Journal of Pathology of Nepal

Esthesioneuroblastoma: Case series of a rare tumour and review of literature

Geetha V, Srilatha PS, Padmapriya J, Kailesh P

Aim: To study the clinico-pathological features, treatment modalities and prognosis of esthesioneuroblastoma.

Materials and methods- Retrospective study of patients who were diagnosed with esthesioneuroblastoma at a tertiary care hospital between January 2012 and May 2019 was conducted. The research was performed according to the World Medical Association Declaration of Helsinki. Institutional research committee approval (IEC:473/2019) was obtained.

Results- Clinicopathological profile of 8 patients who were diagnosed with esthesioneuroblastoma during the time period were included. Among the eight patients, five were female and three were male. Common presenting complaints were nasal obstruction, difficulty in breathing, epistaxis, local pain and anosmia. Average age of presentation was 52 years, ranging from 14 to 73years. Anterior rhinoscopic examination in these cases showed polypoid mass located in the nasal cavity. On histology, low-grade tumour had a lobular growth pattern with discrete nests of small round tumor cells in a fibrillary stroma and Homer Wright pseudorosettes. Flexner Wintersteiner rosettes, necrosis and mitoses were seen in high grade tumors. Three of the eight tumour were grade-2 and remaining were grade-3 Hyams histological grade. Further three cases exhibited foci of ganglioneuroblastic transformation. Three patients had metastases to cervical lymph nodes and three patients had recurrence.

Conclusion- Esthesioneuroblastoma is a rare aggressive malignant tumor with a marked tendency for late local and regional recurrences. It can exhibit divergent epithelial or ganglionic differentiation. A proper diagnosis should be made through clinical, radiographic and histopathological findings and the tumor should be graded and staged before proceeding to treatment.

Evaluation of tumor infiltrating lymphocytes in breast carcinomas

Shovana Karki, Sansar Babu Tiwari, Alina Basnet — Fri, 30 Sep 2022 00:00:00 +0000

Background: Among the parameters that have a prognostic and/or predictive significance to therapeutic response, in the case of breast carcinoma, the study of tumor-infiltrating lymphocytes in breast carcinomas is emerging. The present study aimed to access the clinicopathological profiles of tumor-infiltrating lymphocytes in patients with primary breast carcinoma.

Materials and Methods: Information was collected from the archive of the Department of Pathology, about invasive breast cancers diagnosed between April 2019 –March 2020. Hormone receptor status and Ki-67 index were assessed. For tumor-infiltrating lymphocytes, hematoxylin and eosin sections were evaluated following the guidelines of the “International Working Group for tumor-infiltrating lymphocytes in Breast Cancer—2014”.

Results: High tumor-infiltrating lymphocytes were seen in 64.2% and 43.8% in ages < 50 and > 50 respectively. All cases of invasive lobular carcinoma had low tumor-infiltrating lymphocytes. 62.5% of T1 tumors were associated with low TILs whereas 80% of low tumor-infiltrating lymphocytes were T3. 71.4% of lymph node-positive tumors had low tumor-infiltrating lymphocytes. All breast cancers showed lymphocytic infiltrate. 40% of the tumors showed intermediate to high tumor-infiltrating lymphocytes. Lymphocyte-predominant breast cancers were 30%. Among the LPBC, 55.5% were triple-negative breast cancers, 33.3% were HR+, and 11.2% were HER2 positive.

Conclusions: Low tumor-infiltrating lymphocytes presented at an advanced stage of the disease at the time of diagnosis. tumor-infiltrating lymphocytes in breasts decreased with increasing age. LPBCs were predominantly TNBCs. All breast cancers were immunogenic, stating the necessity to report tumor-infiltrating lymphocytes in all breast carcinomas.

Histomorphological pattern of lesions of cystoscopic bladder biopsies in a tertiary center in Nepal- A retrospective descriptive study

Fri, 30 Sep 2022 00:00:00 +0000

Background: Bladder cancer accounts for 3% of all cancer diagnoses and is one of the most common cancers worldwide. Bladder tumors have different subtypes and behavioral patterns. This study is performed in the pathology department of Shree Birendra Hospital. It is a data review done on cystoscopic bladder biopsy results for the past 5 years to study the histomorphological patterns of various bladder lesions.

Materials and Methods: This is a descriptive cross-sectional study done on cystoscopic bladder biopsy results. A hospital register-based retrospective study was conducted on the data of five years duration. The epidemiological parameters were calculated using Microsoft Excel.

