Publications by authors named "Muhammad Usman Tariq"

46 Publications

Concordance Between Clinical and Pathological Response Assessment After Neo-Adjuvant Chemotherapy in Patients With Invasive Lobular Carcinoma.

Cureus 2021 Apr 7;13(4):e14341. Epub 2021 Apr 7.

Radiology, Aga Khan University Hospital, Karachi, PAK.

Background Neo-adjuvant chemotherapy (NAC) is frequently administered in breast carcinoma patients. The clinical response to NAC guides further treatment. The pathological response is not only an independent prognostic factor, but it also guides further treatment and prognosis. Objectives The aim of our study was to find the degree of concordance between clinical and pathological response assessments after NAC in Invasive lobular Carcinoma (ILC) cases by using World Health Organization (WHO) criteria and different pathological systems, respectively. We also tried to identify any useful parameter of clinical assessment that could better correlate with pathologic assessment and provide a better estimation of residual tumor. Methods This retrospective study was conducted on 26 ILC tumors diagnosed in 24 patients who were treated with NAC followed by surgical resection between January 2009 and December 2020. Medical records and microscopy glass slides were reviewed for clinical and pathological response assessments, respectively. Results The pre-treatment tumor area ranged from 1.8-255 cm and the mean±SD was 52.2±66.8 cm. After NAC, complete clinical response was observed in four (15.3%) cases. The clinically assessed mean tumor area significantly reduced from 52.2±66.8 cm to 17.2±22.6 cm (value<0.001). The pathologically assessed mean tumor area (27.4±24.1 cm) didn't differ significantly from the clinically assessed mean tumor area (17.2±22.6 cm) (value=0.114). Pathologically, the majority of the cases showed partial response, and a complete pathological response was achieved in only two (7.7%) cases. The concordance rates between clinical assessment by the WHO method and pathological assessment of the breast using the Sataloff method, Miller-Payne (MP) system, Residual Cancer Burden system, and Chevallier method were 26.7%, 15.8%, 9%, and 3.5%, respectively, with insignificant -values. Percentage reduction in clinical size and percentage reduction in tumor cellularity differed significantly (-value=0.038). Conclusion Clinical response assessment provides a less accurate estimation of residual disease, as it shows poor concordance with pathological assessment using different assessment systems/methods.
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http://dx.doi.org/10.7759/cureus.14341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103980PMC
April 2021

The many faces of solitary fibrous tumor; diversity of histological features, differential diagnosis and role of molecular studies and surrogate markers in avoiding misdiagnosis and predicting the behavior.

Diagn Pathol 2021 Apr 20;16(1):32. Epub 2021 Apr 20.

Emeritus Professor, Kyung Hee University, School of Medicine Vice President of Asia, International Academy of Pathology, U2Labs, Jangwon Medical Foundation 68 Geoma-ro, Songpa-gu, Seoul, 05755, South Korea.

Background: Solitary Fibrous Tumor (SFT) is a distinct soft tissue neoplasm associated with NAB2-STAT6 gene fusion. It can involve a number of anatomic sites and exhibits a wide spectrum of histological features.

Main Body: Apart from diversity in morphological features seen even in conventional SFT, two histologic variants (fat-forming and giant cell-rich) are also recognized. In addition, a malignant form and dedifferentiation are well recognized. Owing to diverse histological features and involvement of diverse anatomic locations, SFT can mimic other soft tissue neoplasms of different lineages including schwannoma, spindle cell lipoma, dermatofibrosarcoma protuberans, liposarcoma, gastrointestinal stromal tumor (GIST), malignant peripheral nerve sheath tumor (MPNST), and synovial sarcoma. SFT is classified as an intermediate (rarely metastasizing) tumor according to World Health Organization Classification of Tumors of Soft tissue and Bone, 5th edition. The management and prognosis of SFT differs from its malignant mimics and correct diagnosis is therefore important. Although SFT expresses a distinct immunohistochemical (IHC) profile, the classic histomorphological and IHC profile is not seen in all cases and diagnosis can be challenging. NAB2-STAT6 gene fusion has recently emerged as a sensitive and specific molecular marker and its IHC surrogate marker signal transducer and activator of transcription 6 (STAT6) has also shown significant sensitivity and specificity. However, few recent studies have reported STAT6 expression in other soft tissue neoplasms.

Conclusion: This review will focus on describing the diversity of histological features of SFT, differential diagnoses and discussing the features helpful in distinguishing SFT from its histological mimics.
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http://dx.doi.org/10.1186/s13000-021-01095-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059036PMC
April 2021

Eccrine spiradenoma: a rare adnexal tumour with atypical presentation: A case report.

J Pak Med Assoc 2021 02;71(2(A)):553-555

Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.

First described in 1934, eccrine spiradenoma (ES) is a rare, benign adnexal tumour arising from eccrine sweat glands. It commonly presents as a slow-growing nodule on the upper trunk, and head and neck region, mostly in the age bracket of 15-35 years, with no gender preference. While no established guidelines exist for optimal management of malignant ES, some therapies have been studied. The diagnosis of this entity is extremely important as it can harbour a malignant component with disastrous outcomes which may be missed due to its strong resemblance to benign lesions, such as a papilloma. Here, we present the case of a 35-year-old lady who presented with a papilloma-like growth on the upper medial aspect of the thigh which was diagnosed as eccrine spiradenoma upon excision.
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http://dx.doi.org/10.47391/JPMA.1199DOI Listing
February 2021

Giant Juvenile Fibroadenoma of the breast in a 13-year-old Pakistani girl with excellent cosmetic outcome after subareolar enucleation - A case report.

Int J Surg Case Rep 2021 Feb 28;79:450-454. Epub 2021 Jan 28.

Section of Breast Surgery, Department of Surgery, The Aga Khan University, P.O. Box 3500, Stadium Road, Karachi, 74800, Pakistan. Electronic address:

Introduction: Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5-2% of all fibroadenomas.

Presentation Of Case: In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan.

