Turkish Journal of Pathology - 2013; 29(1)

Activity-Based Costing for Pathology Examinations and Comparison with the Current Pricing System in Turkey

Ferda AK ERG�N, �smail A�IRBA�, I��nsu KUZU — 2013-01-01

Objective: To demonstrate the real cost data of the pathology examinations by using the activity-based costing method and to contribute to the financial planning of the departments, health managers and also the social security institution. Material and Method: Forty-four examinations selected from the Healthcare Implementation Notification system list and performed at the Ankara University Faculty of Medicine Pathology Department during September 2010 were studied. The analysis and the real cost calculations were done according to the duration of the procedures. Calculated costs were compared with the Healthcare Implementation Notification system and Medicare price lists. Results: The costs of the pathology tests listed within the same pricing levels in the Healthcare Implementation Notification system list showed great differences. The minimum and maximum costs in level 1, 2, 3, and 4 were 15,98-80,15 TL, 15,95-258,59 TL, 42,38- 236,87 TL, and 124,42-406,76 TL, respectively. Medicare price levels were more consistent with the real costs of the examinations compared to the Healthcare Implementation Notification system price list. Conclusion: The prices of the pathology examination listed at different levels in the Healthcare Implementation Notification system lists do not cover the real costs of the work done. The principal parameters of Activity-Based Costing system are more suitable for making the most realistic cost categorization. Although the prices could differ between countries, the Medicare system categories are more realistic than the Healthcare Implementation Notification system. The Healthcare Implementation Notification system list needs to be revised in order to reflect the real costs of the pathology examinations.

Hemophagocytic Syndrome in Patients with Unexplained Cytopenia: Report of 15 Cases

Heidarali ESMAILI, Omid RAHMANI, Rohollah F FOULADI — 2013-01-01

Objective: To investigate the frequency of hemophagocytic syndrome in a series of patients with otherwise unexplained cytopenia. Material and Method: In this cross-sectional, single-centre study, bone marrow specimens (n=288) were obtained from the patients with unexplained cytopenia. The diagnosis of hemophagocytic syndrome was made according to universally accepted criteria. Characteristics of the patients, as well as the clinical and laboratory findings were reported. Results: Fifteen cases (5.2%) fulfilled the hemophagocytic syndrome criteria, including 8 males (53.3%) and 7 females (46.7%) with a mean age of 39.7�20.7 (range: 14-72) years at the time of diagnosis. The main clinical and laboratory findings were cytopenia (100%), fever (73.3%), hyperferritinemia (66.7%), elevated erythrocyte sedimentation rate (60%), hypertriglyceridemia (60%), organomegaly (53.3%), elevated liver enzymes (53.3%), lymphadenopathy (26.7%), neurological symptoms (20%), and skin rash (13.3%). Two patients (13.3%) died before a diagnosis was made. Conclusion: Our findings indicate that the hemophagocytic syndrome is not a rare pathologic condition in patients with otherwise unexplained cytopenia. Without treatment, the mortality rate may be high.

Gastric Histopathological Findings and Ghrelin Expression in Morbid Obesity

Mehmet G�NDO�AN, Ne�e �ALLI DEM�RKAN, Koray TEK�N, H�lya AYBEK — 2013-01-01

Objective: The role of Ghrelin, also known as the appetite hormone, is not fully explained in the development of morbid obesity. Plasma Ghrelin level is low in obese and high in slim subjects. Ghrelin-expressing cells were investigated histopathologically in the stomach of morbid obese patients in this study. Tissue Ghrelin expression was also compared with various parameters such as the distribution of endocrine cells, age, gender, body mass index, preoperative plasma Ghrelin level and presence of accompanying diseases. Material and Method: The study included 33 morbidly obese patients, and 8 non-obese control patients. Plasma Ghrelin levels were measured preoperatively. Sleeve gastrectomy resection materials of 33 cases were evaluated with histopathological and immunohistochemical (Ghrelin and Chromogranin-A) techniques. The results were statistically evaluated by nonparametric tests. Results: Histopathological findings observed in sleeve gastrectomy resection materials were interstitial lymphocytic infiltration (63.6%), hyperplasia of lymphoid follicles in the lamina propria (60.7%) and microvesiculation / dilatation of parietal cells (57.6%). The number of Ghrelin immunopositive cells in the gastric mucosa in females was significantly higher compared to males (p=0,007). Additionally, the number of Ghrelin immunopositive cells was significantly higher at the fundus-proximal corpus compared to the distal corpus of the stomach (p=0.0001). No significant correlation was found between Ghrelin-chromogranin immunopositive endocrine cell distribution and preoperative plasma Ghrelin levels and endocrine cell hyperplasia. Conclusion: Our study confirms that Ghrelin producing cells are most dense in the proximal stomach. Increased number of Ghrelin expressing cells in the gastric mucosa in females compared to males suggests that gender may also be a factor in determining the method for treatment of morbid obesity.

