Ductal carcinoma in situ (DCIS) in Karachi

Objective: To study the frequency of ductal carcinoma in situ (DCIS) in a large pathology series. DCIS is a proliferation of non-invasive, malignant epithelial cells within the ductolobular system of the breast. It is a heterogeneous entity with several morphologic variants that differ in gross appearance, growth pattern, cytologic features, mammography, and malignant potential. Methods: The data of The Aga Khan University\u27 Pathology Department, diagnosed on the basis of histopathology, during a 6-year period (1st January 1998 to 31st December 2003) was reviewed, all cases of DCIS studied, and data was analyzed with the help of analytical software SPSS. Results: Thirty-eight cases of DCIS were reported to the Aga Khan University Pathology Department, during a 6-year period (1998 to 2003), comprising approximately 1% of all breast cancers reported to the unit in the same period. The mean age of the patients at diagnosis was 48.95 years (CI 95% 44.6; 53.3). Approximately half the cases occurred in the 45-54 year age group (figure 1). Two cases (5.3%) were recurrences with previous lumpectomy scars. Comedo necrosis was observed in five (13.2%) cases, whereas 33 (86.8%) cases were non-comedo type. The clinical presentation was a palpable mass (92.1%), nipple discharge (5.3%) or clinically occult lesions diagnosed on mammography (2.6%). Approximately half the patients presented with a grade 2 disease. Atypical ductal hyperplasia was observed in a third of the cases, predominantly associated with a grade 1 and 2 disease. The estrogen and, progesterone receptor status was studied in 12 (31.6%) cases. Estrogen positivity was observed in 11 (91.7%) cases and progesterone positivity in 7 (58.3%) cases. Microcalcification was observed in four (10.6%) cases. Conclusion: The cases reported in this study are the indolent grade 1 or 2 cases with a non-comedo pattern, and a positive estrogen and progesterone receptor status. If untreated, only 40% of these innocuous forms of DCIS become invasive over a time span of approximately 25-30 years. In Pakistan we are missing the more aggressive forms of DCIS which have a shorter transition to invasive carcinoma

Validity of frozen section in the diagnosis of breast lumps: 5 years experience at the Aga Khan University Hospital.

Abstract Objective: To determine the accuracy of frozen section in the diagnosis of breast lump. Methods: Frozen section diagnosis given in consecutive breast biopsies performed in 5 years in our laboratory was evaluated against the final pathology report of permanent sections. Results: The Aga Khan University Hospital Lab receives more than 400 cases per year for frozen section. Three hundred and nineteen consecutive frozen sections of breast lumps examined from 1999-2003 were considered for analysis. Age of patients ranged between 22 and 90 years (mean age 49 years). In 316 cases (99%) there was no difference between the frozen section diagnosis and the final diagnosis. Three cases (0.94%) were incorrect; 2 cases (0.62%) were false positive. One case was false negative (0.31%). In 7 cases (2.19%), frozen section diagnosis was deferred to permanent sections. Frozen section diagnostic accuracy was 99%. Sensitivity and specificity was 99.3% and 93% respectively. Positive predictive value and negative predictive values of frozen section were 96.6% and 99.3% respectively. Conclusion: High accuracy of the frozen-section diagnosis in the breast lumps was confirmed in our study (JPMA 55;533:2005)

Breast carcinoma grading, estimation of tumor size, axillary lymph node status, staging, and nottingham prognostic index scoring on mastectomy specimens.

