Validation of Dual-Color Dual In Situ Hybridization for HER2/neu Gene in Breast Cancer

CONTEXT.—

Human epidermal growth factor (HER2/neu) gene amplification, a poor prognostic factor in invasive breast cancer, has shown substantial utility as a predictive marker, with significantly improved survival following anti-HER2 therapies like trastuzumab. Dual-color dual in situ hybridization (D-DISH), a recently introduced fully automated assay for HER2/neu evaluation on light microscopy, has several advantages over fluorescence in situ hybridization (FISH).

OBJECTIVE.—

To standardize and validate the D-DISH assay using FISH as the gold standard and assess interobserver reproducibility in interpreting the D-DISH assay.

DESIGN.—

D-DISH was performed using the latest HER2 Dual ISH DNA Probe Cocktail assay (Ventana Medical Systems Inc, Tucson, Arizona) in 148 cases of invasive breast cancer. The same block was used for performing immunohistochemistry by Ventana PATHWAY anti-HER2/neu (4B5) antibody and FISH assay by ZytoLight SPEC ERBB2/CEN17 Dual Color Probe. D-DISH was separately interpreted by 4 pathologists blinded to FISH results.

RESULTS.—

Concordance of 98.65% and a Cohen κ value of 0.97 were observed between FISH and D-DISH. Intraclass correlation coefficient (0.93-0.97) and κ values (0.98-1.0) for interobserver reproducibility showed almost perfect agreement by D-DISH. Interobserver reproducibility was also evaluated for genomic heterogeneity, HER2 group categorization, and polysomy (κ values 0.42-0.74, 0.89-0.93, and 0.98-1.0, respectively).

CONCLUSIONS.—

We successfully validated the latest version of D-DISH assay as a substitute for FISH in predicting HER2 gene status with significant interobserver reproducibility, concluding that this D-DISH assay may be introduced in routine diagnostic services as a reflex test to ascertain HER2 gene status.

Conventional versus Liquid-based Cytology: "Man versus Machine"

Background

Liquid-based cytology (LBC) can improve adequacy, monolayer quality with a clean background compared to conventional smears (CS).

Aims and Objectives

The objective was to compare the quality and diagnostic yield of CS and LBC in routine cytological investigations.

Materials and Methods

This retrospective study consisted of 306 samples (255 gynecological, 39 nongynecological, and 12 fine needle aspiration cytology [FNAC]) during a 2-year period (2019-2020). From each patient, two samples were collected in the same manner in the same sitting and processed by CS and LBC (ThinPrep® 2000, Hologic Inc.). Both CS and LBC were compared for adequacy, quality, representativeness, inflammation, hemorrhage, necrosis, preservation, reactive changes, organisms, atypia/dysplasia/malignancy, and preparation/screening time. Statistical analysis was performed.

Results

No statistically significant difference was noted for adequacy, representativeness, reactive changes, preservation, and atypia/dysplasia/malignancy. CS was better in cellularity and diagnosis of inflammation and organisms, whereas LBC had a clean background and the difference was statistically significant (P = 0.0005).

Conclusions

CS was equivalent to LBC in adequacy, representativeness, reactive changes, and atypia/dysplasia/malignancy. Adequacy comparable to LBC can be achieved in CS by careful sample collection, processing, and screening by trained cytotechnologists. CS was better in detecting organisms and inflammation than LBC. The advantages of LBC were monolayer smear, clean background, and lesser screening time, but the demerit was higher cost and longer processing time. Therefore, LBC is best suited to those laboratories having high sample inadequacy rates, lack of competent cytotechnologists, and no financial constraints. Either man or machine, appropriate and adequate sample collection by trained personnel forms the cornerstone for ensuring adequacy in both CS and LBC.

Validation of Remote Digital Pathology based diagnostic reporting of Frozen Sections from home

Background

Despite the promising applications of whole-slide imaging (WSI) for frozen section (FS) diagnosis, its adoption for remote reporting is limited.

Objective

To assess the feasibility and performance of home-based remote digital consultation for FS diagnosis.

Material & Method

Cases accessioned beyond regular working hours (5 pm-10 pm) were reported simultaneously using optical microscopy (OM) and WSI. Validation of WSI for FS diagnosis from a remote site, i.e. home, was performed by 5 pathologists. Cases were scanned using a portable scanner (Grundium Ocus®40) and previewed on consumer-grade computer devices through a web-based browser (http://grundium.net). Clinical data and diagnostic reports were shared through a google spreadsheet. The diagnostic concordance, inter- and intra-observer agreement for FS diagnosis by WSI versus OM, and turnaround time (TAT), were recorded.

Results

The overall diagnostic accuracy for OM and WSI (from home) was 98.2% (range 97%-100%) and 97.6% (range 95%-99%), respectively, when compared with the reference standard. Almost perfect inter-observer (k = 0.993) and intra-observer (k = 0.987) agreement for WSI was observed by 4 pathologists. Pathologists used consumer-grade laptops/desktops with an average screen size of 14.58 inches (range = 12.3-17.7 inches) and a network speed of 64 megabits per second (range: 10-90 Mbps). The mean diagnostic assessment time per case for OM and WSI was 1:48 min and 5:54 min, respectively. Mean TAT of 27.27 min per case was observed using WSI from home. Seamless connectivity was observed in approximately 75% of cases.

Conclusion

This study validates the role of WSI for remote FS diagnosis for its safe and efficient adoption in clinical use.

Updates in staging of penile cancer: the evolution, nuances, and issues

Staging based on the tumor (T), node (N), and metastasis (M) schema of the American Joint Committee on Cancer (AJCC) is usually the most important prognostic factor for any tumor type. Although a rare tumor, in penile cancers, this staging has evolved rapidly in the last two editions of the AJCC Cancer Staging manuals. These changes and updates are largely based on the advancement in our knowledge of the complex anatomy of the penis, the role of histopathological variables in disease biology, and the results of multicentric studies comprising large data sets. In this review, we present the evolution of the AJCC staging model from its inception to the present day. The evidence and data that entailed these changes are also discussed. We highlight a few issues with the current staging model and also briefly discuss the future perspectives and the road map which, with the help of global efforts, can further refine the staging models.

Plasmacytoid urothelial carcinoma - A clinicopathological case series of an aggressive variant of urothelial cancer

Background

Many new morphological variants of urothelial carcinoma of urinary bladder have been described in the literature, plasmacytoid/signet ring cell/diffuse variant being one of the rare amongst these. Till date, no case series has been reported from India, describing this variant.

Materials and Methods

We retrospectively analyzed the clinicopathological data of 14 patients diagnosed at our center with plasmacytoid urothelial carcinoma.

Results

Seven cases (50%) were pure forms while the remaining 50% of cases had a concurrent conventional urothelial carcinoma component. Immunohistochemistry was performed to rule out other mimickers of this variant. Treatment-related data were available for seven patients, while follow-up was available for nine cases.

Conclusion

Overall, plasmacytoid variant of urothelial carcinoma is considered to be an aggressive tumor with poor prognosis.