The Prognostic Value of Tumor-Stroma Proportion in Laryngeal Squamous Cell Carcinoma

2013-01-01

Objective: Tumor-stroma proportion of tumor has been presented as a prognostic factor in some types of adenocarcinomas, but there is no information about squamous cell carcinomas and laryngeal carcinomas. Material and Method: Five digital images of the tumor sections were obtained from 85 laryngeal carcinomas. Proportion of epithelial tumor component and stroma were measured by a software tool, allowing the pathologists to mark 205.6 μm2 blocks on areas as carcinomatous/stromal, by clicking at the image. Totally, 3.451 mm2 tumor areas have been marked to 16.785 small square blocks for each case. Results: Median follow up was 48 months (range 3-194). The mean tumor-stroma proportion was 48.63+18.18. There was no difference for tumor-stroma proportion when tumor location, grade, stage and perinodal invasion were considered. Although the following results were statistically insignificant, the mean tumor-stroma proportion was the lowest (37.46�12.49) for subglottic carcinomas, and it was 52.41�37.47, 50.86+19.84 and 44.56�16.91 for supraglottic, transglottic and glottic cases. The tumor-stroma proportion was lowest in cases with perinodal invasion and the highest in cases without lymph node metastasis (44.72�20.23, 47.77�17.37, 50.05�17.34). Tumor-stroma proportion was higher in the basaloid subtype compared with the classical squamous cell carcinoma (53.76�14.70 and 48.63�18.38 respectively). The overall and disease-free survival analysis did not reveal significance for tumor-stroma proportion (p=0.08, p=0.38). Only pathological stage was an independent factor for overall survival (p=0.008). Conclusion: This is the first series investigating tumor-stroma proportion as a prognostic marker in laryngeal carcinomas proposing a new method, but the findings do not support tumor-stroma proportion as a prognostic marker.

Immunohistochemical Expression of p16 in Pleomorphic Salivary Adenoma

Bassel TARAKJI, Kusai BAROUDI, Shorouk DARWISH, Salah SAKKA, Salah HANOUNEH — 2013-01-01

Objective: This study aimed to characterize alteration in the immunohistochemical expression of p16 in normal tissue of the salivary gland surrounding pleomorphic adenoma, and the tumor cells of pleomorphic adenomas. Material and Method: A selected series of 120 cases of pleomorphic adenomas were examined. Results: The results showed that p16 expression in non tumor duct cells was strong positive nuclear staining in 98 (81.6%) cases out of 120, while there were 20 (16.6%) with moderate staining, and 2 (1.6%) with weak staining in the components of normal tissue of the salivary gland surrounding pleomorphic adenoma. p16 expression in pleomorphic adenomas showed 71 (59.1%) cases with moderate nuclear staining in the duct cells, 45 (37.5%) cases with nuclear weak staining, and 4 (3.3%) cases with negative staining. p16 nuclear staining in myxochondroid tissue was identified in 4 (3.3%) cases with strong staining, 65 (54.1%) cases had moderate staining, and 51 (42.5%) cases had weak staining. Conclusion: This study suggests alteration of p16 expression in pleomorphic adenomas. P16 might have a role in the development of pleomorphic adenoma.

