Large sporadic abdominal wall desmoid tumor due to repeated caesarean sections, a rare and long-term unexpected morbidity

We present a case of large abdominal wall desmoid tumor (DT) arising due to repeated caesarean sections (CS) in a young woman of reproductive age group and managed with wide resection of tumor and abdominal wall reconstruction (AWR). Our patient was a 30-year-old female, came with complaints of persistent abdominal pain associated with mass on abdominal wall and difficulty in walking for 2 years. Patient had 3 living children, all were delivered by CS. Ultrasonography and CT scan of abdomen with contrast revealed a large solid abdominal wall mass and FNAC was suggestive of benign spindle cell neoplasm. We performed a wide surgical excision of tumor. Abdominal wall reconstruction done with prolene mesh. Post-operative period was uneventful with satisfactory wound healing. DTs are rare tumors that occur anywhere in the body and have quite variable clinical behavior. In our patient this tumor had occurred sporadically about 4-5 years of last child birth. Repeated trauma of surgeries on the abdominal wall led to the catastrophic destruction of the musculature in our patient. In this case CT scan revealed solid lump on abdominal wall without any evidence of incisional or inguinal hernia and associated intraabdominal pathology. Our specimen tested positive for β catenin confirming DT. Surgery remains the main stay of treatment in all patients. In female patients presenting with lower abdominal wall tumor with history of previous CS or gynecological surgeries, DT should be considered.

A case of large cervical lipoleiomyoma simulating malignancy: an intraoperative dilemma

Primary lipomatous tumors of the uterus are very unusual benign neoplasms with an incidence of 0.03% to 0.2%. Most commonly described in the uterine corpus, lipoleiomyomas (LLM) have been reported in cervix, broad ligament and retro peritoneum. Here we report a case of perimenopausal women with cervical LLM which was highly friable simulating cervical malignancy, creating an intraoperative dilemma. A 45 year old perimenopausal woman presented with severe abdominal pain with difficulty in passing urine and motion, excessive bleeding per vaginum with increased frequency of menses, since 6 months. Ultrasonography revealed a well-defined rounded to oval heterogeneous hyperechoic lesion with minimal vascularity measuring 10.4×11.0×7.7 cm, volume-469 cc, probably arising from anterior lip of cervix. Patient was taken for laparotomy. Intraoperative friability and vascularity of the mass was suggestive of malignancy. LLM, if asymptomatic, requires no treatment. But symptomatic cases require surgical management

Thanatophoric dysplasia- a rare cause of stillbirth and perinatal mortality: a case report

Lethal skeletal dysplasia is estimated to occur in 0.95 per 10,000 deliveries. Thanatophoric dysplasia affects about 1in 25000 to 50000 births. The term thanatophoric is Greek word for “death bearing”. Children with this condition are usually stillborn or die shortly after birth from respiratory failure. We report a case of LSD (Thanatophoric dysplasia), in an unbooked patient where previous two children and couple were absolutely normal.  Our patient, 31 years old, unbooked case presented with history of amenorrhea 8 months and unable to perceive fetal movements. Her husband’s age was 33 years. This was her third pregnancy. She had previous 2 deliveries by LSCS. Ultrasonography revealed single intrauterine live fetus in breech presentation with multiple fetal anomalies. There was shortening and deformity of all four limbs (micromelia) with poor mineralization of all bones. Thorax was pear shaped with short horizontal ribs and abnormal cardiothoracic ratio. LSCS was done in emergency for impending rupture of previous LSCS scar. Post-delivery examination and X-ray of the fetus revealed decreased skull mineralization, frontal bossing, hypoplastic nasal bone, midface hypoplasia, mandibular hypoplasia, pear shaped chest, protuberant abdomen, micromelia, dumbbell shaped appearance of all long bones. TD is caused due to mutation of the fibroblast growth factor receptor 3 gene (FGFR3), which is located on the short arm of chromosome 4. Type I TD is characterized by marked underdeveloped skeleton and short-curved long bones. Conventional radiographic examination remains the most useful means of studying the dysplastic skeleton. Bony evaluation is best done on X-rays or ultrasonography. The diagnosis of TD can be established with ultrasound and molecular confirmation in the second trimester can help in genetic counselling and termination of such lethal pregnancies. LSD’s are rare event. If our patient had undergone anomaly scan in second trimester of pregnancy, this defect could have been detected earlier. The outcome of fetus is lethal but maternal morbidity can be reduced if diagnosed early

Assessment of the pregnancy rates using sequential day 3 and day 5 embryo transfer in IVF/ ICSI patients

Background: To assess the pregnancy rates using sequential day 3 and day 5 embryo transfer in IVF/ ICSI patients.Methods: This prospective study was conducted in Aarogya Hospital and test tube baby Centre, Raipur from 1st January 2013 to 30th November 2019. Total 100 patients undergoing IVF/ICSI in the study period were offered sequential transfer.Results: Our fertilization rates were 80% with 85.7% grade I embryos on day 3. Blastocyst formation rate was 71.42%. Cycle cancellation rates were nil. Clinical pregnancy rates per retrieval cycle were 50% and implantation rates were 24% with acceptable multiple pregnancy rates of 12%.Conclusions: We advocate that this technique is useful in all patients having good quality embryos in adequate number for double transfer as this optimizes the chance of selection of the most viable embryo for transfer which is probably the key for a successful IVF program.