Results: A total of 56 cystoscopic biopsies were performed during the study period of 5 years. Among them, 45(80.36%) were male and 11(19.64%) were female. The peak incidence was seen in the age group 70-79 years (26.78%). The majority of the patients had neoplastic lesions (83.92%). The peak incidence of neoplastic lesions also belonged to the age group 70-79 years (31.19%). The most common malignant lesion was papillary urothelial carcinoma i.e. 45 cases (95.74 % among the neoplastic lesions and 80.36% among all the total bladder lesions)

Conclusions: Among the bladder lesions that have undergone cystoscopic biopsies, urothelial carcinoma is the most common with male predominance. The early and definitive diagnosis with accurate grading and staging of bladder tumors can be done by histopathology. Early identification of bladder tumors has an impact on the therapeutic approach as well.

Histopathological spectrum of intrathoracic lesions

Mridula Kamath, Padma Shetty — Fri, 30 Sep 2022 00:00:00 +0000

Background: Any suspicious lesion in the chest on radiology needs further workup. Conventional bronchoscopy or CT-guided fine needle aspiration may help in evaluating these suspicious lesions.

Materials and methods: The study was carried out in the pathology department of a tertiary care hospital over a period of 2 years. Clinical details were taken from the records. Samples were processed by routine histological techniques and stained with hematoxylin and eosin.

Results: A total of 100 cases were analyzed. Most of the lesions were in the lungs (97%), 2% in the pleura, and 1% in the mediastinum. The most common malignancy was squamous cell carcinoma (29%) followed by adenocarcinoma (24%) and small cell lung carcinoma (9%). The most common benign lesions were tuberculosis (4%), organizing pneumonia (3%), and bronchiectasis (2%).

Conclusions: The present study concludes that histopathological examination gives maximum accuracy in diagnosing a patient with suspicious intrathoracic lesions so that the patient can be started on treatment immediately.

Tumor-associated tissue eosinophilia in preinvasive and invasive squamous cell carcinoma of cervix

Radhika C Sasturkar, Ramesh BH, Sunita Nyamagoudar, Sateesh S Jigjini — Fri, 30 Sep 2022 00:00:00 +0000

Background: Differentiating between preinvasive and invasive squamous neoplasms of the cervix can be a challenge in small, superficial fragments of cervical biopsy, particularly when inflammatory infiltrates obscure the epithelial stroma interface and due to tangential sectioning of the acanthotic squamous epithelium. This study evaluates whether thresholds of eosinophils in stroma serve as a morphological marker for the presence of tumor invasion in squamous neoplasms of the cervix.

Material and methods: Sixty-five cases of invasive squamous cell carcinoma and preinvasive squamous neoplasia were evaluated. In each case, the number of eosinophils per HPF and per 10 HPF in the tissue adjacent to the neoplastic epithelium was counted. For statistical purposes, the elevated eosinophils were categorized as > 3 eosinophils/HPF, > 5 eosinophils/HPF, and >10/10 HPF.

Results: Stromal eosinophils were present in 1/5 cases of LSIL, 3/8 HSIL cases, 15/16 cases of microinvasive squamous cell carcinoma, and 34/36 cases of invasive squamous cell carcinoma, signifying an increase in eosinophil count from a spectrum of preinvasive to invasive carcinoma. Greater than 5 eosinophils/HPF and >10 eosinophils/10 HPF had sensitivity, specificity, and positive predictive values of 55%, 100%, 100%, and 75%, 100%and 100%, respectively. The difference of >5eosinophils/HPF and >10eosinophils/10 HPF between SIL and SCC was statistically significant.

Conclusions: Our study suggests that the presence of increased eosinophils in squamous neoplasia of the cervix can be associated with tumor invasion and should prompt a thorough evaluation when evidence of invasion is absent.

Increment in hemoglobin and hematocrit levels after blood transfusion in a tertiary care hospital

Prakriti Shah, Manisha Shrestha, Aasiya Rajbhandari, Rohit Khadgi, Prayash Chand — Fri, 30 Sep 2022 00:00:00 +0000

Background: Blood transfusion is considered to be the first line of therapy for all types of anemia. One unit of blood transfusion is known to increase the hemoglobin level by 1g/dl and hematocrit by 3%. This study aims to analyze the mean increment in hemoglobin and hematocrit levels after 1-unit of blood transfusion in a tertiary care hospital.

Materials and Methods: A retrospective study was done. 133 patients with 1-unit of blood transfusion (whole blood or packed red blood cells)having pre and post-transfusion hemoglobin and hematocrit values were enrolled in the study.