Discussion: Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases.

Conclusion: The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility.
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http://dx.doi.org/10.1016/j.ijscr.2021.01.094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851354PMC
February 2021

Kaposiform Hemangioendothelioma: clinicopathological characteristics of 8 cases of a rare vascular tumor and review of literature.

Diagn Pathol 2021 Mar 15;16(1):23. Epub 2021 Mar 15.

Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: Kaposiform Hemangioendothelioma (KHE) is a rare vascular tumor of intermediate malignant potential which shows locally aggressive growth but only rarely metastasizes. It is mostly considered to be a tumor of pediatric population but its occurrence in the adults is not uncommon as once considered. Histologically, KHE can mimic other soft tissue neoplasms of different behaviors (e.g. Kaposi Sarcoma, hemangioma) and establishing the correct diagnosis is important for appropriate treatment. Herein, we describe the clinicopathological features of 8 cases of KHE which will be helpful in making their diagnosis.

Methods: We reviewed pathology reports, microscopy glass slides and obtained follow up information about 8 cases of KHE which were diagnosed at our institution from January 2008 till June 2020. Immunohistochemical stain for HHV8 was also performed.

Results: Age ranged from 7 months to 25 years. Seven patients were less than 20 years of age and one patient was 25 years old. Equal gender distribution was observed. Extremities were the most common sites of involvement, followed by head and neck, pancreas and ischiorectal region. 2 cases were resection specimen and all others were incisional biopsies. The largest tumor size was 5.5 cm in one of the resections. The incisional/fragmented tissues were all less than 5 cm in aggregate. Most cases showed predominance of nodular growth and a minor component of spindle cell population along with lymphangiomatosis like vascular channels, with evidence of microthrombi in 2 cases. Few multinucleated giant cells were observed in 2 cases. None of the cases exhibited significant nuclear atypia or mitotic activity. One of the cases arising in dermis showed underlying bone involvement. HHV8 was negative in 7/7 cases.

Conclusions: KHE can also involve adult population and it should always be considered in the differential diagnoses of a vascular lesion. Presence of multinucleated giant cells is a rare finding. Knowledge about histological features and potential mimics is helpful in avoiding misdiagnosis.
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http://dx.doi.org/10.1186/s13000-021-01080-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962213PMC
March 2021

Retiform hemangioendothelioma: a case series and review of the literature.

J Med Case Rep 2021 Feb 17;15(1):69. Epub 2021 Feb 17.

Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: Retiform Hemangioendothelioma (RH) is an extremely rare vascular tumor of intermediate biological behavior, which is prone to local recurrence but rarely shows metastasis to distant sites. It may harbor areas resembling Dabska tumor in some cases and angiosarcoma, which in its well differentiated form may exhibit similar pathological appearance in some areas, making it problematic to rule out a possibility of a malignant diagnosis on a core biopsy. Therefore, complete surgical resection with negative margins is essential for accurate diagnosis and local control.

Results: In our series, two of the three Pakistani cases were in females, with an age range between 18 and 50 years. Our first patient presented with symptoms of cardiac compromise and pulmonary hypertension. Her computed tomography scan showed multiple tumor masses within the mediastinum. The second patient presented with an ulcerated lesion on his scalp, at right temple. The third patient presented with a hard growth on her left 4th toe which was amputated. Histologically, all cases exhibited retiform arborizing vascular spaces lined by bland endothelial cells with hobnail nuclei, characteristic of retiform hemangioendothelioma. Immunohistochemical markers CD31, CD34 and ERG confirmed the vascular nature of the tumor. The first and the second patient are alive and healthy at 4 and 7 months follow up respectively, while the third patient is lost to follow up.

Conclusion: Owing to the rate of local recurrence, RH should always be considered in the differential diagnosis of vascular tumors showing arborizing blood vessels, as it may have an atypical presentation and it should be carefully differentiated from Dabska tumor and an angiosarcoma.
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http://dx.doi.org/10.1186/s13256-021-02671-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887779PMC
February 2021

Methods for Proteogenomics Data Analysis, Challenges, and Scalability Bottlenecks: A Survey.

IEEE Access 2021 25;9:5497-5516. Epub 2020 Dec 25.

School of Computing and Information Sciences, Florida International University, Miami, FL 33199, USA.

Big Data Proteogenomics lies at the intersection of high-throughput Mass Spectrometry (MS) based proteomics and Next Generation Sequencing based genomics. The combined and integrated analysis of these two high-throughput technologies can help discover novel proteins using genomic, and transcriptomic data. Due to the biological significance of integrated analysis, the recent past has seen an influx of proteogenomic tools that perform various tasks, including mapping proteins to the genomic data, searching experimental MS spectra against a six-frame translation genome database, and automating the process of annotating genome sequences. To date, most of such tools have not focused on scalability issues that are inherent in proteogenomic data analysis where the size of the database is much larger than a typical protein database. These state-of-the-art tools can take more than half a month to process a small-scale dataset of one million spectra against a genome of 3 GB. In this article, we provide an up-to-date review of tools that can analyze proteogenomic datasets, providing a critical analysis of the techniques' relative merits and potential pitfalls. We also point out potential bottlenecks and recommendations that can be incorporated in the future design of these workflows to ensure scalability with the increasing size of proteogenomic data. Lastly, we make a case of how high-performance computing (HPC) solutions may be the best bet to ensure the scalability of future big data proteogenomic data analysis.
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http://dx.doi.org/10.1109/ACCESS.2020.3047588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853650PMC
December 2020

Malignant Eccrine Adenoma With Sarcomatous (Heterologous) Components: Report of a Rare Skin Adnexal Neoplasm With Literature Review.

Cureus 2020 Dec 30;12(12):e12390. Epub 2020 Dec 30.

Histopathology, Aga Khan University Hospital, Karachi, PAK.