Making caesarean myomectomy safe and feasible: a 12 year single center experience

Background: To standardize our protocol of caesarean myomectomy to make it safe and feasible for all patients.Methods: This prospective study was conducted in Aarogya Hospital and test tube baby Centre, Raipur from 1st January 2008 to 1st August 2020. Total 45 patients who had documented fibroid in index pregnancy and consented for the procedure were included. B- Lynch sutures were prophylactically applied in all cases to prevent PPH.Results: Our maximum patients were between the age of 20-30 years (66.67%) and 75.56% were primigravida. 44.45% cases were of intramural fibroids and in 53.34% cases the size of myoma was >5 cm. Malpresentation was seen in 15.56% cases. 62.22% myomas were removed through single incision. 33.33% patients had uneventful second CS with us with excellent scar healing in 93.33% cases. 20% cases had secondary infertility and are advised further evaluation to find cause of infertility.Conclusions: The decision to proceed with elective myomectomy at time of CS should be approached with proper pre-operative evaluation of the patient, thorough counseling for hysterectomy if required, expert team, arrangement of blood and adequate correction of medical factors like anemia, hypertension, and diabetes mellitus. Prophylactic application of B -Lynch sutures in all the cases made a dramatic improvement in tone of uterus which we observed intra operatively

Postmenopausal endometrial carcinoma presenting as urinary incontinence: a case report

Endometrial carcinoma (EC) most commonly presents with postmenopausal bleeding (PMB) or blood tinged vaginal discharge. Watery vaginal discharge is usually reported in fallopian tube malignancy. We reported a case of EC where she had profuse watery discharge from private part mimicking urine and so patient visited urologist for urinary incontinence and was later diagnosed as endometroid adenocarcinoma. A 73 year old female presented with history of passing urine involuntarily for last 3 months. Endometrial biopsy revealed endometrial endometroid adenocarcinoma-FIGO grade-2. FDG PET-CT scan revealed primary neoplastic pathology of uterus or endometrium with no lymphadenopathy. PMB or vaginal discharge in women with high risk factors like obesity, diabetes mellitus, unopposed oestrogen exposure needs prompt evaluation. PMB is highly suspicious of malignancy arising from cervix or uterus but copious watery discharge should also be evaluated thoroughly with ultrasound and confirmation of underlying malignancy with hysteroscopic guided endometrial sampling should be done

Acceptance of emerging renal oncocytic neoplasms: a survey of urologic pathologists

Oncocytic renal neoplasms are a major source of diagnostic challenge in genitourinary pathology; however, they are typically nonaggressive in general, raising the question of whether distinguishing different subtypes, including emerging entities, is necessary. Emerging entities recently described include eosinophilic solid and cystic renal cell carcinoma (ESC RCC), low-grade oncocytic tumor (LOT), eosinophilic vacuolated tumor (EVT), and papillary renal neoplasm with reverse polarity (PRNRP). A survey was shared among 65 urologic pathologists using SurveyMonkey.com (Survey Monkey, Santa Clara, CA, USA). De-identified and anonymized respondent data were analyzed. Sixty-three participants completed the survey and contributed to the study. Participants were from Asia (n = 21; 35%), North America (n = 31; 52%), Europe (n = 6; 10%), and Australia (n = 2; 3%). Half encounter oncocytic renal neoplasms that are difficult to classify monthly or more frequently. Most (70%) indicated that there is enough evidence to consider ESC RCC as a distinct entity now, whereas there was less certainty for LOT (27%), EVT (29%), and PRNRP (37%). However, when combining the responses for sufficient evidence currently and likely in the future, LOT and EVT yielded > 70% and > 60% for PRNRP. Most (60%) would not render an outright diagnosis of oncocytoma on needle core biopsy. There was a dichotomy in the routine use of immunohistochemistry (IHC) in the evaluation of oncocytoma (yes = 52%; no = 48%). The most utilized IHC markers included keratin 7 and 20, KIT, AMACR, PAX8, CA9, melan A, succinate dehydrogenase (SDH)B, and fumarate hydratase (FH). Genetic techniques used included TSC1/TSC2/MTOR (67%) or TFE3 (74%) genes and pathways; however, the majority reported using these very rarely. Only 40% have encountered low-grade oncocytic renal neoplasms that are deficient for FH. Increasing experience with the spectrum of oncocytic renal neoplasms will likely yield further insights into the most appropriate work-up, classification, and clinical management for these entities