Introduction: Breast carcinoma is the most common malignant tumor and the leading cause of cancer death in women. In western countries, a sharp increase in the detection of breast carcinoma, largely due to widespread use of mammography, has recently led to a fall in breast cancer mortality. This, however, is not true for less developed countries, in which mortality continues to rise.Objective:The aim of this study was to acquire information about the extent and spread of breast carcinoma in our Patients by grading the tumors, determining the tumor size, and axillary lymph node status, staging of the tumors and Nottingham Prognostic Index (NPI) scoring on the available material. Materials AndMethods:One hundred and twenty consecutive mastectomy specimens with axillary lymph node sampling removed for breast carcinoma and received in the section of histopathology, Aga Khan University, in the year 2005, were included in the study. Standard protocols were used for the processing of the specimens, and reporting was done using a standard format incorporating all relevant tumor parameters. NPI was applied to the cases.Results:Out of the 120 cases, 5 (4.17) were grade 1, 91 (75.83) were grade 2, and 24 (20%) were grade 3. Also, 9 cases (7.5%) were T1 (4 were T1b, and 5 were T1c), 53 (44.16%) were T2, 50 (41.66%) were T3, and 8 (6.66%) were T4. Axillary lymph nodes were available in 107 cases. In 13 cases, no lymph nodes were recovered. Out of 107 cases 27 (25.23%) lymph nodes were negative for metastases pN0, 29 (27.10%) cases were pN1, 26 (24.30) were pN2, and 25 cases (23.36%) were pN3. Extranodal spread was present in 56 (70%) out of the 80 cases in which lymph nodes were positive. The average microscopic size of nodal metastasis was 1.7 cms. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). Tumor necrosis was present in 76 out of 120 cases (63.33%). Vascular invasion was present in 43 out of 120 cases (35.83%). NPI scores were greater than 5.4 in 60 out of 107 cases (56.1%) indicating poor prognosis.Conclusion:The large majority of the cases were grade 2 tumors. Most cases (all grades) were T2 or T3, and were axillary lymph node positive. Large majority of cases with nodel metastases showed extra nodal spread. The majority of Patients had NPI scores greater than 5.4 indicating poor prognosis. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). The findings show extensive and advanced disease trends in our Patients

Aleukemic myeloid sarcoma of the breast

Myeloid sarcoma is a solid collection of leukemic blast cells outside bone marrow. It is seen infrequently in association with overt Acute Myeloid Leukemia (AML), however, it invariably transforms into this aggressive condition. A28-year woman presented with a lump in left breast for last 2 years. Morphological and immunophenotypic results of breast mass were consistent with myeloid sarcoma. Bone marrow aspirate and biopsy were normal, however, patient died after one and a half years of diagnosis. Myeloid sarcoma at any extramedullary site heralds development of overt acute myeloid leukemia and should be appropriately managed at the time of diagnosi

Malignant vascular tumours associatedwith the breast: A study of 7 cases

Angiosarcomas account for less than 0.05% of the malignant neoplasms of the breast. We present here 7 cases of malignant vascular neoplasms of the breast, including 2 cases of postmastectomy Stewart-Treves syndrome. In this case series, most of the patients were young. Tumour was bilateral at presentation in one case. The size of the tumours ranged from 1.6 cm to 11 cm. Although breast angiosarcomas are rare neoplasms, with the increasing use of radiation therapy for breast cancer patients, post-radiation skin lesions should not be ignored

Lipoblastoma: a clinicopathologic review of 23 cases from a major tertiary care center plus detailed review of literature

Objective: Lipoblastoma is a rare neoplasm that occurs mostly in infants and children. Although benign, it has a tendency for local recurrence.Results: Clinical and pathological features of 23 cases of lipoblastoma described. Patients’ age ranged from 8 months to 18 years with mean and median age 4.1 and 2.5 years, respectively. Male:female ratio was 2.8:1. Most common sites were lower extremities (9 cases), followed by abdominal cavity and retroperitoneum (4 cases), and scrotum/groin (3 cases). Grossly, 22 tumors were well circumscribed and multi nodular. All cases showed lobules composed of adi‑ pocytes and lipoblasts with intervening fbrous septa and fne vascular network. Myxoid change, capsule formation and septation were seen in all cases. Zonation was seen in 2 cases. Follow-up was available in 14 out of 23 patients. Of these, 13 were alive and free of disease with no evidence of any recurrent lesion. One patient with a mediastinal infltrating lipoblastoma experienced 4 recurrences. Lipoblastoma is a benign adipocytic neoplasm of infants and young children. Correlation of clinical and histological features helps in reaching a correct diagnosis. Owing to a high recurrence rate following incomplete resection, a complete resection is essential. Prognosis is excellent after complete resection

Metaplastic carcinoma of the breast, an intriguing rarity.

