Pure red cell aplasia is rare in children. The case study aims to review causes of pure red cell aplasia in children to reconsider use of drugs for longer duration.

Keywords: Acquired red cell aplasia, anticonvulsants, Diamond Blackfan syndrome

   AEP129 Top

   Hematopathology Top

Mixed phenotype acute leukemia – A rare case

Shreya Pawaskar, Neelkanth Potdar, Umesh Kanade

Dr. Potdar Laboratories, Solapur, Maharashtra, India

Case Report: 35 year old male came to surgery OPD with chief complaints of massive PR bleed since 3 days. He complained of low grade fever with night sweats and generalised weakness since 15 days. He is farmer by occupation with no significant past, personal or family history. On clinical examination, pallor ++ seen. No skin bleeds, gum hypertrophy, lymphadenopathy, organomegaly.

CBC report

Hb - 4.6 gm/dl

TLC - 600/cumm

DLC Blasts - 20% P -30% L - 20% M - 30%

Plat. - 10000/cumm

PBS: Normochromic normocytic anemia with Pancytopenia

ESR 68 mm at 1 hour

Biochemistry: normal except LDH-980 U/L

Bone marrow aspirate: Hypercellular marrow, blasts 70 %

Blast morphology:

a) Small blasts, high N:C ratio, coarsely clumped chromatin, no or indistinct nucleoli? L1 type

b) Medium to large sized, variable N:C ratio, pale blue scanty-moderate cytoplasm, fine chromatin, 1-3 nucleoli, no Auer rods

c) Variant blasts – Hand-mirror like

Erythroid & megakaryocyte lineage markedly decreased

BM Trephine Bx: Replacement of marrow by sheets of blasts, vesicular nuclei, prominent nucleoli

Flow cytometry- Morphologic & immunophenotypic findings are consistent with mixed phenotype acute leukemia

Cytogenetics- Signal pattern showed evidence of loss of ABL1 allele and 3 copies of PBX1 allele due to structural rearrangement of 1 qregion in 90% cells. Discussion: Immunophenotypic analysis is required for diagnosis of MPAL. Morphologically, MPAL blasts have hand-mirror morphology, small to intermediate size, and variable cytoplasm. Occasionally, the 2 blasts could have distinctive phenotype, morphology, and size. The WHO doesn't mandate certain percentage of lineage-specific antigens, The WHO stipulates a myeloid lineage in MPAL with the detection of MPO by cytochemistry, FC, monocytic differentiation, or IHC, and when blasts meet the criteria for B or T lineage. The debate on most appropriate initial therapy should be based on immunophenotype, cytogenetics, or molecular biology is still on. MPAL has a poorer prognosis than AML or ALL. Conclusion: Redefining the classification and discovering the genomic underpinnings of MPAL are some of the significant advancements that have been made in the past decade. Contextualizing the emerging understanding of the biology of MPAL to allow homogeneity in treatment strategies would enable the risk stratification of patients and treatment approaches between MPAL subsets.

Keywords: BMA, immunophenotypic analysis, lymphoid, MPAL, myeloid

   AEP130 Top

   Hematopathology Top

Aplastic anemia with 13q deletion, paroxysmal nocturnal hemoglobinuria and ABCB7 gene mutation responding to low dose immunosuppressive therapy

Shivangi Degaon, Girish Kamat

SDM Medical College of Medical Sciences and Hospital, Dharwad, Karnataka, India

Case Report: A 32-year-old male came with complaints of fever, headache and purpuric rashes all over the body. On routine investigation, peripheral smear showed pancytopenia and bone marrow revealed hypocellularity. On further investigations, PNH clone was seen on flow cytometry and cytogenetics study showed 13q deletion. Next generation sequencing showed mutation in ABCB7 (-) gene on Exon 8 suggestive of X-linked recessive inheritance pattern and is associated with Sideroblastic anemia with Spinocerebellar ataxia. Patient was treated with immunosuppressive therapy consisting of Cyclosporine A along with anabolic steroids-Danazol. Patient showed complete hematological response at end of 2 months. Discussion: Pathophysiology of acquired aplastic anemia is unknown. Several genes related to cell growth and differentiation such as RB gene and leu 1 are located at 13q. 13q clone detection has been shown to be an innocent clone and suggests the presence of immune mechanism in the affected bone marrow. Therefore, presence of 13q deletion In AA may be an indicator for response to conventional therapy rather than evolution to acute leukemia. Conclusion: AA with 13q deletion is a rare condition. Thus, recognition of this deletion as a benign marrow failure is important as it has good prognosis with immunosuppressive therapy (IST).

Keywords: 13q deletion, aplastic anemia, IST

   AEP131 Top

   Hematopathology Top

Non-secretory multiple myeloma: A rare subtype of plasma cell disorder

Greeshma Sasmal

Command Hospital Airforce, Bengaluru, Karnataka, India

Case Report: A 61 year old with no history of any commodities presented with history of lower back ache for 2 years duration insidious in onset, gradually progressive, round the clock pain with no diurnal variation. Radiological investigations revealed multiple lytic lesions in vertebrae. Yet, serum protein electrophoresis did not reveal any abnormal band or 'M' spike. Bone marrow biopsy revealed hypercellular marrow for age with sheets of plasma cells (95%) which were mature to intermediate with kappa restriction. Hence the diagnosis of non-secretory multiple myeloma was made. Discussion: The incidence of these non-secretory multiple myelomas (NSMMs) ranges from around 3% to 5% of the total MM population and if oligo-secretors are not taken into consideration the incidence falls further to 1-2%. Conclusion: Since small proportion of patients encounter the criteria for NSMM and the systematic exclusion of these patients from the clinical trials, it is difficult to define if the prognosis of these patients is significantly different from secretory ones. Hence this case has been presented due to its rarity.

Keywords: Non-secretory multiple myeloma

   AEP132 Top

   Hematopathology Top

Transient abnormal myelopoiesis

Madhuchhanda Mallik, Pragya Lisha Panda, Anubhav Sahu, Asaranti Kar, Lity Mohanty

SCBMCH, Cuttack, Odisha, India

Case Report: A 7 days old boys presented with respiratory distress &fever. on general examination he had saddle gap, wide palpebral fissure, mongoloid slant, low set ears and was diagnosed to be Down syndrome by Hall's criteria. Peripheral blood smear revealed Hb 13.1 gm/dl, TLC 55,000/cumm, total platelet count 1.5 lakh/cumm and differential count showed 50%of blasts. Discussion: Blasts were medium to large sized cells with scant cytoplasm, few showing granules in cytoplasm, round nucleus and 1-3 nucleoli. Blasts were negative for myeloproxidase & positive for periodic acid Schiff. Conclusion: TAM is a rare entity, characterized by high rate of spontaneous remission. However progression of disease can also be seen in numerous cases. Therefore a close follow up, monitoring of clinical signs & symptoms, CBC, Peripheral smear is extremely significant.

Keywords: Down syndrome, myeloproxidase, periodic acid Schiff

   AEP133 Top

   Hematopathology Top

Hemphagocytic lymphohistiocytosis

Jules Kurian Mathew, Jayapriya

Government Medical College, Kottayam, Kerala, India

Case Report: A 22 year old male presented with fever & dry cough for 2 weeks. He had decreased appetite, myalgia, headache & altered sensorium but no rashes, bleeding or significant family history. Physical examination noted conjunctival congestion & splenomegaly only. Direct & indirect bilirubin, liver & pancreatic enzymes were elevated. PT, INR & aPTT were prolonged. Blood culture was negative. Serology became positive for IgM dengue. There was hypertriglyceridemia, hyperferritinemia, hypofibrinogenemia & hypoalbuminemia. Peripheral smear showed leucopenia & moderate thrombocytopenia with giant & large platelets. Ultrasound showed evidence of hepatitis & splenomegaly. Bone marrow examination revealed hemophagocytosis. A diagnosis of Secondary HLH was made. Symptomatic treatment, antibiotics, platelet transfusion & FFP were given. Patient recovered thereafter. Discussion: HLH can be 1) Familial/Primary-classified into 5 types based on the mutation & those associated with various syndromes 2) Secondary-due to malignant histiocytosis or reactive conditions (infections, malignancy, drugs, autoimmunity, sarcoidosis etc). Diagnosis is by molecular tests or when atleast 5 out of 8 features are present-fever, splenomegaly, cytopenias, hypertriglyceridemia/hypofibrinogenemia, hemophagocytosis, low/absent natural killer cell activity, hyperferritinemia, elevated sCD25. Treatment is mainly symptomatic but if deterioration/non-response occurs immunosuppressants, stem cell transplant or monoclonal antibodies have role. Conclusion: HLH is a rare disease that must be diagnosed early to initiate adequate treatment for recovery of the patient.

Keywords: Cytopenias, hemophagocytosis, histiocytosis

   AEP134 Top

   Hematopathology Top

Acute panmyelosis with myelofibrosis

Shivam Subudhi, Pragyan Lisha Panda, Sujata Sarangi, Dilleswari Pradhan, Asaranti kar, Lity Mohanty

SCB Medical College, Cuttack, Odisha, India

Case Report: A 62-year-old male presented with acute onset generalized weakness and body ache. On clinical examination he had severe pallor with history of two units of blood transfusion. There was no hepatosplenomegaly and lymphadenopathy. Peripheral blood smear revealed pancytopenia with circulating blasts (26%). Blasts were negative for myeloperoxidase. Bone marrow aspiration was hemodiluted. Bone marrow biopsy yielded intertrabecular spaces comprised of mostly fibrotic areas along with numerous atypical megakaryocytes, and scattered hematopoietic cells with myeloblasts. Reticulin and Masson trichrome stain showed marrow fibrosis. Discussion: APMF is a rare and fulminant variety of 'AML NOS' according to the WHO 2017 classification. Due to its poorer prognosis, it warrants an early diagnosis. Conclusion: A high degree of suspicion should be kept in mind if a patient presents with abrupt onset pancytopenia, 'dry tap' at bone marrow aspiration and absence of any organomegaly.

Keywords: Acute myeloid leukemia, bone marrow fibrosis, myelofibrosis, pancytopenia

   AEP135 Top

   Hematopathology Top

Inherited factor V deficiency – A diagnostic conundrum in a rare case of parahemophilia

SindhuraLakshmi, KoulmaneLaxminarayana, Sushma Belurkar

Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Case Report: A gentleman in his early twenties presented to orthopaedic outpatient department with complaints of sudden onset pain over the left gluteal region, thigh and knee, severe in intensity, more noticeable at night, along with difficulty in bearing weight and walking. Left limb was in flexion at hip, knee, with tenderness over the posterior left hip joint line. The laboratory evaluation revealed prolonged prothrombin time (PT) (56.2 Sec) and activated partial thromboplastin time (APTT) (98.2 Sec). Neither PT nor APTT was not corrected by mixing studies using aged serum indicating a common pathway factor deficiency suggestive of FV deficiency. Inhibitor screen was negative. He was treated with fresh frozen plasma and given supportive therapy. He is currently stable at the end of 5 years after the initial diagnosis. Discussion: FV deficiency is an autosomal recessive disorder due to mutation in FV gene (1q23). Globally, < 200 cases have been documented so far. It is characterized by symptoms ranging from easy bruising, delayed bleeding post-trauma or surgery to severe joint bleeds. It can be categorized into mild, moderate, or severe based on the percentage of FV in the plasma (>10%, 1 to 10%, <1%, respectively). Conclusion: Inherited and acquired forms may be differentiated by mixing plasma studies. Inhibitor screen must be performed in these cases to exclude delayed inhibitors which may mimic FV deficiency.

Keywords: Factor V deficiency, inhibitor screen, mixing studies

   AEP136 Top

   Hematopathology Top

Hidden amyloidosis in liver and bone marrow

J Gayathri, M Archana, K S Nataraj, Sandeep Desai, Vishnu Kurpad, Rekha V Kumar

Sri Shankara Cancer Hospital and Research Centre, Bengaluru, Karnataka, India

Case Report: Here is a 60-year-old female presenting to the surgical oncology department with abdominal fullness. Evaluation revealed multiple small lytic lesions in the axial and appendicular skeleton without pathological fractures. CT scan abdomen revealed enlarged hypodense liver and spleen without focal lesions. Serum Alpha Feto Protein was 1.43 ng/mL (0-6.05). M band was seen on serum electrophoresis. Bone marrow aspiration showed 35-40% plasma cells with binucleate, trinucleate forms suggesting plasma cell myeloma. Trephine biopsy showed plasma cells with homogenous eosinophilic material in the interstitium raising a suspicion of amyloid deposits. Conventional karyotyping and FISH were non-contributory. Liver biopsy showed sheets of plasma cells with amyloid deposits. Congo red stain confirmed amyloid on both liver and bone marrow biopsies. Discussion: MM is common in the elderly. Amyloidosis commonly affects the heart, kidneys, gastrointestinal tract/liver, and the peripheral or autonomic nervous systems. Amyloid deposits in multiple organs predicts a poorer prognosis when compared to single organ involvement, and addition of Daratumumab improves the response and reduces organ deterioration. Conclusion: Amyloidosis is an independent poor prognostic factor not only for symptomatic multiple myeloma but also smouldering multiple myeloma. This case highlights the importance of diagnosing amyloidosis when plasma cells are found, especially in non-haematological tissues, for early initiation of intense chemotherapy.

Keywords: Amyloidosis, apple green birefringence, daratumumab, multiple myeloma

   AEP137 Top

   Hematopathology Top

Homozygous delta-beta (δβ) thalassemia – A case report

Sneha Debbarma, Ravikiran N Pawar, Nilesh Bhamare, Sheetal Yende, Swati Mali, Asif Mirza, Prashant Shetty

Manipal Trutest Reference Laboratory, Bengaluru, Karnataka, India

Case Report: 40 year male (propositus), with mild anemia presented in the out-patient department. There were no other definitive causes of anemia with adequate nutritional status and no response after treatment with hematinics. HPLC was advised to look for any qualitative/quantitative defect. HPLC findings reveal 96% HbF, a very small quantity of HbA and absent HbA2. In view of this data, followed up with parental studies. Both parents had elevated HbF, similar grades of anemia. These supported the presence of heterozygous state of δβ thalassemia in parents and homozygous δβ thalassemia in propositus. Discussion: In δβ thalassemia there is a deletion of the δ and β genes on Chromosome 11. Expression of the gamma gene increases to compensate, causing increased production of gamma globulin for HbF (α2 β2). On HPLC or electrophoresis, heterozygosity shows as normal HbA2 and elevated HbF, and as absent HbA2 with almost 100% HbF for homozygous individuals. Clinical presentation is mild even in homozygotes. Conclusion: Considering the cost, limited availability and higher turnaround time for molecular studies, parental studies help to narrow down the differential. Implementation of premarital counseling, awareness programs for schools and newborn screening help to prevent or intervene early in the management of hemoglobinopathies.

Keywords: Anemia, chromatograph, homozygous

   AEP138 Top

   Hepatobiliary and Pancreatic Pathology Top

Eosinophilic pancreatitis: A case report with review of literature

Divya Ashireddy, R Kalyani, Mohan Kumar, K Shilpa, Nikhil

Sri Devaraj Urs Medical College, Kolar, Karnataka, India

Case Report: A 35 years old man presented with 1 ½ month history of pain abdomen, loss of appetite and nausea was admitted in the hospital. He is a chronic alcoholic. USG showed chronic pancreatitis with collection in peri gastric region, organized collection in peri splenic space, minimal ascites, left sided pleural effusion, hepatosplenomegaly. CT (plain and contrast) revealed necrotizing pancreatitis with multiple intraparenchymal, extra parenchymal collections, pseudocyst, hepatosplenomegaly, gallbladder grossly distended, minimal pleural effusion with passive collapse of underlying lung. He was treated with antibiotics and antiemetics but there is no improvement. Distal pancreatectomy with pancreatojejunostomy and splenectomy was done, and specimen was sent for histopathological examination which showed features of eosinophilic pancreatitis. Discussion: Eosinophilic pancreatitis (EP) is a rare form of pancreatitis, with very few cases reported in the literature. It is usually not diagnosed until patient undergoes pancreatic resection. This condition may mimic pancreatic neoplasm. Cytotoxic and inflammatory mediators may elicit pancreatitis. Histopathological patterns include – Diffuse, periductal, acinar, septal. The differential diagnosis for eosinophils in pancreas includes lympho plasmacytic sclerosing pancreatitis, pancreatic allograft rejection, inflammatory myofibroblast tumor, systemic mastocytosis and parasitic infection. EP can be treated with steroids, 40-60 mg daily cures recurrent attacks. Proper treatment can prevent eosinophilic gastroenteritis and hyper eosinophilic syndrome. Conclusion: It is a rare case often misdiagnosed as pancreatic cancer

Keywords: Chronic pancreatitis, eosinophils, eosinophilic pancreatitis

   AEP139 Top

   Hepatobiliary and Pancreatic Pathology Top

Poorly cohesive carcinoma of gallbladder – A case report

Ketki Mendhey, Ketki S Mendhey, Anne Wilkinson, Sabiha Maimoon, Kalpana Bothale, Trupti Dongre

Department of Pathology, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India

Case Report: A 72 years old female came with complaint of pain in abdomen since 15 days. USG abdomen and pelvis showed luminal narrowing of third part of duodenum causing gastric outlet obstruction with abdominal lymphadenopathy, cholelithiasis, mild ascites and right sided pleural effusion. Esophago-gastro-duodenoscopy showed gastric outlet syndrome with severe gastric gastropathy. Barium meal study revealed narrowing at D3 segment of the duodenum suggestive of stenosis. Operative procedure- Exploratory laparotomy with roux-en-y gastrojejunostomy with cholecystectomy was done. Discussion: The poorly cohesive cells carcinoma is rare in the gallbladder. It is defined by presence of poorly cohesive cells forming more than 50% of the tumor. They are classified most often higher than T3 at the time of diagnosis, with a very poor prognosis, being the most aggressive gall bladder carcinoma. When a poorly cohesive cell carcinoma of the digestive tract with an indeterminate primary site is diagnosed, the gallbladder should be taken into consideration when searching for the primary site. Conclusion: Poorly cohesive carcinomas are rare tumours in the gallbladder.

Keywords: Carcinoma, gallbladder, poorly cohesive cells

   AEP140 Top

   Hepatobiliary and Pancreatic Pathology Top

An indolent tumor – Solid pseudopapillary neoplasm of pancreas

S Shravani, Shravani, L Chaitra, Vijaya Mysorekar

MS Ramaiah Medical College, Bengaluru, Karnataka, India

Case Report: 30-year-old female complaints of pain in the left side of abdomen since 2 months. CT scan showed well defined isodense soft tissue mass with mild homogenous enhancement. The mass measures 5.6 x 3.8 x 6.5 cm. Also, focal calcification measuring 9 mm was seen in the mass. Gross – The cut surface of partial pancreatectomy specimen showed a mass in the tail of pancreas measuring 5 x 4.5 x 4.5 cm with solid and cystic areas. Microscopy – Showed features suggestive of solid pseudopapillary neoplasm of tail of pancreas. Immunohistochemical studies revealed tumor cells positive for beta catenin (diffuse), PR (60%), CD 10 (focal), synaptophysin (weak, patchy) and negative for chromogranin. Discussion: SPN is most frequently localized in the head or tail of the pancreas. Most exhibit benign behaviour but malignancy can occur in about 15% of cases, manifesting as metastasis to liver, regional lymph nodes, mesentery, omentum and peritoneum commonly. Histopathological findings, radiologic imaging and IHC markers establish a diagnosis of solid pseudopapillary neoplasm of pancreas. Curative treatment is best by excision of primary and distant metastasis. Conclusion: The correct diagnosis depends on comprehensive analysis of clinical features, imaging and histopathologic characteristics. Timely resection on diagnosis provides long-term survival.

Keywords: Pancreatic tumor, solid pseudopapillary neoplasm

   AEP141 Top

   Hepatobiliary and Pancreatic Pathology Top

Large cell neuroendocrine carcinoma (LCNEC) of the gall bladder

Namisha Goyal, Urmila Senapati, Ashim Das, Ruchi Mittal, Ranjana Giri

KIMS, Bhubaneswar, Odisha, India

Case Report: A 50-year-old female, presented with complaints of multiple episodes of vomiting, pain abdomen and dyspepsia of 2 months duration. On examination, abdomen was soft, with no organomegaly, guarding or rigidity. USG abdomen revealed a polypoidal lesion of gallbladder. Histopathological examination of the cholecystectomy specimen revealed a diffusely infiltrating undifferentiated tumor with brisk mitosis and focal necrosis. With a differential diagnosis of large cell Non-Hodgkin's Lymphoma and Poorly Differentiated Carcinoma, IHC for Pan Cytokeratin and LCA was advised which were negative. On further work up, tumor cells were negative for HMB-45, and chromogranin; however positive for Synaptophysin; Ki-67 showed a proliferative index of 80%. Hence, diagnosis of Large Cell Neuroendocrine Carcinoma was rendered. CT thorax and UGI endoscopy were unremarkable. CT abdomen after 4 weeks demonstrated a hepatic lesion which showed involvement by tumour. Presently the patient received palliative care and lost to follow-up. Discussion: Histogenesis is either from undifferentiated stem cell or mucosal neuroendocrine cell in the background of chronic inflammatory induced intestinal or/and gastric metaplasia leading to malignant transformation. Conclusion: Because of the rarity, high degree of suspicion and its exclusion is warranted in cases with a morphological high-grade malignancy.

Keywords: Gallbladder, Ki67, large cell neuroendocrine carcinoma, synaptophysin

   AEP142 Top

   Hepatobiliary and Pancreatic Pathology Top

A fungal mass masquerading a pancreatic neoplasm

Subramanayam Marepalli, Jeenu Varghese, Deep Kumar Raman, Sagar Soman

Command Hospital, Bengaluru, Karnataka, India

Case Report: A 45-year-old female known diabetic presented with complaint of abdominal pain, recurrent vomiting, fatigue since 4 months. Per abdomen examination revealed a globular, firm, ill-defined swelling in epigastric region. MRCP & PET scan showed periampullary mass likely neoplastic. This patient was taken for Whipple's procedure following exploratory laparotomy. Primary HPE revealed only areas of fibrosis with surrounding normal pancreatic acini. However, in view of the radiological finding further sections submitted revealed a fungal ball, reported as Hyalohyphomycosis on special stains. Discussion: Fungal Ball Hyalohyphomycosis is a very rare case of an occult fungal collection mimicking a pancreatic head neoplasm. Conclusion: Major high-volume medical centers, up to 10.6% of Whipple resection cases have been found to be negative for neoplastic disease, when 85% of those cases were performed under the clinical suspicion of malignancy. In this case, an earlier diagnosis of the non-malignant cause of the pancreatic enlargement may have resulted in less invasive treatment of the fungal mass and prevented the Whipple resection. This case is presented for its rarity.

Keywords: Fungal ball hyalohyphomycosis

   AEP143 Top

   Hepatobiliary and Pancreatic Pathology Top

Conglomerate lesions of abdomen in an infant

S T Ramesh, J P Geetha, Rajendra Prasad

Sri Siddhartha Medical College, Tumkur, Karnataka, India

Case Report: A 11 months old infant presented with jaundice, and abdominal mass. Gross examination of Choledochal cyst measures 16x5.5x4 cms with ulcerated mucosa and thickened wall. Microscopy shows cyst lined by columnar epithelium with ulceration, mixed inflammatory cells and fibrous wall with normal pancreatic tissue. Liver shows nodular architecture with cholestasis, bile lakes, fibrosis with ductular proliferation. Discussion: Choledochal cyst is a rare congenital anomaly, more common in female infants. Choledochal cyst should be seriously considered in infants with Cholestatic jaundice as it is an important and treatable cause of cholestasis of infancy. A delay in diagnosis may lead to fatal complications like cholangitis and secondary biliary cirrhosis. Heterotrophic pancreatic tissue present on the wall of Choledochal cyst is a very rare entity. Conclusion: Choledochal cysts present in infantile form are an important cause of cholestasis of infancy. Early diagnosis is essential to prevent complications like secondary biliary cirrhosis and death. Prognosis after surgery is good.

Keywords: Biliary cirrhosis, choledochal cyst, infant

   AEP144 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

A malignant squeeze in an adolescent girl: A rare manifestation of a lymphoma

Haritha Chinthakayala, A S Ramaswamy, B N Kumarguru, Saranya Shankar

Department of Pathology, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Case Report: A 16 year old female was admitted to the cardiac critical care unit with clinical diagnosis of cardiac tamponade. She had a history of fever, breathlessness on exertion and cough since 1 week. Pericardiocentesis yielded 450 ml of reddish fluid. The cytological evaluation of the fluid revealed blasts of FAB ALL-L3 morphology. The peripheral blood evaluation also revealed these blasts. The flow cytometric evaluation of the blood sample confirmed diagnosis of B cell precursor ALL, CD 10 negative. The karyotype revealed hyperdiploidy clone, the findings suggestive of lymphoid malignancy of B cell type. Discussion: Hematolymphoid neoplasms have varied presentations of which pericardial effusion and cardiac tamponade are rare manifestations. Though described in ALL, AML, CML and primary effusion lymphomas, the number of cases are few in literature. In patients with lymphocytic effusions recognition of the lymphoma is challenging and requires the appropriate clinical context. Conclusion: Laboratory physicians must be aware for the critical diagnosis of hematolymphoid neoplasms which may rarely present as a cardiac tamponade.

Keywords: ALL, cardiac tamponade, effusion cytology

   AEP145 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Amoebic liver abscess – An immunological diagnosis!!!!!!