Results: Patients of all diagnoses, who received blood transfusion were enrolled, with the highest proportion (27.1%) in the age group 18-35 years. Male predominance was seen (57.1%) and a majority of the patients were on hemodialysis (57.9%). The most common blood group was B positive (30%) and 90.9% were Rh positive. 48 patients were transfused with whole blood and 85 were transfused with packed red blood cells. The mean increment in hemoglobin and hematocrit levels were 0.75 ± 2.21 and 2.47 ± 6.84 respectively. A significant increment in post-transfusion parameters was seen compared with pre-transfusion parameters (p <0.001).

Conclusions: A mean increment in hemoglobin and hematocrit level was seen in patients after transfusion. However, the value of the increment is low in our study as compared to the literature. This may be due to varied reasons, ranging from a history of chronic disease, acute bleeding, the volume of other fluids administered, and the characteristics of the donor.

Scope of mean neutrophil volume as an indicator of neonatal sepsis

Chaitra B E, Raja Parthiban, Shilpa G, Indrani Krishnappa, Impana Gowda — Fri, 30 Sep 2022 00:00:00 +0000

Background: Neonatal sepsis is one of the leading causes of mortality in developing countries because of its non-specific presentation. Blood culture is the gold standard for diagnosing sepsis, but culture results take 48 – 72 hours. Therefore, there is a need for an indicator that could be used as a simple parameter to indicate the possibility of evolving sepsis to the clinician. The efficacy of mean neutrophil volume as an indicator must be evaluated.

Materials and methods: The study aims to evaluate the utility of the mean neutrophil volume in the early diagnosis of neonatal sepsis. Following ethical clearance, the study involved analyzing mean neutrophil volume from peripheral smears of 50 newborns clinically diagnosed with neonatal sepsis. The control group included mean neutrophil volume findings from peripheral smears of normal newborns. Maternal or fetal factors like pregnancy-induced hypertension and birth asphyxia that could cause changes in neutrophils were excluded. The mean neutrophil value was calculated after establishing the mean diameter of 100 neutrophils per case using the National Institutes of Health Image J software.

Results: The average mean neutrophil volume was found to be significantly increased in the sepsis group (181x10⁴fl) than in the control group (739x10³fl). A statistically significant difference (p= < 0.0001) in the mean neutrophil volume was observed.

Conclusions: Mean neutrophil volume is a potential indicator to distinguish neonates with and without sepsis and help clinicians in the early diagnosis and management of sepsis.

Histological study of endoscopic biopsies from the lower gastrointestinal tract

Laxman Banstola, Suresh Thapa, Suresh Raj Poudel, Bhoj Raj Gautam — Fri, 30 Sep 2022 00:00:00 +0000

Background: Endoscopy of the gastrointestinal tract is seen as an essential diagnostic tool because it can provide an in-depth visual assessment of gastrointestinal mucosa and allows for tissue sampling. This study aims to find out the histological diagnosis of various tissues biopsied from the lower GIT endoscopically.

Materials and methods: It is a retrospective observational study conducted in the Department of Pathology, Fewa City Hospital and Research Center, Pokhara, Nepal from March 2021 to February 2022.

Results: Total number of samples taken into the study was 174. Nonspecific inflammation was the commonest lesion in ileal, colon, and rectal biopsies.

Conclusions: Lower GI tract is targeted to a wide range of diseases, ranging from inflammatory to malignant entities. Endoscopy and biopsy for suspected lesions is a trusted approach for investigating and managing GI tract pathologies.

Complete blood counts parameters and neonatal sepsis

Fri, 30 Sep 2022 00:00:00 +0000

Background: Neonatal sepsis is one of the common causes of neonatal mortality. Blood culture is the gold standard procedure to confirm sepsis. However, the rapid rate of disease progression makes its timely diagnosis and prompt management very crucial before the availability of culture. The study aimed to determine the significance of complete blood count parameters including platelet indices in diagnosing neonatal sepsis.

Materials and Methods: This study included 129 suspected cases of neonatal sepsis admitted to KIST Medical College Teaching Hospital from 15^th April 2018 to 14^th April 2019. Complete blood count, platelet indices, micro erythrocyte sedimentation rate, C-reactive protein, and blood culture were performed and analyzed.

Results: Of 129 suspected neonatal sepsis, abnormal leukocyte count was encountered in 31 (24.0%) patients. Culture-proven sepsis was seen in 25 (19.1%) patients. The sensitivity and specificity of Neonatal Sepsis Screening Criteria were 10.0% and 80.0% respectively.