Abstract Metaplastic carcinoma breast is categorized as a rare heterogenous neoplasm generally characterized by a mixtureof adenocarcinoma with dominant areas of spindle cell, squamous and/or other mesenchymal differentiation. Todetermine the epidemio-demographic and histopathologic characteristics of this rare entity a retrospective studywas conducted to review all cases at the Aga Khan University Hospital (AKUH) Karachi, received during 1st January2000 to 31st August 2005. Twenty-four patients were identified with a mean age at diagnosis of 46.4 (±SD 3.8) years,and an age range of 28-68 years. The mean tumor size was 7.9 cm, range 2.0–17.0 cms (±SD 4.77). The specimenswere mostly obtained by modified radical mastectomy(54.2%) followed by biopsy (29.2%), lumpectomy (8.3%),and total mastectomy (4.2%). Skin ulceration was found in 37.5% cases. Component sub-categorization showed 13(54.2%) cases of infiltrating ductal carcinoma with squamous metaplasia, followed by 2 (8.3 %) cases with heterologouselements, 4 (16.7%) cases with spindle cell component, 2 cases of matrix producing carcinoma and one case ofsquamous cell carcinoma. The malignancy was high grade, modified Bloom Richardson’s grade III (54.2 %) andgrade II (12.5%). Such grading was not applicable to 4 cases of spindle cell component and 1 case with extensivechondroid areas. Twelve patients had information available on the nodal status. Five (41.6%) were node-negative,four (33.33%) had 1-3 lymph node involvement positive, and three (12.5%) had more than 3 lymph nodes positive.The median 3 year Event Free Survival (EFS) was 10% and overall survival was 30%. MCB is an aggressive diseasewith a poor prognosis. This aspect appears bleaker in our population either due to the biological characteristic of themalignancy in a high risk group or the lack of availability and accessibility of health coverage, resulting in a delayedpresentation. MCB is an uncommon breast malignancy and due to the lack of sufficiently large studies there islimited knowledge as to the pathogenesis, progress, best treatment protocols and prognosis. Collaborative studiesare therefore recommended to allow for better understanding of this intriguing neoplasm

Phylloides tumors in adolescent girls and young women in Pakistan.

Abstract The objective of this study was to determine the frequency of phylloides tumor (PT) in adolescent girls and youngwomen (less than and equal to 25 years of age) and to define the clinico-pathological features of PT in this unusualclinical setting. This descriptive study was carried out at the Aga Khan University Hospital (AKUH) pathologydepartment. All consecutive cases of PT diagnosed during the last sixteen years in the section of histopathology from1st January 1990 to 31st June 2005 were included. Selection of cases was restricted to patients up to 25 years of age.A total of 42 cases of PT in up to 25 years of age were diagnosed. This comprised 11% of the total PT cases (totaln=363). The number of benign (BPT), borderline (BLPT) and malignant (MPT) was identical i.e. 14 (33.3%) each.Clinically all cases presented with a solid, mobile, palpable mass. The mean age was 19.1 years (95% CI, 16.7-21.6),21.9 years (95% CI, 20.7-21.9) and 19.7 years (95% CI, 17.2-22.3) in BPT, BLPT and MPT respectively. In majorityof cases the surgical procedure performed was lumpectomy (50% of BPT, 78% of BLPT and 64% of MPT). Highgrade PT (BLPT and MPT) is an uncommon mammary tumor in adolescent girls and young women but seems to beoccurring with increased frequency in the study population. This observation may indicate the biological behavior ofPT in a high risk population, though chances of referral bias are also present. In view of the rarity of the disease,larger population studies are suggested to confirm our findings

Ovarian primary neuroendocrine carcinoma of non-small cell type: Report of an extremely rare neoplasm

Paraffin block sections of a uterus and ovarian mass from a 31 year old female were sent for second opinion to the Pathology Laboratory of Aga Khan University. Histologic examination and immunohistochemical features gave a diagnosis of primary neuroendocrine carcinoma of non-small cell type admixed with benign mucinous cystadenoma. This is a rare tumour with only eight being reported in literature

Rhinosporidiosis presenting as an urethral polyp

Rhinosporidiosis is an inflammatory disease caused by Rhinosporidium seeberi, a protoctistan mesomycetozoa, member of a group of novel aquatic parasites, characterized by hyperplastic polypoid lesions of the nasal cavity and rarely other mucous membranes. We report an unusual presentation of rhinosporidiosis as an urethral polyp, which is only the second case of rhinosporidiosis reported from Pakistan