Comparative Assessment of DNA Extraction Techniques From Formalin-Fixed, Paraffin-Embedded Tumor Specimens and Their Impact on Downstream Analysis

OBJECTIVES

Good-quality nucleic acid extraction from formalin-fixed, paraffin-embedded (FFPE) specimens remains a challenge in molecular-oncopathology practice. This study evaluates the efficacy of an in-house developed FFPE extraction buffer compared with other commercially available kits.

METHODS

Eighty FFPE specimens processed in different surgical pathology laboratories formed the study sample. DNA extraction was performed using three commercial kits and the in-house developed FFPE extraction buffer. DNA yield was quantified by a NanoDrop spectrophotometer and Qubit Fluorometer, and its purity was measured by the 260/280-nm ratio. A fragment analyzer system was used for accurate sizing of DNA fragments of FFPE DNA. The downstream effects of all extraction methods were evaluated by polymerase chain reaction (PCR) and Sanger sequencing.

RESULTS

In comparison with the commercial kits, the in-house buffer yielded higher DNA quantity and quality number (P < .0001). In addition, DNA integrity and fragment size were preserved in a significantly greater number of samples isolated with the in-house buffer (P < .05). The target PCR amplification rate with the in-house buffer extracted samples was also significantly higher, with 98% of the samples showing interpretable sequencing results.

CONCLUSIONS

The in-house developed FFPE extraction buffer performed superior to other methods in terms of suitability for downstream applications, time, cost-efficiency, and ease of performance.

How We Use Immunohistochemistry to Arrive at a Diagnosis in Breast Lesions

Immunohistochemistry (IHC) is an essential tool available to pathologists for facilitating diagnosis and as well as guiding the prognosis of breast lesions. Newer markers are increasingly being added to the pathologists' armamentarium. However, the selection and interpretation of the IHC markers should be judicious. In light of an appropriate morphological assessment, they should complement each other and produce accurate reports. We have briefly outlined here the immunohistochemical approach used in the diagnosis and management of breast cancers at our tertiary care cancer center.

Metastatic epithelioid trophoblastic tumor in retroperitoneal nodes in a case of regressed germ cell tumor of testis: An extremely rare occurrence

Epithelioid trophoblastic tumor is an extremely rare tumor which occurs in women of the reproductive age group following a previous gestation. Its occurrence in male patients is remarkably rare, with only six cases reported in the English literature. Herein, we discuss the unusual occurrence of this tumor in a 31-years-old male patient as a component of non-seminomatous germ cell tumor. It presented as retroperitoneal metastasis with associated testicular microlithiasis (regressed germ cell tumor).

Eosinophilic solid cystic renal cell carcinoma: A series of 3 cases elucidating the spectrum of morphological and clinical features of an emerging new entity

Eosinophilic solid cystic renal cell carcinoma (ESC-RCC) is a recently described entity, which demonstrates distinct clinical, pathological and molecular features. We present a series of three cases, the first to be reported from the Indian subcontinent. All three patients were over 50 years of age; and presented with a large kidney mass. One patient had a locally advanced disease while the other two presented with metastases. Microscopic examination revealed a tumor displaying solid-cystic and/or papillary areas composed of clear as well as eosinophilic cells in all three cases. On immunohistochemistry, all the three cases showed a unique CK20+/α-methyl-acyl-CoA-racemase + immunophenotype. Melan-A was focally positive in Case 2. Cytokeratin 7 was focally but strongly positive in Case 3. The two patients with metastatic disease were diagnosed on core biopsies and were advised oral tyrosine kinase inhibitor therapy. The third patient underwent upfront radical nephrectomy. Due to its peculiar morphology and immunoprofile, the diagnosis of ESC-RCC can be confidently made even on a core biopsy. Most cases reported till date had an indolent course. The metastatic presentation in two of our patients emphasizes the need to gather further evidence to ascertain the biological behavior of this emerging entity.

Validation of a Portable Whole-Slide Imaging System for Frozen Section Diagnosis

Background

Frozen section (FS) diagnosis is one of the promising applications of digital pathology (DP). However, the implementation of an appropriate and economically viable DP solution for FS in routine practice is challenging. The objective of this study was to establish the non-inferiority of whole-slide imaging (WSI) versus optical microscopy (OM) for FS diagnosis using a low cost and portable DP system.

Materials and Methods

A validation study to investigate the technical performance and diagnostic accuracy of WSI versus OM for FS diagnosis was performed using 60 FS cases[120 slides i.e, 60 hematoxylin and eosin (H & E) and 60 toluidine blue (TOLB)]. The diagnostic concordance, inter- and intra-observer agreement for FS diagnosis by WSI versus OM were recorded.

Results

The first time successful scanning rate was 89.1% (107/120). Mean scanning time per slide for H and E and TOLB slide was 1:47 min (range; 0:22-3: 21 min) and 1:46 min (range; 0:21-3: 20 min), respectively. Mean storage space per slide for H and E and TOLB slide was 0.83 GB (range: 0.12-1.73 GB) and 0.71 GB (range: 0.11-1.66 GB), respectively. Considering major discrepancies, the overall diagnostic concordance for OM and WSI, when compared with the reference standard, was 95.42% and 95.83%, respectively. There was almost perfect intra as well as inter-observer agreement (k ≥ 0.8) among 4 pathologists between WSI and OM for FS diagnosis. Mean turnaround time (TAT) of 14:58 min was observed using WSI for FS diagnosis, which was within the College of American Pathologists recommended range for FS reporting. The image quality was average to best quality in most of the cases.

Conclusion

WSI was noninferior to OM for FS diagnosis across various specimen types. This portable WSI system can be safely adopted for routine FS diagnosis and provides an economically viable alternative to high-end scanners.

Gastrointestinal stromal tumor presenting with lower urinary tract symptoms - A series of five cases with unusual clinical presentation

Spindle cell tumors of the prostate are very uncommon and the majority involve the prostate secondarily from adjacent organs. Gastrointestinal stromal tumors (GISTs) are specific C-kit (CD 117) expressing mesenchymal tumors occurring in the gastrointestinal tract, commonly in the stomach and intestine; however, it is seldom seen involving the prostate. Although primary prostatic GISTs have been described, majority of them are secondary involvement from rectal GIST. The patient usually presents with urinary tract symptoms or prostate enlargement simulating a prostatic neoplasm. GIST as a differential diagnosis for prostatic mass is never thought of. We present a series of five cases of GIST arising from/involving the prostate mimicking a primary prostatic malignancy and the challenges associated with them for diagnosis and treatment.

Programmed cell death ligand - 1 expression in triple negative breast carcinoma and its prognostic significance in Indian population

Background

The programmed cell death protein - 1 (PD-1) - programmed cell death ligand - 1 (PD-L1) axis is emerging as a promising target for immunotherapy in triple-negative breast cancers (TNBC).

Aims

We analyzed the expression of PD-L1 in TNBC cases, with special emphasis on lymphocyte-predominant tumors along with correlation of the same with clinicopathological features and outcome.

Settings and Design

Tissue microarrays (TMA) were prepared from resection specimens of TNBC cases diagnosed from 2004 to 2008.