Malignant eccrine spiradenoma (MES) is an exceedingly rare skin adnexal tumor that arises from pre-existing benign eccrine spiradenoma (BES). MES tumors show a wide spectrum of morphological features, posing a diagnostic challenge to the pathologist. Sarcomatous (heterologous) elements are seen in a few of these tumors, further complicating the morphological picture. We herein describe a case of a 66-year-old male who presented with a recently enlarging, ulcerated, nodular skin lesion over the right leg that had been present for the last 25 years. The patient underwent wide local excision of the tumor. Microscopic examination revealed a neoplastic lesion comprising benign and malignant components. The carcinomatous component showed features of infiltrating adenocarcinoma, not otherwise specified, whereas the sarcomatous component showed predominant osteosarcomatous and focal chondrosarcomatous differentiation. The benign component showed morphological and immunohistochemical features of BES. No adjuvant treatment was administered. The patient was alive and disease-free for 14 months, after which he was lost to follow-up. Careful identification and knowledge related to histological diversity are keys to the correct diagnosis of this rare tumor. MESs are potentially aggressive tumors, and therefore, close long-term follow-up should be maintained.
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http://dx.doi.org/10.7759/cureus.12390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845752PMC
December 2020

Encapsulated papillary carcinoma of breast; a clinicopathological study of 25 cases and literature review with emphasis on high grade variant.

Ann Diagn Pathol 2020 Dec 28;49:151613. Epub 2020 Aug 28.

Histopathology Section, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan. Electronic address:

Encapsulated Papillary Carcinoma (EPC) is a rare breast tumor with excellent prognosis. Treatment and stage of EPC is influenced by invasion and high nuclear grade. Our aim was to study the clinicopathological features of EPC, especially high grade tumors and to compare the features of invasive and non-invasive tumors. We reviewed clinicopathological features of 25 cases of EPC diagnosed at our institution from 2006 till 2020. Patients' age ranged from 21 to 75 years (median 55 years). Tumor size ranged from 1 to 9 cm (median 3.5 cm). Overall, invasion was present in 44% cases. High nuclear grade was observed in 24% cases. Majority of these high grade tumors were below 40 years. All of these tumors were 4 cm or larger in size. Two third of these tumors were invasive. Hormone receptor negativity and lymph node involvement was observed in 1 out of 3 cases, when performed. Clinicopathological and histological features of invasive and non-invasive tumors were compared and only lymph node involvement was found to be significantly more frequent in invasive tumors (p = 0.049). Median follow up duration was 18 months. All patients were alive and disease free except for a single patient who died of cerebrovascular accident. EPC has excellent clinical course. Invasion and high nuclear grade should be carefully searched for as these features determine tumor stage and treatment.
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http://dx.doi.org/10.1016/j.anndiagpath.2020.151613DOI Listing
December 2020

Bilateral Gonadoblastoma With Dysgerminoma in a Phenotypically Normal Female With 46XX Karyotype: Report of a Rare Case and Literature Review.

Cureus 2020 Jul 3;12(7):e8990. Epub 2020 Jul 3.

Histopathology, Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK.

Gonadoblastoma is a rare ovarian neoplasm which belongs to "germ cell-sex cord-stromal tumor" category. This tumor is frequently associated with invasive germ cell malignancy. It commonly arises in dysgenetic gonads of young individuals who are phenotypically females but possess 46XY karyotype. It has been rarely reported in females with normal phenotype and genotype. We herein describe a case of 10-year-old female who presented with abdominal pain, abdominal distention and fever. CT scan of the abdomen and pelvis revealed bilateral ovarian masses, ascites and pelvic and para-aortic lymphadenopathy. Serum lactate dehydrogenase levels were also elevated. She underwent left salpingo-oophorectomy, right ovarian biopsy, omentectomy and para-aortic lymphadenopathy. Microscopically, tumor showed in situ and invasive components. In situ component was arranged in nests and lobules formed by immature sertoli cells forming acini and encircling large polygonal primitive germ cells. Immature sertoli cells were positive for immunohitochemical (IHC) stains cytokeratin AE1/AE3, inhibin and calretinin, while germ cells were positive for SALL4, Oct 3/4, placental alkaline phosphatase (PLAP) and CD117. Invasive component was arranged in sheets of large-sized, polygonal-shaped primitive germ cells which were also positive for SALL4, Oct 3/4, PLAP and CD117 IHC stains. Hence, the diagnosis of "gonadoblastoma with dysgerminoma" was made. The tumor was limited to both ovaries. Cytogenetic analysis of peripheral blood revealed normal female 46XX karyotype. The patient received two cycles of adjuvant chemotherapy and was then lost to follow-up. We conclude that gonadoblastoma, although rare, should be considered as a differential diagnosis in ovarian tumors of young females. Invasive germ cell component should always be carefully searched for as it guides about treatment and predicts prognosis.
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http://dx.doi.org/10.7759/cureus.8990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402429PMC
July 2020

Invasive Breast Carcinoma Arising in a Nipple Adenoma After 15 Years: Report of a Rare Case and Literature Review.

Cureus 2020 Jun 12;12(6):e8586. Epub 2020 Jun 12.

Pathology and Laboratory Medicine/Histopathology, Aga Khan University Hospital, Karachi, PAK.

Nipple adenoma (NA) is a rare benign breast neoplasm that seldom co-exists with breast carcinoma (BC). Majority of these BC are separate from NA, and their origin from NA is an extremely rare event. We herein describe a case of 65-year-old female who had a painless lump for 15 years which increased in size and ulcerated for last six months. Microscopic examination of the wedge biopsy of nipple showed features of NA at superficial aspect and invasive carcinoma from it at the deeper aspect. The patient underwent mastectomy and axillary clearance, which revealed a 4-cm invasive breast carcinoma, no special type with axillary lymph node involvement. The patient received adjuvant chemotherapy, radiotherapy and adjuvant hormonal therapy. The patient is alive and disease-free after 36 months. NA should be carefully evaluated for co-existent BC because it completely changes the treatment plan and prognosis.
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http://dx.doi.org/10.7759/cureus.8586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358932PMC
June 2020

Outcome of Non-Malignant Papillary Lesions of the Breast on Core Biopsy: An Experience from a Tertiary Care Center in Pakistan.

