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Background and Aims: Angiosarcoma (AS) is a rare malignant vascular tumor that phenotypically and functionally recapitulate normal endothelium. They constitute approximately 2–4% of soft tissue sarcomas. We present 36 cases of head and neck AS diagnosed for 11 years at a tertiary care hospital in South India to analyze the clinical, pathological, and immunophenotypic profiles with special emphasis on their differential diagnoses and diagnostic pitfalls. Materials and Methods: Head and neck AS diagnosed from January 2006 to December 2017 were included. Clinical characteristics, treatment received, and follow-up data were obtained from electronic medical records. Hematoxylin and eosin (H&E)-stained slides and immunohistochemistry (IHC) slides were reviewed, and the histomorphological features, immunohistochemical staining, and their utility in resolving differential diagnosis were assessed. Results: Twenty-two females and 14 males were diagnosed with head and neck AS in the study period. Histomorphological patterns observed were mixed vasoformative and solid (n = 22), pure vasoformative (n = 13), and pure solid (n = 1). Neoplastic cells showed epithelioid, spindly, signet cell-like, clear cell, and rhabdoid morphology. CD31 was positive in 100% of cases, and CD34 was positive in 40% of cases. Differential diagnoses included melanoma, rhabdomyosarcoma, and large-cell lymphoma. Surgery, radiotherapy, and chemotherapy were the treatment modalities used. Twelve patients developed local recurrence, and 12 patients developed metastasis on follow-up. Twenty-five patients died of disease, on an average of 24 months after diagnosis. Conclusion: Head and neck AS pose a significant diagnostic challenge due to their broad morphologic spectrum. Proper clinicopathologic correlation is necessary to avoid misdiagnosis.

Papillary thyroid carcinoma is the most common form of thyroid cancer and is usually associated with a good outcome. However, there are some aggressive variants wherein the prognosis may not be as good as for a conventional papillary thyroid carcinoma. Three cases of aggressive variants of papillary thyroid carcinoma are reported in the present series, namely, tall cell, hobnail, and columnar cell variants. This series is being reported to highlight the characteristic histopathological features which help in diagnosing these variants, especially diagnostic challenge in recognizing columnar cell variant due to lack of the classical nuclear features of papillary thyroid carcinoma in this variant. This case series also highlights the clinical importance of recognizing these variants because, according to American Thyroid Association, these variants come under intermediate risk with a poor clinical outcome, requiring aggressive management with neck dissection, radioiodine ablation, and closer disease surveillance.

Context: Differentiating NSCLC as either adeno or squamous type and identification of Epidermal Growth Factor Receptor (EGFR) mutations is clinically relevant for lung cancer patients for selecting treatment. Thyroid transcription factor-1 (TTF-1) and p63 were demonstrated as useful markers for histologic typing of lung cancer. Mutation and overexpression of EGFR has been reported in a subset of non-small cell lung cancers. If these markers can be validated for the differential diagnosis of adenocarcinoma in a sputum sample itself, it will be highly beneficial for lung cancer patients. Aims: To evaluate whether immunocytochemical expression of TTF-1, p63, and EGFR proteins in sputum samples can be used for differential diagnosis of lung adenocarcinoma by comparing with that of the corresponding tissue samples. Settings and Design: Ninety sputum samples and matched tissue samples were used for the study. Subjects and Methods: Monolayered smears and cell blocks of sputum and the corresponding tissue samples were immunostained with the standard ABC method. The expression patterns of these markers were analyzed statistically and compared with clinic-pathological parameters. Statistical Analysis Used: Chi-square test and paired t-test. Results: The p63 protein had a positive expression in 73.9% of SCC whereas TTF1 had positive expression in 75.8% of ADC. The EGFR expression was positive in 27 cases of adenocarcinoma, 21 cases of SCC and 19 cases of NSCLC. Conclusions: Immunocytochemistry of the aforementioned antibodies in sputum samples can be used as supplementary evidence for the subtyping of NSCLC.