Disha Vyas, Shilpi Sahu, M B Hoogar, Naresh Kulkarni, Richa Shinglot, Shweta Munot

MGM Medical College, Navi Mumbai, Maharashtra, India

Case Report: A 57 year old male came with complaints of abdominal pain since 4 months, no other postive history. On CT scan, it was liver abscess. USG guided aspiration of pus was done and was sent for cytology and serum was sent for Enzyme immune assay for IgG against entomoeba histolytica. Discussion: 3 ml of venous blood in gel vacutainer is used and tested for Indirect hemagglutination test by enzyme immune assay [EIA]. IHA test detects antibody specific to E. Histolytica. Antibodies against serum IgG is positive. Conclusion: A simple blood test can diagnose amoebic liver abscess which is difficult to diagnose on stool sample or on radiological investigation. A simple, rapid, noninvasive test can diagnose the amoebic liver abscess and thus make the diagnosis easy and thus the timely treatment of the case.

Keywords: Amoebic liver abscess, pyogenic liver abscess

   AEP146 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

CSF eosinophilia: A diagnostic clue to allergic meningitis associated with ventricular shunt malfunction

Triza Shirole, Nina Desai, Rupali Parikh

Bombay Hospital, Mumbai, Maharashtra, India

Case Report: A 37 year old female, operated for posterior fossa meningioma with Ommaya reservoir presented with pseudomeningocele and CSF leak. The symptoms recurred a week later. CSF examination showed a raised eosinophil count of 80%. After an extensive workup was done to rule out fungal, bacterial or parasitic infection it was concluded that the cause of eosinophilia is noninfective. Eosinophilic meningitis associated with allergic reaction to the shunt material was diagnosed. Dexamethasone treatment significantly reduced the eosinophil count. Discussion: CSF eosinophilia is mainly associated with infections due to parasites, bacteria or fungi, but in the above case it was diagnosed to be as a result of the hypersensitivity reaction to the silicone of the Ommaya reservoir. Previous case reports by C R Kennedy et al. and Tanaka T et al. showed similar findings. In India only infectious eosinophilic meningitis has been reported in 2 case studies and 2 case reports. Conclusion: Detection of eosinophils in CSF is an important indicator of shunt malfunction and can lead to an appropriate diagnosis of an allergic reaction.

Keywords: Allergic meningitis, CSF eosinophilia, ventricular shunt malfunction

   AEP147 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Haemoglobin J Meerut: A rare structural haemoglobin variant

Elsie DSouza, A M Shanthala Devi

St John's Medical College, Bengaluru, Karnataka, India

Case Report: A 44 year old woman, native of Andhra Pradesh, underwent a routine health checkup and a variant haemoglobin (Hb) was detected on assessing HbA1c. She had no clinical symptoms or any significant past or family history. The haematological parameters were: Hb– 13 g/dl, packed cell volume – 41.2%, mean corpuscular volume -86.7 fl, mean corpuscular haemoglobin - 27.4 pg, mean corpuscular haemoglobin concentration – 31.6% and reticulocyte count – 1.65%. Peripheral blood smear was normocytic normochromic. High performance liquid chromatography (HPLC) Bio-Rad Variant II, showed the presence of an abnormal peak in the P3 window with a percentage of 23.7%, eluted at a retention time (RT) of 2.00 minutes with HbA– 67.9%, HbA2 – 2.3% and HbF– 1.1%. A diagnosis of HbJ Meerut was made by matching the RT with the Bio-Rad Library of Variants. Discussion: HbJ Meerut is characterized by the substitution of alanine with glutamate at codon 120 of the α-globin chain. It is a fast moving Hb which migrates anodally to HbA on alkaline gel electrophoresis. It shows an elevated P3 peak on HPLC with values more than 15-25% and a RT of 1.87-2.02 min. It can also spuriously lower HbA1c levels. Conclusion: Awareness of this Hb variant is essential as it is predominantly found in Asian Indians and can affect HbA1c measurements. In such instances its accurate detection can avoid mismanagement of diabetics.

Keywords: Fast moving haemoglobin, haemoglobin J Meerut, α-chain variants

   AEP148 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Cold agglutinin autoimmune haemolytic anaemia: A unique case

Deepali Singh, K Shashikala, Jyothi A Raj

Rajarajeswari Medical College and Hospital, DR M G R Educational and Research Institute, Kambipura, Karnataka, India

Case Report: A 7-year-old girl child presented to our Institute with complaints of fever since a week with cough, anemia and jaundice. Birth history, past medical history and Family history was non-contributory. Haematological and Biochemical parameters confirmed acute haemolytic blood picture with Aglutinins on peripheral smear. Antibody screening at 40 centigrade was positive. Direct agglutination test IgG-negative, C3b, C3d-positive. On USG abdomen and pelvis, hepatosplenomegaly was noted in later days. Discussion: In CAS, episodes of acute hemolysis are more common in winter months. Cold agglutinins were first described by Landsteiner in 1903. The association of cold haemagglutination with haemolysis was described in 1937 by Rosenthal and Corten. Cold agglutinin disease is caused by autoantibodies that react at temperatures <37°C. Etiology include, Idiopathic, Infections and Lymphoproliferative disorders. In Our case infection triggered an episode of acute hemolysis. Conclusion: CAD is not an indolent disease in terms of the major clinical symptoms and the quality of life. The plethora of problems that occur during the laboratory testing of CAD should be known to the pathologist to make an early and accurate diagnosis.

Keywords: Auto-immune haemolytic anaemia, cold agglutinin disease

   AEP149 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Common offender at uncommon site

Sindhu Sindhu, Sruthi Prasad, Chethana Mannem, Thejasvi Krishnamurthy

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: CASE 1: Synovial fluid from a 23-year-old male presenting with chronic pain and swelling in right knee showed caseous necrotic material with demonstrable acid-fast bacilli. Synovial biopsy revealed caseating granulomas. CASE 2: Semen analysis from a 27-year-old male for evaluation of primary infertility showed epithelioid cell granulomas with demonstrable acid-fast bacilli. Discussion: A definitive diagnosis of TB requires direct demonstration of acid-fast bacilli by special stains / culture / nucleic acid amplification. Of these, Ziehl-Nelsen stain is rapid and economical. Demonstration of organisms in synovial fluid and semen is extremely rare, with a positivity rate of 6.12% in the former and only an occasional case report in the latter. A delay in diagnosis of osteoarticular TB can lead to debilitation. Similarly, genital tuberculosis warrants specific treatment with ATT. Conclusion: The high burden of TB in India, warrants judicious screening of all body fluids, even in clinically unsuspected cases.

Keywords: Semen analysis, synovial fluid, tuberculosis

   AEP150 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Ependymoma with extensive microvillous inclusions signetting the morphology

Dega Vamseekrishna, Hemlata panwar, Adesh Shrivastava, Ujjawal Khurana, Ritika Johri, Deepti Joshi

Departments of Pathology and Lab Medicine and Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Case Report: A 50 year female presented with gradually progressive quadriparesis for 2 years, associated with tingling and numbness and incontinence. MRI revealed an intramedullary cervical tumor. Pink soft vascular tumor was excised and sent for squash cytology which revealed low grade glial neoplasm with possibility of ependymoma. Histopathology showed tumor cells arranged in papillary and perivascular pattern with round to oval nuclei, vacuolated eosinophilic cytoplasm, few cells had pseudo signet ring morphology (microvillous inclusions). A second case of 10 year male presented with ataxia and incontinence. MRI revealed malignant tumor in 4th ventricle. Excised tumor sent for squash and histopathological examination. H&E section showed tumor cells arranged in perivascular pseudorosettes with tumor cells depicting intracytoplasmic eosinophilic inclusions. Extracellular hyaline bodies also seen. Discussion: Extensive vacuolation with pseudo signet-ring cells are unconventional histopathological patterns seen in ependymomas probably a common degenerative phenomenon secondary to hypoxic insult. Conclusion: It is important to understand the unconventional pathological patterns of Ependymoma owing to its confusion with metastatic signet-ring cell adenocarcinoma; the management of the two diagnostic entities being entirely different.

Keywords: Ependymoma, inclusions, perivascular, pseudorosettes

   AEP151 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Immunomodulatory potential of circulatory exosomes from renal transplant recipients on in-vitro stimulated T cells: Initial experience from a tertiary care centre

Michael Kaniamparampil, Devika Gupta, Parikshit Sanyal, D K Mitra

Command Hospital (EC), Kolkata, West Bengal, India

Case Report: Exosomes were purified from transplant recipients having well functioning grafts and those having acute graft dysfunction. Acute graft dysfunction is typically diagnosed by measuring serum creatinine concentrations (35% above baseline during post transplant period). Healthy peripheral blood mononuclear cells (PBMCs) were stimulated with exosomes isolated from these patients and healthy controls in the presence CD3/CD28 co stimulation. Production of pro inflammatory cytokines interferon (IFN)-γ, tumor necrosis factor (TNF)-α and anti-inflammatory cytokines interleukin (IL)-10 & transforming growth factor (TGF -β) were measured using flow cytometry. Discussion: Exosomes from renal transplant recipients induced a higher production of TGF-β in T cells compared to healthy exosomes. Levels of IFN-γ, TNF-α and IL-10 in T cells however remained unaffected with exosome stimulation. Exosomes that were mechanically disrupted failed to induce any significant TGF-β production. Amongst renal transplant recipients, those having acute graft dysfunction had reduced TGF β expression in T cells compared to well functioning grafts upon stimulation with exosomes. Conclusion: The circulating exosomes in renal transplant recipients are immunologically active and induces regulatory response and allograft tolerance through production of TGF β in T cells.

Keywords: Acute graft dysfunction, exosomes, renal transplant

   AEP152 Top

   Laboratory Medicine (Biochemistry, Clinical Pathology, Immunology, Microbiology) Top

Microbial profile of phlebotomy tourniquets: An institutional study

Subhashish Das, Nikhil, Arvind Natrajan

Sri Devaraj Urs Medical College, Kolar, Karnataka, India

Case Report: Materials and Methods: Laboratory based cross sectional study performed on 200 tourniquets collected from different hospital wards, ICU and OPD, irrespective of type (plastic or rubber) were sampled and torn tourniquets were excluded. The samples were cultured, and microorganisms were identified and antibiotic sensitivity testing was performed using standard methods. A questionnaire was administered simultaneously to 100 participating health care workers. Descriptive data were represented as frequencies and percentages. Institutional Ethical clearance was obtained. Discussion: Results and Discussion Bacterial colonization rate of the 200 tourniquets was 85%. The highest tourniquet colonization was in the ICU (62.4%), followed by the wards (22.4%). The most prevalent isolate on tourniquets were Coagulase-negative staphylococci (29.4%) followed by Staphylococcus aureus (28.2%) while Escherichia coli was the least (3.5%) encountered isolate. 90% of the respondents agreed that hospital staff and fomites can transmit infection, none identified tourniquets as a potential infective source. Conclusion: Tourniquets are a potential reservoir and vehicle for the spread of nosocomial infections. Knowledge regarding infection control procedures and personal hygiene appears to be deficient and efforts must be made to promote awareness about them.

Keywords: Health care personnel, nosocomial infection, phlebotomy, Tourniquet

   AEP153 Top

   Lymphoreticular Pathology Top

Follicular lymphoma masquerading as submandibular sialadenitis

Ngangkham Shinhenleima, J P Geetha, H Chaithra

Department of Pathology, Sri Siddhartha Medical College, Tumkur, Karnataka, India

Case Report: A 59-year-old male patient presented with left submandibular swelling since 2 years. Clinically diagnosed as Chronic Sialadenitis. PET CT showed the findings of Lymphoproliferative disease. Histopathological correlation of Left Submandibular Sialadenectomy was done. Grossly Multiple grey white nodular soft tissue masses on C/S grey white to in appearance. Microscopically, increased monotonous appearing neoplastic follicles, ill-defined and lacking well preserved mantle zones. The follicles appeared expansile and arranged in back-to-back fashion. The neoplastic follicles showed numerous cetrocytes and few centroblasts. Atypical mitosis noted. Salivary tissue showed both serous and mucinous acini and mild chronic inflammation. IHC was suggested which showed positive for CD20, CD10, Bcl2, Bcl6 and negative for cyclin D1. Discussion: The lesion arising in lymph node in the submandibular region was diagnosed as follicular lymphoma based on histopathological finding that the lesion was composed of number of follicles formed by cells showing irregular segmented nuclei, as well as immunological findings of neoplastic cell express CD10, CD19 and Bcl2. Conclusion: -The manner of spreading of lymphoma indicating that primary lesion originated in submandibular region however nodal non-Hodgkin's lymphoma especially follicular lymphoma arising in the oral region are very rare. A possible relationship of sialadenitis and initiation of lymphoma was not detected by present examination.

Keywords: Chronic sialadenitis, follicular lymphoma, submandibular region

   AEP154 Top

   Lymphoreticular Pathology Top

Primary non-parasitic cystic lesions of spleen mimicking hydatid cyst on radiology – A case series

Sharon Johnson, Vamseedhar Annam, Jyothi A Raj

Rajarajeswari Medical College and Hospital, DR M G R Educational and Research Institute, Bengaluru, Karnataka, India

Case Report: 1. A 31-year-old lady presented with abdominal pain in the epigastric region for 20 days. Radiology findings revealed possibility of chronic abscess or hydatid cyst. Splenectomy was done and sent for histopathology examination which confirmed the diagnosis of dermoid cyst. 2. A 62-year-old-elderly woman presented with upper abdominal pain and nausea for three months. Radiology findings were suspicious of abscess or hydatid cyst. Open splenectomy was done and sent for histopathology which confirmed a simple cyst. 3. A 23-year-old lady presented with abdominal pain for one month. Radiology findings detected epithelial cyst or hydatid cyst. Splenectomy was done and histopathology confirmed diagnosis of epithelial cyst. Discussion: Primary nonparasitic cystic lesions of spleen are unusual. Various hypotheses have been postulated regarding its etiopathogenesis, like developmental misplacement of epithelial tissue, invagination of capsular mesothelium, trauma, etc. have been considered. Though benign in nature, yet surgery is essential to avoid serious complications. Conclusion: Primary nonparasitic splenic cysts are rare lesions. Each type of splenic cyst has a distinctive feature. The diagnosis of type of splenic cyst relies on histopathology.

Keywords: Cyst, primary, spleen

   AEP155 Top

   Lymphoreticular Pathology Top

A case report – Burkitts lymphoma, core needle biopsy

Swapnika Goud, J H Shwetha, Vardendra Kulkarni

JJMMC, Davanagere, Karnataka, India

Case Report: A 11 year girl presented with abdominal distension, pain, swelling in the right lower abdomen since few days. Previously diagnosed as tuberculosis of abdomen and was on antitubercular drugs for 6 months no improvement seen. On examination a solitary swelling noted in the right lumbar region, measuring 5x5 cm, firm, mobile, tender. Imprint taken from core needle biopsy of swelling, grey yellow to grey white aspirate yielded. Microscopy showed cellular smears with monomorphic population of lymphoid cells predominantly of large immature cells with high N:C ratio, vesicular nucleus with inconspicuous nucleoli against haemorrhagic background. Plenty of atypical cells seen with atypical forms. On histopathological examination the section studied showed lymphoid tissue with monomorphic population of lymphoid cells having enlarged nuclei, scant amount of basophilic cytoplasm with infrequent vacuolations. Good number of mitotic figures, tangible body macrophages seen. No evidence of granuloma or necrosis in section studied. Features suggestive of Lymphoproliferative disorder, possibility of Burkits lymphoma. IHC – C myc marker positive. Discussion: Diagnosis of intra-abdominal Burkitt's lymphoma is often delayed, as symptoms could be nonspecific or even absent. Conclusion: Burkitts Lymphoma in childhood have an excellent overall prognosis on chemotherapy.

Keywords: Burkitts lymphoma, intraabdominal lymphnodes

   AEP156 Top

   Lymphoreticular Pathology Top

Unicentric castleman disease – A case report of rare tumor

Ankita Kayande, Purwa R Patil, Sanjay R Bijwe

Grant Government Medical College, Mumbai, Maharashtra, India

Case Report: 15 years female complaining of swelling over left supraclavicular region since birth, increasing progressively in size since past 1 year. On examination, it was mobile, firm, approx. 4x4x3 cm in size. On CECT Thorax and abdomen, suspicious of lymphoma. No evidence of thoracic or abdominal lymphadenopathy. FNAC suggestive of reactive hyperplasia. Discussion: Lymph node was excised and sent for HPR as one large nodal mass measuring 4x3x2 cm. Externally, brown in colour with focally intact capsule. Cut surface was pale, whitish, homogeneous, soft. Microscopy revealed lymph node of well preserved architecture showing increased number of lymphoid follicles containing two or more germinal centres, rich in dendritic cells and with hyaline deposits. Mantle zone showed rings of small lymphocytes. Interfollicular region showed sclerotic blood vessels, plump endothelial cells, few plasma cells and eosinophils. Diagnosed HVCD. IHC performed. HVCD is the most common type, accounting for 80%–90% of cases. Conclusion: UCD is best managed by surgical resection. Concerning the possibility of malignant transformation (lymphoma), do close follow-up.

Keywords: Castleman disease, lymph node, lymphoproliferative

   AEP157 Top

   Lymphoreticular Pathology Top

Giant diffuse large B cell lymphoma in mesentery – An unusual presentation

Sriram Prasad, G V Chaithra

Kasturba Medical College, Mangalore, Karnataka, India

Case Report: • A 54-year-old man presented with mass per abdomen for evaluation • MRI scan of Abdomen revealed a large lobulated heterogeneously enhancing lesion with internal haemorrhage in the mesentery, displacing adjacent bowel loops.• Patient was taken up for surgery with clinical diagnosis favouring GIST. Mass measuring 25x30 cm was seen encasing branches of small mesenteric artery and vein along with multiple lymph nodes. • Excised mass with resected ileum, cecum and part of jejunum was sent for histopathology examination.• Histopathology diagnosis of Non Hodgkin lymphoma was given based on morphology.• Further Immunohistochemistry identified it as Diffuse Large B cell Lymphoma of germinal centre with expression of CD 20, CD 79a, CD 10, Bcl 6 markers. Discussion: DLBCL is a heterogenous tumour of lymphocyte proliferation. It presents as a rapidly enlarging mass, arising from virtually anywhere in the body, and is fatal if left untreated. Clinical presentation of this case as a single large mass in mesentry favoured a diagnosis of GIST. Morphologically, they comprised of sheets of medium sized discohesive cells. Tumor cells expressed CD20, which is a pan B cell marker. Conclusion: Conclusion – High grade B cell lymphoma has to be considered as a possibility in a case of large mesenteric mass.

Keywords: Diffuse large B-cell lymphoma, mesentery, non-Hodgkin's lymphoma

   AEP158 Top

   Lymphoreticular Pathology Top

B cell lymphoma, unclassifiable with features intermediate between classic Hodgkin lymphoma and diffuse large B cell lymphoma

Akshay Kalra, Meetu Agrawal, Vyomika Teckchandani, Kaushal Kalra, Sunil Ranga

Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Case Report: A 14 year-old male patient presented with massive cervical lymphadenopathy. After initial clinical evaluation, a cervical lymph node was biopsied. Grossly, it measured 1.5×1.2×0.8 cms. Sections examined showed effaced architecture, with a polymorphous population of reactive lymphoid cells and large mononuclear (Reed Sternberg like) cells with moderate amount of cytoplasm with round to oval nucleus with prominent nucleoli with perinuclear halo. The atypical cells on IHC showed strong positivity for CD20, CD30 and showed expression for PAX5 in large cells. BCL6 was also variably positive. These cells were positive for LCA. CD3 was positive in background lymphocytes. Discussion: T cell rich B Cell Lymphoma and Hodgkin's Lymphoma were strong contenders for diagnosis in this case. Despite having clearly discernible IHC features, this case posed a diagnostic challenge and was finally decided as a grey zone lymphoma. (B cell Lymphoma-unclassifiable, with features intermediate between DLBL and HL). Conclusion: Careful scrutiny of morphological and IHC features strictly as per the WHO bluebook helps to diagnose these problematic cases.

Keywords: BCL6, CD20, grey zone lymphoma, LCA

   AEP159 Top

   Lymphoreticular Pathology Top

An unusual finding in a case of paraphimosis

Ankitha Hebbar, Vidya Monappa, Mary Mathew

Kasturba Medical College, Manipal, Karnataka, India

Introduction: Paraphimosis in elderly males is often seen in diabetes or following prolonged catheterization. It can rarely be due to an underlying malignancy. Here we report a case of Extranodal NK/T cell lymphoma, nasal type (ENKL) in a patient presenting with paraphimosis. Case Report: A 62 year old male presented with paraphimosis and right hydrocele. Circumcision and right hydrocelectomy was performed. The prepucial skin revealed multiple dermal vessels with focal fibrinoid necrosis, intravascular atypical lymphoid cells and fibrin thrombi. The lymphoid cells were positive for CD45, CD3, CD30 and CD56. CK, CD20, CD5, CD10 stained negatively. A diagnosis of ENKL was offered. The patient meanwhile had burning sensation around the nose and an endoscopic debridement of right paranasal sinuses was performed. Microscopy revealed ulcerated mucosa and diffuse infiltration by sheets of medium to large lymphoid cells with increased mitosis, necrotic areas and angioinvasion consistent with ENKL. Discussion: ENKL most commonly involves the palate and nasal fossa. The histological diagnosis of this EBV associated lymphoma can be difficult due to extensive tissue necrosis, angiodestruction and varied morphology. The neoplastic cells can invade the vascular walls with resultant thrombosis and widespread necrosis. Conclusion: Although ENKL can involve multiple extranodal sites, there are no reported cases of penile foreskin involvement causing paraphimosis. Immunohistochemistry can help in arriving at this diagnosis. Early diagnosis and treatment are key to improve survival of patients with ENKL as it is an extremely rare and aggressive tumor with very low survival rates.

Keywords: Angioinvasion, ENKL, paraphimosis

   AEP160 Top

   Lymphoreticular Pathology Top

Camouflage in a cervical lymphnode; a case record

J P Geetha, C S Gurukiran

Sri Siddhartha Medical College, Tumkur, Karnataka, India

Case Report: A 49 year old male presented with swelling in the neck, treated for granulomatous lymphadenitis elsewhere. Clinician suspected Lymphoma because of persistent enlarged neck nodes. Lymphnode biopsy were sent. It showed partial effacement of architecture with nests and whorls of ovoid to spindle shaped tumour cells. They showed ovoid nucleus with fine chromatin and indistinct cell borders. Variable mitotic activity of 2-4/hpf. Intervening fibrous bands are noted with lymphocytes, plasma cells and eosinophils. Residual lymphoid tissue was seen focally and extranodal soft tissue also showed tumour. Diagnosis of Follicular dendritic cell sarcoma was offered with D/D of metastatic deposit. Immunohistochemistry showed positivity for PanCK, EBER, p40 and p63. Negative for Vimentin and CD21 with a diagnosis of Metastatic Nasopharyngeal carcinoma, EBV associated. Discussion: Few investigators have attributed the high frequency of LN metastasis in Nasopharyngeal carcinomas to the abundance of lymphatic tissues in the posterior wall of the nasopharynx. Conclusion: This case suggests Lymphnode pathology is varied. Morphology, Complete clinical workup and Immunohistochemistry helped in arriving a final diagnosis and proper management of the patient.

Keywords: Cervical lymphnode, follicular dendritic cell sarcoma, immunohistochemistry, metastatic NPC

   AEP161 Top

   Miscellaneous Top

Angiomyofibroblastoma of broad ligament: A case report

Monica Kandoth, Kausalya Kumari Sahu, Cheryl Sarah Philipose, Ashfaque Mohammed, Sharada Rai, G V Chaithra

Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka, India

Case Report: Angiomyofibroblastoma (AMFB) is a rare benign mesenchymal tumour that commonly occurs in the vulva. However, AMFB of the broad ligament is an exceedingly rare occurrence. To the best of our knowledge, the present case is the third report of AMFB arising from the broad ligament. Discussion: A 32 year old female presented with complaints of primary amenorrhea, mass per abdomen and weight loss since 3 months. On examination, an abdominal-pelvic mass corresponding to 32 weeks size occupying the hypogastrium, left and right iliac fossa, right and left lumbar areas and epigastrium was noted. The mass was smooth, firm in consistency and non-mobile. On biochemical examination CA125 level was 24.97 units/ml and CEA level was 1.400 ng/ml. CT scan showed a large well defined heterogeneously enhancing abdominopelvic soft tissue density mass lesion, suspicious of GIST. Histopathology and IHC findings were in favour of Angiomyofibroblastoma of Left Broad Ligament. Conclusion: Angiomyofibroblastoma of the broad ligament is a rare entity and can pose a significant diagnostic challenge to the pathologist and needs to be considered among the differential diagnosis of tumours of the broad ligament.

Keywords: Angiomyofibroblastoma, broad ligament, mesenchymal tumour

   AEP162 Top

   Miscellaneous Top

Cervical hemangioma – A case report

Shradha Sharma, Subhash Bhardwaj, Deepa Hans

Government Medical College, Jammu, Jammu and Kashmir, India

Case Report: We present a case of a 23 years old female who presented to out patient department with complaints of bleeding per vaginum. Discussion: On speculum examination fresh vaginal spotting was present. A tongue shape spongy vascular polypoidal mass was hanging from the posterior lip of the cervix the surface of this mass showed fresh spotting. After routine investigations she was admitted for removal of polyp. Polypectomy was done. The histopathological evaluation of the specimen revealed as the cavernous hemangioma of the cervix. Conclusion: Hemangiomas of the cervix are rare lesions that are often discovered during routine histologic examination of the hysterectomy specimen. To the best of our best knowledge this is the first case of cavernous cervical hemangioma reported from our institute.