Cureus 2020 May 30;12(5):e8364. Epub 2020 May 30.

Pathology, Aga Khan University Hospital, Karachi, PAK.

Background Papillary lesions of the breast constitute a heterogeneous group ranging from non-malignant papillomas to papillary carcinoma. While surgical excision is recommended for atypical papilloma or papillary DCIS/ carcinoma on core biopsy, controversy persists in the management of benign papillomas which are diagnosed with core needle biopsy (CNB) since there are variable reported rates for tumor upgrade. The purpose of this study was to determine the outcome of papillary lesions of the breast diagnosed at image-guided CNB, after surgical excision or follow-up, and to identify potential predictors of high-risk lesions/malignancy on imaging. Materials and methods We retrospectively identified 52 non-malignant papillary lesions on core biopsy between January 2012 and June 2018. The outcome of surgical excision, as well as clinical and imaging features of these lesions, were assessed. The final histologic upgrade was recorded, and variables were compared between benign and atypical lesions on core biopsy as well as between upgraded and non-upgraded lesions after surgical excision.  Results Thirty-six lesions out of 52 lesions were benign papillomas on core biopsy, while 16 were papillary lesions with ADH/DCIS. All of these lesions except four benign papillomas were excised. Of the 32 benign papillomas excised, 7 were upgraded to papilloma with ADH/DCIS and one to DCIS with the focus of invasion. Among the 16 atypical lesions excised, one was upgraded to papillary DCIS with a final upgrade rate of 17.3%. There was no statistically significant clinical or imaging feature among those that were upgraded on excision from those that were not upgraded.  Conclusion Non-malignant papillary lesions have a significant upgrade rate. There are no reliable clinical or imaging features that can pre-surgically predict upgrade. Therefore, surgical excision of all papillary lesions is recommended for definitive diagnosis.
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http://dx.doi.org/10.7759/cureus.8364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325390PMC
May 2020

Breast Imaging Chameleon: Pseudoangiomatous Stromal Hyperplasia Presenting as Breast Malignancy.

Cureus 2020 May 30;12(5):e8359. Epub 2020 May 30.

Pathology, Aga Khan University Hospital, Karachi, PAK.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal proliferative lesion of the breast, often an incidental finding on breast biopsy specimens and rarely presents as a palpable lump. The case being reported is interesting as a lactating female presented with gross left breast enlargement due to a huge firm mass with skin thickening and palpable left axillary lymph nodes. A provisional diagnosis of left breast malignancy was made and the patient extensively worked up with ultrasound, CT scan, bone scan and core biopsy. The histopathology, however, revealed PASH of the breast. There was no invasive or in situ malignancy. The patient was successfully managed conservatively.
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http://dx.doi.org/10.7759/cureus.8359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325414PMC
May 2020

Dedifferentiated Liposarcoma With Meningothelial-Like Whorls: Five Additional Cases and Review of the Literature.

Int J Surg Pathol 2020 Oct 17;28(7):749-758. Epub 2020 May 17.

Aga Khan University Hospital, Karachi, Pakistan.

. Diagnosis of dedifferentiated liposarcoma (DDL) can sometimes be challenging due to a wide variety of histological features. "Meningothelial-like" whorl is an uncommon histological feature of DDL, which is also observed in neural tumors and follicular dendritic cell sarcoma. This feature is frequently associated with metaplastic bone formation. We conducted this study to describe the clinicopathological features of DDL with meningothelial-like whorls that would aid in establishing accurate diagnosis. . Microscopic glass slides of 5 cases of DDL with meningothelial-like whorls, diagnosed between January 2010 and December 2019, were reviewed. . Paratesticular region was the most common site. Whorls occupied 10% to 75% of tumor area and ranged in size from <0.1 cm to >2 cm. In 1 case, these whorls coalesced to form large areas of dedifferentiation. The cells forming whorls were spindle to epithelioid shaped and lacked significant nuclear pleomorphism and increased mitoses. Metaplastic bone formation was observed in 4 cases and cartilage formation in 3 cases. p16 and α-smooth muscle actin (α-SMA) immunohistochemical stains were positive in 2 cases, when performed. MDM2 gene amplification was observed in all cases by fluorescence in situ hybridization technique. These tumors showed aggressive behavior, similar to that of DDL without meningothelial-like whorls. Two patients died, 1 developed recurrence, 1 presented as recurrent tumor, and 1 developed metastasis. . Meningothelial-like whorls in DDL most likely represent an early stage of dedifferentiation. Presence of well-differentiated liposarcoma areas, metaplastic bone formation, positive expressions for p16 and α-SMA immunohistochemical stains, and MDM2 gene amplification are useful diagnostic clues. These tumors have the potential to behave aggressively.
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http://dx.doi.org/10.1177/1066896920921950DOI Listing
October 2020

Mycosis Fungoides: A Clinicopathological Study of 60 Cases from a Tertiary Care Center.

Indian J Dermatol 2020 Mar-Apr;65(2):123-129

Section of Histopathology, Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: Mycosis fungoides (MF) is the most common primary cutaneous lymphoma. It affects usually the covered areas of the body in elderly males in 6 and 7 decades of life. Atypical dermal lymphoid infiltrate is seen along with epidermotropism. Nuclei of neoplastic cells are convoluted. The neoplastic cells demonstrate positivity for CD3 (Pan T) immunohistochemical stain. Majority show increased CD4 to CD8 ratio. The present study was done to study the clinicopathological features, which might be of help in reaching a correct diagnosis in these cases.

Materials And Methods: A retrospective descriptive study was conducted on 60 reported cases of MF. The retrieved slides were reviewed for clinical and histopathological features and immunohistochemical profile.