Subjects and Methods

Immunohistochemical staining was performed on the TMA using the ventana PD-L1 antibody (Clone SP 263).

Statistical Analysis

Chi-square test was used for correlation of PD-L1 positivity in tumor and immune cells with clinicopathological features. Univariate and multivariate survival analyses were carried out using the Kaplan Meir and Cox Regression methods, respectively.

Results

Overall, PD-L1 staining was seen in 35.9% (66 out of 184) tumors. PD-L1 positivity of tumor cells was seen in 14.7% (27 out of 184 cases), whereas stromal immune cell expression was observed in 21.2% (39 out of 184) cases. Lymphocyte-predominant tumors showed statistically significant expression of PD-L1 in both tumor (P < 0.0001) and immune cells (P 0.036). On univariate analysis, PD-L1 in immune cells was associated with good overall survival (P 0.05) as well as disease-free survival (P 0.013). On multivariate analysis, the same was associated with a significantly decreased risk for recurrence (P 0.018).

Conclusion

PD-L1 expression in stromal immune cells proved to be a significant prognostic factor for TNBC. This data can serve as a baseline to plan clinical trials with anti-PD-L1 drugs for TNBC in the Indian setting.

A comparative study of AJCC and the modified staging system in pT2/pT3 penile squamous cell carcinoma- A validation on an external dataset

AIMS

The recent changes in the American Joint Commission on Cancer-8^th edition (AJCC-8E) pT2 and pT3 tumor definitions for penile cancer need robust validation studies. A recent study redefined and modified the pT2 and pT3 stages incorporating the histopathological variables (tumor grade, lymphovascular invasion, perineural invasion) similar to that used in the current AJCC-8E pT1 stage tumor subclassification. In this study, we validate and compare this proposed staging with the AJCC staging systems, on an external dataset.

METHODS AND RESULTS

The dataset from a previously published study was obtained. pT2 and pT3 stages were reconstructed as per AJCC 7^th edition (AJCC-7E), AJCC-8E, and the proposed staging. The staging systems were correlated with nodal metastasis, disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS). All systems were compared using receiver operating characteristics (ROC) curves. A total of 281 cases formed the study cohort. AJCC-8E (p=0.031) and the proposed staging (p=0.003) correlated with nodal metastasis on adjusted analysis, the latter with a better strength of association (AJCC-8E, γ= -.471, proposed, γ= -.625). On adjusted analysis, all the staging systems had a significant correlation with DFS, while only AJCC-8E and the proposed staging correlated with CSS and OS. On ROC curve analysis, the proposed staging had the highest area under the curve and was the only staging system to statistically correlate with all the outcome variables.

CONCLUSIONS

The proposed staging for pT2/pT3 tumor stages in penile cancer may improve the prognostic and predictive ability.

Validation of Whole Slide Imaging for primary surgical pathology diagnosis of prostate biopsies

Context

Whole slide imaging (WSI) is an important component of digital pathology which includes digitization of glass slides and their storage as digital images. Implementation of WSI for primary surgical pathology diagnosis is evolving, following various studies which have evaluated the feasibility of WSI technology for primary diagnosis.

Aims, Settings and Design

The present study was a single-center, observational study which included evaluation by three pathologists and aimed at assessing concordance on specialty-specific diagnosis and comparison of time taken for diagnosis on WSI and conventional light microscopy (CLM).

Materials and Methods

Seventy prostate core biopsy slides (reported between January 2016 and December 2016) were scanned using Pannoramic MIDI II scanner, 3DHISTECH, Budapest, Hungary, at 20× and 40×. Sixty slides were used for validation study following training with 10 slides.

Statistical Analysis Used

Intraobserver concordance for diagnosis between the two platforms of evaluation was analyzed using Cohen's κ statistics and intraclass correlation coefficient (ICC); observation time for diagnosis was compared by Wilcoxon signed-rank test.

Results

Interpretation on WSI using 20× and 40× was comparable with no major discordance. A high level of intraobserver agreement was observed between CLM and WSI for all three observers, both for primary diagnosis (κ = 0.9) and Grade group (κ = 0.7-0.8) in cases of prostatic adenocarcinoma. The major discordance rate between CLM and WSI was 3.3%-8.3%, which reflected the expertise of the observers. The time spent for diagnosis using WSI was variable for the three pathologists.

Conclusion

WSI is comparable to CLM and can be safely incorporated for primary histological diagnosis of prostate core biopsies.

Is Diagnosis of Low-Grade Urothelial Carcinoma Possible in Urine Cytology?

Background:

Urine cytology is a useful modality, primarily for the diagnosis and follow-up surveillance of high-grade urothelial carcinoma (HGUC). Its utility in diagnosing low-grade urothelial carcinoma (LGUC) remains controversial because of low reported sensitivity compared to cystoscopy.

Aim:

To study the cytomorphology of LGUC in voided urine samples and analyze its utility in diagnosis.

Materials and Methods:

This is a retrospective study of one year, including 48 voided urine samples in cases which were confirmed as LGUC on subsequent histology. Urine cytology smears of these cases, originally stained with Papanicolaou stain were reviewed, critically analyzed and the specific cytomorphologic and cystoscopic findings were documented.

Results:

On review 18 samples were re-categorized as LGUC which included 10 samples initially diagnosed as Negative for HGUC, 2 as Atypical Urothelial Cells – Not Otherwise Specified (AUC-NOS) and 6 as Suspicious for Carcinoma. In addition, another 3 samples with initial diagnosis of LGUC remained as LGUC on review. Thus, a total of 21 LGUC samples were identified after the review. 26 (54%) samples with a diagnosis of negative for HGUC remained negative even after review, as the tumor cells were not identified either due to sampling error or unrecognizable morphology. One (2%) samples of AUC-NOS remained the same on review due to very scant atypical cells. In 21 LGUC samples, cytology showed a dual population of benign differentiated urothelial cells and small urothelial cells with subtle nuclear atypia such as irregular and thickened nuclear membrane with increased nuclear cytoplasmic ratio. In 12 false negative LGUC samples, the diagnostic cells were camouflaged by their subtle nuclear atypia coupled with an overwhelming background of differentiated benign urothelial cells as both appeared almost similar in morphology. Papillary fragments were identified only in 2 samples.

Conclusions:

Diagnosis of LGUC on cytology is challenging and depends on the presence of diagnostic cells, pick up of diagnostic cells on screening and accurate interpretation. Special attention to papillary fragments and aforementioned nuclear atypia should be paid as tumor cells may resemble normal urothelial cells and can be easily missed.

Application and comparison of Fuhrman nuclear grading system with the novel tumor grading system for chromophobe renal cell carcinoma and its correlation with disease-specific events

Introduction

The grading system of chromophobe renal cell carcinoma (ChRCC) is not well established. In this study, we aimed to compare the application of Fuhrman nuclear grade (FNG) with the novel chromophobe tumor grade (CTG). We also evaluated the correlation of these two grading systems with the clinical outcome.

Materials and Methods

Consecutive cases of ChRCC diagnosed on nephrectomy during 2005-2014 were identified. The clinical details of the patients were retrieved. Histopathology slides were reviewed and the nuclear grading was assigned using standard FNG and the CTG system. The CTG and FNG gradings were correlated with clinical outcome.