Introduction: Papillary lesions of the breast include a spectrum of entities ranging from benign papilloma to malignant papillary carcinoma. The overlapping morphological features in benign and malignant lesions make their accurate sub categorisation difficult. Definitive surgical management decisions on papillary lesions of breast based on fine needle aspiration cytology report alone is a matter of concern. Aim: To evaluate the cytomorphological features of papillary lesions of breast and its concordance with histopathology. Materials and Methods: This retrospective study was conducted in Department of Pathology at Regional Cancer Centre, Thiruvananthapuram, Kerala, India (tertiary cancer centre) from January 2017 to June 2017. Total 28 cases diagnosed as papillary lesions/neoplasm on nipple discharge/fine needle aspiration cytology (FNAC) from January 2014 to December 2016 were reviewed and concordance with histopathology where ever available was analysed. Cytomorphological features that were analysed included cellularity, complex folded and branching epithelial sheets, stromal bare nuclei, cyst macrophages, single cells and atypia. Results: Total 28 cases of papillary lesions diagnosed by cytology were identified with mean age of 51 years. Out of 28, 22 cases had histopathology concordance. Most common diagnosis in cytology was papillary neoplasm, accurate categorisation into benign or malignant could not be done in cytology in most of the cases. Most common diagnosis in histopathology was carcinoma, in-situ and invasive. Of total 22 cases,16 cases showed true papillae. Majority of the cytomorphological features assessed were statistically insignificant in differentiating benign and malignant lesions. Fifteen cases out of the total 22 cases turned out to be malignant in final histopathology. Out of the total 22 cases wherein histopathology correlation was available, cytology could give a conclusive diagnosis of malignancy in two cases and could give a suggestion of malignancy in seven cases. Out of these nine cases where cytology favoured malignancy, one case turned out to be benign in histopathology while the rest eight cases were malignant. In five cases cytology gave benign diagnosis, one of these turned out to be malignant in histopathology, rest four cases histopathological diagnosis was in concordance with cytology. In eight cases cytology gave an equivocal diagnosis of papillary neoplasm, where further categorisation into benign and malignant category was not possible. Out of these equivocal cases, six turned out to be malignant in histopathology and two were benign. Conclusion: Cytomorphological features of papillary lesions of the breast are not unique and are inadequate for consistent categorisation into benign and malignant lesions. Excision biopsy with adequate sampling and immunostaining with myoepithelial markers and Oestrogen and Progesterone Receptors (ER and PR) are essential for accurate categorisation of papillary neoplasms of breast.

Context: Despite sputum cytology being accepted as a simple and noninvasive diagnostic method for lung cancer, the clinical usefulness of sputum for evaluation of prognosis is yet to be explored. Validation of some of the markers in sputum for prognosis prediction will be highly useful for selective therapy. Aims: This study was aimed to evaluate a reliable panel of immunocytochemical markers for their significance to predict survival. Materials and Methods: We have analyzed the expression of p53, p16, galectin-3, and epidermal growth factor receptor (EGFR) proteins in sputum samples processed in a mucolytic agent/cellblock and compared the same with that of the corresponding tissue samples. Results: Overexpression of p16 and EGFR was found to have a better survival benefit, whereas positive p53 and galectin-3 expressions had shorter period of survival. Expression patterns of all these four proteins were more or less similar in smears, cellblocks of sputum, and tissue samples except for slight changes in staining intensity which was not found to be statistically significant. No significant difference was found in the association of these proteins with survival pattern between sputum and tissue samples. Conclusion: This is the first report of immunocytochemistry of a panel of markers on cells exfoliated in sputum samples which suggests that analysis of immunocytochemical markers in sputum samples can be attempted as a cost-effective and reliable predictor of prognosis and survival. Accumulation of mutated p53, overexpression of galectin-3, and lower expression of p16 and EGFR proteins were found to predict poor prognosis for lung cancer.

Objective: To prospectively investigate the value of rapid on-site evaluation (ROSE) in transthoracic fine needle aspiration cytology (FNAC) of patients with pulmonary nodules. Computed tomography (CT)-guided FNA is commonly employed for the diagnosis of lung lesions and the most common reason for not being able to provide a diagnosis in FNA is inadequacy of samples. Materials and Methods: This was a prospective study conducted in the departments of pathology and radiology of our cancer centre. This study had approval from the institutional review board and ethical committee of our institute. Fifty consecutive cases undergoing CT-guided transthoracic FNAC in our centre were included in the study. The smear submitted for ROSE was stained using toluidine blue stain. The specimen adequacy and diagnosis in ROSE was compared with that of the final cytology report, and the concordance regarding adequacy and diagnosis were noted. Results: Smears were adequate in 34 cases (68%) and inadequate in 16 cases (32%) Out of the 16 inadequate cases, 5 (31%) were converted to adequate due to the application of ROSE, thus increasing the adequate number of cases to 39 (78%). A diagnosis of malignancy was made in all 39 adequate cases. Sensitivity of ROSE in determining adequacy was 92% and specificity was 100%. The most common malignancy was adenocarcinoma in 26 cases. Pnemothorax occurred in 2 cases. No significant complications occurred in other cases. Conclusion: CT-guided FNA with ROSE is a safe and useful tool in the diagnostic work-up of lung cancer patients. A multidisciplinary approach along with onsite evaluation of adequacy will increase the diagnostic utility of cytology in lung lesions.