Keywords: Cavernous, cervical, hemangioma

   AEP163 Top

   Miscellaneous Top

Swyer syndrome in a woman with pure 46, XY gonads – A case report

Khushbu Bhalodiya, Mansi Thacker, D N Lanjewar

Gujarat Adani Institute of Medical Sciences and G K General Hospital, Bhuj, Gujarat, India

Case Report: A 29 year old female presented with primary amenorrhea with underdeveloped secondary sexual characteristics and well-developed external genitalia. USG and MRI showed hypoplastic uterus and bilateral hypoplastic ovaries. The laboratory investigations showed FSH 69.56 mIU/ml, testosterone <0.13 ng/ml and GH 1.29 ng/ml. The karyotyping showed non-mosaic 46XY. She was operated for bilateral salpingectomy and gonadectomy. Histology confirmed bilateral fallopian tubes and streak gonads showed seminiferous tubules and leydig cells. Discussion: The incidence of Swyer syndrome is 1:100,000, only 11 cases are reported in Indian literature. People with Swyer syndrome are typically raised as girls and have an identity of a female. The main differential diagnosis of Swyer syndrome is mixed gonadal dysgenesis. Gonadoblastomas are seen in 20-30% of women with Swyer syndrome. As ovaries are not functional, patients with Swyer syndrome are usually given hormone replacement therapy (HRT) during adolescence. They can conceive using donor oocytes and artificial reproductive techniques. In case of hypoplastic uterus surrogacy can be tried. Conclusion: Histopathology and genetic testing play an important role in diagnosis of Swyer syndrome. There is a need for removal of the gonads as risk of gonadal malignancy is more. Early institution of HRT is important for induction of puberty. Patients need counseling regarding fertility options.

Keywords: Gonadal dysgenesis, gonadectomy, primary amenorrhea, Swyer syndrome

   AEP164 Top

   Miscellaneous Top

Rhabdomyosarcoma of long bone: A case report

Shilpa Thakur, Jyotsna Suri, Deepa Hans

Government Medical College, Jammu, Jammu and Kashmir, India

Case Report: Herein, we present a case report of Rhabdomyosarcoma of the right Proximal Humerus in a 72 year old male. Discussion: A 72 years old male who presented with painful right shoulder mass. It was located at the upper 1/3rd portion of the right arm. MRI of the right shoulder showed ill defined lobulated, moderately enhancing lesion in proximal humerus with cortical destruction and extension suggestive of neoplastic pathology likely metastatic. Wide excision was done and the specimen was sent for HPE. Microscopic examination showed histological features of Rhabdomyosarcoma. Conclusion: This case report demonstrates an exceptionally rare malignancy in an old patient. Rhabdomyosarcoma may present as one of the tumor components in bone sarcomas, such as dedifferentiated chondrosarcoma or malignant mesenchymoma. It is difficult to diagnose due to its relatively rare occurrence, its significant clinical and biological heterogenecity. However, the histo-morphological and immuno-histochemical findings of a tumor are helpful for diagnosis.

Keywords: Humerus, rhabdomyosarcoma

   AEP165 Top

   Miscellaneous Top

Pleomorphic adenoma: A case report

Silvi Sandhu, Ruchi Khajuria, Ameet Kaur

GMC, Jammu, Jammu and Kashmir, India

Case Report: This is a case report of a small 0.8 X 0.5 cm swelling in the left side of the upper lip, near the angle of mouth in a healthy male. The swelling was well circumscribed. Cytological examination of the aspirate from the swelling was done. It was later excised with 2 mm safe margin under local anaesthesia. Wound healed completely with no local complication and no evidence of recurrence in 1 year. Discussion: Minor salivary glands in the head and neck are well documented including the upper lip. Pleomorphic adenoma has a unified histopathological feature that can be diagnosed by expert histopathologist. The differentials include adenoid cystic carcinoma, polymorphous adenocarcinoma, epithelial myoepithelial carcinoma. These can be easily missed especially if the specimen is not sent to histopathology. Conclusion: Pleomorphic adenoma of the lips are rare. The best option of treatment is complete wide surgical excision. For correct diagnosis, the excised lesion must be sent for histopathological examination.

Keywords: Mixed tumor, pleomorphic adenoma, upper lip

   AEP166 Top

   Miscellaneous Top

Lipoleiomyoma: An unusual incidental finding in a case of uterine endometrioid carcinoma

C Deepika, Shilpa, A Hemalatha, Abhay K Kattepur, Nikhil

Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India

Case Report: A 65 year old multigravida female presented with complaints of non foul smelling white discharge per vagina. Endometrial biopsy was done and on histopathology it was reported as an endometrial adenocarcinoma with clear cell changes. USG was done and it was suggestive of endometrial carcinoma. The patient underwent total abdominal hysterectomy with Bilateral Salphingo oophorectomy and specimen was sent for histopathology examination and reported as moderately differentiated endometrioid carcinoma with lipoleiomyoma pT1bN0Mx-stageIB, FIGO grade IB. Discussion: The pathogenesis of lipoleiomyomas is multifactorial. The generally accepted theories are that lipoleiomyoma might arise from direct transformation of smooth muscle cells or transformation of totipotent mesenchymal cells. Also decrease in level of estrogen after menopause appear to play an important key role. The co existence of gynecological malignancies which originate from uterus, cervix and ovaries are reported in only few cases. Conclusion: Uterine Lipoleiomyoma are rare unusual leiomyomas. There are many proposed theories for the pathogenesis of lipoleiomyoma. There are less reports regarding the coexistence of lipoleiomyoma and gynaecological malignancies.

Keywords: Coexistence, lipomatous tumour, malignancy

   AEP167 Top

   Miscellaneous Top

Synchronous dual malignancies diagnosed over 01 year: Solid-solid and solid-hematological tumors, is it rare?

Kumari Ankita, Devika Gupta, Prasanta Sengupta, Kanwaljeet Singh, Arnab Bandyopadhyay, Madan Gopal Vishnoi

Command Hospital (EC), Kolkata, West Bengal, India

Case Report: This was a retrospective analysis of 06 patients diagnosed with histologically & haematologically confirmed synchronous double malignancy over last one year at our centre. Discussion: Out of six cases, four were pure solid organ malignancies whereas other two were solid-hematological malignancy combinations. Two cases were of papillary thyroid carcinoma with coexisting invasive Breast carcinoma, third was a squamous cell carcinoma of Larynx & renal cell carcinoma, fourth was squamous cell carcinoma of cervix with invasive carcinoma breast and fourth and fifth were both carcinoma stomach with AML M4 & MDS-MPN respectively. Conclusion: The present series suggests that the occurrence of second synchronous malignancy is not rare in Indian cancer patients. The double malignancies can occur at any stage and for any type of cancer. Hence, we wish to highlight that the clinicians should always be aware and have high index of suspicion for second malignancy.

Keywords: Dual malignancy, metachronous, synchronous

   AEP168 Top

   Miscellaneous Top

Histoplasmosis – A case report in a 42-years male presenting with ileal perforation

Nikita Soodan, Rupali Bargotra, Ameet Kaur

Government Medical College, Jammu, Jammu and Kashmir, India

Case Report: Here we report a case of Histoplasmosis in a 42-years male who presented with perforation peritonitis. Discussion: Computed Tomography (CECT Scan) of abdomen and pelvis revealed a perforated ileal segment with bowel wall thickening and peritonitis. Patient was taken for Exploratory Laparotomy with primary closure of ileal perforation. Hematoxylin and PAS stained sections from the edge biopsy of the ulcer showed sloughed off necrotic tissue and fungal spores and small, round to ovoid, narrow based budding yeast forms measuring 2-5 micrometers mixed with chronic inflammatory cell infiltrate. Conclusion: Systemic Histoplasmosis is typically acquired through inhalation of microconidia or small hyphal elements in soil contaminated with bird and bat droppings leading to primary infection as acute or chronic pulmonary histoplasmosis or acute or subacute or chronic disseminated histoplasmosis. Gastrointestinal involvement occurs in 70-90% cases. Diagnosis is usually suspected on visualization of characteristic intracellular yeast (blastoconidias), the pathogenic form, with a clear rim and granulomatous cellular infiltrate in tissue specimen.

Keywords: Blastoconidias, histoplasmosis, ileal perforation

   AEP169 Top

   Miscellaneous Top

Association of Naegleria Fowleri with mucormycosis in a known COVID patient: A rare case report

Aarushi Soota, Surekha Bhalekar, Divya Shetty, Rajiv Rao

D Y Patil School of Medicine, Mumbai, Maharashtra, India

Case Report: A 33 year-old man presented with right facial swelling, nasal crusting and discharge. Patient was RT-PCR positive for COVID-19. Tissue from right maxillary sinus and right middle turbinate were sent for histopathology. On histopathology, multiple fungal colonies having broad, aseptate hyphae with right angle branching were seen along with collection of ovoid structures with centrally placed nuclei, foamy cytoplasm and erythrophagocytosis. Fungal organisms as well as the ovoid structures were Periodic Acid-Schiff positive. Trichrome stain was positive in the ovoid structures but CD68 was negative, suggestive of trophozoites of amoeba, possibly Naegleria Fowleri (due to the site of infection). Thus, a diagnosis of mucormycosis and amoebic trophozoites, possibly of Naegleria Fowleri was given. Discussion: Numerous co-infections of different etiology and associated complications have been encountered in patients of COVID-19. N.fowleri is a free-living amoeba that grows best at elevated temperatures. It penetrates through the cribriform plate and causes primary amoebic meningoencephalitis that has a very high mortality rate. Conclusion: In conclusion, this report describes association of N.fowleri with mucomycosis and it's utmost importance for treatment and prognosis of patient. Early diagnosis and aggressive treatment may save lives.

Keywords: Coronavirus, mucormycosis, Naegleria fowleri

   AEP170 Top

   Miscellaneous Top

Acute sickle cell crisis in a primigravida with twin pregnancy: A case report

Neoky Suiam, Surekha Bhalekar, Prakash Dive, Rajiv Rao

D Y Patil School of Medicine, Mumbai, Maharashtra, India

Case Report: A 33 year old female, primigravida with 23 weeks of gestation, presented with vaginal discharge on and off since 1 month. Patient was a known case of sickle cell anaemia since 12 years. On ultrasonography, a twin intrauterine gestation with Diamniotic Dichorionic placenta was noted. She had 3 episodes of sickling crisis during the course of hospitalisation. Second trimester abortion occurred at 25 weeks of gestation. On histopathology: Umbilical cord of Placenta 1 shows features of pan vasculitis, focal funisitis and Placenta 2 shows features of phlebitis. Membranes of both Placenta 1 and 2 show features of Maternal inflammatory response, stage 1 chorionitis, placental disc shows features of Maternal vascular malperfusion. Discussion: Pregnant women with Sickle cell anemia are known to be at high risk of obstetrical complications. Like many observational studies Silva Pinto et al, Leborgne - Samuel et al confirms this high complication rate in both mother and fetus. In our case report there was maternal complication along with fetal mortality. Conclusion: In pregnancy women are at a higher risk of developing acute sickle cell crisis, mainly in the third trimester and therefore early prenatal diagnosis and educating the patients regarding sickle related complications is necessary to avoid maternal and fetal mortality.

Keywords: Maternal and fetal mortality, sickle cell anemia, twin pregnancy

   AEP171 Top

   Miscellaneous Top

Epithelial-myoepithelial carcinoma of the parotid gland – A rare case entity

Ashwini Moger, S R Mangala Gouri, Ayesha Bhavikatti

M S Ramaiah Medical College, Bengaluru, Karnataka, India

Case Report: 74 year old female patient presented with painless swelling of 3X2 cm in left preauricular region since 1 year. No history of fever and no palpable cervical lymphadenopathy. Facial nerve function was intact. All other findings in general examination were within normal limit. Pre-operative FNAC based diagnosis was pleomorphic adenoma of left parotid gland. Histopathological diagnosis was Epithelial- Myoepithelial carcinoma with vascular invasion. The patient was treated with surgery followed by post operative radiotherapy. Discussion: Epithelial- Myoepithelial carcinoma is a rare biphasic tumor with low malignant potential. Although it is a low grade tumor, they are known to have a high rate of recurrence and metastatic potential. Clinical and radiological findings often mimic a benign tumor. FNAC may show a benign histology. Hence FNAC cannot be taken as the confirmatory diagnosis. Diagnosis is mainly done by histopathology and immunohistochemistry. Conclusion: Though Epithelial- Myoepithelial carcinoma is very rare it should not be missed as under treatment can lead to recurrence and reduce the survival of patient.

Keywords: Epithelial myoepithelial carcinoma, parotid gland

   AEP172 Top

   Miscellaneous Top

A conundrum of swelling in neck

Sri Devi, G Gayathri, K Swaminathan

Tirunelveli Medical College and Hospital, Tirunelveli, Tamil Nadu, India

Case Report: A case of 24 y/male admitted for evaluation of swelling left side of neck for 3 months. CT: well defined multilobulated multiseptated cystic lesion - possibility of lymphangioma. No lymphadenopathy. Excision biopsy was done and sent for HPE. Discussion: Received specimen of cystic mass measuring 9x6.5x4.5 cm. External surface: capsule intact, smooth. Cut surface: multiloculated cyst filled with pale yellow coloured clear fluid. No solid areas made out. Microscopically shows classical features of mature cystic teratoma composed of multiple cysts lined by stratified squamous epithelium filled with lamellated keratin flakes, few cysts lined by columnar epithelium filled with eosinophilic secretions and these cysts are intervened by dense fibrous stroma with nerve bundles, strips of skeletal muscle fibres, blood vessels and adnexal structures. Conclusion: Teratomas originates from totipotent germ cells present in ovary, testis and abnormal midline embryonic rests which can differentiate into recognizble mature/ immature cells of >1 germ cell layer and hence give rise to neoplasms in a helter-skelter fashion. Cervical teratomas constitutes 1.5% of all teratomas, most of which are diagnosed before birth, thereby implicating its extreme rarity in adults.

Keywords: Adult, neck, teratoma

   AEP173 Top

   Miscellaneous Top

Metastatic oncocytic carcinoma of the parotid gland to the external auditory canal: A case report

K A Krithika, Prerna Mahajan, Kaniyappan Nambiyar, Nadeem Tanveer, Priyanka Gogoi

University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Case Report: A 46-year-old female initially presented with left parotid swelling of 3 years duration. It was 4x4 cm, firm-hard, non-tender and immobile. CECT neck suggested left parotid neoplasm, extending into neighboring tissue without bony erosions. FNA showed sheets of oncocytic cells in lymphoid background, suggestive of oncocytic neoplasm. The left total parotidectomy specimen showed oncocytic cells in lobules with focal nuclear atypia, infiltrative margins and perineural invasion. Areas of tumor necrosis and desmoplastic areas with sclerotic changes were seen. Based on this, a diagnosis of oncocytic carcinoma was offered. The tumor was resected in total with negative margins. The patient later presented with a left auditory canal mass, after 18 months of initial presentation. Histopathological examination confirmed the presence of metastasis from the parotid oncocytic carcinoma. Discussion: Oncocytic carcinoma is most commonly reported in the parotid followed by the submandibular gland. Its malignant nature is defined by cellular atypia, perivascular, perineural or lymphatic invasion, mitosis, necrosis and local or distant metastasis. Distant metastasis has been reported to be the most important prognostic factor. Conclusion: As oncocytic carcinoma is a rare entity, we report this case to document its histopathological features and to emphasize the prognostic significance of metastasis.

Keywords: Metastasis, oncocytic-carcinoma, parotid

   AEP174 Top

   Miscellaneous Top

Nasal meningoencephalocele – A rare entity

N Rashmi, M B Bharati, S M Choukimath, Purushotham Reddy

Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Case Report: 18 year/male with right sided nasal obstruction since 10 years associated with mouth breathing, snoring, hyponasal speech. Past history of hospital admission for meningitis 2 years back (details unknown). Examination: NOSE: Externally:Dorsum deviated to right Cold spatula test – Decreased on right side Anterior rhinoscopy & diagnostic nasal endoscopy: Septum deviated to left side. A pale, mildly bosselated polypoidal tissue arising from cribriform plate, covering the entire nasal cavity on right middle meatus. So, diagnosis of Nasal meningoencephalocele with basal defect is made. CT suggesting as Nasal polyp. MRI suggesting as Nasal meningocele. Endoscopic excision of meningocele with base defect repair was done. Specimen sent for histopathological examination. Histopathology report: Diagnosed as Nasal meningoencephalocele. Discussion: Encephalocele consists of meninges alone are called meningocele and can also include brain tissue called meningoencephalocele. Rare condition with congenital, traumatic and spontaneous origin. First medical report was published in 16th century. Divided into 3 main groups depending on the defect location-Basal, sincipital and occipital (most common). Nasal gliomas & encephalocele predominantly appear in pediatric age group. Conclusion: Children with breathing difficulties who were diagnosed with tissue mass in nasal cavity, meningoencephalocele/ meningocele should be in one of the differential diagnosis. Nasal mass on the floor of anterior fossa are an absolute indication for histopathological examination.

Keywords: Multidisciplinary, management, success rate, outcome

   AEP175 Top

   Miscellaneous Top

Biphenotypic sinonasal sarcoma – Is it really so rare?

Gauri Kumari, Nimisha Dhankar, Varuna Mallya, Shramana Mandal, Nita Khurana, Ravi Mehar

Maulana Azad Medical College, New Delhi, India

Case Report: Total 18 spindle cell lesions over a span of 7 years were independently reviewed by 2 pathologists. 13 cases showed low grade morphology and were subjected to IHC panel of CK, Vimentin, SMA, S 100, Myogenin, Myo D1, Desmin, CD34, bcl2 and CD1a. Out of 13 cases, 3 showed characteristic features of BSNS, composed of infiltrating monomorphic spindle cells arranged in fascicles showing no necrosis, infrrequent mitosis & dual expression of S100 & SMA. Discussion: These 3 lesions were identified at extranasal sites: uvula, parapharyngeal space & gingivobuccal sulcus. These patients are currently on follow up & disease free. Conclusion: Histological features of BSNS show a considerable overlap with other spindle cell lesions- monophasic synovial sarcoma, fibrosarcoma, solitary fibrous tumour & malignant peripheral neve sheath tumor. Its diagnosis requires biphenotypic character by expression of neural and myogenic markers. This entity should be considered as a differential for slow growing spindle cell lesion in Head & Neck.

Keywords: Biphenotypic, extranasal, myogenic, neural, sinonasal sarcoma

   AEP176 Top

   Miscellaneous Top

Osseous metaplasia in orbit

Priti Sarker, M Hemlata, C P Manjula

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: A 21 year old female presented with complaints of shrunken, blindness of right eye & white discoloration of cornea with past history of endophthalmitis & leukocoria at the age of 7 months. Enucleation was done & sent for histopathology. Grossly eyeball was bony hard & gritty to cut. Microscopy showed hyperplasia of the retinal pigment epithelium & pre-retinal osseous metaplasia comprising of bony trabeculae & fatty marrow. Discussion: Retinal pigment cells are known to be pluripotent with capacity to differentiate into mesenchymal components namely fibroblasts & osteoblasts. Another mechanism is vascular delivery of osteoblasts to highly vascular tissues such as choroid. Intraocular ossification can occur in subretinal, pre-retinal or in both locations. Bone is usually formed after injury or disease. Conclusion: Intraocular osseous metaplasia is an unusual finding with various causes and requires documentation. The preliminary pathology is difficult to identify after ossification.

Keywords: Enucleation, intraocular osseous metaplasia, phthisis bulbi

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Stewart-Treves syndrome – A case report

S Reshma, S Sankar, Neetha Unnikrishnan

Government Medical College, Kottayam, Kerala, India

Case Report: 73 year old female presented with multiple swelling in right arm. History of edema in right upper limb since 8 years following surgery for carcinoma breast 10 years back and chemoradiotherapy. On examination, multiple swellings in right upper limb. Largest swelling measures 3x3 cm and bleeds on touch. MRI of right arm showed few nodular soft tissue lesions in the subcutaneous tissue in the posterior aspect of the lower third of arm, measures 6.5 x2.8 cm. Biopsy- grossly, multiple grey white tissue bits in aggregate measuring 0.8x0.5 cm. Microscopy showed fragments of tissue focally lined by stratified squamous epithelium with an infiltrating neoplasm composed of numerous irregularly shaped anastomosing vascular channels lined by atypical endothelial cells. Tumor cells are plump and spindle shaped. Increased mitotic activity with atypical forms seen. Neoplastic cells are vimentin, CD31, CD34 positive and SMA, S100 negative. Thus diagnosis of angiosarcoma was made. Discussion: Angiosarcomas account for less than one percentage of all sarcomas. They may occur at any location in the body and have a predilection for skin and superficial soft tissue. 5 year survival of patients with cutaneous angiosarcomas varies from 30-50%. Conclusion: Prompt diagnosis of angiosarcoma is essential due to the occurrence of metastatic spread and poor prognosis.

Keywords: Angiosarcoma, Stewert-treves syndrome

   AEP178 Top

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Histopathological spectrum of post transplant renal biopsies in a tertiary care centre

Niharika Mishra, J K Bhatia, R Tewari, P Sharma, S K Singh, R Devashwar

Army Hospital (R and R), Delhi Cantt, India

Case Report: A cross sectional study with 40 renal transplant biopsies received from Jan 2018- Dec 2021, which were processed in our laboratory were included. Each case was examined and characterization with immunostains was done. We determined TCMR, ABMR and CNI toxicity in transplant biopsies. Discussion: In the present study, out of 40 participants, no normal biopsy was seen and pure ABMR was seen in 13, TCMR was seen in 22 and both ABMR and TCMR was seen in 5 participants. In the present study, out of 27 TCMR rejection 9 were acute and 18 were chronic TCMR rejection. ABMR was present in 18 patients. out of 18 ABMR biopsies maximum 13 belonged to C4d1 followed by 4 belonged to C4d2. CNI toxicity was seen in 3 participants. Conclusion: Renal biopsy is a safe and effective way to monitor a real allograft and diagnose/ confirm rejection and drug toxicity. IHC for c4d adds specificity to diagnosis of ABMR in conjunction with clinical findings and DSA levels. Use of perforin and granzyme adds to the know of T cell activation in TCMR. CNI toxicity may also cause transplant rejection and in correlation with drug levels, treatment can be optimised and targeted so as to add life to the years.

Keywords: ABMR, CNI, rejection, TCMR

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Anal tuberculosis masquerading as malignancy – A case report

S Anuradha, P Shashikala, S N Minakshi, L S Patil

SSIMS and RC, Davangere, Karnataka, India

Case Report: A 39 years old male presented with history of constipation since 2 years, bleeding per rectum since 1 week, reduced appetite &weight loss. Colonoscopy revealed complete destruction of anal canal with multiple ulcerative growths which were friable and were bleeding on touch. Carcinoma of anal canal with proctitis was given as differential diagnosis. Colostomy was done for the same issue. Chest x-ray showed cavitary lesion in the lungs. Microscopically lesions showed extensive necrosis with admixed neutrophils and few epithelioid cells. Focally rectal mucosa with mild inflammation seen. Special stain revealed acid fast bacilli. Discussion: Tuberculosis still poses a risk to individuals especially in highly endemic areas. Anal tuberculosis is one such disease that often goes misdiagnosed. It is very rare entity seen in <1% cases of gastrointestinal tuberculosis. Conclusion: Anal tuberculosis can present with or without lungs being affected. So high level of suspicion of tuberculosis should be kept in mind in almost all cases of perianal lesions with varied etiology such as non-healing ulcers, multiple or recurrent fistula in ano and lesions with diagnostic problems.

Keywords: Acid fast bacilli, anal tuberculosis, extrapulmonary tuberculosis

   AEP180 Top

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Pseudocyst adrenal gland a rare case

Aparna Rajasekhar, B S Disha, P Shashikala

RGUHS, Bengaluru, Karnataka, India

Case Report: A 27 years female presented with complaints of pain abdomen. CT scan showed large exophytic cyst arising from VI segment of liver with possibility of hydatid cyst. Intraoperatively retroperitoneal cyst was found posterior to the right lobe of liver. Cut open cyst structure was sent measuring 5.5x3×2.5 cm. Microscopic examination showed encapsulated gland comprised of cortex with three layers of Zona glomerulosa, Zona fasiculata and Zona reticularis. Cyst wall comprised of thick fibrocollagenous tissue, calcification at places and fibrin. Epithelium lining was absent in the cyst wall. Discussion: Chances of malignancy is rare and pseudocyst in adrenal gland is rare finding. To rule out chances of malignancy histopathology plays a main role. Conclusion: We are presenting this case as it is a rare and incidental finding. Pathological finding is definitive and it also helps in ruling out the malignancy.

Keywords: Adrenal gland, pseudocyst

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Sieves in the Pink lake – A case of adenoid cystic carcinoma eX pleomorphic adenoma

Deepika Mohan, Sandhya Sundaram, N Priyathersini, G Vasugi, L Somu1

Departments of Pathology and 1Otorhinolaryngology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Case Report: A 55 years old male presented with complaints of swelling in the left parotid region for 1 year. The clinicoradiological diagnosis was pleomorphic adenoma. The patient underwent Left superficial parotidectomy. The specimen was sent for histopathological examination. Cut section of specimen revealed a fairly circumscribed, grey white, solid and cystic lesion measuring 2.2x2x1.2 cm. Microscopic examination revealed tumor cells arranged in predominantly tubules and sheets with focal areas showing cribriform pattern. In a chondromyxoid and focally sclerosed stroma. The tumor cells showed moderate degree of atypia. By Immunohistochemistry, the Adenoid cystic carcinoma component showed diffuse positivity for CD117. Thus, a diagnosis of Adenoid cystic carcinoma ex pleomorphic adenoma was given. Discussion: CXPA constitutes 12% of malignant salivary gland tumors. The development of Adenoid cystic carcinoma component is uncommon. The cribriform growth pattern in histopathological examination is supportive of the diagnosis. Conclusion: The important factor related to patient prognosis in Adenoid cystic carcinoma is tumor grade. Most cases of Adenoid cystic carcinoma ex pleomorphic adenoma were low grade. However, it has been associated with development of distant metastasis without regional lymph node involvement. Hence, Adenoid cystic carcinoma ex pleomorphic adenoma, though rare, warrants for close clinical follow up.