Histopathologic Analysis of Female Genital Tuberculosis: A Fifteen-Year Retrospective Study of 110 Cases in Eastern India

Santosh Kumar Mondal — 2013-01-01

Objective: Tuberculosis remains a global health problem and is an important cause of morbidity and mortality. Female genital tuberculosis is rare in the western world, but relevant in developing countries like India. The aim of this study was to determine histologic findings of different parts of the female genital tract affected by tuberculosis and to correlate it with other features. Material and Method: A total number of 110 cases of female genital tuberculosis from 92 patients were included over a period of 15 years. The age range of the patients was 17 to 45 years with a mean of 26.3. The diagnostic procedures used were curettage biopsy, hysterectomy, histologic examination, culture, Mycobacterium Tuberculosispolymerase chain reaction, laparoscopy, hysterosalpingography and ultrasonography. Results: Patients with female genital tuberculosis presented with infertility (65-70%), pelvic/ abdominal pain (50-55%) and menstrual disturbances (20-25%). Female genital tuberculosis involved the vulva (2), vagina (1), cervix (5), endometrium (66), fallopian tube (24) and ovaries (12). Out of 66 endometrial tuberculosis cases, proliferative, secretory endometrium and atrophic endometrium were seen in 53, 9, and 4 cases, respectively. HIV co-infection was found only in 5 cases and acid-fast bacilli in tissue sections were detected in 7 cases. Conclusion: Female genital tuberculosis is not uncommon in developing countries and is an important cause of infertility. Though the fallopian tube was the most common site in many studies, the endometrium was the commonest site in this study.

Distribution of Uterin Cervical Lesions and Relation Between Age and Parity Rates in the Mardin Province

Gonca �ZG�N, G�lay AYDO�DU — 2013-01-01

Objective: The aim of this study is to evaluate the incidence and distribution of cervical lesions and compare characteristics such as parity and age of the women in Mardin province. Material and Method: Pap smears were drawn from the women screened at Mardin Gynecology and Pediatric Diseases Hospital from 2008 to 2011. All cervicovaginal smears were conventional Pap smear samples evaluated according to the 2001 Bethesda system. Results: There were 3.332 patients in total, whose smears showed no lesions in 3.125 patients. The mean age and number of parities of those patients were 37.34�11.25 and 4.78�3.28. There were 207 smears showing any lesions in cervix; ASC-US, ASC-H, LSIL, HSIL, AGC, squamous cell carcinoma and endocervical adenocarcinoma in 151 (72.94%); 16 (7.72%); 20 (9.66%); 8 (3.86%); 10 (4.83%); 1 (0.48%) and 1 (0.48%) patient, respectively. The mean age and the parities of the patients were 37.63�10.77 years and 4,74�2,92. Although there was no difference between the control and lesion groups, the parity and the age of patients who had ≥4 births in both the control and lesion groups were significantly higher than the patients with parities <4 births (p=0.000). There was no difference within the cervical lesion group comparing the ASC-US group with the total of the other lesions. Conclusion: High parity was one of the risk factor for having a lesion in uterine cervix in this population. This study represents an initial attempt to reflect the prevalence and the distribution of cervical lesions and their relation with the parity rates in the eastern regions in Turkey.

A Review on the Impact of IUD in Cervical Cytology: Mardin Region Data

I��k �kbal BARI�, Ay�e Nur KELE� — 2013-01-01

Objective: The aim of the study was to provide an overview to infectious and reactive cytological effects of intrauterine devices, which are one of the most widely used methods of contraception, with the results we obtained in the Mardin region. Material and Method: We evaluated together the pap smears of the 300 intrauterine device (+) and 300 intrauterine device (-) patients sent to the pathology department in the period of 2010-2011. Genital infection rates and frequency of reactive-dysplastic cellular changes were statistically compared between the groups together with the literature data. Results: In the intrauterine device (+) group, 2 (+) and more severe inflammation was observed in 66.3% of cases. Bacterial vaginosis (26%), candida (12%) and trichomonas vaginalis (8%) were recorded as the most common infectious agents, followed by actinomyces (4%). Between the groups of intrauterine device (+) and (-), no significant difference was observed in terms of the incidence of squamous cell abnormalities, except ASC-US (p=0.02). In the intrauterine device (+) group, the presence of atypical glandular cells and reactive findings was significantly higher than the control group. After the removal of the intrauterine device, 61 cases that had control smears showed regression, with a rate of %75.4 (n=46). Conclusion: The local irritative and inflammatory effect of intrauterine devices basically causes reactive and regenerative changes mostly in glandular cells. Intrauterine devices disrupt the genital flora and significantly increase the frequency of genital infection by creating a foreign body reaction.