Results

A total of 80 cases were retrieved. Distribution of FNG was as follows: FNG-1, 1 (1.3%); FNG-2, 23 (28.3%); FNG-3, 44 (55.0%); and FNG-4, 12 (15%). CTG distribution was as follows: CTG-1, 48 (60.0%); CTG-2, 20 (25.0%); and CTG-3 12 (15.0%). Follow-up data was available in 46 cases; the median follow-up was 23.9 months (range 1-96.4 months). The median time to recurrence/metastasis was 17.2 months (range 3.2-31.2 months). Mean disease-free survival (DFS) was 68.5 months. Both CTG (P < 0.001) and FNG (P = 0.001) correlated with DFS; however, only CTG retained this significance when only the nonsarcomatous cases were analyzed. On receiver operating characteristics curve analysis, CTG had higher predictive accuracy for DFS for the entire group, while FNG lost the statistical significance when the nonsarcomatous cases were analyzed. CTG (P = 0.001) but not FNG (P = 0.106) correlated with the disease-specific adverse events in non-sarcomatous cases.

Conclusions

It is possible to apply CTG in ChRCC. It is a better predictor of DFS and disease-specific adverse events. CTG is more appropriate and applicable than the FNG in grading ChRCC.

Dual-color dual-hapten in situ hybridization (D-DISH) - Comparison with fluorescence in situ hybridization (FISH) for HER2/neu testing in breast cancer

Context

HER2/neu testing in breast cancer is a mandate due to availability of trastuzumab, a monoclonal antibody targeted against this biomarker. Dual-color dual-hapten in situ hybridization (D-DISH) is a new test for assessment of HER2/neu gene overexpression on light microscopy.

Aims

This was a validation study for D-DISH in our laboratory and was conducted to study the concordance between fluorescence in situ hybridization (FISH) and D-DISH for HER2/neu testing in breast cancer.

Materials and Methods

In all, 150 cases of invasive breast carcinoma requested for FISH analysis were selected. Immunohistochemistry by Ventana PATHWAY anti-HER2/neu (4B5) antibody, FISH by ZytoLight SPEC ERBB2/CEN17 Dual Color Probe, and D-DISH using the Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay was carried out.

Statistical Analysis

Cohen's kappa coefficient was used to calculate concordance between FISH and D-DISH assays. The ratios and average number of signals were compared with Lin's concordance correlation coefficient.

Results

About 93.1% of the cases showed concordance between FISH and D-DISH results. Cohen's kappa correlation coefficient was 0.836, indicating almost perfect level of agreement. Lin's concordance correlation coefficient (ρc) showed moderate strength of agreement for HER2/chromosome 17 ratios between FISH and D-DISH assays (ρc 0.9452). As per the American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) 2018 updated guidelines, four of the cases that were nonamplified on FISH showed low-level amplification on D-DISH due to counting errors caused by faint signals or background dust. Genomic heterogeneity and larger red chromosome 17 signals on D-DISH led to discordance of the six cases amplified by FISH. D-DISH failure rate was 3.33%.

Conclusion

Overall, D-DISH showed good concordance with FISH but needs expertise for reporting.

Survival outcomes with 12 weeks of adjuvant or neoadjuvant trastuzumab in breast cancer

Background

There is limited access to 1 year of adjuvant trastuzumab in resource-constrained settings. Most randomized studies have failed to prove non-inferiority of shorter durations of adjuvant trastuzumab compared to 1 year However, shorter durations are often used when 1 year is not financially viable. We report the outcomes with 12 weeks of trastuzumab administered as part of curative-intent treatment.

Methods

This is a retrospective analysis of patients treated at Tata Memorial Centre, Mumbai, a tertiary care cancer center in India. Patients with human epidermal growth factor receptor (HER2)-positive early or locally advanced breast cancer who received 12 weeks of adjuvant or neoadjuvant trastuzumab with paclitaxel and four cycles of an anthracycline-based regimen in either sequence, through a patient assistance program between January 2011 and December 2012, were analyzed for disease-free survival (DFS), overall survival (OS), and toxicity.

Results

A total of 102 patients were analyzed with a data cutoff in September 2019. The median follow-up was 72 months (range 6-90 months), the median age was 46 (24-65) years, 51 (50%) were postmenopausal, 37 (36%) were hormone receptor-positive, and 61 (60%) had stage-III disease. There were 37 DFS events and 26 had OS events. The 5-year DFS was 66% (95% Confidence Interval [CI] 56-75%) and the OS was 76% (95% CI 67-85%), respectively. Cardiac dysfunction developed in 11 (10.7%) patients.

Conclusion

The use of neoadjuvant or adjuvant 12-week trastuzumab-paclitaxel in sequence with four anthracycline-based regimens resulted in acceptable long-term outcomes in a group of patients, most of whom had advanced-stage nonmetastatic breast cancer.

Mucinous tubular and spindle cell carcinoma of the kidney: A case series with a brief review of the literature

Background

Mucinous tubular and spindle cell carcinoma (MTSCC) is a rare low grade renal tumour exhibiting characteristic morphological features. We share our experience and discuss briefly, a review of the current literature.

Methods

Electronic medical records were searched between January 2005 to January 2017. The histopathology and immunohistochemistry slides were retrieved and reviewed.

Results

Eleven cases of MTSCC were identified. Mean age at presentation was 53.9 (age range 41 to 71) years with a slight female preponderance (F: M=6:5). Clinical stage at presentation was: Stage I (4 cases), Stage II (3 cases), Stage III (1 case), and Stage IV (3 cases). The average tumour size was 7.5cm (range 3.5 to 17cm). Microscopically, characteristic biphasic tumour with tubular and spindle cell morphology with variable mucinous stroma was noted in all. The prominent immunohistochemical profile revealed positivity for CK7 (7/8, 87.5%), AMACR (6/8, 75%), AE1/3 (4/4, 100%), CD10 (3/10, 27.3%), and Vimentin (3/3, 100%). Seven patients (Stage I and II) had been treated with nephrectomy, whereas only a diagnostic biopsy was available in four patients who presented with locally advanced disease (n=1) or distant metastasis (n=3) at presentation. The mean follow-up was 37.8 months (range 8 to 96 months), available in 10 out of 11 patients, without recurrence in nine while one died 8 months after diagnosis.

Conclusion

MTSCC is an indolent renal cancer with characteristic morphology. However, presentation with locally advanced disease or distant metastasis may be seen in a subset of these patients. This warrants close follow-up in even localized tumors.

Identification of Luminal Subtypes of Breast Carcinoma Using Surrogate Immunohistochemical Markers and Ascertaining Their Prognostic Relevance

BACKGROUND

Therapeutic decisions in breast carcinoma are being made on the basis of tumor cell proliferation using exorbitant genomic tests. The 2013 St Gallen meeting advocated surrogate definitions for classifying tumors into luminal subtypes on the basis of immunohistochemical (IHC) markers. We studied the classification of estrogen receptor (ER)-positive tumors using these definitions as well as different methods for Ki-67 labeling index (LI) estimation.