Keywords: Adenoid cystic, carcinoma, ex pleomorphic adenoma

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Samiksha Deshmukh, P Shashikala, B S Disha

S S Institute of Medical Science and Research Center, Davangere, Karnataka, India

Case Report: A 60 Years old male patient presented to Surgery OPD with complaints of swelling over left 4th toe. Clinical diagnosis was given as Implantation Dermoid. Grossly, open cystic structure with soft tissue measuring 2.5x2x1 cm. External Surface showed grey white area. Microscopic examination showed fibrocollagenous cyst wall with aggregates of foamy macrophages, epithelioid cells, foreign body type of giant cells and mixed inflammatory infiltrate comprised of lymphocytes and neutrophils. Lumen showed fibrinoid necrosis with few fungal hyphae which are thin elongated septate and showed branching, cholesterol clefts. Discussion: Subcutaneous phaeohyphomycosis is a rare infection however, the cases are increasing in recently. Infection usually occurs through traumatic inoculation of the skin and subcutaneous tissue with contaminated matter, majority of lesions occurr on the feet and legs of outdoor workers. Conclusion: Subcutaneous soft swellings must also be considered under differential diagnosis for fungal infections as they may be mistaken for lipoma, fibroma, epidermal cyst, or foreign body reaction.

Keywords: Deep local infections, phaeohyphomycosis, subcutaneous

   AEP183 Top

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A common tumour but uncommon location: A pot-pourri of four cases

Vaishnavi Patange, Sramana Mukhopadhyay, Garima Goel, Deepti Joshi

Department of Pathology and Lab Medicine, AIIMS, Bhopal, Madhya Pradesh, India

Case Report: Case-1: A 65 y/F with suspected multinodular goitre underwent total thyroidectomy. Histopathology showed an infiltrating SCC with areas of spindling raising a possibility of squamous cell variant of anaplastic carcinoma. However the exceedingly rare occurrence of a primary SCC could not be ruled out. Case-2: A 71 y/F underwent hysterectomy for chronic uterine inversion with fundal submucosal fibroid. Histology showed a well differentiated SCC in the submucosal fibroid. In absence of sarcomatous elements, and a primary SCC elsewhere a diagnosis of well differentiated SCC arising in a leiomyoma was rendered. Case-3: 4 A 47 y/F was operated for a left ovarian mass and showed a mature cystic teratoma with malignant transformation into SCC. Case-4: A 41 y/M with left submandibular region swelling showed moderately differentiated SCC involving the salivary gland. A metastatic involvement was considered in view of the patients post operative status for left buccal SCC. Discussion: Primary SCC in organ systems lacking a squamous epithelial lining is exceedingly rare. Relevant clinical and radiological findings may be helpful in arriving at a correct diagnosis. Conclusion: SCC though a common malignancy can present with diagnostic challenges in uncommon locations. Awareness of this wide spectrum of location is important for a prompt and accurate diagnosis.

Keywords: Fibroids, squamous, thyroid, unusual

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An unusual presentation of metastatic papillary carcinoma of thyroid at frontal lobe mimicking brain tumour

Bhumi Desai, M Samantha

Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India

Case Report: A 84-year-old female presented with pain and growth on forehead for 2-3 months with obscuring vision. On CT scan it was reported as malignant meningioma/osteosarcoma. Superficial biopsy revealed colloid filled micro follicles and papillary foci with nuclear features. CT scan of thyroid revealed well defined lobulated, hyperdense thyroid mass arising in frontal lobe causing distention of both frontal and orbital roofs. Multiple sections from thyroid lobectomy revealed follicular variant papillary thyroid carcinoma. Discussion: PTC is the most common type of thyroid carcinoma accounting for 80% of all thyroid cancers. It is associated with slow progression, with regional spread to the lymph node in the neck. Distant metastasis occurs rain 10% of cases. Most common sites are lungs and bone. Only around 0.1-0.25% cases metastasis into brain. Conclusion: Papillary thyroid carcinoma is a indolent tumour. Brain metastasis from papillary thyroid carcinoma has poor prognosis. However, the prognosis can be improved if it is treated aggressively. RAIT, TIKs and PD-1 showed good prognosis.

Keywords: Brain metastasis, papillary thyroid carcinoma, skull metastasis

   AEP185 Top

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Granular cell tumor – A case report

Irshad Rasool, Rupali Bargotra

Government Medical Collage, Jammu, Jammu and Kashmir, India

Case Report: Here we present a case of Granular cell tumor in a 40-year-old female patient who presented with swelling on the floor of mouth. Discussion: Swelling was single rapidly progressed to present size of 3 x 2 cm and was firm in consistency. A clinical diagnosis of sublingual dermoid cyst was made. Gross examination revealed globular soft tissue piece measuring 3 x 2.5 x 2 cm. on cut section it was firm and granular. Histopathological examination of H and E-stained section revealed nests of round to polygonal cells with small dense nuclei and abundant eosinophilic granular cytoplasm separated by collagenous bands. Conclusion: Granular cell tumor is a relatively uncommon benign lesion that occurs at various sites of the body with preponderance in the oral cavity. The tumors are usually small although some cases have been seen measuring up to 5 cm in diameter. Granular cell tumor exhibits round to polygonal cells with small nuclei and abundant pale eosinophilic granular cytoplasm. The nucleus is eccentrically placed. Cells are usually arranged in unencapsulated sheets but may be found in cords and nests. Cell borders are generally indistinct giving rise to syncytial appearance.

Keywords: Abundant granular cytoplasm, granular cell tumor, tongue

   AEP186 Top

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A very rare liposarcomatous differentiation in a case of malignant phyllodes tumor of breast

Paritosh Shringi, Matariswa Samanta, Komi Vyas

Pacific Institute of Medical Sciences, Udaipur, Rajasthan, India

Case Report: A 35 year old woman with no family history of breast cancer presented with a 5 months history of palpable mass in right breast gradually increasing in size. Ultrasound imaging revealed heteroechoic mass in right breast with some cystic areas. On FNAC differential diagnosis of Ductal carcinoma of breast and Malignant phyllodes were made. Modified radical mastectomy was done and on histopathological examination of the lump shows malignant phyllodes with liposarcomatous differentiation. Discussion: FNAC has high sensitivity and specificity for preoperative diagnosis of breast cancers, however sensitivity in the diagnosis of phyllodes tumor has lower range betwen 32% to 77%. On FNAC predominance of epithelial elements over stromal elements mimics ductal cell carcinoma. Histopathological examination shows tumor cells composed of spindle to epitheliod cells having vesicular nuclei and moderate amount of eosinophillic cytoplasm. Large areas shows liposarcomatous differentiation with numerous pleomorphic lipoblast like cells. Conclusion: The liposarcomatous differentiation of malignant phyllodes is a very rare entity and it cant be confirmed by imaging and cytology alone. In this case the histopathological examination revealed the final diagnosis.

Keywords: Heteroechoic, liposarcomatous, phyllodes

   AEP187 Top

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ANCA negative orbital granulomatosis with polyangitis

Amith Vinayak, S R Niveditha, Sruthi Prasad, Raghuraj Hegde

Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India

Case Report: A woman aged 38 years presented with pain and swelling in the right orbit of 1 month duration. She had no other systemic complaints. Clinically she was diagnosed as dacryoadenitis and was found unresponsive to antibiotics. Serological testing for ANCA was negative. Excision biopsy of the right lacrimal gland was done. A diagnosis of GPA was suggested on histological evaluation. Ancillary studies for tuberculosis and mycosis were negative. Discussion: Orbital GPA can present as ocular pain, edema of the eyelids, limited ocular movements, proptosis and diplopia. Untreated cases can lead to optic nerve compression with atrophy and vision loss. Differential diagnoses of granulomatous dacryoadenitis include tuberculosis, sarcoidosis, mycosis and GPA. However the presence of vasculitis with fibrinoid necrosis favours GPA. Serological investigation with elevated ANCAs is vital, but a quarter of patients with limited GPA have no detectable ANCA. Therefore, in such cases histology remains the diagnostic gold standard. Conclusion: Histopathological evaluation is indispensible in the diagnosis of ANCA negative limited GPA as they require appropriate therapy with immunosuppressive agents.

Keywords: Accurate diagnosis, GPA, limited form, orbit, histopathology

   AEP188 Top

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A rare case of giant cell tumor of the mandible

Helen Paul, Aradhana Mishra, Saranya Singaravel

Rajawadi Hospital, Mumbai, Maharashtra, India

Case Report: A 32 yrs old female presented with a progressive swelling of the right side of the jaw. CT showed a welldefined oval shaped hypodense lesion in the right posterior mandible. A right partial mandibulectomy was performed. Grossly, the bone was expanded by a tumor measuring 4x3.5x3 cm. The cut surface of the tumor was solid, variegated with grey white and red brown areas. Microscopy showed a relatively circumscribed tumor composed of evenly distributed multinucleated giant cells interspersed between mononuclear stromal cells and diagnosed as GCT. Discussion: GCT makes up 4.9-5% of all osseous neoplasms. It chiefly occurs at the end of long bones. Head and neck region accounts for 2%. Most of GCTs occur in the ethmoid, sphenoid and temporal bones; the occurrence in the mandible is less than 2%. The case being discussed involves the mandible. The common differential diagnosis of GCT includes Central giant cell granuloma (CGCG), aneurysmal bone cyst and brown tumor of hyperparathyroidism The final diagnosis is established only on the basis of histopathological examination. Conclusion: GCT of mandible is exceptionally rare. The possibility of GCT should be always be included in the differential diagnosis of a bony lesion involving the craniofacial bones.

Keywords: Central giant cell granuloma, giant cell tumor, jaw swelling, mandible.

   AEP189 Top

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Comprehensive review of ophthalmic IgG4 related disease: A clinico-pathological study from a tertiary care institution in North India

Aditi Aggarwal, Neha Bakshi, Seema Rao, Shashi Dhawan, Sonia Badwal

Sir Ganga Ram Hospital, New Delhi, India

Case Report: 36 cases suspected or diagnosed as IgG4-ROD were retrospectively included. Detailed review of histopathologic, immunohistochemical and clinical features was done. Discussion: Women outnumbered men. Wide age range was noted; mean age at diagnosis being 40 years. Eyelid swelling & proptosis were the commonest presenting complaints. Involvement of lacrimal glands, orbital soft tissue and extraocular muscles was commonly seen. Raised serum IgG4 levels were noted in 10 (31.25%) cases. Histopathologically, most cases showed marked lymphoplasmacytic infiltration, with frequent lymphoid follicle formation. On immunohistochemistry, the ratio of IgG4: IgG was found to be a more helpful indicator than the number of IgG4 positive plasma cells. Fibrosis was variable from patchy, diffuse to storiform type. Obliterative phlebitis was an uncommon finding. Conclusion: Clinically high index of suspicion for IgG4-RD and accurate diagnosis by biopsy have important implications for prognosis and treatment as these patients respond well to glucocorticoid and/or immunosuppressant therapy.

Keywords: IgG4-Related ophthalmic disease, IgG4-ROD, ophthalmic IgG4 disease

   AEP190 Top

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Tale of two fascinating cases of co-existing benign tumors where histomorphology is the key to diagnostic distinction

Seetu Palo, Gunvanti Rathod, Krishna Ramavath, Srinivas Reddy Kalyam

Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Hyderabad, Telangana, India

Case Report: Case 1: A 50-year old lady presented with a mobile, 9x6 cm, right breast lump of one year duration and 3x2 cm, left breast lump of 3 months' duration. Histopathological examination showed benign phyllodes in right breast and fibroadenoma in left breast. Case 2: A 50-year old man presented with two discrete, mildly painful swellings, 2x1 cm and 1x1 cm in size, over lower back since past ten years. There was no history of trauma to the site or similar lesions elsewhere. Histopathological examination of the excision biopsies revealed dermal neurofibroma and subcutaneous schwannoma. Discussion: It can be challenging to distinguish cellular fibroadenoma and benign phyllodes on imaging, FNAC or trucut biopsy, with no specific immunohistochemical or molecular marker available. The distinction is imperative as management differs. In case 1, adequate sampling was the key to diagnosis as the phyllodal features were only focally present. Also, the surgical margin was positive. In case 2, distinction between neurofibroma, schwannoma and its close mimic palisaded encasulated neuroma is possible upon diligent histomorphological observations. These three entities share overlapping immunohistochemical and molecular signatures that do not aid much in diagnostic decision making. Conclusion: These cases depict rarely encountered synchronous presentation of benign tumors and highlight the fact that adequate sampling and histomorphology is often the key to diagnostic distinction.

Keywords: Benign, fibroadenoma, neurofibroma, phyllodes, schwannoma

   AEP191 Top

   Miscellaneous Top

Three rare intracranial tumors

P Anupama, Janaky Ramakrishnan, Anupama Raj, N Fazna, P P Sathi

KMCT Medical College, Kozhikode, Kerala, India

Case Report: 1. Benign mature teratoma of posterior fossa-48 year old female, 2. Haemangiopericytoma/Solitary fibrous tumor-65 yeal old, 3. Ganglioglioma-62 year old. Discussion: These are three benign lesions from central nervous system in different locations. Conclusion: However the morphology and the locations decide the outcome of these rare tumors.

Keywords: Ganglioglioma, haemangiopericytoma, teratoma

   AEP192 Top

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Monocytic incidental cardiac excrescences (cardiac MICE) – A rare case report

Sakthisankari Shanmugasundaram, S Vidyalakshmi, S Shanthakumari, M S Murugan

PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Case Report: A 45-year-old lady presented with complaints of dyspnoea on exertion, facial puffiness, and bilateral lower limb swelling. Echocardiogram revealed constrictive pericarditis. She underwent a pericardectomy with a clinical diagnosis of tuberculosis. Histopathology showed a nodular lesion composed of a monomorphous population of cells arranged in nests punctuated by many vacuoles, entrapped in fibrinous exudate. The cells had clear to granular eosinophilic cytoplasm. The possibility of a metastatic lesion was entertained and a panel of markers including cytokeratin, EMA, CD10, and synaptophysin was performed. All the immunohistochemistry markers turned out to be negative A re-evaluation of the histopathology slides made the nuclear grooves of these cells obvious and guided the further markers. Most of the cells stained strongly with CD68 and were calretinin negative. Hence a diagnosis of MICE was offered. Discussion: Cardiac MICE is usually encountered as an incidental finding in cardiac chambers or valves, the exact pathogenesis is not yet established. The postulated hypotheses include artefactual or reactive etiology. Morphological features are known to mimic mesothelioma, metastatic carcinoma, or paraganglioma. Conclusion: The significance of the lesion lies in the fact that these can potentially be misdiagnosed as primary or secondary neoplasm. Pathologists must be aware of the existence of these incidental lesions to avoid a delayed or misdiagnosis.

Keywords: Cardiac MICE, mesothelial/monocytic incidental cardiac excrescences, pericardium

   AEP193 Top

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Female hyperandrogenaemia, think beyond the common-leydig cell tumour of ovary: A case report

Crysle Saldanha, Sujaya Rao, Sanjana

Father Muller Medical College, Mangalore, Karnataka, India

Case Report: A 62-year-old woman (gravida 4, para 4) postmenopausal with history of hair growth on her face, torso, and arms, requiring shaving and loss of scalp hair for 1 year. She is a known diabetic and hypertensive since 10 years on treatment. Laboratory Investigations revealed: Serum testosterone - 9.57 nmol/l, CA 125 – 20.28 units/mL, DHEA – S- 132.7 IU/L. Ultrasound abdomen and pelvis: Uterine fibroid and a Solid lesion in right adnexa - ?subserosal fibroid was identified. Magnetic resonance imaging (MRI) findings revealed mildly bulky uterus with large intramural fibroid along left lateral wall – 8.7 x6.9 x7.1 cm suggestive of intramural fibroid. T1 hypointense, T2 hyperintense heterogeneously enhancing nodular lesion measuring about 3.7 x 3.5 cms was noted in the Right iliac fossa. The patient underwentTotal abdominal hysterectomy bilateral salpingo oophorectomy. On histopathological examination she was diagnosed with Right ovarian Leydig cell tumor. Discussion: Sex cord- Stromal Leydig Cell Tumor is a rare tumor, accounting for less than 1% of all primary ovarian tumours. Hirsutism caused by ovarian tumors accounts for roughly 1% of all cases of hirsutism. Conclusion: Although clinically challenging, Androgen-secreting neoplasms of the ovary being a rare cause of androgen excess accounting for only 5% of all ovarian tumors must be considered in the differential diagnosis of severe hyperandrogenism.

Keywords: Leydig cell tumour, ovary, testosterone

   AEP194 Top

   Miscellaneous Top

Ocular surface squamous cell carcinoma with intraocular and orbital invasion – A retrospective analysis

Seema Sen, Sheetal Chauhan, Sahar Choudhary, Seema Kashyap, Neelam Pushker, Mandeep S Bajaj, Rachna Meel

AIIMS, New Delhi, India

Case Report: Of the 65 patients of OSSCC diagnosed, 20 (31%) underwent enucleation/exenteration for extensive disease and rest of the tumors were surgically excised. Twelve (18%) had intraocular/orbital invasion. Mean age of these 12 patients was 65 (±13.2) years and all were males. Tumor was on the right side in 7 (58%). Both upper and lower eyelid involvement was observed in 4/12 cases (33.3%). On histopathological analysis 5 (42%) were well differentiated SCC and 7 (58%) poorly differentiated. Intraocular spread was present in 3 (12%), orbital in 2 (17%) and 7 (58%) had both intraocular and orbital involvement. Tumor size varied between 0.8 cm-5 cm, with a mean largest dimension of 3 cm (±1.4). Discussion: Ocular SCC occurs predominantly in elderly males. It can cause orbital and intraocular invasion, recurrence, lymphnode metastasis and rarely death. Conclusion: Delay in presentation of Ocular squamous cell carcinoma patients results in intraocular or orbital spread for which enucleation or exenteration was done in nearly one-third of the patients. The use of preoperative Systemic Neoadjuvant Chemotherapy can prove to be a useful alternative to minimize disfiguring procedures.

Keywords: Enucleation/exenteration, ocular SCC, orbital/intraocular invasion

   AEP195 Top

   Miscellaneous Top

Serial estimation of Hemoglobin, packed cell volume and rbc indices in stored packed red cells – A study in the blood bank of a tertiary care centre

Kirana Pailoor

Father Muller Medical College, Mangalore, Karnataka, India

Case Report: Materials and Methods: This was an observational time bound study conducted over a period of three months. A total of 100 samples of Packed Red Blood Cells were analysed. Samples were collected from the tubal segment of the component blood bag. Serial estimation of Hb, PCV and RBC Indices were done on day 1 and day 15 of storage by a trained Laboratory technologist, using a 7-part Automated cell counter, Beckman Coulter LH750. The data collected was analysed using ANOVA test of significance. A p value of less than 0.05 was considered significant. Discussion: Results: A total of 100 Packed Red Blood Cells (PRBCs) samples were analysed. The maximum number of donors belonged to 21 to 30 years of age (42%) and least were between 18 to 20 years (11%). O Rh positive was the commonest blood group (44%) and AB Rh positive was the least (1%). There was a slight increase in Hb, PCV and RBC Indices, when stored over a period of 15 days with a significant p value of 0.000. There was no deterioration in the values on calculating the mean. Conclusion: This study depicts that the quality of Hb, PCV, RBC indices tends to be almost stable till the end of 15 days with no deterioration. Hence, usage of components is beneficial in order to avoid the adverse reactions of whole blood transfusion. However, due to the constant heavy consumption of PRBCs, the samples could not be analysed till the end of 35 days. Therefore, further study is suggested to conclude the efficacy till the end of recommended storage period.

Keywords: Hemoglobin, packed red blood cells, serial estimation

   AEP196 Top

   Miscellaneous Top

A rare case of synchronous tumor – Adenoid cystic carcinoma of palate and papillary carcinoma thyroid

V Srinivasamurthy, B R Vani, N Anvita, Rashmi Budha

ESIC Medical College and Post Graduate Institute of Medical Sciences and Research, Bengaluru, Karnataka, India

Case Report: A 59-year-old female presented with septal and palatal mass, along with a Thyroid swelling on the left side S/P Right hemithyroidectomy. Radiological examination revealed a primary aggressive destructive sinonasal malignant tumor with secondary to metastasis from adjacent papillary carcinoma of thyroid-TIRADS 4 lesion. Fine needle aspiration from a vague swelling measuring 3 x 2.5 cm yielded a hemorrhagic aspirate. A cytological diagnosis of Pleomorphic adenoma was made. FNAC from Thyroid swelling was done and a cytological diagnosis of Suspicious of Papillary Carcinoma- Thyroid. Endoscopic biopsy sample of septal mass and floor of nasal cavity was sent for Histopathological examination and a final diagnosis of Adenoid cystic carcinoma- Nasal Septum was made. Discussion: Of all the anatomical sites at which to perform a fine needle aspiration biopsy (FNAB), perhaps the head and neck area is the most complex. This area is homeof many structures, all of which have the potential to produce benign and malignant tumors. Adenoid cystic Carcinoma is clinically deceptive by virtue of its small size and slow growth, which believes its extensive subclinical invasion relentlessly into adjacent structures. Conclusion: Synchronous occurrence of Adenoid cystic carcinoma and Papillary carcinoma thyroid is rare and it is important to evaluate the patient thoroughly for a favourable prognosis.

Keywords: Adenoid cystic carcinoma, papillary carcinoma thyroid, synchronous tumor

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A case of papillary thyroid carcinoma in struma ovarii

Aditi Bhattacharjee, Shubhendu Pal Choudhury

South Eastern Railway Main Hospital, Kharagpur, West Bengal, India

Case Report: A 70-year-old female presented to gynecology clinic with abdominal pain and distension for last few months. Abdominal ultrasound revealed a large solid cystic mass in the left adnexal region. Tumor marker CA125 was raised (2715 U/ml). A total abdominal hysterectomy with bilateral salpingo-oopherectomy was performed along with omental biopsy. Gross pathological examination of left ovary measuring 10×9×5 cm showed a multiloculated complex cystic ovary with solid areas. The external surface of the cyst was smooth with a small area of greenish discoloration. Cut section showed solid mass and cysts filled with amber coloured fluid. Histopathological examination revealed benign thyroid follicles with abundant colloid and focal complex papillary architecture exhibiting enlarged, ovoid, crowded and overlapping nuclei with ground-glass nuclear chromatin and nuclear grooves. No other teratomatous tissue identified. Therefore, the case was reported as papillary thyroid carcinoma (PTC) in struma ovarii. Positive TTF-1 and Thyroglobulin immunohistochemical stains confirmed the diagnosis. Discussion: Malignant struma ovarii is a medical rarity which is best diagnosed by hematoxylin and eosin (H&E) stain and corroborated by TTF-1 and Thyroglobulin immunohistochemical stains. Conclusion: Papillary carcinoma attributes to 70% of malignant struma ovarii where 44% of the tumors are of classical type and 26% are follicular variant of PTC.

Keywords: Malignant struma ovarii, papillary thyroid carcinoma, teratoma

   AEP198 Top

   Miscellaneous Top

Fictitious cases of Squamous cell carcinoma; a series of five cases with literature review

Priya Sahu, Gurmeet Singh, Nily S Kujur, Raju Bhaisare, Manisha Kango, M Ravindranath

JLNH and RC, Bhilai, Chhattisgarh, India

Case Report: This study reports five cases of SCC with varied and unusual presentation. In first case, a 69 year old male presented with complaints of difficulty in voiding urine. Complete work up of this case brought out a synchronous dual malignancy. Second Case was a 67 year old female presented with intermittent pain on right side of abdomen, her abdominal ultrasound suggested acute cholecytitis with gall bladder sludge. Third case was of uncommon recurrence site in 51 year old male presented with melena and endoscopy revealed friable growth in stomach and colon. Histopathology unveiled SCC with uncommon recurrence site. In fourth case 84 year old male presented with urinary complaints, cystoscopy showed firm fixed growth and histopathology revealed a rare variant. The fifth case was a psoriasis patient received cryotherapy and presented with a non-healing ulcer in sacral region. Discussion: Though SCC is one of the commonest cancer, it's rare variant or unusual presentation can sometimes delay the diagnosis and management. In this regard, complete clinical details and approach to these cases will be discussed further. Conclusion: Understanding the facts and facets of cancer is vital. Clinicians/oncologists and pathologists need to be vigilant in terms of high index of suspicion and early detection of such uncommon variants and presentations of cancer in order to provide prompt and appropriate management.