Congenital Mesoblastic Nephroma: A Rare Pediatric Neoplasm

Varuna MALLYA, Rashmi ARORA , Kusum GUPTA, Uma SHARMA — 2013-01-01

Congenital mesoblastic nephroma is a stromal neoplasm of infancy. It has been referred to as mesenchymal, cystic or leiomyomatous hamartoma. These tumors are centered around the hilus of the kidney. Mesoblastic nephromas need to be distinguished from other pediatric renal neoplasms as these lesions are treated by complete surgical excision without chemotherapy unless gross residual tumor remains. Here, we describe the gross and microscopic features of mesoblastic nephroma in a twenty-day old infant.

Tubercular Mastitis - A Great Masquerader

Sonia GON, Aditi BHATTACHARYYA, Bipasa MAJUMDAR, Soumya KUNDU — 2013-01-01

Tubercular mastitis is a rare clinical entity as mammary gland tissue, like spleen and skeletal muscle, offers resistance to the survival and multiplication of the tubercle bacillus. Tuberculosis of the breast can mimic carcinoma, whereas in young patients it can be mistaken for a pyogenic breast abscess, thus labeled a “great masquerader” in recognition of its multifaceted presentation. Breast tuberculosis commonly affects women in the reproductive age group, between 21 and 30 years, and is rare in prepubescent females and elderly women. Fine needle aspiration cytology is very useful and it is a promising technique in expert hands. In tuberculosis-endemic countries, the finding of granuloma on fine needle aspiration cytology warrants empirical treatment for tuberculosis even in the absence of positive acid-fast bacilli and without culture results. We hereby report a case of tubercular mastitis in a post-menopausal seronegative female diagnosed on fine needle aspiration cytology with a positive acid-fast bacilli and a review of the recent literature.

Coexistence of Multiple Gastrointestinal Stromal Tumors and Signet Ring Cell Carcinoma of Stomach in a Patient with Neurofibromatosis Type-1: Case Report

2013-01-01

Gastrointestinal stromal tumors are mesenchymal neoplasias which are derived from Cajal's interstitial cells. The most common site of involvement is the stomach. It may be multiple in patients with Neurofibromatosis Type-1, while the small intestine is the most common location. In this case report, we aimed to present a Neurofibromatosis Type-1 patient, showing coexistence of multiple gastrointestinal stromal tumors in the stomach and small intestine with a signet ring cell carcinoma in the stomach. A 74-year-old female patient with poor appetite, vomiting and stomach ache was admitted to the hospital. After detection of a tumoral lesion with an ulcerated surface in stomach during the upper gastrointestinal tract endoscopic examination, the patient underwent surgery. During the operation, multiple nodular lesions were observed in the serosal surfaces of the small intestine and stomach. Gastrectomy and partial small intestine resection specimens were evaluated and the patient was diagnosed as signet ring cell carcinoma in the stomach, and multiple gastrointestinal stromal tumors in the serosal surfaces of both the stomach and small intestine. Resection specimens of patients with GIST need to be evaluated carefully on macroscopic examination, considering the possible presence of a coexistent tumoral lesion.

Malignant Rhabdoid Tumor of the Orbit

2013-01-01

Malignant rhabdoid tumor is a rare and malignant tumor of childhood. Generally it originates from the kidney and central nervous system, but occasionally it may arise from the orbit. Differential diagnosis from other childhood soft tissue sarcomas should be done. We report here an 8-week-old female infant with malignant rhabdoid tumor of the orbit who was treated with chemotherapy and surgery. The 8 week-old girl was referred to our hospital with a history of right proptosis first noted at birth. Physical and laboratory evaluation of the patient was normal except for right proptosis. The mass was removed surgically. Histopathologic examination and immunohistochemical findings of the specimen were evaluated as malignant rhabdoid tumor. Chemotherapy was administered. While in clinical remission, she succumbed during a febrile episode. Malignant rhabdoid tumor can rarely originate from the orbit. Malignant rhabdoid tumor should be kept in mind in the differential diagnosis of orbital masses, and surgery, chemotherapy and local radiotherapy should be used as combined therapy due to the poor prognosis.