Among platelet-derived indices, PDW (full form) had a sensitivity of 80% and specificity of 56% with a cut of 17.02 CV. MPV (full form), with a cut-off value of 9.78 fL had a sensitivity of 88 % with a specificity of 59%. Both MPV and PDW had low positive predictive values (33.3%) but a high negative predictive value (95.2%).

Conclusions: Along with total leukocyte count, platelet indices have shown their significance in determining neonatal sepsis with significant negative predictive value. The addition of MPV and PDW to the Neonatal Sepsis Screening Criteria might help the treating physician to rule in or rule out neonatal sepsis and manage it accordingly.

Hematologic parameters in thrombocytopenic patients with dengue fever

Aasiya Rajbhandari, Manisha Shrestha, Prakriti Shah, Sushil Adhikari — Fri, 30 Sep 2022 00:00:00 +0000

Background: Dengue fever is an endemic disease in Nepal that has shown increasing incidence each passing year. Dengue has a wide range of clinical presentations and laboratory findings. Thrombocytopenia is a common finding in dengue-infected patients along with other findings like leukopenia, lymphocytosis, raised hematocrit, and elevated liver enzymes. Thrombocytopenia is an indicator of disease severity and can lead to severe bleeding manifestations. This study aims to find the association of thrombocytopenia with other hematologic parameters.

Materials and methods: This retrospective study enrolled 651 dengue patients tested at Patan Academy of Health Sciences who also underwent complete blood count at presentation.

Results: Dengue-infected patients of all age groups with a slight male predominance. Thrombocytopenia was noted in 48.69% of cases. Thrombocytopenia showed a significant association with age (p=0.009), total leukocyte count(p=0.00), and hemoglobin levels (p= 0.015).

Conclusions: Thrombocytopenia in dengue patients is frequently encountered. Increasing age, leukopenia, and anemia are factors significantly associated with thrombocytopenia at presentation.

Utility of D-dimer and other biomarkers in COVID-19 patients - A prospective study in a tertiary care center

Indira Priyadarshini A, Jayalaxmi Yadav K, Shridevi SH, Bharat C — Fri, 30 Sep 2022 00:00:00 +0000

Background: Clinical status and concurrent comorbidities of COVID-19 patients largely determine the need for their admittance to ICUs, similarly, several laboratory parameters like D-dimer, LDH, serum ferritin, CRP, and IL-6 may facilitate the assessment of disease severity and rational triaging. Therefore, their role in the management of COVID-19 patients has to be assessed.

Materials and methods: Prospective study was done on patients who were tested positive for COVID-19 infection and admitted to various centers under the Vijayanagara Institute of Medical Sciences, India. Patients were divided into mild, moderate, and severe cases. Demographic data and serum levels of biomarkers like D-dimer, LDH, ferritin, CRP, and IL-6 were collected in these patients, and data were statistically analyzed.

Results: A total of 164 cases were included in this study, of which, 62 were mild, 47 moderate, and 55 were severely infected COVID-19 patients. There was male predominance in patients infected with COVID-19. The median age of presentation was 53, 60, and 57 years in mild, moderate, and severe cases respectively. Median was also derived for D-dimer, LDH, serum ferritin, CRP, and IL-6 in mild, moderate, and severe cases. Changes in D-dimer, LDH, and serum ferritin levels in mild, moderate, and severe cases showed statistical significance(p<0.05).

Conclusions: D-dimer helps in the early identification of mild, moderate, and severe cases and can be used for the vigilant monitoring of patients. LDH and serum ferritin helps in the identification of oxygen-dependent and oxygen-independent patients. The role of CRP and IL-6 in the management of COVID-19 patients has to be further investigated.

Role of image guided fine needle aspiration cytology of lung lesions in patients visiting Gandaki Medical College

Sunita Ranabhat, Suman Poudel, Gita Pun, Anita Awale — Fri, 30 Sep 2022 00:00:00 +0000

Background: Computed Tomography guided Fine needle aspiration cytology of lung mass is an effective modality to diagnose lung cancer. Its use has been extended in differentiating lung tumors into various cytomorphological types so that it becomes easier for further treatment. The study is aimed to study the morphological features of various types of lung lesions, correlate with histopathology wherever possible and evaluate the sensitivity, specificity, and accuracy of fine needle aspiration cytology procedure.

Materials and Methods: It is an observational cross-sectional study conducted in the Department of Pathology of Gandaki Medical College and Teaching Hospital from April 2018 to December 2020 and 109 cases were included.