Keywords: Dual malignancy, recurrence, squamous cell carcinoma

   AEP199 Top

   Neuropathology Top

Cranio-cerebral madura mycosis mimicking a glial tumor

Mounica Bellamkonda, V Tejeswini, I V Renuka

NRI Medical College, Guntur, Andhra Pradesh, India

Case Report: A 51-year-old male, presented with complaints of headache, behavioral abnormalities and memory disturbances since 3 months. MRI showed a well-defined mass lesion of 3.3x3.2x1.8 cm arising from right frontal bone with mass effect on the frontal lobe; suggesting atypical meningioma. Right frontal craniotomy with excision was done. We received a grey-brown nodular mass measuring 3.3x3x1 cm and on cut section multiple grey-black areas were seen. Histology revealed fungal colonies with Splendore Hoeppli phenomenon, with microabscesses and granulomatous reaction. Special stains Periodic acid Schiff stain (PAS) and Grocott-Gomori silver methanamine stain (GMS) were done which demonstrated radially arranged, septate filamentous hyphal fungal colonies. Discussion: Craniocerebral eumycetoma is rare and was first reported by Natarajan et al. and usually presents as a swelling with discharging sinuses. Behera et al reported cerebral eumycetoma with no swelling or discharging sinus which is similar to our case. Conclusion: We present this case of Cerebral Maduramycosis mimicking a glial tumor with no evidence of soft tissue involvement or discharging sinuses, which is an extremely rare occurrence. Advanced imaging like CT, MRI may not always help in diagnosing these cases and histopathology alone aids in the final diagnosis.

Keywords: Craniocerebral, eumycetoma, madura mycosis

   AEP200 Top

   Neuropathology Top

Rhythmic palisading; an unusual morphological pattern causing diagnostic dilemma

Swarna Saraswati, Noopur Gupta, Ranu Tiwari Mishra, Vijay Shrivastava, Sanjay Totade

Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India

Case Report: A 19-year-old female presented with headache, vomiting for 6 months. Imaging showed mixed solid, cystic, heterogeneously enhancing mass lesion measuring 7.6*4.1*5.6 cm, adjacent to trigone and posterior body of right lateral ventricle causing mass effect, ipsilateral ventricular compression with hemorrhagic areas. Patient underwent right parieto-occipital craniotomy, near-total excision. Grossly received multiple greyish-white soft tissue pieces, largest measuring 3.5* 3*1.7 cm with soft greyish-white cut surface. Microscopy revealed neuroparenchyma diffusely infiltrated by tumor composed of neoplastic astrocytes displaying rhythmic palisading, moderately pleomorphic, oval to elongated, hyperchromatic nuclei set against a fibrillary background. Areas of hemorrhage seen along with rich network of thin walled variably caliber blood vessels. No definite neovascular proliferation or necrosis noted. IHC was positive for EMA, Vimentin with 15% Ki67 index. Olig2, S100, IDHp.R132H, H3p.K27M, H3p.G34V, Desmin, SMA, BCOR, INI1, p53 negative with retained expression of ATRX, H3. p.K27me3. Final diagnosis was Supratentorial ependymoma, NOS, CNS WHO grade 3. Discussion: Supratentorial ependymoma are amongst the only pediatric neoplasm showing good long-term survival after gross total resection and post-op radiotherapy despite being high grade. Hence its correct and prompt diagnosis is essential. Conclusion: One must be aware that common neoplasm like ependymoma can present with rare morphological pattern causing diagnostic dilemma.

Keywords: Pediatric neoplasm, rhythmic palisading, supratentorial ependymoma

   AEP201 Top

   Neuropathology Top

Conjoint tumour of ancient schwannoma and cavernous haemangioma with sickled RBCs

Shraddha Biradar, Swati Ghanghurde, Vaibhav Bari

Rajiv Gandhi Medical College, Thane, Maharashtra, India

Case Report: 25 yrs old male presented with a painless gradually increasing ankle swelling since childhood. Gross: We received a skin covered, irregular firm mass measuring 8x4.5x2 cm. Cut surface was focally grey-white, firm and congested with areas of haemorrhage. Microscopy: Revealed a well encapsulated spindle cell tumour in the dermis, composed of hypercellular Antoni A areas and hypocellular Antoni B areas. Focal perivascular hyalinization, areas of haemorrhage, necrosis and mild nuclear atypia seen. Adjacent to the tumour, many large dilated vascular channels lined by single layer of endothelial cells filled with sickled RBCs were seen. There was no evidence of mitosis. IHC showed diffuse immunostaining for S-100 protein. The final diagnosis of Conjoint tumour of Ancient Schwannoma with and Cavernous Haemangioma with Sickled RBCs was rendered. Discussion: Ancient schwannomas show nuclear atypia with degenerative changes like cyst formation, calcification, hyalinization and haemorrhage. After thorough literature review, we found few case reports of conjoint association of schwannoma with haemangioma, however none of these were associated with ancient changes in schwannoma or sickled RBCs making it a first of its kind. Conclusion: We are presenting this case for its rarity, unique combination & to create awareness of different morphological features of ancient schwannoma which are coexisting with cavernous haemangioma and sickled RBCs.

Keywords: Ancient schwannoma, cavernous haemangioma, sickled RBCs

   AEP202 Top

   Neuropathology Top

A case of brain metastasis as the cardinal manifestation of lung cancer

Sangita Jha, Priyadarshini, Jyothi A Raj

Rajarajeswari Medical College and Hospital, DR M G R Educational and Research Institute, Bengaluru, Karnataka, India

Case Report: A 40-year female patient came with chief complaints of occipital headache associated with a pricking type of pain in the neck, vomiting, regurgitation, and generalized weakness. CT brain showed irregular hypodensity in the right frontotemporal region measuring around 3.0X3.1 cms suggestive of a Brain abscess. Biopsy revealed metastatic carcinoma which was confirmed by IHC markers, CK and TTF1 positive. PET-CT whole body revealed a mass in the medial segment of the right lung middle lobe abutting the mediastinal pleura suggestive of the primary tumor & hypermetabolic subcarinal lymph node which is a concern for metastasis. Discussion: The most common tumor in the brain is a metastatic tumor which commonly metastasizes from the lung, breast, skin, or colorectum. Bone and brain metastases are a very common secondary localization of disease in patients with lung cancer. The prognosis of these patients is still poor with a median survival of less than 1 year. The neurological signs and symptoms are due to increased intracranial pressure and local effects. Conclusion: Brain metastases are a common complication of cancer and the most common type of brain tumor. The development of brain metastases is associated with poor prognosis and harms survival & quality of life. Histopathological examination along with the use of immunohistochemical markers can profoundly and reliably distinguish primary from secondary CNS tumors.

Keywords: Brain metastases, Cytokeratin (CK), lung cancer

   AEP203 Top

   Neuropathology Top

Extra-cranial manifestation of glioblastoma – A case report

K P Nabeela, Lincy Joseph, T Suvidha

Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Case Report: A 24 year old male operated for glioblastoma 2 years ago and undergoing chemotherapy, presented with complaints of severe bone pain over left hip & difficulty in moving around. CT scan showed multiple enhancing lesions in the right hemisphere and a lytic lesion in the left iliac wing. Iliac bone biopsy was done. Microscopy Biopsy from iliac bone showed a neoplasm composed of cells arranged in sheets. The tumour cells have pleomorphic nuclei and moderate amount of vacuolated to pink cytoplasm. Mitotic figures, necrosis & micro-vascular proliferation are noted. IHC – CK negative, GFAP positive, Final diagnosis, epithelioid glioblastoma with left pelvic bone metastasis. Discussion: Glioblastoma is known for its devastating intra-cranial infiltration and unfavourable prognosis, with younger patients being more susceptible for extra-cranial metastasis. The osseous tissue continues to be an exceptionally rare site for metastasis with the pelvic bone being an even rarer site. Conclusion: This case indicates the importance of recognizing extra-cranial metastasis of glioblastoma as timely detection and early treatment can improve overall quality of patients life.

Keywords: Glioblastoma, osseous metastasis, pelvic metastases

   AEP204 Top

   Neuropathology Top

Suprasellar rosette forming glioneuronal tumor

Bishnupriya Shial, Kalpalata Tripathy, Pragyan Lisha Panda, Lity Mohanty

SCB Medical College and Hospital, Cuttack, Odisha, India

Case Report: A 13-year-old female presented with diminution of vision for 2 years and seizure for 1 year. MRI showed solid cystic lesion along the stalk. Squash smear showed a neoplasm composed of glial cells with oval dark nuclei, long hair like processes and Rosenthal fibers. These cells were seen in groups, forming rosettes with central eosinophilic fibrillary material. Discussion: Histopathological analysis showed neurocytes forming rosettes. On Immunohistochemistry, glial fibrillary acidic protein (GFAP) was immunoreactive in glial component, but absent in rosettes. Synaptophysin was positive in the central areas of neurocytic rosettes, which on contrary, did not show any immunoreactivity for the GFAP. The diagnosis was made to be Suprasellar Rosette forming glioneuronal tumor. Conclusion: RGNT of the fourth ventricle should be considered in the differential diagnosis of a posterior fossa tumor, especially in relation to fourth ventricle and vermis in a young adult and has to be differentiated from other lesions for its indolent course and favorable prognosis.

Keywords: Glioneuronal tumor, rosette-forming, suprasellar

   AEP205 Top

   Neuropathology Top

Intramedullary Schwannoma of the brain stem: Rare clinical presentation

Mukesh, KumarPradhan, Prajna Das, Ruchi Mittal, Kanakalata Dash, Urmila Senapati, Narendra Kumar Das

KIMS, Bhubaneswar, Odisha, India

Case Report: A 46-year-old male patient presented with complaints of right shoulder pain, neck tightness and headache for 4 months. Patient had stable vitals and normal motor activity. CEMRI of spine showed an exophytic lobulated peripherally enhancing lesion involving posterior part of right hemimedulla & cervico medullary junction with provisional diagnosis of Astrocytoma. Histopathological examination from biopsy fragments showed a partially circumscribed tumour with predominantly cellular and focally hypocellular areas comprising of spindle to oval cells with fibrillary cytoplasm. There were areas of increased cellularity, mild nuclear pleomorphism. Thick walled hyalinized vessels were noted. Endothelial cell proliferation and necrosis were absent. Immunohistochemistry was performed to exclude Glial tumors and Meningioma. IHC revealed strong expression of S100, SOX10 and Ki67 (<5%) with patchy strong GFAP expression (25%) and negativity for EMA. This confirmed the diagnosis of Ancient Schwannoma. Discussion: Intramedullary schwannomas exhibited heterogeneous intensity, containing cystic and solid enhancing component. Surgical treatment for these lesions has been the mainstay of therapy, and prognosis remain good. Conclusion: Intramedullary Schwannoma are rare tumors, require strong degree of suspicion and IHC correlation for correct diagnosis.

Keywords: Astrocytoma, brain stem, immunohistochemistry, intracerebral, intramedullary, schwannoma

   AEP206 Top

   Neuropathology Top

Extra ventricular neurocytoma

Gaurav Singh, Samarth Shukla, Sourya Acharya, Preeti Mishra, Sunita Vagha

Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Case Report: A 35-year-old woman presented to hospital with complaints of progressive visual disturbances, nausea, vomiting and dull headache for two months. MRI revealed a well-defined, mixed cystic heterogeneously solid lesion involving cerebral hemispheres deep white matter. The solid portion showed varying degrees of enhancement and calcification. Intraoperative findings after total resection demonstrated a greyish mass measuring 5×5×6 cm. Discussion: On gross pathology lobulated, well-circumscribed, grey coloured mass was identified. On microscopy, EVNs are solid lesions composed of neurocytic tumor cells arranged in sheets, clusters, ribbons, or rosettes with neuropil dispersed either in broad zones (neuropil islands) between these cell arrangements or localized within the rosettes. Conclusion: The best therapeutic approach has not yet been determined due to its rarity, which also affects its clinical, radiologic, and histological characteristics. In contrast to the infrequent descriptions of EVNs in literature, we intend to share and discuss our experience.

Keywords: Cerebral neurocytoma, CNS neoplasm, extraventricular neurocytoms

   AEP207 Top

   Neuropathology Top

Unusual spindle cell tumour of CNS posing diagnostic challenge

K Jayaprakash Shetty, H L Kishan Prasad, Shruthi, Apoorva, J Aaslesha

K S Hegde Medical Academy, Mangaluru, Karnataka, India

Case Report: A 39-year-old female presented with complaints of headache and dizziness. CT brain showed well defined hyperdense lesion measuring 5 x 5.1 x 3.4 cms, noted in the parasagittal right parietal region, given the possibility of meningioma. Patient underwent craniotomy and excised lesion sent for HPE, which revealed morphologic diagnosis of solitary fibrous tumor WHO grade 3, and suggested IHC for definite diagnosis. IHC was performed, which showed STAT6, CD34, EMA, VIMENTIN positive, with these findings we confirmed the diagnosis of SFT. Discussion: SFT is an uncommon tumor that occurs mostly in the visceral pleura. Cases have been reported in other visceral organs also. Also been rarely reported in CNS. Patients may present with non-specific symptoms. SFT has a mesenchymal origin rather than a meningothelial origin. Diagnosis is confirmed through positive staining for CD-34 and negative staining for S-100, Distinguished from meningioma, which is negative for CD34 and positive for S-100. The treatment of choice is complete resection. Conclusion: SFT is a rare mesenchymal origin neoplasm, especially in the CNS. Imaging and IHC correlation are crucial for its definitive diagnosis. Surgery is the treatment of choice, and close follow-up is necessary as recurrences have been reported.

Keywords: CNS, IHC, solitary fibrous tumor

   AEP208 Top

   Pediatric Pathology Top

Ocular medulloepithelioma – A case report

Kavita Rakwal, Jyotsna Suri, Sabina Syed, Palka Gouria

Government Medical College, Jammu, Jammu and Kashmir, India

Case Report: Here we present a case of ocular medulloepithelioma in a 7-year-old male child presented with growth on right eye. Discussion: The growth was 6x4 cm in size. It was gradual in onset, soft in consistency and covers whole of the eye. It had variegated surface and the overlying skin was intact. CT PNS revealed exophytic right orbital mass lesion protruding out of right lobe with loss of normal morphology of right eye. Enucleation was done and the mass lesion was sent for histopathological examination, and it showed histological features of Medulloepithelioma. Conclusion: Medulloepithelioma can be easily confused with retinoblastoma or soft tissue tumors on radiological analysis. Histopathological examination is the only way to designate tumor's morphological identity and that could be topped off with special tumor markers to conclude a proper patient care and prognosis.

Keywords: Medulloepithelioma, retinoblastoma

   AEP209 Top

   Pediatric Pathology Top

Gravid neonate – A rare congenital anomaly

A K Subaida, P S Jayalakshmy

MES Medical College, Angadipuram, Kerala, India

Case Report: Term (39 weeks) AGA (3.12 kg) male baby born to G3P1A1IUD1 mother by LSCS. Physical examination of the neonate showed 6x4 cm mass in left lumbar quadrant. USG abdomen on Day 2 showed features of fetal adrenal teratoma/ FIF. MRI on Day5 showed well defined complex cystic mass suggestive of FIF. Laparotomy and resection of retroperitoneal mass was done and showed well-formed fetus of 10 week size with limb buds, attached umbilical cord and placenta. Histopathology showed organized structures like skin, brain tissue, GIT, limbs and vertebra. The fetal tissue was attached to the adrenal gland of the neonate. The mass was thus confirmed as FIF. Discussion: Spencer (2001) criteria for FIF (One/more of the following): (a) enclosed within a distinct sac, (b) partially/ completely covered by skin, (c) grossly recognizable anatomic parts, (d) attached to host by only few large blood vessels, (e) either be located immediately adjacent to one of the sites of attachment of conjoint twins or be associated with neural tube/ GIT. The presence of vertebral column distinguishes FIF from teratoma. Conclusion: FIF is a rare benign condition with a common presentation of retroperitoneal mass. It should be differentiated from teratoma as the latter is associated with risk of malignancy.

Keywords: FIF – Fetus in fetu, spencer criteria, teratoma

   AEP210 Top

   Pediatric Pathology Top

Primary lung tumors in children and adolescents: An institutional experience

Shruti Madan, Nishtha Ahuja, Kirti Gupta, Nandita Kakkar, Nitin J Peters, Amita Trehan

Post Graduate Institute of Medical Education and Research, Chandigarh, India

Case Report: All resected specimens and biopsies of primary pulmonary neoplasms in paediatric age group (<18 years) over a period of 10 years were analyzed for their clinicopathological features including follow-up. TP53 mutations were determined in cases of pleuropulmonary blastoma using immunohistochemistry. Fluorescent in-situ hybridization for EWS rearrangements was performed for confirmation in Ewing's sarcoma. Discussion: Our cohort comprised of 19 cases of primary pulmonary tumors with age range of 2-18 years, (mean 8 years) and M:F ratio 2.8:1. The spectrum included pleuropulmonary blastoma (PPBL, n=10/19), Ewing's sarcoma/primitive neuroectodermal tumor (n=5/19), carcinoid tumor (n=2/19) and one case each of inflammatory myofibroblastic tumors (IMFT) and mucoepidermoid carcinoma. Among PPBL, Type II, composed of sheets of highly pleomorphic cells constituted the majority (7/10) followed by type II featuring mixture of both solid and cystic areas. TP53 mutation was found in 30% of PPBL. EWS rearrangement was confirmed in Ewing's sarcoma. Conclusion: Primary lung tumors in children are rare and histopathologically diverse. The tumor spectrum involves many types which are not seen in adults. While PPBL and Ewing's sarcoma are the most commonly encountered tumors in this age group, some rare tumors like carcinoid and mucoepidermoid carcinoma may also be seen. IMFT have excellent prognosis while PPBL are associated with poor clinical outcome.

Keywords: Pediatric lung tumors, pleuropulmonary blastoma, TP53 mutation

   AEP211 Top

   Pediatric Pathology Top

A rare case report of fetus in fetu

Milana Halehuru, Hephzibah Rani, Deepti Dixit, Aditya Agnihotri, Ravikala Rao, Akshay Kalavant

SDM Medical College, Dharwad, Karnataka, India

Case Report: A 6 day old female neonate presented with abdominal mass. Antenatally USG suggested fetal complex cyst/ dermoid cyst. CT abdomen performed postnatally revealed a large, heterogeneous lesion measuring 7.5x7.5x5.1 cm with solid - cystic areas and displacing bowel loops to one side, suggestive of fetus in fetu/ mature teratoma. Excised specimen was sent for histopathological examination. Grossly, single skin covered mass with four limb buds within a sac noted. Cut section showed solid and cystic areas with foci of cartilagenous areas. Microscopy showed stratified squamous epithelium with adnexal structures comprising of hair follicles, sebaceous glands, mature cartilage, bony spicules, foci lined by respiratory epithelium, intestinal glands, mature neural tissue and nerve bundles. Discussion: The term fetus in fetu was first coined by Meckels in 18th century. In 2001, Spencer suggested one or more of 5 criteria for diagnosis which included distinct sac encasement, partial or complete skin coverage, grossly recognizable anatomical parts, feeding vessels from host and closely associated with Gastrointestinal system or neural tube. Present case met 4/5 criteria for diagnosis of FIF. Conclusion: Histopathology confirms the diagnosis of intraabdominal masses in neonates. Spencer's criteria aids in differentiating FIF from teratoma.

Keywords: Abdominal mass, fetus in fetu, teratoma

   AEP212 Top

   Pediatric Pathology Top

Nasal chondromesenchymal hamartomas: A rare and diagnostically challenging entity

Mahesh Patel, Mukta Ramadwar, Poonam Panjwani, Sajid Qureshi, Maya Prasad, Girish Chinnaswamy

Tata Memorial Hospital, Mumbai, Maharashtra, India

Case Report: Retrospective study of three cases from 2012 to 2021 was done. Age range was from 1 month to 4 years. All three patients were females and had nasal obstruction. Radiological examination revealed heterogeneous mass with solid cystic component. All patients underwent complete excision of the mass after biopsy confirmation of diagnosis. Histological examination showed stroma composed of fibroblastic/myofibroblastic proliferation and chondroid islands. DICER1 gene mutation was done in one patient (negative). All three patients are well upon surgery. Discussion: NCMH are rare benign tumors which can be locally aggressive. Histologically they show a mixture of fibroblasts/myofibroblasts and cartilage. In this short series of 3 patients with NCMH, we wish to highlight the diagnostic difficulty while biopsy interpretation. Each of our 3 cases posed a differential diagnosis of malignant bone tumor, especially osteosarcoma. Radiology findings were equivocal due to large, expansile albeit non-infiltrating lesions. In all cases, there was irregular spindle cell proliferation and cartilage islands lacking cytological atypia. There were no mitotic figures. Correct diagnosis of NCMH prevented use of neo-adjuvant chemotherapy and also extensive surgical planning was avoided. Conclusion: To conclude, NCMH is a rare tumor. It poses diagnostic challenges in the form of differential diagnosis of osteosarcoma as in our series. Attention to lack of atypia in all tissue components and absence of mitotic figures helps arrive at the correct diagnosis.

Keywords: DICER1, excision, nasal chondromesenchymal hamartoma

   AEP213 Top

   Pediatric Pathology Top

Primary retroperitoneal teratoma, pre-pubertal type with two simultaneous somatic-type malignancies in a young child

Deena Mishael, Ashwini Nargund, G Champaka, C Srinivas

Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India

Case Report: A 3-year-old male child presented to the surgical out patient department with the complaints of mass per abdomen of 6 months duration. Investigations revealed a solid-cystic retroperitoneal mass which was excised. Macroscopically, it was a capsulated solid cystic mass with few of the cysts filled with sebaceous material and hair. Areas of calcification and extensive bony hard grey white areas noted. Microscopically, it was a teratoma with somatic-type malignancy composed of mature elements, grade 1 neuroendocrine tumour and malignant components namely, squamous cell carcinoma and chondrosarcoma. Germ cell neoplasia in situ was not identified even after extensive sampling. Discussion: Somatic-type malignancies occur in 3-6% of testicular germ cell tumors, virtually only in post-pubertal patients in the age range of 15-68 years. They arise most commonly in metastatic sites especially retroperitoneal lymph nodes after chemotherapy rather than in primary site. Sarcomas are the most common histologic type whereas most carcinomas are adenocarcinomas. Development of two simultaneous malignant components in a teratoma is rare. Conclusion: This is a rare case of primary retroperitoneal teratoma, pre-pubertal type with grade 1 neuroendocrine tumor and two uncommon secondary malignancies namely, squamous cell carcinoma and chondrosarcoma in a young 3-year-old child which has not been reported before. Hence, we present this case.

Keywords: Pre-pubertal type, retroperitoneal teratoma, simultaneous somatic-type malignancies

   AEP214 Top

   Pediatric Pathology Top

Acute leukemia to alveolar rhabdomyosarcoma: The journey; featuring morphology, imaging, immunohistochemistry and FISH

Seyed Rabia, Arathi Srinivasan, Suresh Babu

Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India

Case Report: A 3-year-old developmentally normal female child was brought to the OPD with complaints of difficulty in walking and bone pains for a month. MRI of the foot was suggestive of a soft-tissue sarcoma. Pre-operative CBCs showed leucoerythroblastic blood picture. Biochemical parameters were suggestive of Tumour Lysis syndrome. Discussion: Excision biopsy of the foot mass was done along with a simultaneous bone marrow aspiration. The bone marrow showed 80% atypical cells in clusters and dispersed singly. Flow cytometry was deferred due to distribution pattern and in anticipation of histopathological examination (HPE). HPE of the leg mass and subsequent Immunohistochemistry were confirmatory of Alveolar Rhabdomyosarcoma. Fusion studies showed positive PAX fusions [ t (1;13) and t (2;13)]. A consensus diagnosis of Metastatic Rhabdomyosarcoma: High Risk; Stage 4; Fusion positive was reached. Conclusion: A thorough clinical examination and algorithmic diagnostic approach is required for non-hematological bone malignancies as they can closely mimic Acute Leukemia.

Keywords: Acute leukemia, alveolar rhabdomyosarcoma, bone marrow

   AEP215 Top

   Thoracic Pathology Top

Talc granulomas in intravenous drug abusers: All that glitters is not gold!

Bhawana Dhiman, Ridhi Sood Valliapan, Amanjit Bal

PGIMER, Chandigarh, India

Case Report: We present 3 cases of young males, with history of gradually progressive dyspnea. Radiology revealed ground glass opacities in bilateral lungs more in lower lobes. Microscopy of all three cases showed distortion of the alveolar architecture by interstitial fibrosis and interstitium showed clusters of multinucleated giant cells especially in vicinity of bronchovascular bundles. Deposition of pale blue crystalline foreign material was seen which was birefringent. These needle to thin plate shaped crystals were gray-violet on Masson's trichrome stain. Special stains were performed to rule out causes of infectious granulomatous infections and final diagnosis of talc associated pneumoconiosis was made. Retrospectively a history of drug abuse was found in all the three cases. Discussion: Patients with talcosis present with dyspnea and often have history of drug abuse. For pathologists, birefringence is an important clue to clinch the diagnosis. Special stains for amyloid, collagen and elastic tissue can be used to distinguish talc from similar looking materials and identify its correct location. The history of route of administration is also helpful in localizing the pathology. Conclusion: Awareness is the first step in diagnosing talcosis as a rare cause of pulmonary fibrosis due to its deep social impact.

Keywords: Birefringence, drug abuse, pulmonary talcosis

   AEP216 Top

   Thoracic Pathology Top

Neuroendocrine tumour grade 1 presenting in lung: A rare case report

Debaditya Haldar, Mamta Kumari, Bipin Kumar

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Case Report: A 23 year old male presented with history of haemoptysis for 2 years. He had taken anti-tubercular medications for suspicion of pulmonary Koch's made by a local physician. CECT chest showed an endobronchial mass involving right bronchus intermedius, bronchoscopy confirming the same with luminal occlusion. Endobronchial biopsy was done, showing features favouring a Neuroendocrine tumour. He underwent Right pneumonectomy here at IGIMS Hospital, and a solid tumour was seen in the hilum of middle lobe of right lung. Histomorphological examination showed features of a well differentiated neuroendocrine tumour, with no adverse prognostic features or lymph node extension. Immunohistochemistry was done with the help of Synaptophysin, Ki67, TTF-1, LCA and PAX5 to rule out other differentials and the diagnosis of Neuroendocrine tumour Grade 1 was confirmed. Discussion: Carcinoid tumours tend to grow very slowly when compared with other types of lung cancer. However if left unresected, can lead to worsening of obstructive symptoms and complications like bronchiectasis. Conclusion: Although a rare entity, carcinoid tumour must be kept in mind on encountering a patient with pulmonological symptoms, and careful histomorphological and immunohistochemical examination must be done to reach an accurate diagnosis.