Phyllodes Tumor of the Vulva: Report of Two Cases

2013-01-01

Ectopic breast tissue can occur anywhere along the primitive embryonic milk line and can be the site of the same pathologic processes found in the normal breast. Phyllodes tumor is an extremely rare fibroepithelial neoplasm that occurs in ectopic breast tissue of the vulva. To date, only 8 cases of phyllodes tumor in the vulva have been reported in the literature. This paper presents two additional case of benign phyllodes tumor in the vulva. The first patient was a 43-year-old woman, presenting with a lesion on the left anterior mons pubis that had increased in size in the last three months. The second patient was a 50-year-old woman, presenting with a two-month history of a mass in the right labium majus. The patients underwent excisional biopsy. The histological examination of both specimens revealed a characteristic pattern of benign phyllodes tumor. In conclusion, the pathologists need to be aware that the lesion can occur in this location. Herein, the concepts about the histogenesis of phyllodes tumor in the vulva are discussed and a brief review of the previously reported cases is given.

Intrauterine Fetal Loss Associated with Candida Glabrata Chorioamnionitis: Report of Two Cases

Erdener �ZER, Mehtat �NL�, Ay�a ER�EN, B�lent G�LEKL� — 2013-01-01

Chorioamnionitis is most commonly the result of an ascending infection caused by bacteria found within the lower genital tract. Yeast infections causing chorioamnionitis are very uncommon. Candida glabrata is a yeast that is considered to be a commensal of the vagina but vaginitis and rarely upper genital tract infection have been described. We report two cases of fungal chorioamnionitis occurring in pregnancies with a history of in vitro fertilization and cervical cerclage, both resulting in fetal loss. The histological features in conjunction with the positive cultures enabled C. glabrata to be identified as the causative organism producing severe chorioamnionitis. C. glabrata was probably introduced into the cervix at the time of embryo transfer, and during stitching the cervix. To prevent unfavorable outcomes in pregnant women, we recommend that vaginal and in particular cervical swabs should be taken prior to cervical procedures and appropriate treatment should be provided.

Actinomyces Lymphadenitis: Case Report

Deniz ARIK — 2013-01-01

In this paper an unusual case of lymphadenopathy associated with Actinomyces infection is reported. In the literature, there are only two cases presented with histopathologic features. A forty-year-old male patient was admitted to the hospital with painless mass on the neck. Clinical examination revealed a firm mass on the right submandibular region. The patient had no malignancy history. A cystic mass radiologically compatible with abscess was detected adjacent to the submandibular gland. Sialadenitis and lymphadenitis were considered but the mass was refractory to the antibiotherapy. The mass and the right submandibular gland were excised. Histopathologic evaluation of the lymph node revealed characteristic sulfur granules of Actinomyces.

Metachronous Malignant Mesothelioma and Pulmonary Adenocarcinoma

2013-01-01

The prevalence of multiple primary malignant neoplasms in a single patient is reported in a wide variation. The co-existence of malignant mesothelioma and pulmonary carcinoma is a rare entity. Herein, we reported a 60-year-old man who was a retired employee and heavy smoker. He had a suspicious history of asbestos exposure. He complained of chest pain and computerized tomography revealed a mass in the lower lobe of left lung. The patient underwent a left lower lobectomy and was diagnosed as pulmonary adenocarcinoma. During follow-up two years after surgery, the patient complained of dyspnea and chest computerized tomography scan revealed right pleural effusion and diffuse pleural thickening. For the differential diagnosis, the patient underwent wedge biopsy from the right lower lobe and was diagnosed as epithelial diffuse malignant mesothelioma. The development of malignant pleural mesothelioma and lung carcinoma could be associated with asbestos exposure. However, a history of asbestos exposure is not required for the diagnosis. The influence of effective anticancer therapies that improve the survival rates and increase the population ages could be related to the occurrence of a second malignancy.