A 36-year-old female presented with lump in the left breast of 2 months duration. Fine-needle aspiration cytology (FNAC) and trucut biopsy confirmed the diagnosis of carcinoma. Clinically, it was T3N1Mx disease. Computed tomography (CT) of the chest detected bilateral lung metastasis. CT head and neck detected a nodule in the thyroid which on FNAC was suspicious of papillary carcinoma. The patient was started on chemotherapy for breast disease with a good initial response; however, while on-follow up, there was progression of disease at primary site. The patient was taken up for surgery. Radical mastectomy along with total thyroidectomy was performed. Histopathological examination showed infiltrating duct carcinoma, not otherwise specified type and papillary carcinoma thyroid. There was a 0.4 cm × 0.4 cm metastatic focus, from breast carcinoma within the papillary carcinoma thyroid. The metastasis was confirmed by immunohistochemistry. Metastasis to thyroid is rare. However, tumor-to-tumor metastasis with papillary carcinoma serving as recipient to breast carcinoma is exceedingly rare with very few case reports in the literature. We report this case for its rarity and also for highlighting the fact that pathologists should keep in mind the possibility of metastasis also when coming across unusual morphology in thyroid lesions.

A 48-year-old man presented to our surgical oncology division with incidentally detected abdominal mass. On examination, a ballotable swelling was present in the right lumbar region. His imaging studies showed a large multicystic mass in the lower pole of the right kidney. With radiological diagnosis of cystic renal cell carcinoma (RCC), the patient was taken up for surgery. Histopathology showed tubulocystic RCC (TC-RCC) with a focus of papillary RCC. Though closely related to papillary RCC, TC-RCCs of kidney are a distinct group of RCC. Analysis of more cases is required to understand the exact tumor biology and to ascertain prognosis.

A 58-year-old female, a known diabetic and hypertensive, presented with left-sided swelling on the anterior aspect of the neck of 1-year duration, which was rapidly increasing in size for the past 6 months. She was on Eltroxin for hypothyroidism for the past 1 year. Computed tomography study of the neck showed a nodule in the left lobe of thyroid which on fine-needle aspiration was suspicious for malignancy. Total thyroidectomy with left posterolateral lymph node dissection was done. Histopathological examination showed sclerosing mucoepidermoid carcinoma with eosinophilia (SMECE) of the thyroid gland with lymph node metastasis. SMECE of the thyroid was initially thought to be a low-grade malignancy with indolent clinical behavior. However, our case showed extra thyroidal spread with lymph node metastasis, necessitating adjuvant therapy for our patient. Such aggressive behavior has been noted in few earlier case reports also.

Rectus sternalis muscle, either unilateral or bilateral is an uncommon anatomical variant among the anterior chest wall muscles. During the routine dissection as a part of undergraduate medical teaching in the department of Anatomy, a unilateral rectus sternalis muscle was noticed on the right hemi thorax in one cadaver, located adjacent to the sternum between the pectoralis major muscle and the superficial fascia of the region. Though rare in occurrence, when present, rectus sternalis muscle demands proper awareness and attention by the clinicians especially radiologists and surgeons, as the ignorance of the existence of this muscle may lead to misinterpretation, incorrect diagnosis and unnecessary clinical interventions. Such anatomical variations should be borne in mind while doing radiological investigations, radiotherapy and surgical procedures in the chest region.