Results: In the study, 109 cases were included, female were 61(56%) while males were 48(44%) with an M: F ratio is 1:1.2. The maximum number of cases was seen in the age >70 years (45.9%), mean age being 68.4years. Smoking was seen in 66(60.6%) cases. Squamous cell carcinoma (SCC) 32( 29.4%) was the most common cytological finding followed by adenocarcinoma 20(18.3%). Similarly, SCC was the most common histopathological finding which comprised 30( 53.5%) followed by adenocarcinoma 14(25%). Fine needle aspiration cytology and histopathological diagnosis are significantly associated with a p-value <0.001. The sensitivity, specificity, and accuracy of fine needle aspiration cytology were 76%,80%, and 76.6% respectively.

Conclusions: Computes tomography-guided fine needle aspiration cytology is a relatively safe, inexpensive, and accurate procedure in the diagnosis of different lung lesions for early diagnosis and appropriate treatment.

Filarial granuloma presenting as a fibroadenoma

Agya Shrestha, Samriddhi Karki — Fri, 30 Sep 2022 00:00:00 +0000

Filariasis is an infectious disease endemic in Nepal and the Indian subcontinent. However, filariasis of the breast is not very common. We present a case of a 24-year female with a breast nodule diagnosed with filariasis of the lymph node on the breast on histopathological examination. An infectious pathology should always be borne in mind in the endemic region for the timely management of the patient.

A digital fibromyxoid tumor: a case report

Krishna Jha, Sabrina Yamu Shrestha, Santosh Kafle — Fri, 30 Sep 2022 00:00:00 +0000

A digital fibromyxoma is a rare soft tissue tumor, which occurs in the finger and toes around the subungual and periungual region. Histopathologically, it consists of a well-circumscribed unencapsulated dermal tumor composed of spindle and stellate cells in a loose fascicular pattern embedded in a myxocollagenous stroma. We report this rare case of superficial acral fibromyxoma presenting as an asymptomatic subungual mass in the greater toe in a middle age female.

Ambiguity in pathology reporting: Our intent versus their interpretation!

Palzum Sherpa — Fri, 30 Sep 2022 00:00:00 +0000

Ambiguity is the quality of being open to more than one interpretation. We, pathologists, use ambiguous terms such as “suspicious for, indefinite for, cannot rule out, consistent with, compatible with, in keeping with, raises possibility of, suggestive of, favors” to express varying degrees of certainty in our diagnosis. The embracement of such terminologies is a common practice and could be attributed to a lack of absolute diagnostic certainty or owing to ritualistic caution to avoid liability risk. Studies from US showed that ambiguous terminologies were used in 35% of their reports¹ and 17.7% of the pathologists reported using it more than often (≥ 50%)². In the Nepalese context, where access to immunohistochemistry is limited and sense of superspecialization is just emerging, this percentage can be expected to be higher.

We optimistically assume that clinicians perceive these terminologies as analogous to what we want to convey. However, discordance is observed between the pathologist’s intent and the clinician’s interpretation.^1,3,4 In a survey, “favors” was assigned median diagnostic certainty of 35.3% by pathologists and 60.3% by clinicians, and the difference was statistically significant.² Existence of inter-observer variability even between pathologists adds to the concern.¹ For instance, the probability associated with the term “in keeping with” ranged from 25 to 100% among pathologists.⁴ This inconsistency stems from the unavailability of standard guidelines on phraseology in pathology reporting.

Nakao et al recommends the usage of numerical rather than verbal descriptions of certainty.⁵ Assigning an exact number to words feels controversial as it may provide a false sense of confidence in scenarios where the level of certainty is uncertain. A “standardized scheme for reporting certainty in pathology reports” was introduced by Amin et al. The ambiguous terms were assigned numerical certainty levels with accompanying recommendations including whether or not a definite treatment should be offered.²

We need to be aware of the possible implications related to ambiguous reporting on patient management. Adopting a culture of peer reviewing can boost our diagnostic certainty and limit linguistic ambiguity in reporting. Direct communication with our clinical colleagues can bring about homogeneity in our understanding of ambiguous terminologies. Development of regional guidelines defining commonly used ambiguous terms, their range of diagnostic certainty, and recommendations to clinicians can prevent us and our reports from being misunderstood.

Let our reports be clear and comprehensible. Let us not resonate, in the matter of Pathology reporting, with Italian film director Bernando Bertolucci who quoted “I left the ending ambiguous because that is the way life is”.