PATIENTS AND METHODS

A total of 541 ER⁺ invasive breast carcinoma cases from January 2012 to December 2012 were evaluated for Ki-67 LI by the average and hot spot methods. The IHC results of ER, PR, and human epidermal growth factor receptor 2 (HER2) were noted. HER2 IHC equivocal (2+) samples were subjected to HER2 fluorescence in-situ hybridization testing. Luminal subgroups created on the basis of the 2013 St Gallen meeting guidelines were correlated with clinicopathologic variables and disease-free survival.

RESULTS

The distribution of luminal subtypes was as follows: luminal A-like, 13.3%; luminal B-like (HER2^-), 57.9%; and luminal B-like (HER2⁺), 28.8%. Approximately 6% of cases were recategorized into different subgroups when the average method was used instead of the hot spot method for Ki-67 LI assessment. Younger patients (≤ 50 years), grade 3 tumors, positive axillary nodes, recurrence, and distant metastasis had a positive statistical correlation with luminal B-like (HER2^-) subtype. Patients with luminal B-like (HER2^-) tumors had a shorter disease-free survival compared to patients with luminal A-like tumors.

CONCLUSION

Ki-67 LI, irrespective of the method of assessment, along with PR, can be efficiently used to divide ER⁺ tumors into prognostic subgroups in Indian patients.

Abstract P3-03-03: Sentinel node biopsy (SNB) vs Low axillary sampling (LAS) in predicting nodal status of post-chemotherapy axilla in women with breast cancer

Introduction

There is no safe method of avoiding complete axillary lymph node dissection in women with breast cancer after neo-adjuvant chemotherapy. sentinel node biopsy (SNB) has had prohibitively high false negative rate. We tested low axillary sampling (LAS) and SNB performed in same patient to predict axillary lymph node status in clinically node negative women undergoing breast conservation or modified radical mastectomy after neo-adjuvant chemotherapy.

Methodology

Post neo-adjuvant chemotherapy 751 women who had no palpable axillary lymph node underwent LAS (all lymph nodes below intercosto-brachial nerve). Of these 751 women, 730 also underwent SNB by dual technique after injection of blue dye as well as radio-isotope. SN was identified within and outside axillary sampling specimen. SN as well as LAS specimens were distinctly examined for nodal metastasis. The rest of the axillary dissection was completed in all patients. Post NACT 292/751(38.9%) had residual positive lymph nodes on pathology. The identification rate, false negative rate (FNR), and negative predictive value (NPV) of SNB and LAS were compared for predicting negative axillary lymph node status.

Results

The median clinical tumor size was 5cm (1-15cm) and 533(71%) patients were N1 or N2 at presentation. The SNB identification rate was 87.1% (636 of 730), with a median of 5 nodes and node positive in 238 of 636 (37.4%). LAS identification rate was 98% (736 of 751), with a median of 7 nodes and node positive in 292 of 736 (39.6%). In all but one case, the SN was found within the LAS specimen. The FNR of SNB (blue, hot and adjacent palpable nodes) was 19.7% (47 of 238, one sided 95% upper CI 24.0) compared to LAS with FNR of 9.9% (29 of 292, one-sided 95% upper CI 12.8) (p&lt;0.001). Comparative NPV for SNB and LAS were 89.4% and 93.9% respectively. If SNB was confined to blue/hot node excluding adjacent palpable nodes, FNR was 31.6% (74 of 234, 95% upper CI 36.6).

Conclusions

LAS is superior to SNB in identification rate, FNR and NPV in predicting node negative axilla post-neoadjuvant chemotherapy. LAS can be safely used to predict negative axilla with less than 10% chance of leaving residual disease.

Citation Format: Parmar V, Nair NS, Vanamali V, Hawaldar RW, Siddique S, Shet T, Desai SB, Rangarajan V, Patil A, Gupta S, Badwe RA. Sentinel node biopsy (SNB) vs Low axillary sampling (LAS) in predicting nodal status of post-chemotherapy axilla in women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-03.

Epidermal growth factor receptor (EGFR) gene amplification in high-grade gliomas: Western Indian tertiary cancer center experience

BACKGROUND

EGFR gene amplification is the hallmark of primary glioblastomas; however, its frequency in patients of Indian origin remains sparsely investigated.

AIMS

The aim of this study was to explore the frequency of EGFR amplification in high grade gliomas (HGGs) in Indian patients and to study its correlation with p53 protein overexpression.

METHODS AND MATERIALS

324 cases of HGGs, where EGFR gene amplification was evaluated by fluorescence in-situ hybridization formed the study group. Ratio of >2 was considered as EGFR gene amplification. Immunohistochemically, p53 overexpression was evaluated and graded as positive for strong intensity staining in more than 50% of tumour cells.

RESULTS

249 patients were male and 75 female (M: F-3.3:1); their age range was 8-91 years [paediatric glioblastoma (pGBM; 8-18yrs; n = 24)], adult HGGs [>18yrs; n = 300]}. 258 patients were having a GBM [including 31 with a GBM with oligodendroglioma component (GBM-O)], 31 with a gliosarcoma, 13 with an anaplastic astrocytoma (AA), 12 with an anaplastic oligodendroglioma (AO), and 10 with an anaplastic oligoastrocytoma (AOA). 79/233 cases (34%) with an adult GBM, (including 10/31 with a GBM-O [32.2%]), 1/31 (3.2%) with a GS and 1/10 (10%) with an AOA showed EGFR gene amplification. None of the pGBMs (n = 24) showed amplification. Amplification was seen in 19/81 (23.4%) of diffuse p53 protein positive cases and 53/143 (37%) of cases with focal or negative p53 protein expression.

CONCLUSIONS

34% of our adult GBM patients showed EGFR gene amplification. The amplification was uncommonly associated with a strong diffuse p53 protein expression.

Utility of Alternate, Noncentromeric Chromosome 17 Reference Probe for Human Epidermal Growth Factor Receptor Fluorescence In Situ Hybridization Testing in Breast Cancer Cases

Context PathVysion-a US Food and Drug Administration-approved dual-probe human epidermal growth factor receptor ( HER2) fluorescence in situ hybridization (FISH) assay-provides the HER2: CEP17 ratio, a centromeric enumeration probe ratio for determining HER2 status in breast cancers. However, pericentromeric amplifications might then skew the HER2: CEP17 ratio, underestimating the HER2 status, which calls into question the use of CEP17 as the reference probe. Objective To analyze the utility of a noncentromeric chromosome 17 reference locus ( D17S122) to assess HER2 gene status in cases showing "nonclassical" FISH patterns with the CEP17 probe. Design The HER2 status of breast cancers accessioned in the years 2015-2017, displaying "nonclassical" or "equivocal" results by the PathVysion (Abbott Molecular Inc, Des Plaines, Illinois) HER2 DNA Probe Kit were reflex tested using an alternate FISH probe (ZytoLight SPEC/D17S122, ZytoVision, Bremerhaven, Germany) and interpreted with American Society of Clinical Oncology/College of American Pathologists 2013 guidelines. Results Of 37 cases, 17 were FISH equivocal. With the alternate D17S122 probe, 13 (76.4%) were reclassified as amplified, 3 (17.6%) as nonamplified, and a single case retained an equivocal result. Of the 17 cases with a chromosome 17 polysomy pattern, disomy, polysomy, and monosomy patterns were seen with 14 cases, 2 cases, and 1 case, respectively. Within the 17 cases with polysomy pattern, 3 (17.6%) demonstrated an unusual colocalization pattern of HER2 and CEP17, which was not observed with the alternate probe. Conclusions The denominator-stable alternate probe is a useful adjunct in the diagnostic armamentarium to analyze HER2 status in cases with FISH equivocal and complex patterns.