Results: The ages ranged from 20-84 years, mean age was 47 years. Majority (75%) of patients were male. Trunk and extremities were the sites most commonly affected. There was significant inverse correlation between epidermal thickness and tumor stage ( = 0.02). Thickened epidermis was seen in patch stage and thickness reduced with progressing stage. The intensity of dermal infiltrate and cell size was also statistically significantly linked to stage progression ( < 0.001 each). In addition, proliferation index also correlated significantly with tumor stage ( = 0.002).

Conclusion: Clinical information and histological features are equally important in the accurate diagnosis of MF. Papillary dermal fibrosis is a useful diagnostic clue. CD4:CD8 ratio is not increased in all cases; it may be decreased or remain unchanged.
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http://dx.doi.org/10.4103/ijd.IJD_602_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059469PMC
March 2020

Androgen Receptor: Evaluation and Correlation with Recurrence and Clinicopathological Parameters in Papillary Urothelial Carcinomas of the Urinary Bladder.

Cureus 2020 Jan 20;12(1):e6715. Epub 2020 Jan 20.

Pathology, Liaquat National Hospital and Medical College, Karachi, PAK.

Papillary urothelial carcinoma (PUC) is the most common malignant tumor of the urinary bladder. Urothelial tumors are notorious for frequent recurrences and follow a chronic relapsing course in most of the patients. In Pakistan, the incidence of PUC is showing a rising trend. Various immunohistochemical (IHC) markers including androgens have been studied as prognostic and predictive markers in PUC with conflicting results. Androgen is a steroid-based sex hormone and plays an important role in different body organs such as urinary bladder, prostate, muscles, and brain. We aimed to investigate the role of the IHC expression of androgen receptor (AR) as a predictor of recurrence in papillary urothelial carcinoma patients. Eighty-four patients were included in the study. Tissues from the biopsy specimens of these cases were stained with antibodies against AR; 17% of the cases demonstrated a positive AR IHC expression. The expression was slightly more common in low-grade carcinoma. The AR expression was not significantly associated with clinicopathological features. Recurrence was observed in 49% of the cases, and it was significantly more common in AR-negative cases (p-value: 0.025). Eighteen out of 19 patients who died of disease were AR- negative, but no statistical significance was observed. We conclude that the IHC expression of AR can be used as a predictive marker for PUC as it correlates with the recurrence rate.
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http://dx.doi.org/10.7759/cureus.6715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7032596PMC
January 2020

Utility of Ultrasound and Mammography in Detection of Negative Axillary Nodal Metastasis in Breast Cancer.

Cureus 2020 Jan 17;12(1):e6691. Epub 2020 Jan 17.

Pathology, Aga Khan University Hospital, Karachi, PAK.

Objective The status of axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. A precise noninvasive evaluation of axillary lymph node status preoperatively, although challenging, is vital for optimization of the treatment plan for patients. The objective of our study was to assess the utility of ultrasound and mammography in detecting the absence of axillary lymph nodal metastasis in patients of breast cancer, taking histopathology as gold standard. Methods A cross-sectional study was conducted in the Department of Radiology, Aga Khan University Hospital, Karachi. All female patients between 20 and 95 years of age with a known diagnosis of breast cancer with mammographic and ultrasound imaging done at our institute were included. Patients with abnormal lymph nodes on mammography or on ultrasound, patients already operated for breast cancer, patients who already underwent axillary lymph node dissection and those whose histopathology reports were not available or who did not undergo surgery were excluded. Results A total of 262 women with breast carcinoma who had both ultrasound and mammography done and also had surgery performed at our institution were included. At final surgical pathology, a total of 45 of the 262 patients (17.2%) with breast carcinoma had one or more positive lymph nodes. Out of the total 262 patients, 217 patients were found to be true negatives as they had absent axillary nodal metastasis on imaging as well as on histopathology. In all, 45 out of 262 patients were found to be false negatives as they had absent axillary nodal metastasis on imaging; however, they were found to be positive for metastasis on histopathology. The negative predictive value was 82.8%. Patient age was considered as a factor that may influence the outcome of results; the patients were stratified into age ranges seven groups with the age range of 10 years, ranging from 26 to 95 years. Chi-square test showed a -value of 0.148, which showed no significant difference in the effect of age on diagnosing the absence of metastasis by ultrasound and mammography. Conclusion Our study shows that ultrasound and mammography even when used in combination cannot safely exclude axillary metastasis and thus cannot eliminate the need for sentinel node biopsy.
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http://dx.doi.org/10.7759/cureus.6691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7026874PMC
January 2020

Spectrum of histological features of Denosumab treated Giant Cell Tumor of Bone; potential pitfalls and diagnostic challenges for pathologists.

Ann Diagn Pathol 2020 Apr 14;45:151479. Epub 2020 Feb 14.

Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan. Electronic address:

Objectives: Denosumab is Receptor Activator of Nuclear factor Kappa-B Ligand (RANKL) inhibitor which is being used in the treatment of locally advanced, recurrent and metastatic Giant Cell Tumor of Bone (GCTB). It causes reduction in monocyte recruitment and Osteoclast-Like Giant Cell (OLGC) formation which limits bone destruction. After Denosumab treatment, GCTB exhibit diverse morphological features which can pose diagnostic challenge. Our aim was to study the spectrum of histologic features seen in Denosumab treated GCTB which could be helpful in establishing correct diagnosis.

Methods: We retrieved and reviewed H&E stained microscopic glass slides of 38 GCTB cases who received Denosumab as neoadjuvant treatment. These cases were treated at different institutes and diagnosed at our institute between January 2017 and October 2019. Morphologic features such as presence of residual OLGC, appearances of mononuclear stromal and bony components were assessed along with other non-specific features.