Keywords: Carcinoid, lung, neuroendocrine

   AEP217 Top

   Urogenital Pathology Top

Benign cystic teratoma of ovary with coexisting dermal appendageal tumor resembling hidrocystoma: Case report of a rare entity

Kavithareddy Gade, B N Kumarguru, S Saranya, G K Swethadri, A S Ramaswamy

PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Case Report: A 26-year-old female presented with mass per abdomen and pain over the right lower quadrant. Bimanual examination revealed a cystic mass measuring 6x4 cm. Pelvic ultrasonography revealed a complex solid-cystic lesion in the right adnexal region. Right salphingo-oophorectomy with left salpingectomy was performed. Left ovarian tumor was reported as benign cystic teratoma on frozen section. Cut-section showed globular cystic lesion measuring 7.5x5x0.5 cm. The lumen of the cyst showed thick pultaceous material. The wall of the cyst appeared thickened at places. Routine histopathology showed a cystic tumor lined by stratified squamous epithelium and pseudostratified ciliated-columnar epithelium at places. The cyst wall showed skin appendageal structures, adipose tissue and smooth muscle bundles. Also seen was a cystic lesion with papillary projections lined by inner columnar and outer cuboidal epithelium. A final diagnosis of benign cystic teratoma with cystic lesion resembling hidrocystoma component was offered. Post operative period was uneventful. Patient was discharged in stable condition. Discussion: The wall of ovarian cystic teratoma shows various kinds of morphological patterns. Some of them show features resembling dermal and epidermal tumors. Conclusion: Benign cystic teratoma with coexisting hidrocystoma is a rare occurrence. This calls for meticulous grossing of the specimen. Appreciation of an unusual tumor component in a common entity necessitates diligent observation by microscopy.

Keywords: Epithelium, neoplasms, tissues

   AEP218 Top

   Urogenital Pathology Top

46 XY sexual development disorder (DSD) in a 21 year old girl: A case report

Ayushi Sharma, Subhash Bhardwaj, Rupali Bargotra

Department of Pathology, GMC, Jammu, Jammu and Kashmir, India

Case Report: Here we present a case of 21 year old, brought up as a female who presented to the gynecology outpatient department of GMC Jammu with complaints of primary amenorrhea and absent cyclical abdominal pain. Discussion: General physical examination revealed normal breast development with absent pubic and axillary hair. Karyotyping showed XY pattern. Bilateral laparoscopic gonadectomy was done. Gross examination revealed two firm and two fibro fatty soft tissue pieces measuring 4*2 cm and 2.5*2 cm respectively. Histopathological examination revealed testicular tissue. No ovarian tissue was identified in the multiple sections examined. The patient was discharged and managed with multi disciplinary approach and fertility issues discussed with the patient. Conclusion: 46 XY disorder of sexual development is a rare disorder diagnosed by combination of tests including chromosomal analysis, hormonal testing, radiographic investigations and histopathological examination. Prophylactic gonadectomy should be done as such patients are prone to develop gonadal ridge tumors like gonadoblastoma, dysgerminoma, yolk sac tumor's and choriocarcinomas.

Keywords: 46 XY karyotype, ovotesticular disorder

   AEP219 Top

   Urogenital Pathology Top

Synchronous invasive urothelial carcinoma – High grade

R Chythanya, M Girish, H R Vanisri

Chamarajanagar Institute of Medical Sciences, Yadapura, Karnataka, India

Case Report: 69 years male presented with hematuria and left flank mass. Patient underwent left nephroureterectomy and transurethral resection of bladder tumor (TURBT). On histopathological examination, it was diagnosed as Synchronous Invasive Urothelial Carcinoma - High grade. Discussion: The diagnosis of synchronous invasive urothelial carcinoma is infrequent. So far, about 50 cases of synchronous renal tumors have been reported in the literature. Patient usually presents with hematuria, flank pain or palpable mass. These tumors are often seen in the 6th decade of life and usually occur in the left kidney. Cases reported in the previous literature about synchronous renal tumors showed tumor mass in one of the pole of the kidney and in renal pelvis. In the present case, an infiltrating tumor mass was seen in renal pelvis extending up to the ureter and involved urinary bladder. Conclusion: Occurrence of genitourinary tumors is on the rise and the frequency of encountering synchronous tumors has also increased. Hence adequate preoperative diagnosis and histopathological examination can lead to early diagnosis and treatment.

Keywords: Renal cell carcinoma, synchronous, TURBT, urothelial carcinoma

   AEP220 Top

   Urogenital Pathology Top

Morphological molecular subtyping of endometrial carcinomas using immunohistochemistry: Insights to new TCGA/WHO 2020 (5th) classification

MalaKrishna Neha, Devika Gupta, Prasanta Sengupta, Kanwaljeet Singh, Geetu Bhandoria, Raju Agarwal

Command Hospital (EC), Kolkata, West Bengal, India

Case Report: This was retrospective analysis of 30 diagnosed cases of EC over last 03 years at this tertiary centre. The cases were retrieved from archives and reclassified using immunohistochemical markers (ER, PR, MLH 1, MSH2, MSH6, PMS2, p53, & Her2neu) as MMR d, p53 mutant and p53 wild type/NSMP. Discussion: 30 cases comprising of 24 EEC, 04 serous & 02 undifferentiated carcinoma were reclassified using molecular IHC markers. 03/24 (12.5%) cases of Endometroid EC showed loss of MSI markers, suggestive of MMRd (age <50 years). 01/12 cases (8.33%) of Grade I EEC, 02/12 cases (16.6%) of Grade II & III were p53 mutated. All serous & undifferentiated carcinomas were p53 mutated. Conclusion: 'Histo-molecular approach' helped us to define the groups into prognostically favorable & unfavorable categories. Drawback of the study was that we didn't analyze POLE ultramutation as it requires molecular techniques unavailable at this centre. We hereby, propose use of basic IHC panel to prognosticate & classify EC as it will guide clinical management & add to decision making on use of adjuvant chemo/radiotherapy which may improve patient survival. Also, detection of germline MSI cases would be subjected to timely genetic counselling.

Keywords: Endometrial carcinoma, dMMR, molecular subtyping

   AEP221 Top

   Urogenital Pathology Top

Uterine didelphys with leiomyoma and adenomyosis – A case presentation

D Darshitha, M Usha

M S Rammiah Medical College, Bengaluru, Karnataka, India

Case Report: A 45 old lady who is para 3 living 3 with history of tubectomy and hypothyroidism since 4 years complaints of pain abdomen since about 4 to 5 months. Upon further examination and investigations uterus didelphys with leiomyoma and adenomyosis was noted. Patient underwent hysterectomy with bilateral salphingectomy. Gross and microscopic examination further confirmed the diagnosis along with presence of multiple leiomyoma and adenomyosis along with chronic non specific cervicitis and nabothian cyst. Discussion: Uterine didelphys is a rare congenital anomaly associated with significant morbidity and infertility. It is also associated with Herlyn-Werner-Wunderlich syndrome which was not seen in our case. Much remains to be understood on the exact etiopathogenesis of this condition and its possible association with leiomyoma which was seen in our case. Conclusion: Uterine didelphys is a rare mullerian duct anomaly and we hereby represent a case which was incidentally associated with leiomyoma and adenomyosis.

Keywords: Leiomyoma, mullerian duct anomalies, uterine didelphys

   AEP222 Top

   Urogenital Pathology Top

Ectopic adrenal cell rest in ovary

Atithi Bansal, S Sudhamani, Sneha Chavarkar, Kritika Singh, Rajiv Rao

D Y Patil School of Medicine, Navi Mumbai, Maharashtra, India

Case Report: A 50/F presented with post-menopausal bleeding since 9 months associated with dysmenorrhea. USG revealed bulky uterus with submucosal fibroid - 7.7 x 6.6 cm. Received uterus with right adnexa. Gross - single submucosal leiomyoma uterus with well encapsulated yellow nodule - 0.3 cm in diameter in right ovary. Histopathology of right ovary revealed incidental ectopic adrenal cell rest in ovary with no evidence of atypia/necrosis/malignancy. Discussion: Ectopic adrenal tissue is found in 50% neonates, and most of them undergo atrophy. Adrenal rests are usually identified in specimens of gynecological surgery or in the context of inguinal hernia repair procedures. Conclusion: Even though very rare, the histopathologist should be aware of this entity to avoid misdiagnosis.

Keywords: Ectopic adrenal cell rest, ovary, uro-genital tract

   AEP223 Top

   Urogenital Pathology Top

Incidental sex cord stromal tumor with annular tubules in undescended testis – A rare case report

Swathi Krishna, P Aravind, Thoppil Reba Philipose, K Thushara

A J Institute of Medical Science and Research Centre, Mangalore, Karnataka, India

Case Report: A 33 year old male patient complaints of right inguinal swelling since 4 years. USG showed right inguinal hernial sac with right testis and fat. He was clinically diagnosed as Cryptorchidism. Hence right orchidectomy was done. Grossly tunica appears intact, epididymis and rete testis was not identified. Microscopically a foci of tumor composed of simple annular tubules with peripherally oriented nuclei around a central hyalinised body was identified. Discussion: Testicular SCTAT are infrequent. The clinical behaviour of which has features intermediate between those of the Granulosa cell tumor and those of the Sertoli cell tumor, focal differentiation to either may occur. This was an incidental finding which was extremely rare condition found in an orchidectomy specimen, excised for unrelated conditions. Conclusion: SCTAT is a rare ovarian tumor and it was incidentally found in the testis. However this rare SCTAT presented as a long standing hernia with undescended testis and no other serious clinical symptoms, infertility or Peutz-Jeghers syndrome (PJS). Hence it would be recommended that SCTAT should be a microscopic differential when dealing with incidental tumors in the testis. Though malignancy and metastasis are known to occur in 20% of Non Peutz-Jeghers syndrome SCTAT, these tumous are considered to be of low malignant potential.

Keywords: Incidental finding, SCTAT, testis

   AEP224 Top

   Urogenital Pathology Top

A rare case of splenogonadal fusion – Continuous variant without associated congenital anomalies in a young adult

A S Ragashree, T N Chandrashekhar

Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India

Case Report: 27-year-old man referred for evaluation of a palpable, mobile, and painless left scrotal mass. The patient had no history of trauma, cryptorchidism, external anomalies or malformations. On examination revealed no signs of inflammation in the scrotum. The mass was located inside the scrotum just beneath the epididymis attached to testis, and was slightly painful on palpation. Discussion: SGF is a condition that usually presents as inguinal hernia, cryptorchidism, or scrotal swelling/mass. Other malformations include limb defects such as peromelia, micrognathia, cleft palate, spinal malformations, craniosynostosis, anal malformations, Poland syndrome and Moebius syndrome. Conclusion: Splenogonadal fusion is a rare entity in which continuous type without intratubular germ cell neoplasia and other anomalies is extremely rare. SGF should be considered during the evaluation of an undescended testis or testicular mass evaluation in younger age-groups. Preoperative misdiagnosis is common and may lead to unnecessary orchidectomy if testicular neoplasm is suspected. Familiarity with this lesion allows frozen section study which can avoid unnecessary radical surgery and testicular preservation.

Keywords: Congenital, continuous, splenogonadal fusion

   AEP225 Top

   Urogenital Pathology Top

Intra renal papillary urothelial carcinoma of renal pelvis mimicking as renal cell carcinoma – A case report

V Keerthana, U Geethalakshmi

Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India

Case Report: 65 yr old male presented with complaints of painless hematuria for 1 year and flank pain for past 15 days. He was a smoker for past 15 years with no history of fever/ urine frequency/nocturia. There was nothing significant in general, systemic examination and routine laboratory tests. Patient was subjected to USG and CECT abdomen showed a solid mass in the upper pole of left kidney with extension to pelvis, suspicious for neoplastic growth. Patient underwent total nephrectomy with clinical diagnosis of Renal cell carcinoma (RCC). On gross examination there was a large papillary friable growth replacing upper pole of kidney measuring 4x3.5x3 cms with involvement of pelvis and proximal ureter, renal pelvis slightly dilated. Microscopy revealed high grade invasive papillary urothelial carcinoma of renal pelvis, extending to kidney and ureter with pathologic staging PT3 Nx Mx. Discussion: Urothelial carcinoma present with high histologic grade and advanced stage. They also display unusual morphologic features and metaplastic phenomena. Many pelvis urothelial carcinomas tend to be aggressive and when extended in to renal parenchyma pose a diagnostic challenge in identifying the lesion. Conclusion: Papillary urothelial carcinomas of renal pelvis with renal parenchymal involvement can simulate RCC kidney clinically and radiologically. Therefore histopathological examination is crucial for definitive diagnosis and further management of patients.

Keywords: High grade, papillary, RCC, urothelial carcinoma

   AEP226 Top

   Urogenital Pathology Top

Renal angiomyolipoma masquerading as a renal cell carcinoma

Y Aishwarya, M Usha, D Clement Wilfred

M S Ramaiah Medical College, Bengaluru, Karnataka, India

Case Report: A 46 year old perimenopausal women complains of lower backpain since 6 months with no hematuria. PETCT scan showed a ill defined lesion suggestive of retroperitoneal mass in the right perinephric region likely neoplastic etiology. Microscopy- The final histopathological examination of the resected specimen confirmed Renal angiomyolipoma. Immunohistochemical studies show positive for HMB-45. Discussion: Angiomyolipoma belongs to a family of neoplasms called Perivascular Epithelioid cell tumours. Prevalence is higher in middle aged woman. Most of these neoplasms are found incidentally on imaging. Because of abundant fat tissue they give characteristic appearance on imaging and hence easily diagnosed. However, sometimes they contain too little fat to be detected. This increases the difficulty in differentiating them from Renal Cell Carcinoma. The cornerstone of the treatment remains surgery. Conclusion: A combination of increased clinician awareness, imaging, pathological evaluation and immunohistochemical studies help in early diagnosis and increase survival rate of patients.

Keywords: Angiomyolipoma, renal cell carcinoma

   AEP227 Top

   Urogenital Pathology Top

Clinical and radiological mimicker of ovarian malignancy – Struma ovarii a rare benign ovarian tumor

Amaya Bhaskaran, Sunitha Vernekar, M B Bharathi, S M Choukimath, Purushotham Reddy

Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Case Report: 62 yrs/F came to our hospital presented with abdominal pain since one month. On P/A examination, 16 weeks size, mobile, firm to hard mass noted. CT scan whole abdomen shows heterogenous solid lesion with internal cystic areas and peripheral rim of calcification in pelvis measuring 11.3x 9.3 cm in close relation to uterine fundus and separate from the uterus -suspicious of carcinoma. Scrape cytology report given as Benign Surface Epithelial Tumor. Microscopy showed ovarian stroma with multiple nodules composed of thyroid follicles, separated by fibro collagenous tissue with areas of hemorrhage, diagnosed as STRUMA OVARII. Discussion: Germ cell tumors are heterogenous group of neoplasm arising from primordial germ cells. Teratomas are the most common type of germ cell tumors. Struma Ovarii are rare type of monodermal teratoma containing more than 50% thyroid tissue. A small percentage of benign Struma Ovarii can undergo malignant transformation. Conclusion: Struma Ovarii, a clinical and radiological mimicker of ovarian malignancy should be kept in mind and also it should be differentiate from serous and mucinous tumors. So histopathology study is important to differentiate this tumor from other ovarian tumors.

Keywords: Benign ovarian tumor, mature cystic teratoma, struma ovarii

   AEP228 Top

   Urogenital Pathology Top

TTF-1 positive small cell neuroendocrine carcinoma ovary – A rare case report

P C Aiswarya, Purushotham Reddy, Sunitha Vernekar, S M Choukimath, M B Bharathi

Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Case Report: 20 year old nulligravida came with abdominal pain. MRI pelvis shows enlarged heterogenous left ovary with internal cystic areas with peripheral cysts within measuring 9.4X 7.2X 7.6 cm suggesting the possibility of neoplastic etiology. On histopathology, it was diagnosed as Small cell carcinoma ovary. Immunohistochemistry showed positive for Pan CK (Perinuclear dot like positivity), Synaptophysin, Chromogranin, CD56, CD99, EMA, TTF-1 and negative for Vimentin, FLl-1, WT-1. Discussion: SC NEC of ovary is rare and extremely aggressive malignancy. The term “Ovarian small cell carcinoma pulmonary type” is no longer included but encompassed within the category of “Small cell neuroendocrine carcinoma” in WHO 5th edition. For definite diagnosis, thorough histopathologic examination and IHC features are needed to avoid misdiagnosis and for improved clinical outcomes. Conclusion: Neuroendocrine carcinoma of ovary is exceptionally rare with plunging course. Though surgical resection and adjuvant, platinum- based chemotherapy is the current standard treatment thorough clinico- radiological assessment, early tissue diagnosis and multimodality treatment are essential. With limited number of cases reported, there are limited treatment guidelines available.

Keywords: Immunohistochemistry, neuroendocrine carcinoma ovary, TTF-1

   AEP229 Top

   Urogenital Pathology Top

A rare case of persistent Mullerian Duct syndrome

B Lavanya, Jayashree G Pawar, Swethadri, A S Ramaswamy

PES Institute of Medical Sciences, Kuppam, Andhra Pradesh, India

Case Report: A 52 year old male presented with swelling in the left groin region since 2 years. General examination vitals stable, systemic examination normal. Per abdomen examination solitary swelling seen in left groin. Local examination it is pyriform in shape extending from above inguinal ligament to root of scrotum and medial to pubic tubercle. Ultrasonograhy showed left inguinal hernia, Patient got operated for inguinal hernia, during intraoperative sac was opened, omentum got resected after that pink coloured structure was seen and after pulling a well developed uterus with fallopian tubes was found, cervix was atrophied. Contents sent for histopathological examination, Histopathological examination of uterus proper showed proliferative endometrial glands and normal myometrium, tissue alleged to be cervix showed fibrocollagenous tissue, cord like structures adjacent to uterus on one side showed vas deferens and epidydimal ducts, on other side fibro collagenous tissue. Gonads attached to uterus had atrophic seminiferous tubules and Leydig cell hyperplasia. No ovarian tissue seen. Karyotyping done which is 46 XY. Discussion: PMDS is very rare, may occur sporadically or inherited X-linked or autosomal recessive. PMDS coincidently detected during surgery. Conclusion: Mullerian duct structures may go unnoticed in phenotypically genotypically normal males, may present as indirect inguinal hernias, careful imaging technique like MRI may help in diagnosis preoperatively.

Keywords: Hysterectomy, inguinal hernia, male

   AEP230 Top

   Urogenital Pathology Top

Malignant mixed mullerian tumor of the cervix: A rare case report with review of literature

Haneena Kukkamgai, R Kalyani, Abhay K Kattepur, M D Shilpa, P Rathnamma

Sri Devaraj Urs Medical College, Kolar, Karnataka, India

Case Report: A 65-year-old woman presented with post-menopausal bleeding since 20 days. She attained menopause at 45 years of age. On per speculum examination there was an ulcero-proliferative growth of 3.5x5 cm that appears to be arising from the cervix. Two cervical biopsies were done at different times and reported as Benign mixed mullerian tumor. The patient underwent total abdominal hysterectomy with bilateral salpingectomy and unilateral oophorectomy and the specimen was sent for histopathological examination and reported as Malignant mixed mullerian tumor of cervix. Patient lost for follow up. Discussion: Malignant mixed mullerian tumor is a rare biphasic tumor of the Female Genital Tract with most cases arising from the uterine corpus and very few cases reported in cervix. The median age of presentation is at 65 years and the most common presenting complaint is post-menopausal bleeding. It is difficult to diagnose clinically and requires histopathological examination for diagnosis. This case had a mesenchymal component of chondromyxoid stroma and an epithelial component of squamous cell carcinoma. A neuroendocrine component was also observed in this case. Conclusion: Malignant mixed mullerian tumor of the cervix can present with diverse histological features. The management is based on the histomorphology of the tumor and hence identifying the predominant epithelial and mesenchymal component on microscopy is critical.

Keywords: Cervix, malignant neoplasm, mixed mullerian tumor

   AEP231 Top

   Urogenital Pathology Top

Study of histomorphological spectrum of various kidney lesions

Mahima Vinodia, Reena Jain, Sudha Iyengar, Rajesh Gaur

Gajra Raja Medical College, Gwalior, Madhya Pradesh, India

Case Report: A hospital- based restrospective analysis was done over a period of two years (September 2020 to Sepetember 2022). All nephrectomy specimens received in the Department of Pathology, Gajra Raja Medical College, Gwalior were recorded from histopathology registers and analysed with regard to age group, gender distribution, gross features, microscopic features, nuclear grading and histopathological type. A total of 38 cases were analysed in this study. Discussion: Males (52.6%) were affected more than females (47.3%). Lesions more commonly involved the right side (71.0%) than the left side (28.9%). Neoplastic lesions (52.6%) were reported more in number than non-neoplastic conditions (47.3%). Among benign cases, inflammtory conditions (66.6%) were more than obstructive conditions (33.3%). Angiomyolipoma (5%) was also reported. Clear cell Renal Cell Carcinoma (90%) was the most common variant reported among neoplastic lesions followed by papillary variant (10%), Chromophobe (5%) variant and unclassified type (1%) of Renal Cell Carcinoma. Majority neoplastic lesions showed WHO ISUP Grade II (55%). Adenocarcinoma (10%) was also diagnosed in neoplastic lesions. Conclusion: Wide age distribution of renal pathologies was observed in this study. Neoplastic conditions were the chief indications for nephrectomies closely followed by non-neoplastic conditions.

Keywords: Chronic pyelonephritis, nephrectomy, renal cell carcinoma

   AEP232 Top

   Urogenital Pathology Top

Invasive stratified mucin-producing carcinoma: An arduous diagnosis

Garima, Prerna Mahajan, Kaniyappan Nambiyar, Nadeem Tanveer

University College of Medical Sciences, New Delhi, India

Case Report: A 57-year-old female, P7L7, presented with post-menopausal bleeding for the past five months. On per vaginal examination, a friable cervical growth was present. Microscopic examination of the cervical biopsy showed an invasive tumor with two distinct patterns and cytomorphology. The first was composed of nests of stratified columnar cells with peripheral palisading and a variable amount of (alcian blue positive) intracytoplasmic mucin. The second was composed of sheets and nests of polygonal cells with eosinophilic cytoplasm. Keratin pearl was not seen. Based on these findings, a diagnosis of ISMC occurring as a mixed form with non-keratinizing squamous cell carcinoma (SCC) was made. Discussion: ISMC is a subtype of mucinous adenocarcinoma of cervix. It can either occur as a pure form or mixed form, where it coexists with SCC or other subtypes of HPV-associated adenocarcinoma or neuroendocrine carcinoma. Combined morphological and immunophenotypic features help in differentiating ISMC from its morphological mimics like adenosquamous carcinoma. Conclusion: Awareness of the morphological features and ancillary stain result of ISMC can aid in picking up the diagnosis in a small biopsy. These findings are of prognostic value as most cases of ISMC behave aggressively.

Keywords: Adenosquamous carcinoma, HPV-associated adenocarcinoma, invasive stratified mucin-producing carcinoma

   AEP233 Top

   Urogenital Pathology Top

A rare case of atypical proliferative (boderline) seromucinous tumour with focal areas of intraepithelial carcinoma

Pooja Patel, Prashant Patel, Hemali Tailor, Rahul Modi, Chintal Patel

Government Medical College, Surat, Gujarat, India

Case Report: A 32 years female complaining of abdominal pain and on examination it showed approximately (7x8) cm2 freely mobile mass on right side with normal CA 125 level. On USG possibility of hemorrhagic ovarian cyst. Laproscopic cystectomy specimen was sent for histopathological examination which on microscopy show cyst wall predominantly lined by endocervical mucinous type of epithelium and focally by flat cuboidal epithelium showing varying degree of stratification, tufting and at places forming hierarchical branching and complex glandular architecture. Mitotic activity with atypical mitosis at places. Necrosis and stromal invasion absent. Tumor cells immunoreactive for CK 7, p53 and immunonegative for CK 20 and WT1. Finally reported as Atypical Proliferative (Borderline) Seromucinous tumor with focal areas of intraepithelial carcinoma. Discussion: Seromucinous tumors are commonly present as borderline category with frequently as bilateral tumor and associated with endometriosis. They are 5-7% of all borderline ovarian tumors. These tumors have an excellent disease-free survival after surgical treatment so accurate diagnosis is important. Conclusion: Seromucinous ovarian tumors have overlapping morphology which can mimic with endometrioid carcinomas and low-grade serous carcinoma. However morphological examination along with IHC is useful in differentiating them from their histological mimics.