A comparative analysis of immunohistochemistry and fluorescent in situ hybridization assay to detect anaplastic lymphoma kinase status in lung adenocarcinoma cases: A search for a testing algorithm

INTRODUCTION

Testing for echinoderm microtubule-associated protein-like 4 (EML4) anaplastic lymphoma kinase (ALK) translocation by fluorescence in situ hybridization (FISH) is well established whereas the Food and Drug Administration (FDA) ALK immunohistochemical (IHC) test is relatively new.

AIMS AND OBJECTIVE

The aim of this study is to compare FDA-approved ALK IHC test (D5F3 clone) with the standard ALK FISH test.

MATERIALS AND METHODS

A validation and a test arm with 100 and 200 cases of Formalin-Fixed, Paraffin-embedded blocks of lung adenocarcinoma, respectively, comprised the material. All cases had ALK IHC test on automated Ventana Benchmark XT IHC slide stainer using anti-ALK D5F3 rabbit monoclonal primary antibody; when positive tumor cells (any percentage) showed strong granular cytoplasmic staining. For the FISH test, Vysis ALK Dual Color Break Apart Rearrangement Probe (Abbott Molecular Inc.,) was used to detect ALK gene 2p23 rearrangements; when positive the red and green signals were split two signal diameter apart and/or isolated 3'red signal were detected in more than 15% tumor cells. The ALK FISH results were available in all 100 validation cases and 64-test arm cases which formed the basis of this analysis.

RESULTS

The ALK IHC test was positive in 16% cases; four discordant cases were ALK IHC positive but ALK FISH negative, but no case was ALK IHC negative and ALK FISH positive. There was 100% sensitivity, 90.5% specificity, and 93.75% accuracy.

CONCLUSION

A negative ALK IHC result obviates the need for a FISH test barring those with a strong clinical profile, and a positive ALK IHC result is sufficient basis for the initiation of treatment.

Pilomatrix Carcinoma Masquerading as Breast Carcinoma

Pilomatrix carcinoma is an exceedingly rare skin adnexal neoplasm derived from piliferous follicles, usually occurring in the head and neck region. Localization of this tumor in the breast is a rarity. We now report an unusual case of a 49-year-old female who presented with a palpable mass in the left breast for 2 years. Mammogram revealed a large, lobulated opacity with calcification, and positron emission tomography–computed tomography showed a metabolically active soft tissue mass measuring 15 cm involving all the quadrants of the left breast. Subsequently, the patient underwent radical mastectomy, and histopathologic diagnosis of pilomatrix carcinoma of the breast was offered. Pilomatrix carcinoma, although exceedingly rare, can have an intramammary location and can be misdiagnosed as breast carcinoma on limited material. A high index of suspicion is required to arrive at an accurate diagnosis so as to obviate neoadjuvant chemotherapy.

Triple-Negative Breast Cancer: A Comprehensive Study of Clinical, Histomorphological, and Immunohistochemical Features in Indian Patients

Triple-negative breast cancers (TNBCs) are characterized by negative expression for estrogen (ER), progesterone (PR), and human epidermal growth factor 2 (HER2) receptors. Although the majority of basal-like breast cancers (BLBCs) diagnosed based on gene expression profiling belong to the TNBC group, both entities are not synonymous. Core BLBCs are TNBCs, which are positive for basal cytokeratin (CK) and/or epidermal growth factor receptor (EGFR). We aimed to study and correlate a TNBC cohort for various histomorphological features and immunohistochemical (IHC) profile in Indian patients. We studied 205 naïve TNBCs for histopathological features, which were further evaluated for basal CKs-namely, CK5/6, CK14, CK17-and EGFR expression to classify them as core BLBCs, using criteria of any basal CK and/or EGFR positivity and 7-negative phenotype (7NP). Among 205 TNBCs, 91% of cases were core BLBCs, and absence of ductal carcinoma in situ (DCIS) was significantly associated ( P = .014) with core BLBC. Geographic necrosis was correlated with expression of CK17 ( P = .002) and EGFR ( P = .038). A ribbon-like trabecular pattern and absence of DCIS were associated with CK17 ( P = .0002 and P = .043, respectively) and CK14 ( P = .04 and P = .0008, respectively). TNBC is a heterogeneous subgroup with adverse clinicopathological features, and many of them show significant correlation with basal CKs. TNBCs cannot be classified as core BLBC or 7NP based on morphological features, except absence of DCIS. However, this study illustrates the heterogeneity in TNBCs on the basis of IHC markers.

Abstract P4-14-07: Outcome with use of 12 weeks of adjuvant or neoadjuvant trastuzumab in a resource constrained setting

Background: Adjuvant trastuzumab has improved overall survival in women with HER2 receptor positive breast cancer. However, only a small fraction (4%) of eligible patients in resource constrained settings have access to this drug. A patient assistance program of 12 weeks of adjuvant or neoadjuvant trastuzumab was thus started for those who did not have any access to trastuzumab due to financial constraints. We undertook a retrospective analysis of outcomes in women who were enrolled between January 2011 to December 2012 in this patient assistance program.

Methods: Patients received four cycles of anthracycline based chemotherapy (AC/CAF/ EC/CEF) and 12 doses of weekly paclitaxel (80mg/m2) with trastuzumab (4mg/kg loading followed by 2mg/kg) in the neoadjuvant or adjuvant setting in either sequence (anthracycline followed by taxane trastuzumab or taxane trastuzumab followed by anthracycline). Patients received adjuvant hormonal therapy depending on the hormone receptor status. The primary endpoint of this analysis was disease free survival (DFS).

Results: A total of 103 patients with HER2 receptor positive breast cancer were analysed. The median age was 46 (24-65) years, 50% were premenopausal, 60.7% had stage III disease (86.8% had node positive disease) and 37% patients had ER and or PR positive disease. Forty patients (38.8%) had breast conserving surgery while the rest had modified radical mastectomy. At a median follow-up of 34 (7-46) months the 3-year DFS and overall survival was 77.2% and 82.7% respectively. Among patients who developed recurrence one had only local recurrence, 4 had both local and distant recurrence and 11 had distant metastasis alone. Of the 15 patients who developed distant metastasis 7 had brain involvement . Symptomatic cardiac dysfunction developed in four patients, two of whom died while in the other 2 ejection fraction recovered. The results are summarised in the table.