Results: Patients' median age was 29 years. Male to female ratio was 1.53:1. Femur was the most commonly involved bone. Microscopically, peripheral shell of reactive bone was observed in all cases. In 20 (52.6%) cases, there was complete elimination of OLGC. Mononuclear stromal cells were predominantly bland spindle shaped and arranged in fascicular and storiform patterns. Focal atypia was noted in 3 cases. Bony component manifested as trabeculae of woven bone with osteoblastic rimming and immature trabeculae of unmineralized osteoid with haphazardly present osteoblasts. Spectrum of stromal changes included cystic spaces, foamy macrophages, inflammatory infiltrate, hemangiopericytoma-like (HPC-like) vessels, hyalinization, edematous areas and hemosiderin pigment. The tumors showed areas which resembled other bony and soft tissue lesions such non-ossifying fibroma, fibrous dysplasia, osteoblastoma, sclerosing epithelioid fibrosarcoma and osteosarcoma.

Conclusion: Denosumab treatment induces a variety of changes in GCTB. Clinical history and knowledge of these features are necessary for excluding differential diagnoses and avoiding misdiagnosis.
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http://dx.doi.org/10.1016/j.anndiagpath.2020.151479DOI Listing
April 2020

Mantle cell lymphoma presenting as synchronous bilateral breast lumps and arm mass.

Breast J 2020 07 18;26(7):1395-1397. Epub 2020 Feb 18.

Department of Pathology, Aga Khan University Hospital, Karachi, Pakistan.

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http://dx.doi.org/10.1111/tbj.13789DOI Listing
July 2020

Frequency of Transducer-like Enhancer of Split 1 Immunohistochemical Expression in Synovial Sarcoma: An Institution-based Cross-sectional Study.

Cureus 2019 Dec 11;11(12):e6357. Epub 2019 Dec 11.

Pathology and Laboratory Medicine, Aga Khan University Hospital , Karachi, PAK.

Background Soft-tissue sarcomas comprise a diverse group of sarcomas with characteristic histologic features. However, histology alone is not adequate for a definitive diagnosis for many tumors. In such cases, immunohistochemistry (IHC) plays a key role in determining the line of differentiation and exact characterization. Transducer-like enhancer of split 1 (TLE1) has been recently described as a novel marker for synovial sarcoma (SS). Its high sensitivity and specificity make it a potential marker that distinguishes SS from histologic mimics such as malignant peripheral nerve sheath tumor (MPNST), Ewing's sarcoma (ES), and fibrosarcomatous dermatofibrosarcoma protuberans (FS-DFSP). The objective of our study was to assess the frequency of TLE1 immunohistochemical expression on SS cases of various subtypes. Methods This cross-sectional study was conducted at the Department of Histopathology, Aga Khan University, Karachi, Pakistan from February 3, 2018 to February 10, 2019. Tissue samples of 89 SS cases were selected for this study. Tumor sections were stained with hematoxylin and eosin (H&E), cytokeratin AEI/AE3 (CKAE1/AE3), epithelial membrane antigen (EMA), and TLE1 immunohistochemical stain. TLE1 expression was assessed based on the Remmele scoring system. Results Tissue samples of 89 SS cases were processed for the study. Mean (±) standard deviation (SD) of age was 25 (±7.36) years. Male:female ratio was 1.1:1. Of the 89 SS cases, 42 (47.2%) were monophasic, six (6.7%) were biphasic, and 41 (46.1%) were poorly differentiated. All the 89 cases showed positivity for TLE1 immunostain: 86 (96.6%) cases showed strong positivity, one (1.1%) case showed moderate expression, and two (2.2%) showed weak positivity. Conclusion This study shows that TLE1 is a highly sensitive immunostain for SS irrespective of the histologic type. However, it may show weak-to-moderate staining in poorly differentiated types. No statistically significant association was seen with respect to age group, gender, or type of SS.
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http://dx.doi.org/10.7759/cureus.6357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952034PMC
December 2019

Solid papillary carcinoma of breast; a detailed clinicopathological study of 65 cases of an uncommon breast neoplasm with literature review.

Breast J 2020 02 18;26(2):211-215. Epub 2019 Sep 18.

Histopathology Section, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Solid papillary carcinoma (SPC) is an uncommon breast tumor whose prognosis depends on invasive component. We studied clinicopathological features of SPC by reviewing 65 cases. Invasive component was seen in 75.4% cases. Almost all tumors with grade III nuclei had invasive component. Mean patients' age of invasive tumors was significantly higher than that of non-invasive tumors (P = .036). All patients were alive and disease free except for a single patient who developed distant metastasis and died of disease. SPC have excellent clinical course. Careful search for invasive component is mandatory, especially in tumors with older patient's age and higher nuclear grade.
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http://dx.doi.org/10.1111/tbj.13521DOI Listing
February 2020

Assessment of Factors Affecting Quality of Life in Oral Squamous Cell Carcinoma Patients Using University of Washington Quality of Life Questionnaire.

Cureus 2019 Jan 16;11(1):e3904. Epub 2019 Jan 16.

Plastic Surgery, Patel Hospital, Karachi, PAK.

Introduction Post-treatment Quality of Life (QOL) is considered an important outcome in cancer patients. A number of questionnaire tools have been designed for its assessment. University of Washington Quality of Life (UW QOL) questionnaire version four is a reliable tool for assessment of post-treatment QOL in oral squamous cell carcinoma (OSCC) patients. Our aim was to identify the post-treatment problems faced by OSCC patients and to assess the impact of clinical factors affecting post-treatment QOL by using UW QOL (version four) questionnaire. Methods The study was conducted on 59 patients with OSCC who were treated with curative intent at Patel Hospital, Karachi from August 2015 to September 2015. Patients were asked to fill the UW QOL questionnaire (version four) on their follow-up visit. Results Overall mean composite QOL score was 66.59 ± 16.98. Chewing and saliva (dryness of mouth) had the lowest scores (38.98 ± 37.2 and 56.78 ± 41.4, respectively) among all domains while pain and anxiety had the highest scores (80.93 ± 20.4 and 79.66 ± 29.8, respectively). Patients having tumors of the tongue, late stage (III and IV) tumors, and restricted mouth opening had significantly lower mean composite QOL scores. Patients with tongue tumors revealed significantly lower scores for pain, swallowing, mood, and anxiety. Patients with late-stage tumors showed significantly lower scores for chewing, swallowing, taste, saliva, appearance, anxiety, and recreation. Patients with restricted mouth opening had significantly lower scores for pain, speech, appearance, recreation, and anxiety domains. Conclusion Different clinical features have different impacts on QOL in terms of problems faced by the patients. Features having a significant effect should be identified, and measures focused on most relevant problems should be employed in order to improve the post-treatment QOL.
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http://dx.doi.org/10.7759/cureus.3904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424547PMC
January 2019

Serous cystadenoma of pancreas: A clinicopathologic experience of 23 cases from a major tertiary care center.