Reporting trends, practices, and resource utilization in neuroendocrine tumors of the prostate gland: a survey among thirty-nine genitourinary pathologists

Background: Neuroendocrine differentiation in the prostate gland ranges from clinically insignificant neuroendocrine differentiation detected with markers in an otherwise conventional prostatic adenocarcinoma to a lethal high-grade small/large cell neuroendocrine carcinoma. The concept of neuroendocrine differentiation in prostatic adenocarcinoma has gained considerable importance due to its prognostic and therapeutic ramifications and pathologists play a pivotal role in its recognition. However, its awareness, reporting, and resource utilization practice patterns among pathologists are largely unknown. Methods: Representative examples of different spectrums of neuroendocrine differentiation along with a detailed questionnaire were shared among 39 urologic pathologists using the survey monkey software. Participants were specifically questioned about the use and awareness of the 2016 WHO classification of neuroendocrine tumors of the prostate, understanding of the clinical significance of each entity, and use of different immunohistochemical (IHC) markers. De-identified respondent data were analyzed. Results: A vast majority (90%) of the participants utilize IHC markers to confirm the diagnosis of small cell neuroendocrine carcinoma. A majority (87%) of the respondents were in agreement regarding the utilization of type of IHC markers for small cell neuroendocrine carcinoma for which 85% of the pathologists agreed that determination of the site of origin of a high-grade neuroendocrine carcinoma is not critical, as these are treated similarly. In the setting of mixed carcinomas, 62% of respondents indicated that they provide quantification and grading of the acinar component. There were varied responses regarding the prognostic implication of focal neuroendocrine cells in an otherwise conventional acinar adenocarcinoma and for Paneth cell-like differentiation. The classification of large cell neuroendocrine carcinoma was highly varied, with only 38% agreement in the illustrated case. Finally, despite the recommendation not to perform neuroendocrine markers in the absence of morphologic evidence of neuroendocrine differentiation, 62% would routinely utilize IHC in the work-up of a Gleason score 5 + 5 = 10 acinar adenocarcinoma and its differentiation from high-grade neuroendocrine carcinoma. Conclusion: There is a disparity in the practice utilization patterns among the urologic pathologists with regard to diagnosing high-grade neuroendocrine carcinoma and in understanding the clinical significance of focal neuroendocrine cells in an otherwise conventional acinar adenocarcinoma and Paneth cell-like neuroendocrine differentiation. There seems to have a trend towards overutilization of IHC to determine neuroendocrine differentiation in the absence of neuroendocrine features on morphology. The survey results suggest a need for further refinement and development of standardized guidelines for the classification and reporting of neuroendocrine differentiation in the prostate gland

Global impact of the COVID-19 pandemic on cytopathology practice: Results from an international survey of laboratories in 23 countries

Background To the authors' knowledge, the impact of the coronavirus disease 2019 (COVID-19) pandemic on cytopathology practices worldwide has not been investigated formally. In the current study, data from 41 respondents from 23 countries were reported. Methods Data regarding the activity of each cytopathology laboratory during 4 weeks of COVID-19 lockdown were collected and compared with those obtained during the corresponding period in 2019. The overall number and percentage of exfoliative and fine-needle aspiration cytology samples from each anatomic site were recorded. Differences in the malignancy and suspicious rates between the 2 periods were analyzed using a meta-analytical approach. Results Overall, the sample volume was lower compared with 2019 (104,319 samples vs 190,225 samples), with an average volume reduction of 45.3% (range, 0.1%-98.0%). The percentage of samples from the cervicovaginal tract, thyroid, and anorectal region was significantly reduced (P < .05). Conversely, the percentage of samples from the urinary tract, serous cavities, breast, lymph nodes, respiratory tract, salivary glands, central nervous system, gastrointestinal tract, pancreas, liver, and biliary tract increased (P < .05). An overall increase of 5.56% (95% CI, 3.77%-7.35%) in the malignancy rate in nongynecological samples during the COVID-19 pandemic was observed. When the suspicious category was included, the overall increase was 6.95% (95% CI, 4.63%-9.27%). Conclusions The COVID-19 pandemic resulted in a drastic reduction in the total number of cytology specimens regardless of anatomic site or specimen type. The rate of malignancy increased, reflecting the prioritization of patients with cancer who were considered to be at high risk. Prospective monitoring of the effect of delays in access to health services during the lockdown period is warranted