Keywords: Boderline ovarian tumour, ovarian tumour, seromucinous tumour

   AEP234 Top

   Urogenital Pathology Top

A rare case of primary fallopian tube high grade serous carcinoma masked as endometrial carcinoma

Mili Jadav, Hemali Tailor, Prashant Patel, Rahul Modi, Archana Patel, Chintal Patel

Government Medical College, Surat, Gujarat, India

Case Report: A 60 years female with complaint of post-menopausal bleeding per vaginum. Endometrial biopsy was taken which showed possibility of Endometrial Adenocarcinoma. Hysterectomy with bilateral salpingectomy was done considering this biopsy finding and specimen was sent for histopathological examination. Grossly uterine cavity found to be unremarkable but one-sided fallopian tube shows small, whitish, fragile furry papillary growth like areas in lumen and adjacent cystic areas. Microscopic features showed moderate to markedly pleomorphic malignant epithelial cells arranged in papillary pattern, cribriform, glandular pattern and solid nests with areas of necrosis. Occasional mitotic activity was seen. Few psammoma bodies and calcification were seen. Sectioning of endomyometrium and both ovaries showed no tumor involvement. Immunohistochemistry studies showed cells immunoreactive for p53 and WT1 and immunonegative for ER, PR, CEA and Vimentin. Final diagnosis was Primary Fallopian Tube High Grade Serous Carcinoma. Discussion: Due to its rarity, preoperative diagnosis of primary fallopian tube carcinoma is extremely rare like in the range of 0%-10%, and up to 50% are missed intraoperatively. It is typically misdiagnosed as ovarian carcinoma or uterine carcinoma like in our case on biopsy. Vaginal discharge is the most common symptom. Conclusion: Histological and immunohistochemical study of postoperative material allows assessment of the exact site and degree of malignancy along with tumor spread which allows selection of appropriate therapeutic tactics.

Keywords: Fallopian tube, high grade serous carcinoma, immunohistochemistry

   AEP235 Top

   Urogenital Pathology Top

Cystic myopericytoma involving lower cervix and upper vagina – An uncharacterized entity in FGT

Swati Shukla, Vamseedhar Annam, J S Deepthi, Jyothi A Raj

Rajarajeswari Medical College and Hospital, DR M G R Educational and Research Institute, Bengaluru, Karnataka, India

Case Report: A 37-year-old lady presented with pain in the lower abdomen. Radiology findings suggested a complex cystic lesion with haemorrhagic content involving the lower cervix and upper vagina. Laparoscopic cervical cystectomy surgery was performed and specimen was sent for histopathological examination. Based on morphology, a diagnosis of intravascular papillary endothelial hyperplasia was given. Immunohistochemistry confirmed the diagnosis of Myopericytoma. The details will be elaborated in the Poster. Discussion: MPC have morphological features similar to myofibromas, angioleiomyomas, and glomus tumors. It has been hypothesized that the neoplastic cells are derived from pluripotent periendothelial cells capable of differentiating along smooth muscle, pericytic and glomus cell lineages. Histologically, myopericytoma consists of oval-to-spindle shaped myoid-appearing cells with smooth muscle differentiation (actin expression) arranged in a concentric, perivascular pattern. Conclusion: MPC are rare solid neoplasms and involving the lower cervix and upper vagina is still more rare. Here, MPC presented as a complex cyst. Also, it can be considered as a differential diagnosis in cystic lesions of the lower cervix.

Keywords: Complex cyst, lower cervix, myopericytoma, solid neoplasm

   AEP236 Top

   Urogenital Pathology Top

Unusual presentation of low-grade endometrial stromal sarcoma as urinary bladder mass: A case report

Siddhi Pandey, Ranu Tiwari Mishra, Noopur Gupta, Vijay Kumar Shrivastava, Sanjay Kumar Totade

Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh

Case Report: 48 year old female presented with complaints of hematuria, burning micturition and right flank pain since 7 month. She was earlier diagnosed outside as leiomyoma of urinary bladder on biopsy& had a past history of hysterectomy 9 years back which showed adenomyosis. CT scan showed heterogeneously enhancing lobulated mass measuring 43x50 mm, attached to posterior wall of urinary bladder with exophytic component and loss of fat plane. It also showed few nodular opacities in lungs which were suggestive of metastasis. TURBT was done. Histological examination showed tumor with features suggestive of Endometrial stromal sarcoma, which was confirmed by IHC. So diagnosis of Endometrial stromal sarcoma urinary bladder in post hysterectomy patients was given. Discussion: Low grade ESS has low malignant potential but can cause late recurrence, hence patient required long-term follow-up. ESS involving urinary bladder is extremely rare. When ESS occur as late recurrence with urinary tract symptoms at presentation it causes diagnostic dilemma specially when primary tumor diagnosis is not known. Conclusion: Low grade endometrial stromal sarcoma is often misdiagnosed in unusual location and causes significant diagnostic dilemma specially when primary tumor diagnosis is unavailable. Though uncommon, it can be suspected because of characteristic morphology and pattern of muscle invasion and confirmed by immunohistochemistry.

Keywords: Endometrial stromal sarcoma, TURBT, urinary bladder

   AEP237 Top

   Urogenital Pathology Top

Squamous cell carcinoma evolving in mature cystic teratoma ovary with omental deposits

Khadija Irum, Siddaganga, Rajashree Ingin, Chanrakanth

Gulbarga Institute of Medical Science, Kalaburagi, Karnataka, India

Case Report: Case profile: A 50 year female presented with sudden onset of pain and mass per abdomen. Underwent hysterectomy 10 years back for UV prolapse. USG abdomen - large cystic mass with mixed echo pattern. Surgical procedure – Complete excision of the mass with omentectomy. Gross: Cystic globular mass measuring 19x13x8 cm. External surface shows congested blood vessels. Cut section – Cyst cavity filled with pultaceous material, tuft of hairs, myxoid areas and solid grey white area ms-7x6 cm. Discussion: Malignant transformation (MT) is a rare and the worst complication of MCT. MT occurs in 1–3% of cases, especially in postmenopausal women. Nearly 80% of the histological type of malignant transformations is squamous cell carcinoma (SCC), followed by adenocarcinoma, carcinoid tumor, melanoma, and sarcoma. Here we present a rare case of postmenopausal women who developed SCC in MCT with omental deposits. Conclusion: SCC arising in mature cystic teratoma is rare. The prognosis is based on the size and stage of the tumor. Hence early diagnosis and treatment are very critical for better prognosis.

Keywords: Malignant transformation, mature cystic teratoma, ovary, squamous cell carcinoma

   AEP238 Top

   Urogenital Pathology Top

Rare presentation of female adnexal tumor of probable wolffian origin

Suranjana Dutta, Soumit Dey, Pranamita Ray, Ayan Sarkar, Sougata Bhattacharjee

Ramakrishna Mission Seva Pratishthan, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India

Case Report: A 56 years old female patient was present with acute pain in the upper abdomen. She had undergone total abdominal histerectomy with bilateral salpingoophorectomy 14 years ago. Radiological finding:intrapelvic SOL. Discussion: grossly specimen was capsulated, bilobed, multinodular, dumbbell shaped measuring 8 cmx6.5 cmx5 cm. Cut surface was grey white and lobulated in appearence. Microscopically nodular lesion composed of scattered tubules, cords, composed of round to oval cells in a fibrous stroma are seen. Abundant capillaries and small blood vessels are also seen. IHC markers:PAN cytokeratin:focally positive, ER:+VE, EMA: -VE, INHIBIN A: -VE, MELAN A: -VE, CD10: -VE. Conclusion: Despite having total abdominal histerectomy with bilateral salpingoophorectomy, the patient presented with the tumor (female adnexal tumor of probable Wolffian duct origin). So it is a rare presentation.

Keywords: Female adnexal tumor, intrapelvic SOL, Wolffian duct

   AEP239 Top

   Urogenital Pathology Top

Primary signet ring cell adenocarcinoma arising in exstrophy of urinary bladder

Nupur Harinkhede, Gwendolyn Fernandes, Gloria Khumanthem, Amey Rojekar

Seth G S Medical College and K E M Hospital, Mumbai, Maharashtra, India

Case Report: •A 32 year old man with congenital, untreated bladder exstrophy, presented with a large fungating mass on the lower abdominal wall. Physical examination revealed a 15 x 12 cm exophytic mass with penile epispadias. •Ultrasonography showed replacement of the urinary bladder by a heterogeneously hyperechoic lesion of size 9x8x7 cm with a defect in the abdominal wall. On CECT, a mass protruding from a large, inferior abdominal wall defect of 5.3 cm was seen. Widened pubic symphysis with divarication of recti and absent urinary bladder, were also noted which was consistent with bladder exstrophy. A biopsy showed malignant signet ring cells with a possibility of PSRCA of the bladder. A radical cystectomy with ileal conduit and left inguinal lymph node dissection was done. Histopathology examination revealed a PSRCA with metastasis to the left inguinal lymph nodes. Prostate, seminal vesicles and vas deferens were identified and were free of tumor. Immunohistochemistry supported the diagnosis. The patient was lost to follow up. Discussion: PSRCA shows aggressive behaviour, as was seen in our case, which had metastatic inguinal lymph nodes at the time of presentation. Metastatic signet ring cell adenocarcinomas from other sites need to be ruled out. Conclusion: Bladder exstrophy can develop high grade malignancies at a young age. Hence, close follow up, early diagnosis and surgical treatment is recommended.

Keywords: Epispadias, exstrophy, signet ring cell adenocarcinoma, urinary bladder

   AEP240 Top

   Urogenital Pathology Top

Malakoplakia in a graft kidney masquerading malignancy

Prajna Gopalakrishna, Ipsita Panda, Nandita Kakkar, Ashish Sharma

Post Graduate Institute of Medical Education and Research, Chandigarh, India

Case Report: A 50-year-old female, post-renal transplant in 2021, presented with high-grade fever and reduced urine output. On examination, her creatinine was increased (5.83 mg/dl), urine routine showed increased pus cells (50-60/HPF). Initial ultrasound revealed an ill-defined hypoechoic area measuring 3.1*2.4 cm in the upper pole of the right kidney. CECT confirmed multiple endo and exophytic hyperdense mass lesion in the interpolar and inferior pole of the transplanted kidney. Core biopsy from this mass was performed with a provisional clinical diagnosis of post-transplant lympho-proliferative disorder. Microscopically, there was the presence of dense sheets of foamy and eosinophilic macrophages admixed with plasma cells and lymphocytes. Few entrapped native tubules were also seen. Characteristic Michaelis Guttman bodies highlighted on PAS and Von-kossa were seen. No evidence of any lymphomatous infiltration or malignancy was seen. A diagnosis of malakoplakia was rendered. Subsequently, urine culture reported E Coli positivity and patient was treated with antibiotics. The patient responded well and is currently doing well till the last follow-up. Discussion: Malakoplakia is a granulomatous condition with an infectious aetiology that typically affects the urinary tract. It manifests as a recurrent urinary tract infection. One of its key contributing variables, immunosuppression, is becoming more frequently mentioned in patients who have undergone solid organ transplantation, particularly kidney transplantation. Conclusion: Inflammatory lesions like malakoplakia may be mass-forming, especially in immunocompromised patients. A high index of suspicion is essential to accurately diagnose this uncommon but curable condition.

Keywords: Immunosuppression, malakoplakia, renal graft

   AEP241 Top

   Urogenital Pathology Top

A rare case of ovarian lymphangioma

C Poojashree, B R Ashwini

Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Case Report: We present a case of 35 years old woman who presented with pain abdomen. Abdominal and pelvic ultrasound was suggestive of dermoid cyst. Left oophorectomy was done and histopathological examination revealed enlarged ovary measuring 4x3x2 cm. Cut surface showed multiloculated cysts of varying sizes filled with straw coloured fluid. Microscopic examination revealed multiple thin walled cavernous cystic spaces containing thin proteinaceous fluid with intervening ovarian tissue. Luminal space and ovarian stroma showed lymphocytic infiltrates. No immature elements or ectodermal tissue noted. Diagnosis of ovarian lymphangioma was made. Discussion: Lymphangioma is a benign lesion occurring due to developmental malformations of lymphatic system and commonly involves head and neck region. Visceral lymphangioma is rare and confined to intestine and mesentery. Ovarian lymphangioma is extremely rare entity and hence its pathogenesis is little understood. Some authors suggest it to be a hamartomatous process caused by sequestration of lymphatic tissue during embryonic development whereas some authors argue that it is a true neoplasm. Malignant transformation is extremely rare. Complete excision and long term follow up is advised to exclude the possibility of malignant transformation. Conclusion: We present this case owing to its rarity and to highlight the importance of considering this entity in differential diagnosis of cystic lesions of ovary.

Keywords: Histopathology, lymphangioma, ovary

   AEP242 Top

   Urogenital Pathology Top

Ectopic ovarian pregnancy – A rare entity

Soumya Kori, Shwetha Ramu

JJM Medical College, Davanagere, Karnataka, India

Case Report: 30 years, G3P2L2 at 13 weeks, complaints intermittent lower abdominal pain since 2-3 days. USG - Uterus normal. No gestational sac seen in endometrium, well-defined tubo-ovarian mass noted with multiple septations, echogenic contents. Grossly - Received right sided ruptured ovary with fetus and placenta, ovary measuring 8x5.5x3 cm. External surface (E/S) - grey white (g/w) to grey brown (g/b), ruptured. C/S (cut surface) –g/w, friable, g/b areas of hemorrhage. Right FT measuring 4.5cm. E/S and C/S - Unremarkable. Placenta measuring 8x5.5x0 8 cm, Umbilical cord measuring 10.5 cm and Fetus measuring 8x4x3 cm. Left FT- E/S and C/S– Unremarkable. Microscopic - Section studied (s/s) (A) of normal looking ovary with adjacent friable tissue shows ovarian stroma with lobules of decidual tissue. (s/s) from friable tissue (B-D) show chronic villi (C,D)- fibrotic and necrotic villi with foci of decidua (C) large areas of fibrino-haemorrhagic material and fibrotic decidua. (s/s)(E) shows attached FT-Unremarkable. (s/s) (F) membranous tissue bit and chronic villi shows ischemic changes. (s/s) (G) Placenta shows chronic villi of varying sizes. s/s (H,I) Umbilical cord shows 2 arteries and 1 vein embedded in loose connective tissue. s/s (J) Left FT -Unremarkable. Discussion: Intraoperative findings and histopathology satisfied Spiegelberg's criteria (intact FT on affected side; fetal sac occupying ovary; ovary-uterus connected by ovarian ligament; definite ovarian tissue found in sac wall). Conclusion: Ovarian ectopic pregnancy considered important differential diagnoses in reproductive age with history of amenorrhea.

Keywords: Amenorrhea, ectopic pregnancy, spiegelberg criteria

   AEP243 Top

   Urogenital Pathology Top

Testicular Lymphoma – A case report

Ravikanti Kavitha, G Vandana, B Laxmi narayana, Praneetha

Kakatiya Medical College, Warangal, Telangana, India

Case Report: A 40 yr old male presented with a complaint of Right scrotal swelling since 5 months, gradually progressing in size. On further investigation, Ultrasonography shows an evidence of single well defined, bulky, hypodense mass measuring 7.5×5×4 cm. Patient underwent Right Orchidectomy and specimen was sent for histopathological evaluation. On gross: received orchidectomy specimen measuring 7.5 × 5 ×4.5 cm with an attached cord measuring 6.5 cm. External surface was congested On cut section well circumscribed greywhite, lobulated, homogenous, solid lesion was seen. Discussion: Primary testicular lymphoma is rare, clinically aggressive form of extranodal lymphoma accounting for 1-2% of all lymphomas and 5% of primary testicular tumors. Most of these (80-90%) are DLBCL with a mean age of 60 yrs. Han's algorithm is used to know the cell of origin and to subtype the tumor. Conclusion: Diagnosis of DLBCL must include a good set of IHC markers to know the cell of origin, as it aids to distinguish it from other entities and also helps in therapy, management and prognosis.

Keywords: DLBCL, testis

   AEP244 Top

   Urogenital Pathology Top

A rare case of malignant leydig cell tumor with metastasis

Seelya Sunny, Neetha Unnikrishnan

Government Medical College, Kottayam, Kerala, India

Case Report: 63 year old male with presented with urinary hesistancy and right sided scrotal swelling since two years. On clinical examination right sided enlarged haard hemiscrotal swelling. Tumors markers AFP, bHCG, and PSA were normal. MRI pelvis showed larger mixed intense mass lesion involving RIGHT sac measuring 13.8x13 cm. CT thorax showed bilateral lung nodules. Patient underwent Right high inguinal orchidectomy. Gross Enlarged testicular mass measuring 13x13x10 cm. Cut section showed encapsulated solid light brown lesion with variegated appearance measuring 11.5x10x10.5 cm. Epididymis appeared stretched out on the surface. Microscopy Encapsulated neoplasm arranged in nodules separated by collagenous stroma, in trabeculae and insular pattern. cells are polygonal with abundant eosinophilic cytoplasm, round/oval vesicular nucleus, some show prominent nucleoli. 2-3 mitosis noted/hpf. Areas of necrosis and focal vascular invasion. Immunostaining showed cells positive for inhibin A. Discussion: Malignant leydig cell tumor seen in adults metastasize to lymph node, lung and liver. Cytological atypia, increased mitotic activity, large size > 5 cm, older age vascular invasion, infiltrative margin. Inhibin A show diffuse positivity and negative germ cell markers AFP, HCG, PLAP. Orhidectomy with early peritoneal lymphadenectomy to prevent metastasis. Poor response to chemotherapy/radiotherapy. Conclusion: malignant leydig cell tumors are rare, inguinal orchidectomy therapeutic decision of choice with long term follow up required for recurrences.

Keywords: Inhibin A, malignant, testicular leydig cell tumor

   AEP245 Top

   Urogenital Pathology Top

Sclerosing stromal tumour of ovary: Case report of a rare entity presenting as diagnostic challenge

Yallamsetty Gurusekhar, B N Kumarguru, C A Arathi, A S Ramaswamy, Reshma Anegundi

PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Case Report: A 14-year-old unmarried female presented with irregular menstrual cycles for one year. On pelvic examination, an ill-defined mobile, non-tender mass was palpable in the left iliac fossa extending to umbilical region. Pelvic ultrasonography showed a well-defined heterogeneously hypoechoic lesion measuring 9.5x8.3 cm suggesting left ovarian neoplasm. Magnetic resonance imaging suggested a diagnosis of left ovarian dysgerminoma. Clinical diagnosis of left ovarian dysgerminoma was considered. Staging laparotomy was performed. Left ovarian tumour was subjected to intra-operative frozen section. A diagnosis of benign spindle cell neoplasm was offered. Cut-section of tumour showed grey-white areas with cystic degeneration. Routine histopathology showed tumour tissue displaying hypocellular and hypercellular areas. Hypercellular area showed cellular nodules composed of bland epithelioid cells and spindle cells. At places hemangiopericytoma-like pattern was appreciated. A diagnosis of sclerosing stromal tumour was offered. However, a possibility of solitary fibrous tumour was also considered. Immunohistochemistry showed focal positivity for inhibin and calretinin. A final diagnosis of sclerosing stromal tumour was offered. Post-operative period was uneventful. Patient was discharged in stable condition. Discussion: Sclerosing stromal tumour is a benign tumour, characterized by distinct clinical and pathological features. Conclusion: Sclerosing ovarian tumour is an uncommon diagnostic entity. Clinically, it poses a diagnostic dilemma. Histopathology is challenging but helpful in establishing correct diagnosis. Immunohistochemistry is confirmatory.

Keywords: Cells, neoplasm, tissue

   AEP246 Top

   Urogenital Pathology Top

A rare case of aggressive angiomyxoma of the posterior wall of uterus clinically misdiagnosed as fibroid

Rahul Kanungo, Vijayalaxmi S Patil

Department of Pathology, Shri B M Patil Medical College, Hospital and Research Centre, BLDE (Deemed to be University), Bijapur, Karnataka, India

Case Report: A 35 years old female presented with heavy menstrual bleeding for 4 months and with pain abdomen for 1 month. On examination, the uterus was found to be of 22-24 weeks size of a gravid uterus, along with the presence of a palpable, uniform, non-mobile mass. Ultrasonography revealed 2 large hetero-echoic lesions along the posterior wall and fundus of the uterus, having central vascularity and showing peripheral cystic changes suggestive of fibroid with cystic change. Surgical excision of the mass was performed and its histopathological examination established the diagnosis as Aggressive Angiomyxoma. Discussion: AA arises commonly from the vulvovaginal region, perineum, or pelvis and is usually misdiagnosed as other common entities in these regions. The female to male ratio is around 6.6:1. Majority of cases tend to be women of reproductive age group, with peak incidence between the third and fourth decades of life. Conclusion: This case report reveals the importance of histopathology in the diagnosis of Aggressive Angiomyxoma which is a rare, locally aggressive mesenchymal tumor. Patients should be warned of the high risk of recurrence and the necessity of long-term follow-up after surgical removal.

Keywords: Aggressive angiomyxoma, posterior wall, uterus

   AEP247 Top

   Urogenital Pathology Top

Primary transitional cell carcinoma of endometrium; a rare and unclassified epithelial neoplasm of endometrium

Rakesh Behera, Adil Aziz Khan, Charanjeet Ahluwalia, Sunil Ranga

Vardhman Mahavir Medical College and Safdurjung Hospital, New Delhi, India

Case Report: A 70-year-old female had undergone staging laparotomy with total abdominal hysterectomy with bilateral salpingo-oophorectomy. We received an already cut opened uterus and cervix with bilateral tubes and ovaries measuring 6×4×2 cm in size. On serial sectioning a grey, white tumor identified in the endometrium and invading >50% of the myometrium reaching up to the serosa. Multiple H&E-stained sections revealed a highly cellular tumor arranged in tightly packed papillary architecture with thin fibrovascular cores covered by urothelial like multi-layered polygonal neoplastic cells. Individual cells had abundant eosinophilic cytoplasm with well-defined borders and round to ovoid vesicular to hyperchromatic nuclei & 0-1 prominent nucleoli. Necrosis was absent & mitotic rate was in the range of 2-3/10 HPF. Bilateral tubes and ovaries with attached parametrium and omentum were microscopically uninvolved. Immunohistochemically tumor was positive for ER, PR, CK7 and focally positive for P16 with Ki proliferation index ≈10%. Considering the morphology and immunohistochemistry a diagnosis of PrTC of endometrium was made. Discussion: These cases possess diagnostic dilemma to pathologists due to their unusual morphology and paucity of studies in literature. Conclusion: Identification and acknowledgement of PrTC of endometrium will broaden the morphological spectrum of malignant epithelial neoplasms of endometrium and their proper diagnosis.

Keywords: Endometrium, primary transitional cell carcinoma, urothelium

   AEP248 Top

   Urogenital Pathology Top

Mixed tumor of the vagina in a 12 year old: A case report

M V Mohammed Shuiab, Vishwapriya Mahadev Godkhindi

Department of Pathology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India

Case Report: We report a case of a 12-year-old female who presented with a swelling in the left side of the vagina for 1 month. On examination a 2x2 cm pedunculated mass was seen in the left side of vaginal wall, at introitus and was excised in toto and sent for histopathology. On Gross, single polypoidal tissue bit measuring 2x2x0.5 cm with an attached stalk seen. Microscopy showed a polypoidal lesion lined by inflamed & focally ulcerated stratified squamous epithelium, overlying subepithelium with proliferation of epithelioid to spindle cells, alternating hypo and hypercellular areas, dilated glandular & acinar elements with metaplastic change surrounded by moderate lymphoplasmacytic infiltrate and multiple variably sized blood vessels. Mitotic activity was inconspicuous with no tumour cell necrosis. IHC profile: Epithelial/glandular elements – Diffusely positive for cytokeratin and ER. Stromal/mesenchymal elements - Diffusely positive for CD10, CD34, BCL2, ER, focal-weak positive for pan-CK and negative for SMA and Myogenin. Discussion: MVTs are benign neoplasms with an admixture of spindle and epithelial elements. Patient age has a wide range, often asymptomatic or report with compressive symptoms due to mass. Several studies support the epithelial origin from the remnant of vestibular gland. Grossly these tumours are well circumscribed, solid and soft ranging from 1.5-5 cm. The essential diagnostic criteria is the identification of benign spindle cell and epithelial components. The cells show minimal nuclear atypia with varying mitotic activity. These often express epithelial and mesenchymal markers (AE1/AE3, CK7, CD10, SMA, desmin, BCL2 and CD34). Surgical excision is the treatment of choice but may recur if incompletely excised. Conclusion: Mixed Vaginal tumor is an extremely rare benign neoplasm originated from the epithelial cells of the remnant of vestibular gland and should not be confused with mixed tumor at other anatomic location. Familiarity with this rare tumor by gynecologists and pathologists is essential in avoiding misdiagnosis.

Keywords: Hymenal ring, mixed tumors, vagina

   AEP249 Top

   Urogenital Pathology Top

Granulosa cell tumor

Kitty Kuruvilla, T S Anisha, Jyothi A Raj

RRMCH, Bengaluru, Karnataka, India

Case Report: A 63-year-old female, presented to the OPD with complaints of fullness for 3 months. On examination, an abdominal mass, 32 weeks in size was noted. CT abdomen and pelvis showed a large pelvic and abdominal multiloculated cystic lesion which most likely suggested a malignancy. Patient underwent an exploratory laparotomy with left oophorectomy. Grossly there were two large separate globular cystic masses-one of which measured 20x14 x7 cms & the other measured 22x16x7 cms. External surface of both showed a lobulated appearance with intact capsules and a variegated solid and cystic appearance on cut section. A diagnosis of Adult Granulosa cell tumour was given on histopathology, which was later confirmed by IHC diagnosis with strong positivity for Inhibin, Calretinin, Vimentin, Smooth Muscle Actin and MIC2. Discussion: Granulosa cell tumor has bimodal age distribution & are of 2 types - Juvenile and Adult. Concomitant endometrial pathology in form of hyperplasia is a common finding. Complete tumor resection is considered as primary treatment. Majority of patients have favourable prognosis. Conclusion: Granulosa cell tumor of the ovary is rare. Paramount prognostic factor is staging of the tumor. Other prognostic factors are tumor histology, mitotic activity and nuclear grade.