Rare Tumors 2018 5;10:2036361318809183. Epub 2018 Nov 5.

Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: Serous cystadenomas of pancreas are rare benign epithelial neoplasms, which predominantly occur in the pancreatic body and tail of elderly females. Majority of these tumors have microcystic appearance. Macrocystic and solid variants have also been described. A number of more aggressive cystic pancreatic lesions are included in the differential diagnosis. Distinction from such lesions is important for optimal management.

Objective: Our aim was to study the clinical and histological features of serous cystadenomas which would be helpful in making their correct diagnosis and understanding their behavior.

Methods: We reviewed 23 cases of serous cystadenomas diagnosed in our institution between January 2001 and June 2018.

Results: Mean age at presentation was 53.43 years. Female to male ratio was 4.75:1. Over half (56.5%) of the cases were diagnosed incidentally. Abdominal pain was the most common symptom. Body and tail (either alone or in combination) were the most common locations. Tumor size ranged from 2 to 16 cm. Central scar was seen in 43.4% cases. Two cases were unilocular (macrocystic). Microscopically, all cases showed simple cuboidal to flattened epithelium with round, uniform nuclei, and glycogen-rich clear cytoplasm. Focal micropapillae formation was seen in eight cases (34.7%). Surgical resection was performed in 82.6% cases. Recurrence occurred in only one single case.

Conclusion: Pancreatic serous cystadenomas are benign neoplasms with excellent prognosis. The tumors showed typical morphological features in all cases. Surgical resection was performed in the majority of cases in our study owing to lack of optimal and complete radiological workup pre-operatively and the concern for not missing and adequately treating pancreatic mucinous cystic neoplasms.
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http://dx.doi.org/10.1177/2036361318809183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236590PMC
November 2018

Clinicopathological prognostic factors of oral squamous cell carcinoma: An experience of a tertiary care hospital.

J Pak Med Assoc 2018 Jul;68(7):1115-1119

Department of ENT, Patel Hospital.

Locoregional recurrence accounts for majority of the treatment failures in oral cancer patients. Current study aimed to determine the predictors of recurrence and survival in patients with biopsy proven Squamous Cell Carcinoma (SCC) of the oral cavity. This study included 88 patients of squamous cell carcinoma treated at our institution from 2007 till 2013. Primary intervention was surgery in all patients with radiation and chemotherapy in selected patients. Primary end point was locoregional recurrence, distant metastasis and death. Out of 88 patients, 23 (26.1%) patients developed locoregional recurrence and 6 (6.8%) patients developed distant metastasis. Overall survival rate was 77.3%. Follow up ranged from 1 month to 63 months with mean of 17.8±16.2. On multivariate analysis, lymph node involvement and loco-regional recurrence were independent parameters related to decrease overall survival. Lymphovascular invasion, perineural spread, TNM stage and lymph node involvement had significant impact on recurrence.
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July 2018

Role of ADC values and ratios of MRI scan in differentiating typical from atypical/anaplastic meningiomas.

J Pak Med Assoc 2018 Sep;68(9):1403-1406

Department of Internal Medicine, Aga Khan University Hospital, Karachi.

Atypical/anaplastic meningiomas are prone to aggressive behaviour which affects treatment planning and prognostication. Our aim was to assess the role of Apparent Diffusion Coefficient (ADC) values of MRI brain in differentiating typical from atypical/anaplastic meningioma. We reviewed 84 typical and 37 atypical/anaplastic meningiomas and compared mean ADC values and ADC ratios of their preoperative MRI brain. At 3 Tesla, mean ADC value for typical meningioma was1.03±0.10x10-3 and 0.63±0.05x10-3 for atypical/anaplastic meningioma. At 1.5 Tesla, mean ADC value for typical meningioma was 1.05±0.11x10-3 and atypical/ anaplastic meningioma was 0.70 ± 0.04x10-3. The mean ADC ratios were 1.08 ± 0.17 and 0.85 ± 0.15 for typical and atypical/anaplastic meningomas respectively. Mean ADC ratios and the mean ADC values of typical and atypical/anaplastic meningiomas were significantly different (p< 0.001). ADC values and ADC ratios have important role in differentiating typical from atypical/anaplastic meningioma and it must be part of the routine preoperative MRI reporting.
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September 2018

Meningeal solitary fibrous tumor/hemangiopericytoma: Emphasizing on STAT 6 immunohistochemistry with a review of literature.

Neurol India 2018 Sep-Oct;66(5):1419-1426

Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, Pakistan.

Background: The 2016 central nervous system (CNS) World Health Organisation (WHO) Update has merged the entities of meningeal solitary fibrous tumor (SFT) and hemangiopericytoma (HPC) into a single entity based on the presence of the nerve growth factor 1A (NGFI-A) binding protein 2 (NAB2)- signal transducer and activator of transcription 6 (STAT6) gene fusion in these tumors. Immunohistochemical (IHC) staining with STAT6 results in a strong nuclear positivity confirming the diagnosis. Meningeal SFT/HPCs are currently histologically graded according to a three-tiered system. Grade I (SFT phenotype) is benign, whereas grades II and III (HPC phenotype) are malignant and require radiotherapy in addition to gross total resection.