Introduction: Chronic lymphocytic thyroiditis [Hashimoto thyroiditis (HT)] is a common thyroid lesion diagnosed on fine-needle aspiration cytology (FNAC). Apart from FNAC, various other parameters, such as clinical features, ultrasonographic findings, antithyroid antibody levels, hormone profiles, and radionuclide thyroid scan, are also taken into consideration in making a diagnosis of HT. Aims: To grade lymphocytic thyroiditis based on the cytomorphology and to correlate the cytological grades with the levels of antithyroid peroxidase antibody (ATPO), antithyroglobulin antibody (ATG), and thyroid stimulating hormone (TSH). Materials and Methods: During a period of one and half years, 1,667 cases underwent FNAC of thyroid at our tertiary care center. Of these, 128 cases had cytological evidence of lymphocytic thyroiditis. Out of these, in 60 cases the levels of ATPO, ATG, and TSH were known. The cytological grades of lymphocytic thyroiditis in these cases were correlated with these parameters. Results: Out of the 60 cases, 55 were females. Age ranged from 5 years to 70 years, with majority of patients in third decade. Diffuse enlargement of thyroid was the commonest presentation. However, 14 cases presented with nodular disease. Majority of the patients had grade 1 thyroiditis (27 cases), followed by grade 2 thyroiditis (22 cases). Cytomorphology was diagnostic of thyroiditis in all 60 cases. ATPO was elevated in 57 cases and ATG was elevated in 40 cases. Elevated level of TSH was seen in only 18 cases. In 39 cases, TSH value was normal. There was no correlation between the cytological grades of thyroiditis and the levels of antithyroid antibodies and TSH. Conclusion: Lymphocytic infiltration of thyroid follicles is pathognomonic of lymphocytic thyroiditis. Positivity for antithyroid antibodies is strongly associated with HT but no correlation was observed between the grades of thyroiditis and the levels of ATPO, ATG, and TSH.

Background: The knowledge of anatomy of facial nerve and its terminal branches is important for the successful outcome in facial surgeries. The buccal branch of facial nerve due to its characteristic variations in origin and diverse relationship with the parotid duct can be easily injured during parotid duct surgery, parotidectomy or face lift operations. An operating surgeon would find it helpful if the course of buccal branch especially in relation to parotid duct is studied. Aim: To describe the origin, course and number of buccal branches of facial nerve and its pattern of relation with the parotid duct. Materials & Methods: The study was done in 100 cadaveric cranial halves including fetuses. The buccal branch was observed for its origin and course. The relationship of buccal branch to the parotid duct was noted and classified accordingly. Results: Buccal branch originated from the lower trunk of facial nerve in 68 % and from the upper trunk in 28% while the two trunks contributed to the origin in 4%.The buccal branch passed inferior to parotid duct in 41 % and superior to duct in 25%. In 28%, buccal branch formed a plexus over the duct along with other branches. In 6%, there were two branches,one passed superior and the other passed inferior to the parotid duct. Conclusion: The knowledge regarding the variations of buccal branch of facial nerve can be a surgeon’s guide during facial surgeries.

Intracranial meningiomas are not often aspirated unless they erode the skull and present as swelling in the head and neck region. We describe the cytologic findings of fine needle aspiration cytology in a clear cell variant of intracranial meningioma presenting with swelling in the left parietal region of the scalp in a 45-year-old woman. The diagnosis was confirmed by histopathology. Clear cell meningioma is characterized by patternless sheets of clear polygonal cells. Clear cell meningioma is a rare distinctive cytological subtype of meningioma with high recurrence rate and increased mortality, which necessitate frequent follow-up after surgical excision. The recognition of clear cell meningiomas is important here and should be distinguished from other clear cell lesions of the scalp. If clear cell epithelial neoplasm is encountered on fine needle aspiration, it is reasonably possible to provide at least a differential diagnosis of meningioma based upon the focal whorls, sparce vascularity on low magnification, along with the presence of pseudoinclusion and inconspicuous nucleoli at high magnification.

A-62-year-old lady presented with complaints of cough, dyspnea and hemoptysis of 3 months duration. A radiological evaluation revealed a mass lesion in the left lung along with significant lymphadenopathy. With a clinical and radiological diagnosis of carcinoma of the lung, the patient was taken up for biopsy. The specimen consisted mainly of grey-white friable soft-tissue, which on histopathological evaluation showed small cell carcinoma, which was confirmed with immunohistochemistry. Apart from the carcinomatous component, many hyphae and fruiting bodies of Aspergillus were also seen. We are reporting this case because, though the finding of hyphal forms of Aspergillus is not so uncommon in lung biopsies, detection of fruiting bodies of Aspergillus in histopathological section is an extremely rare finding. The hyphal forms of Aspergillus can be confused with the hyphal forms of other fungi, but when fruiting bodies are present a definite diagnosis is possible at the histopathology level itself. We would also like to highlight that contamination should be excluded before labeling a case as Aspergillosis because of the potentially toxic medication implicated in the treatment.