Patient Characteristic and outcome with 12 weks of adjuvant or neoadjuvant TrastuzumabNumber of PatientsNode Positive (%)Hormone Positive (%)DFS at 3 yearsOS at 3 yearsBrain Mets(%)Grade 3/4 Cardiac Toxicity(%)10386.83777.282.76.83.9

Conclusions: These results suggest that 12 weeks of neoadjuvant or adjuvant trastuzumab is an acceptable alternative in patients who lack access to full 1 year of trastuzumab.

Citation Format: Ghosh J, Joy Phillip DS, Ghosh J, Gupta S, Bajpai J, Gulia S, Parmar V, Nair N, Budrukkar AN, Jalali R, Desai SB, Sawant S, Dhir AA, Kembhavi S, Hawaldar R, Banavali SD, Badwe RA. Outcome with use of 12 weeks of adjuvant or neoadjuvant trastuzumab in a resource constrained setting. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-07.

Can combination metronomic therapy overcome chemoresistance in cholangiocarcinoma? A literature review

Cholangiocarcinoma (CCa) is relatively resistant to chemotherapy as well as radiation therapy, and complete resection is the main curative therapy for these patients. The prognosis for patients with unresectable intrahepatic CCa (iCCa) is extremely poor. A 55-year-old woman presented at our hospital with abdominal pain. After evaluation, she was diagnosed to have multifocal iCCa. She did not opt for standard chemotherapy and therefore received oral metronomic therapy with a combination of celecoxib, etoposide, and cyclophosphamide for a total of 30 months. Presently, she is 57 months post diagnosis and 27 months post cessation of all treatment and continues to be in complete radiological remission. In the present report, we review the literature and discuss whether metronomic scheduling of biologic agents and anticancer drugs will be able to overcome chemoresistance and improve the outcome in cholangiocarcinoma. References for the review were identified through searches of Pubmed for the last 10 years as well as searches of the files of the authors themselves. The final list was generated on the basis of originality and relevance to this review.

Collision tumor of kidney: A case of renal cell carcinoma with metastases of prostatic adenocarcinoma

Simultaneous occurrence of prostatic adenocarcinoma and renal cell carcinoma is well documented in the literature. However, metastatic prostatic adenocarcinoma in a kidney harboring a renal cell carcinoma (RCC) is quite rare. Although renal cell carcinoma is the most common tumor that can harbor metastasis, metastatic prostatic adenocarcinoma in a kidney harboring a RCC is quite rare. There are four cases in the literature showing metastasis of prostatic adenocarcinoma to RCC. However, as per our knowledge, this is the first case of a collision between RCC and metastatic prostatic adenocarcinoma.

Retroperitoneal sclerosing PEComa with melanin pigmentation and granulomatous inflammation-a rare association within an uncommon tumor

PEComa, defined as a perivascular epithelioid cell tumor, displays a wide clinicopathological spectrum. Lately, a sclerosing PEComa has been identified as its distinct variant, but with limited documentation, in view of its rarity. Herein, we describe an uncommon case of a 53-year-old lady, who was referred to us with pain abdomen. Radiological imaging disclosed a well-defined, hypodense retroperitoneal mass. The excised tumor was a round, encapsulated soft tissue mass measuring 7 cm with a tan-brown cut surface. Microscopy showed uniform, epithelioid cells with clear cytoplasm, focal melanin pigmentation and mild nuclear atypia, arranged in sheets and nests around capillary-sized vessels in a dense sclerotic stroma. Additionally, co-existing epithelioid granulomas were noted. On immunohistochemistry (IHC), tumor cells were diffusely positive for HMB45; focally for desmin and smooth muscle actin (SMA), while negative for EMA, CD10, S100-P, Melan A, CD34, AMACR and CK MNF116. This case reinforces sclerosing PEComa as an uncommon, but a distinct clinicopathological entity and exemplifies diagnostic challenge associated with it; necessitating application of IHC markers for its correct identification. Presence of melanin pigment and granulomatous inflammation in the present tumor constitute as novel histopathological findings in a sclerosing PEComa.

HER 2 status in invasive breast cancer: immunohistochemistry, fluorescence in-situ hybridization and chromogenic in-situ hybridization

INTRODUCTION

HER2/neu gene status in breast cancers can be evaluated by targeting protein and gene - immunohistochemistry (IHC) and fluorescence in-situ hybridization (FISH). Recent studies have shown chromogenic in-situ hybridization (CISH) as a relatively cheaper alternative.

MATERIALS AND METHODS

Forty-three nonconsecutive, randomly selected primary invasive breast cancer cases were evaluated for c-erbB-2 (HER2 protein) by IHC and gene amplification by FISH and CISH. Results of each of the same were compared.

RESULTS

CISH showed approximately 90% and 100% concordance for IHC negative and positive cases, respectively; while approximately 94.4% and 91% concordance with FISH amplified and non-amplified cases, respectively.

CONCLUSION

This study showed feasibility of incorporation of CISH as a low cost option in routine management of breast carcinoma in the Indian setting. Secondly, reconfirmation of IHC negative and positive cases can be done by CISH.

Ewing sarcoma/primitive neuroectodermal tumor of the kidney: clinicopathologic analysis of 34 cases

The present study describes the clinicopathologic analysis of 34 cases of Ewing sarcoma/primitive neuroectodermal tumor occurring in the kidney. The patients were 21 males and 13 females with an age range of 6 to 44 years. Clinically, patients presented with multiple symptoms including hematuria, pain, and/or lump in the abdomen. Nephrectomy was performed in most of the cases. Grossly, whole of the renal parenchyma was involved by a variegated tumor. Histologically, the tumor was composed of monomorphic, small, and round cells arranged in a variety of patterns. Rosettes, geographical areas of necrosis, and arborizing vascular pattern were the prominent histologic features. The nucleus was monomorphic and round. Anisonucleosis was also noted in some cases. The nucleus was mostly hyperchromatic. A mixture of hyperchromatic and powdery chromatin was noted in few cases. Immunohistochemically, MIC2 (CD99) was positive in 32 of 34 cases followed by neuron-specific enolase (9/12 cases), vimentin (8/14 cases), synaptophysin (1/8 cases), and S-100 protein (1/4 cases). Molecular analysis by reverse transcriptase-polymerase chain reaction that was carried out in 26 cases revealed presence of EWS-FLI-1 type 1 translocation in 12 cases, EWS-FLI-1 type 2 translocation in 10 cases, and both type 1 and type 2 EWS-FLI-1 translocation in 2 cases. Two cases did not demonstrate any translocation. Follow-up data were available for 17 of 34 cases. Local recurrence of the tumor was seen in 4 patients, and 10 patients were recorded to have distant metastasis in various organs, such as lung, bone, and lymph node, during the course of the disease.