Keywords: Granulosa cell tumor, ovarian carcinoma, sex cord stromal tumors

   AEP250 Top

   Urogenital Pathology Top

Crescentic glomerulonephritis with dual positivity for anti-GBM and ANCA

Rahul Ramakrishnan, M Feroze

MES Medical College, Angadipuram, Kerala, India

Case Report: 70 year old female presented with hematuria, uremic features and signs of advanced renal failure and was evaluated with routine blood, urine, imaging, renal biopsy and immunofluorescence studies. Linear core biopsy showed cellular crescents, segmental fibrinoid necrosis and severe tubular atrophy. Special staining with Trichrome showed moderate interstitial fibrosis. Diffuse global linear GBM staining was seen on Immunofluorescence studies with IgG, Kappa and Lambda. Patient was diagnosed to have Crescentic Glomerulonephritis. On follow up, patient was positive for MPO-ANCA (23.5 RU/mL) and anti-Glomerular basement membrane antibodies (39 U/mL). Imaging of chest did not show any lung involvement. Discussion: Anti-glomerular basement membrane disease is characterized by circulating IgG antibodies directed against the non-collagenous domain of alpha-3 chain of type IV collagen, normally present in the GBM and alveolar basement membrane. It can present as Crescentic glomerulonephritis alone (renal limited variant), with pulmonary haemorrhage (Goodpasture syndrome) or associated with positive anti-neutrophil cytoplasmic antibody (ANCA) :“dual antibody disease” or “double positive”; positive for both ANCA and anti-GBM antibody. Conclusion: Dual positive anti-GBM disease is a very rare renal-limited disease and is associated with poor renal outcome with less than one-third retaining renal function after 6 months of treatment, with worse prognosis for those developing renal failure.

Keywords: Anti-GBM, crescentic, glomerulonephritis

   AEP251 Top

   Urogenital Pathology Top

Adenocarcinoma of rete testis – A diagnostic dilemma

Dipush Swarup, Sana Ahuja, Meetu Agrawal, Sunil Ranga

Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Case Report: A 33-year-old male presented with case of scrotal swelling two months back for which left sided orchidectomy was done outside. Cut surface showed a greyish gelatinous nodule near lower pole of testis and a diagnosis of yolk sac tumour was made. We received representative blocks for review. Microscopy revealed tumour arranged as tubules and cribriform pattern centred in paratesticular tissue and seen infiltrating into seminiferous tubules. Tumour cells were cuboidal to columnar exhibiting moderate pleomorphism and marked nuclear overlapping. Abundant mucin pools and brisk mitotic activity was observed. Differential diagnosis of adenomatoid tumour, germ cell tumour, metastasis to testis and adenocarcinoma rete testis were considered. IHC panel was put to differentiate the above entities and revealed positivity for pan-CK, CK7, CDX2 with negative expression for PLAP, OCT ¾, calretinin, inhibin, hCG, CK20, AFP, vimentin, desmin, PSA and TTF-1. Ki67 index was >70%. Thus, a final diagnosis of adenocarcinoma, rete testis was made. Discussion: The localization of the tumour in hilar/paratesticular region along with exclusion of metastatic and primary germ cell tumour to testis with IHC assist in arriving at the diagnosis of this rare malignant tumour. Conclusion: Appropriate IHC, along with morphological correlation helps to diagnose such rare cases.

Keywords: Adenocarcinoma rete testis, CDX2, CK7, pan-CK

   AEP252 Top

   Urogenital Pathology Top

Mesonephric adenocarcinoma of cervix

Aishik Biswas, Rabia Parveen Siddiqui

Pt. JNM Medical College, Raipur, Chhattisgarh, India

Case Report: A 67 years woman with bleeding PV for 2 years was clinically diagnosed as Carcinoma Cervix (Stage IIIA). On biopsy, the tumour showed a predominant retiform pattern with ductal and focally tubular patterns which raised the suspicion of Mesonephric Adenocarcinoma. Individual tumour cells were columnar having scanty eosinophilic cytoplasm and vesicular nuclei with prominent nuclear membrane and inconspicuous nucleoli. It was positive for CD10 (>70%), Vimentin (>50%), Ki67 (>50%), CK7, EMA (Focal positive) and negative for ER and PR. CD10 confirmed their origin from mesonephric remnants. A diagnosis of Mesonephric Adenocarcinoma was made. Discussion: Mesonephric Adenocarcinoma shows different patterns and sometimes making it difficult to diagnose on morphology alone. It should be differentiated from endometrial carcinoma, which are CD10 negative and ER positive and serous carcinoma (CD10 negative). Tumours with bland morphology should be differentiated from mesonephric hyperplasia by Ki67. Conclusion: Mesonephric Adenocarcinoma is the rarest subtype of cervical tumours and should be in the differential diagnosis of adenocarcinomas.

Keywords: CD10, mesonephric adenocarcinoma

   AEP253 Top

   Urogenital Pathology Top

Renal angiomyolipoma with tuberous sclerosis – A case series

Sushmita Vangapandu, Ridhi Sood, Nandita Kakkar, Uttam Kumar Mete

PGIMER, Chandigarh, India

Case Report: Material and methods: Institutional archives were searched for cases of renal angiomyolipoma from the year 2013 to 2022. A total of 7 cases were retrieved, of which 6 were nephrectomy specimens and 1 was nephroureterectomy specimen of 3 male patients and 4 female patients. The age group of these patients varied from 12 to 62 years. Discussion: Microscopic examination revealed tumor comprising of adipose tissue, smooth muscle and blood vessels. Of these, three were diagnosed as Epithelioid Angiomyolipoma. On IHC, tumor cells were positive for HMB 45, Melan A and SMA. Multifocal and bilaterality of tumor raised suspicion of Tuberous sclerosis in 2 cases. One case fulfilled 6 major criteria which included multiple angiofibromas, shagreen patch, ash leaf spots, cortical and subependymal tubers; while the other case fulfilled 5 major and 1 minor criteria including gingival fibromas, retinal hamartoma, ash leaf spots, cortical tubers and subependymal nodules in brain establishing definitive diagnosis of Tuberous sclerosis. Conclusion: Epithelioid Angiomyolipoma is a close differential of Renal cell carcinoma due to relative paucity of fat (compared to classical Angiomyolipoma) and carcinoma like growth pattern. Multifocal and bilateral Angiomyolipoma tumors should prompt genetic testing for Tuberous sclerosis.

Keywords: Angiomyolipoma, tuberous sclerosis

   AEP254 Top

   Urogenital Pathology Top

An unusual variant of renal cell carcinoma

R Shilpa, Jayaram N Iyengar, Anitha, Priya

Anand Diagnostics Laboratory, Bengaluru, Karnataka, India

Case Report: 35 year old female, presented with chief complaints of hematuria. Clinical examination and investigations led to suspicion of Renal cell carcinoma. Elective right nephrectomy was done. Grossly, tumour was solid, grey white and fibrotic mimicking leiomyoma or fibroma. Diagnosis was confirmed by histopathological examination and immunohistochemistry. Discussion: RCC with leimyomatous stroma is an uncommon variant. Presence of fibrosis in a renal specimen should raise the suspicion of RCC with leimyomatous stroma. Possibility of co-existent Tuberous sclerosis should also be considered. Conclusion: RCC with leimyomatous stroma is an uncommon variant. Diagnosis of this tumour requires a constellation of morphological, immunohistochemical and molecular profile.

Keywords: Leiomyomatous stroma, RCC

   AEP255 Top

   Urogenital Pathology Top

A double whammy in the kidneys – A case of Alport syndrome with co-existing IgA nephropathy

R Vidhyalakshmi, B H Srinivas, Sreejith Parameswaran, Vidhya Zacchariah

Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India

Case Report: The patient sought Nephrology consultation following complaints of fatigue and loss of weight. She had a family history of kidney disease in her younger brother and her maternal uncle. Her younger brother was found to have chronic kidney disease (CKD) at the age of 16 years, with complaints of sensorineural hearing loss and lenticonus on examination. A clinical diagnosis of Alport syndrome was made. Genetic testing was not done. Her maternal uncle died at the age of 19 years from kidney disease, further details of his illness were not available. Laboratory investigations of the patient revealed proteinuria and microhematuria with normal eGFR. On imaging her kidneys were small in size. Her genetic testing revealed a pathogenic mutation in α5 chain of type IV collagen (COL4A5) gene on the X chromosome, confirming Alport syndrome. Subsequently a renal biopsy was performed. The light microscopy showed normal to mild increase in mesangial cellularity with evidence of segmental sclerosis in one glomerulus. Immunofluorescence showed diffuse fine granular mesangial deposits of IgA, C3c, kappa and lambda with overall findings consistent with IgA Nephropathy. Electron microscopy of the kidney showed features of both Alport syndrome and IgA nephropathy. Discussion: Alport syndrome, inherited as an X-linked trait in 85% of the cases usually affects young males and is due to mutations of COL4A3/4/5. IgA nephropathy, the most common glomerulonephritis has a positive family history in 10 to 15% of the cases. Both the diseases present with hematuria. While the family history aided in the diagnosis of Alport syndrome, the presentation of proteinuria prompted complete work up which confirmed the co-exiting IgA nephropathy. Paying close attention to the clinical presentation and prudent usage of immunofluorescence and electron microscopy can thus aid to unmask co-existing rarer entities, especially in familial settings. Conclusion: This case is a tale of two nephropathies which underscores the importance of genetic counselling when there is familial association as both these disease have mutations in COL4A3/4/5. Further research is required to ascertain the relationship between these two diseases in familial cases.

Keywords: Alport syndrome, IgA nephropathy, proteinuria

   AEP256 Top

   Urogenital Pathology Top

Unicystic granulosa cell tumor of ovary – A case report

Abdulhakeem Attar, Mandakini, Fasiha Haris

ESIC Medical College, Gulbarga, Karnataka, India

Case Report: A 45 Year old female presented with menorrhagia and lower abdominal pain with abdominal distention for a period of 6 months. She has no symptoms and signs of hyperesterinism and virilization. Abdominal examination revealed a mass extending to the umblicus. C T scan revealed a large cystic mass measuring 20x16x10 cm with a possible diagnosis of serous cyatadenoma / carcinoma was made. The patient underwent abdominal hysterectomy with bilateral salphingoopherectomy. Discussion: Granulosa cell tumor (GCT) constitutes 1.5% to 3.5% of all primary ovarian neoplasm. They may be solid or cystic. Unilocular and multilocular cystic granulosa cell tumors have been reported in the literature but are rare disease processes. Unilocular cystic granulosa tumor of ovary are very rare. Conclusion: We report here a case of 45 year old female with unicystic Granulosa cell tumor (GCT) ovary in which the distinction from serous cystadenoma / carcinoma was made by histopathological examination with both gross and microscopy which showed multiple layers of granulosa cells with a few call-exner bodies.

Keywords: Granulosa cell tumor, ovary, unicystic

   AEP257 Top

   Urogenital Pathology Top

Chemotherapy response score as prognostic parameter in ovarian high grade serous carcinomas

Indu Nair, Anupama Rajanbabu, Janaki Nandakumar, K Pavithran

Amrita Institute of Medical Sciences, Kochi, Kerala, India

Case Report: 100 consecutive patients who underwent NACT for primary ovarian carcinomas during the period, January 2013 to December 2020, were included in the study. CRS scoring was done, patients were followed up for a minimum of 18 months, and the association of CRS score with disease outcome was calculated. Results CRS scoring was done in 100 patients diagnosed to have high grade serous carcinoma who underwent NACT. The non responders (score1) and partial responders (CRS-2) were grouped together as group 1 and the responders (CRS-3) separately as group 2. On follow up, 60% of nonresponders had events in the form of metastasis, progression of disease or death from disease. Whereas, 15% of responders developed events. Discussion: On statistical analysis, CRS score showed significant association with prognosis. Radiological response showed statistically significant association with CRS score whereas CA125 value did not show any association. Thus low CRS score (1 and 2) was associated with poor disease outcome and viceversa. Conclusion: CRS scoring can be used as a reliable parameter to predict the disease otcome in high grade serous ovarian carcinomas and the completion chemotherapy dosage or regimen can be planned /modified accordingly to get a better outcome in poor responders.

Keywords: CRS score, high grade serous ovarian carcinoma, post NACT

   AEP258 Top

   Urogenital Pathology Top

Carcinosarcoma of ovary and uterus – Clinical, morphological and immunohistochemical study of case series

Thamilselvi Ramachandran, K Anbu Lenin, I Poovizhi, R Gowrisankar, M Roopmala, J Sridhar, Jeyamani

Vinayaka Mission's Kirupanandha Variyar Medical College and Hospitals, Salem, Tamil Nadu, India

Case Report: Retrospective study of three cases. Case No-1. 50-year-old woman presented with a Left ovarian tumor with a clinical diagnosis of carcinoma of ovary. Case No-2. 56-year-old woman presented with Mass descending per vaginum – 3 years. Abdominal pain – 3 months. Case No-3. 48 year old woman presented with continuous bleeding per vaginum for 2 months. Discussion: Uterine carcinosarcoma (USC), is a aggressive primary neoplasm of the uterus that represents less than 5% of all uterine malignancies. It usually affects older females & has a worse prognosis than other endometrial carcinomas. Vaginal bleeding or Abdominal mass is the most common presenting symptom of USC of uterus or ovary respectively. Primary ovarian carcinosarcoma is a rare aggressive tumor which accounts for 1-3% of ovarian malignancies. In one of our case, it is found in Ovary with metastatic carcinomatous elements are noted in uterine body & endocervix. Immunohistochemistry studies were done & will be discussed. Conclusion: Ovarian carcinosarcomas are very aggressive tumors that are usually diagnosed at an advanced stage due to its asymptomatic nature, its lack of active screening and early detection techniques. The survival rate after diagnosis varies by stage of disease and Uterine & Ovarian carcinosarcomas are presented for its rarity.

Keywords: Lymphadenectomy and chemotherapy, omentectomy, uterine and ovarian carcinosarcoma

   AEP259 Top

   Urogenital Pathology Top

Renal angiomyolipoma – The good, the bad and the ugly

Hilda Fernandes, Christol Moras

Fr Muller Medical College, Mangalore, Karnataka, India

Case Report: 40 years female presented with severe pain abdomen since 2 days. O/E there was fullness and palpable mass in left Flank. Basic investigations revealed low haemoglobin and neutrophilic leucocytosis. CT scan done showed a large heterogenous Left renal mass with large perinephric haematoma. Presence of fat was noted. A likely diagnosis of Angiomyolipoma of the kidney with close differential of Renal Cell Carcinoma was given. Simple Nephrectomy specimen revealed a well circumscribed greywhite mass with yellow and brown areas occupying lower pole and midpole. Large area of haemorrhage with clotted blood was seen extending into perinephric fat. Microscopy revealed a circumscribed lesion composed of variable amounts of smooth muscle, adipose tissue and thick walled blood vessels. Diagnosis of Angiomyolipoma was confirmed. Discussion: Angiomyolipomas (AMLs) are the most common benign renal tumours. They occur as sporadic, isolated entities in 80% of cases. The remaining 20% of AMLs develop in association with tuberosclerosis complex (TSC) or pulmonary lymphangioleiomyomatosis (LAM), Most of these neoplasms are found incidentally on imaging. However, symptomatic presentation does exist. Spontaneous retroperitoneal haemorrhage leading to life threatening bleeding is seen in less than 15%. The differential diagnoses for macroscopic fat-containing retroperitoneum tumors are AML, lipoma, liposarcoma, teratoma, renal cell carcinoma, and adrenal myelolipoma. Histologically, they classified sporadic AMLs into benign triphasic type and potentially malignant epithelioid type. Conclusion: Despite this tumor's benignity, it can be aggressive with a locoregional extension or can be fatal due to extensive haemorrhage.

Keywords: Angiomyolipoma, renal neoplasm, retroperitoneal haemorrhage

   AEP260 Top

   Urogenital Pathology Top

Aggressive angiomyxoma: Series of four cases

Savita Agarwal, Pinki Pandey, Megha Ralli, Roopak Agarwal, Vineet Chaturvedi

Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India

Case Report: Four females of reproductive age group presented with mass in genita/ perineal region. Tumor was excised and histopathological examination showed hypo-cellular tumor comprising of plump spindle to stellate cells displaying minimal cellular pleomorphism, moderate amount of eosinophilic cytoplasm with fine cytoplasmic projections. Stroma showed extensive myxoid degeneration along with numerous thick and thin walled capillaries with hyalinization around some of them and mild mixed inflammation with haemorrhage. Alcian blue: positive acidic mucin seen. Positive IHC includes ER, PR, Vimentin, Desmin, CD34, and negative markers were S100, CK. Discussion: First described by Steeper and Rosai in 1983. Clinical differentials: fibroepithelial polyp, vulval fibroma, Bartholin cyst, giant acrochordon, angiomyofibroblastoma, cellular angiofibroma and other mesenchymal tumours seen at this site. Hence histopathological examination is almost always required. Histopathological differentials: Angiomyofibroblastoma, fibroma, myxofibrosarcoma, myxoid leiomyoma, fibroepithelial polyp, superficial angiomyxoma, myxoid neurofibroma, myxolipoma, sclerosing hemangioma and myxoid leiomyosarcoma. Conclusion: Rarity of this tumor and lack of sufficient literature leads to deficient clinical knowledge and experience regarding its correct diagnosis and treatment.

Keywords: Aggressive angiomyxoma, fibroepithelial polyp, immunohistochemistry

   AEP261 Top

   Urogenital Pathology Top

Collision tumor of ovary – A rare combination of serous cystadenoma with granulosa cell tumor

Deepak Kumar, V Srinivasa Murthy, B R Vani, Renuka Ramaiah, Sreelatha, Anvita Nilekani

ESIC Medical College and PGIMSR, Bengaluru, Karnataka, India

Case Report: A 48-year-old women, presented with lower abdominal mass of 13*10*8 cm. USG examination showed a cystic lesion of right ovary. MRI showed a large complex cystic lesion in pelvis. Tumour marker levels were within normal limits. Frozen section revealed a biloculated cyst with features of serous cystadenoma. Fixed specimen showed a focal thickened area in the wall measuring 4*3*0.5 cms, microscopy of which revealed features of granulosa cell tumour. Sections from the rest of the wall showed features of serous cystadenoma. A final diagnosis of serous cystadenoma with focal granulosa cell tumour was given. Discussion: Collision tumors though rare, have been found to occur in many organs like skin, kidney, ovary and others. Some of the reasons attributed for formation of collusion tumors are simultaneous proliferation of two different cell lines in the same tissue, common origin from pluripotent stem cell, alteration in the microenvironment by the first tumour, seeding of the metastatic tumour cells and a carcinogenic agent interacting with different tissues and inducing different tumours. Conclusion: A detailed histopathological examination is absolute in cystic ovarian neoplasms as most collision tumors are diagnosed postoperatively on histopathology and have therapeutic and prognostic significance.

Keywords: Granulosa cell tumor, serous cystadenoma

   AEP262 Top

   Urogenital Pathology Top

SS18 expression in testicular synovial sarcoma

Sayali Shinde, Deepika Jain, Sambit Mohanty

Core Diagnostics

Case Report: A 23-years-old male presented with gradually increasing inguinal swelling for which he was operated in June 2022. A 15 cm tan-white firm tumor was seen in the paratesticular tissue without involvement of the testis. Microscopy showed a monophasic spindle cell neoplasm arranged in hemangiomaperictoma-like and storiform pattern. Large areas of necrosis and frequent mitosis were noted. The patient is on adjuvant chemo radiotherapy and is alive with no evidence of recurrence or metastasis. Discussion: The tumor was positive for SS18, TLE1, CK and negative for S100, CD34, OCT3/4, SALL4, SMA, desmin and CD117. The tumor harbored SS18 SSX1 gene rearrangement on FISH assay. Conclusion: Paratesticular SS is an extremely rare sarcoma of the paratestis with poor prognosis with high metastatic potential. Patients with multiorgan metastasis have a more aggressive course and died due to disease. SS18-SSX IHC shows an excellent concordance with the FISH results, therefore may reliably be used as a molecular surrogate for paratesticular SS, particularly in a resource-limited setting.

Keywords: Paratesticular synovial sarcoma

   AEP263 Top

   Urogenital Pathology Top

Superficial spreading squamous cell carcinoma of endometrium and icthyosis uteri with CINIII with p16 expression: Report of 2 unusual cases

Kumarsharad Sinha, Neelam Sood

Aarogyam Diagnostic Centre

Case Report: We report two interesting and rare case reports, a 60 year old with well differentiated squamous cell carcinoma of cervix with superficial spreading into the endometrium, other female, 70 years old with features of CIN III also involving the endometrium with multilfocal epidermidization consistent with icthyosis uteri, involving cervix and endometrium. p16 was used as a surrogate marker which was positive for neoplastic cells in both the cases, showing HPV aetiology. Discussion: Endometrial Invasive squamous cell carcinoma is thought to arise by one of the two mechanisms: if there is an upward spread of a primary cervical lesion or transformation of reserve or stem cells which are positioned between the glandular basement membrane and the endometrial columnar epithelial layer. Conclusion: Superficial spreading squamous cell carcinoma of the cervix is a rare entity, with less than 30 cases reported in the literature. Primary endometrial squamous cell carcinoma usually occurs in postmenopausal women with mean age of presentation being 67 years. It is postulated that tumor may arise from ichthyosis uteri. Demonstration of p16 positivity in tumor cells helps in revealing HPV aetiology was also confirmed thus signifying its usefulness. Hence, we report these rare entities.

Keywords: Endometrium, HPV, icthyosis uteri, squamous cell carcinoma

   AEP264 Top

   Urogenital Pathology Top

Growing teratoma syndrome: A rare entity

Sonam Jain, Radhika Pagey, Meena Pangarkar

National Cancer Institute, Nagpur, Maharashtra, India

Case Report: 26-year-old man presented with left testicular mass, clinically diagnosed as NSGCT. Serum tumor markers LDH, α-Fetoprotein and β-HCG were elevated. Outside CT scan of Abdomen and Pelvis was reported as a heterogenous lesion in the left scrotal sac measuring 2.7x2.5 cm with a necrotic left Para-aortic lymph node. Patient underwent left high orchidectomy at another hospital and histopathology report was reviewed as Non seminomatous mixed germ cell tumor (NSGCT) comprising of 60% embryonal carcinoma and 40% of yolk sac carcinoma. Patient underwent three cycles of chemotherapy in our hospital. To Assess the response, his PET scan was advised which showed no regression in para-aortic lymph node however, tumor biomarker was under normal limit. Therefore, retroperitoneal lymph nodes were dissected at our hospital and was sent for histopathology examination which revealed only component of Post pubertal benign mature teratoma. Discussion: Etiology is unknown yet there are two hypotheses. Firstly, chemotherapy shows response to immature malignant cells whereas mature teratomatous elements don't respond. Secondly, chemotherapy alters the cell kinetics toward transformation from a totipotent malignant germ cell toward a benign mature teratoma. They are considered benign but have rapid expansion and unpredictable behaviour for aggressive local spread. This syndrome has been reported in the retroperitoneum as the most common site. For early recognition of GTS close follow-up by radiological imaging and serum tumor marker is necessary. Surgical resection is the gold standard treatment, since teratomas are resistant to chemotherapy and radiotherapy. Conclusion: Awareness of this syndrome is necessary in order to prevent unnecessary chemotherapy and allow optimal management as surgery is the only treatment. Prognosis is excellent after the excision of these tumors, but surgery has to be as complete as possible.

Keywords: Enlarging metastatic mass, growing teratoma syndrome, non-seminatous germ cell tumors

[TAG:2]AEP 265 [/TAG:2]

   Urogenital Pathology Top

Adenomatoid tumor of the female genital tract: What the mind doesn't know, the eyes won't see

Neha Mittal, Santosh Menon, Bharat Rekhi, Kedar Deodhar

Tata Memorial Center, Mumbai, Maharashtra, India

Introduction: Adenomatoid tumor (AT) is a benign neoplasm of mesothelial origin, most commonly involving the epididymis. Its occurrence in the female genital tract (FGT) is an exceedingly rare and under-recognized phenomenon. Objectives: A retrospective observational study of cases of AT involving FGT diagnosed over 5 years (2018-2022). Materials and Methods: A total of 9 women, aged 39-65 years (mean: 52.6 years) were diagnosed. All but two (7/9) were incidental diagnoses on resected gynecological specimens (5 in myometrium and 3 in Fallopian tubes). Results: Two cases, clinically, mimicked malignancy; one each presenting with an inguinal and fallopian tube mass. The underlying histology warranting surgery were Endometrial endometrioid adenocarcinoma in 3 cases, and one case each of ovarian clear cell carcinoma, high grade serous carcinoma, mature cystic teratoma, endometriotic cyst, and one case of HPV-associated squamous carcinoma. On histology, microcystic angiomatoid histology was seen in 62.5% (5/8), microcystic trabecular in 25% (2/8), and one case each of oncocytoid (12.5%), and Leiomyoadenomatoid (12.5%) subtype. Salient histological findings include microcystic change in 8/9 (86.7%), epithelioid cells in 3/9 (33.3%), flattened cells in 5/9 (55.6%), oncocytoid cells in 1/9 (11.1%), signet ring-like cells in 3/9 (33.3%), fibrous stroma in 5/9 (55.6%), and absence of mitotic activity and necrosis in all (100%). On Immunohistochemistry, all cases were positive for keratins and Calretinin (nuclear and cytoplasmic), and negative for CD31. Conclusion: AT is rare, underdiagnosed, and misdiagnosed as it may mimic malignancy leading to inaccurate staging or management of gynecological tumors. A clonally driven origin due to TRAF mutations, and proposed morphological similarities with mesotheliomas necessitate accurate identification for larger multicentric studies.

Keywords: Adenomatoid tumor, female genital tract

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.362057

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