Objectives: The objectives were to review the cases diagnosed as meningeal SFT or HPC between 2010 and 2017 and classify them into SFT (grade I) or HPC (grades II and III) phenotypes; to confirm the diagnosis by performing STAT6 immunohistochemistry; and to observe and record the histological features in detail and correlate the tumor grades with their behavior. The published literature on the subject was also reviewed.

Materials And Methods: A total of 21 cases diagnosed between 2010 and 2017 as meningeal SFT or HPC were included in the study. All cases were reviewed by the authors and were categorized and graded according to histologic phenotype and mitotic count. STAT6 immunohistochemistry was performed in all the cases. The epidemiological data and histologic findings in each case were recorded in detail. The follow-up of patients was obtained.

Results: Fifteen patients were males and six were females. The mean age was 43.5 years. The mean tumor size was 6.8 cm. The tumor specimens in 20 out of 21 cases corresponded to the HPC phenotype, of which 6 were in grade II while 14 were in grade III. Thus, over 95% cases had malignant lesions. The tumor in all the 21 cases recruited for the study showed immunohistochemical positivity for SAT6, while CD34 was positive in all the 18 tumor in which it was performed. The follow-up was available in 14 of the patients. Recurrence occurred in six patients who had either a grade II or a grade III tumor and three patients died (including one patient with a grade III tumor. This patient died a month after initial resection although there was no evidence of recurrence). Radiotherapy was given to only 4 out of 14 patients in whom follow-up was available.

Conclusion: These rare tumors need to be accurately diagnosed and optimally treated (gross total resection and radiotherapy) to improve the prognosis.
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http://dx.doi.org/10.4103/0028-3886.241365DOI Listing
September 2019

Glioblastoma Multiforme Involving Conus Medullaris in a Child.

Cureus 2018 Jun 22;10(6):e2863. Epub 2018 Jun 22.

Oncology, Aga Khan University, Karachi, PAK.

Primary spinal cord glioblastoma multiforme involving the conus medullaris is an uncommon entity with poor outcomes. An aggressive multimodality treatment approach has been used, but prognosis remains same. There are no guidelines for the treatment of patients with spinal glioblastoma multiforme (GBM). We highlight the case of a child diagnosed with conal GBM. He was treated with definitive surgery followed by adjuvant concurrent chemoradiation. After completion of treatment, he showed a temporary symptomatic improvement, but later on his condition deteriorated. We elaborate the stepwise treatment approach employed in this patient.
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http://dx.doi.org/10.7759/cureus.2863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6107034PMC
June 2018

Low grade Mullerian adenosarcoma of pouch of Douglas recurring as bilateral ovarian high grade Mullerian adenosarcoma with rhabdomyosarcomatous overgrowth after 11 years.

J Pak Med Assoc 2018 Aug;68(8):1263-1266

Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi.

Mullerian adenosarcoma (MA) of ovary with sarcomatous (rhabdomyoblastic) overgrowth is an extremely rare malignant type of female genital tract neoplasm. These tumours are highly aggressive and presence of heterologous elements is associated with worse prognosis. A 44 year old female presented with lower abdominal pain and distension. She had history of removal of tumour from pouch of Douglas in 2006 for which she did not receive any additional treatment nor did she keep continuous follow up. Current preoperative radiological examination revealed bilateral ovarian masses. She underwent abdominal hysterectomy with bilateral oophorectomy. Microscopic examination revealed biphasic tumours exhibiting sarcomatous overgrowth with rhabdomyoblastic differentiation. Review of the previous biopsy revealed low grade Mullerian adenosarcoma without sarcomatous overgrowth. Hence the current tumour was considered recurrent. This report highlights the aggressive nature of MA even with low grade morphological features and emphasizes the importance of continuous follow up and additional treatment.
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August 2018

Torsion of Ovarian Dysgerminoma in a Child: Role of Computed Tomography.

Cureus 2018 Apr 23;10(4):e2522. Epub 2018 Apr 23.

Department of Pathology & Laboratory Medicine, The Aga Khan University, Karachi, PAK.

Dysgerminomas are malignant germ cell tumors of the ovary that most commonly occur in the adolescent population. Ovarian dysgerminoma presenting with complications like torsion is a rare entity in the pediatric age group. Cross-sectional imaging plays a crucial role in diagnosis, tumor staging before surgical resection, and for planning adjuvant chemotherapy. We report a case of a nine-year-old female who presented to the emergency room (ER) with abdominal distention and abdominal pain. Computed tomography scan revealed a large right-sided pelvic mass with areas of low attenuation, speckled calcification, peritumoral free fluid, and a twisted vascular pedicle that was likely originating from the left adnexa. The right ovary was normal in appearance. Suspicion of a left-sided ovarian tumor with torsion was raised, which was later confirmed on surgery and histopathology of the resected specimen.
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http://dx.doi.org/10.7759/cureus.2522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6016000PMC
April 2018

Hepatic, Periportal, Retroperitoneal, and Mesenteric Neurofibromatosis in von Recklinghausen's Disease.

Cureus 2018 Feb 28;10(2):e2248. Epub 2018 Feb 28.

Department of Pathology & Laboratory Medicine, The Aga Khan University, Karachi.

We present a rare case of histologically proven neurofibromatosis of the liver, hepatic hilum, retroperitoneum, and mesentery. An adult male who had been diagnosed with neurofibromatosis (NF) type 1 underwent a computed tomography (CT) scan for abdominal pain and vomiting. The CT scan showed a large low-attenuating lesion in the region of porta hepatis which was infiltrating along portal tracts into the liver, encasing the major vessels, and extending into the retroperitoneum and mesentery. Based on the radiological findings, a differential diagnosis of plexiform neurofibroma was given, although sarcomatous transformation could not have been entirely excluded from imaging alone. The tumor was subsequently biopsied, and the histopathological analysis confirmed the diagnosis of neurofibroma. This case highlights the importance and diagnostic dilemmas in the presence of this tumor at atypical locations in this disease spectrum.
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http://dx.doi.org/10.7759/cureus.2248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5957520PMC
February 2018