Composite epithelial kidney tumor comprising of adeno and neuroendocrine carcinomatous components: an unusual variant of renal cell carcinoma

Renal cell carcinomas accounts for an approximately 2% of human malignancies with at least ten different histological subtypes recognized by the World Health Organization (WHO) 2004 classification. Composite carcinomas with dual divergent epithelial differentiation in kidneys are extremely uncommon. We report an unusual case of a 37-year-old female who presented with symptoms related to renal tumor for the last three years. Computed tomography scan revealed a large heterogeneously contrast enhancing left kidney mass comprising of two distinct histological components of low grade adenocarcinomatous and carcinoid-like low grade neuroendocrine carcinomas with presence of hilar lymph nodal metastases of both the components. The component of adenocarcinoma was immunoreactive to E-cadherin, cytokeratins 7 and 19 with negativity for cluster of differentiation 10, cytokeratin 20, CD117, and vimentin; while the neuroendocrine component was immunoreactive for vimentin, chromogranin and synaptophysin with negativity for CD10, CD117, and cytokeratins 7, 19 and 20. MIB-1 labeling index in the both the components was 2-3%. The present case is the first of its kind to be reported in the kidney and emphasizes the diversity potential of kidney tumors.

Evidence for the presence of high risk human papillomavirus in retinoblastoma tissue from nonfamilial retinoblastoma in developing countries

BACKGROUND

The prevalence of human papillomavirus (HPV) infection in India is high. HPV infection is known to cause cervical cancer and has also been implicated in the pathogenesis of retinoblastoma (RB), a common intraocular malignant tumor of childhood which can be familial or sporadic. Despite the high incidence of RB in India, its familial form is rare. Hence this study was undertaken to investigate whether high-risk HPV types 16 and 18 are involved in the development of RB.

METHODS

Formalin fixed paraffin embedded RB tissues (n = 76) including prospective cases with corresponding maternal cervical smears (n = 10) were analyzed for the presence of HPV DNA sequences. Expression of the cell cycle regulatory proteins viz; p105, p107, p30, p16, E2F-1, E2F-4, and MiB-1 was studied by immunohistochemistry (IHC) (n = 34).

RESULTS

A total of 53 out of 76 (69.7%) cases were positive for HPV, of these 3 cases were positive for HPV-16, 23 for HPV-18, and 27 for both HPV-16 and -18. Of the prospective cases (n = 10) studied, five cases along with the corresponding maternal cervical cytology smear had identical HPV status. HPV-16 positive tumors were classified as well differentiated (P = 0.013). Nuclear expression of pRB2/p130 showed significant association with HPV-16 infection (P = 0.04) or dual infection of HPV-16/-18 (P = 0.02).

CONCLUSIONS

Our study lends support to the hypothesis that infection of HPV-16/-18 may play an important role in the development of nonfamilial form of RB in children in India.

Composite adrenal medullary tumor: A rare cause of hypertension in a young male

Composite tumors of the adrenal medulla, containing pheochromocytoma and ganglioneuroma, are rare. A 27-year-old male presented to us with dyspnea and was found to have labile hypertension. A left suprarenal mass was detected on computed tomography. The patient was operated under the cover of alpha anti-adrenergic drugs. The histopathological examination demonstrated that the tumor consisted of pheochromocytoma and ganglioneuroma elements, and hence, a diagnosis of composite adrenal medullary tumor (CAMT) was made. To the best of our knowledge, this is the first case of CAMT reported from India.

Epidermoid cyst in the kidney

We report an extremely rare case of an epidermoid cyst in the kidney of a 74-year-old man who had presented with painless hematuria. Radiologic examination revealed a cyst in the kidney that was thought to be neoplastic. The patient underwent surgery to remove the cyst, and we received the nephrectomy specimen. A 6-cm cyst with no solid areas was seen. On histologic examination, this was an epidermoid cyst. We reviewed the published data and discuss the possible theories of origin of this rare condition.

Primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old woman: a case report

Introduction

Primary Ewing's sarcoma or primitive neuroectodermal tumor of the genital tract of women is uncommon. Rarer still is its occurrence in the vagina, with only five cases described so far. Out of these, only one case was confirmed using molecular analysis.

Case presentation

We present an extremely rare case of Ewing's sarcoma or primitive neuroectodermal tumor in a 17-year-old Indian girl. She presented with a vaginal mass that was initially diagnosed as a malignant round cell tumor. Immunohistochemistry showed diffuse positivity for vimentin, membranous positivity for MIC2, and positivity for BCL2 and FLI-1. On the other hand, she was negative for cytokeratin, epithelial membrane antigen, desmin, Myo D-1, myogenin and smooth muscle actin. A diagnosis of primitive neuroectodermal tumor was thus offered. Furthermore, a molecular analysis of our patient using reverse transcription-polymerase chain reaction technique showed positivity for t(11; 22) (q24; q12) (EWSR1-FLI1), thus confirming the diagnosis of a Ewing's sarcoma/primitive neuroectodermal tumor. Our patient was offered chemotherapy on Institutional protocol EFT 2001.

Conclusion

This is a rare case of primary vaginal Ewing's sarcoma or primitive neuroectodermal tumor, which was confirmed with molecular analysis, in the youngest patient known so far. This study reinforces the value of integrating morphological features with membranous MIC2 positivity, along with application of molecular techniques in objective identification of an Ewing's sarcoma or primitive neuroectodermal tumor at uncommon sites.

Primary endobronchial synovial sarcoma confirmed by SYT-SSX1 fusion gene transcript by reverse transcriptase polymerase chain reaction

Primary sarcomas of lung are rare compared to metastatic sarcomas. Herein, we report a rare case of primary pulmonary synovial sarcoma with polypoid endobronchial growth in a 35-year-old lady who presented with cough and dyspnea. A malignant pulmonary tumor was suspected and left pneumonectomy was performed. Grossly, a non-encapsulated polypoidal endobronchial tumor measuring 6 cm in greatest diameter, with a solid, tan-white cut surface was identified. Microscopically, tumor was characterized by a proliferation of oval to spindle-shaped cells arranged in sheets and fascicles. Focal hemangiopericytomatous pattern was noted. Immunohistochemically, tumor cells were positive for vimentin, BCL-2, MIC-2 and calponin and focally positive for pancytokeratin and epithelial membrane antigen. A subsequent molecular analysis performed using reverse transcriptase-polymerase chain reaction with RNA extracted from paraffin-embedded tissue, revealed SYT/SSX1 fusion gene which confirmed the diagnosis of synovial sarcoma. The utility of immunohistochemistry and molecular techniques in diagnosis of such a rare case is stressed and the relevant literature is discussed.

Monophasic synovial sarcoma of tongue

Synovial sarcoma is a well defined morphologic entity extensively researched in literature. Synovial sarcoma displays a wide spectrum of clinical presentations and histologic appearances that may give rise to diagnostic dilemmas. One such unusual site in the head and neck area is the tongue. We report a case of monophasic synovial sarcoma of the tongue in a 22-year-old male. Microscopically, this tumor mimicked a poorly differentiated carcinoma which is more common at this site though the patient was young for this type of tumor. On immunohistochemistry, neoplastic cells were positive for cytokeratin, vimentin, calponin, CD99 and bcl2. Molecular studies--viz. reverse transcriptase polymerase chain reaction revealed a SYT-SSX translocation clinching the diagnosis. This paper highlights the immunohistochemistry profile and SYT-SSX translocation which helped arrive at an accurate diagnosis only because the index of suspicion for a monophasic synovial sarcoma is high.