Iranian Journal Of Pathology
Volume:13 Issue: 2, Spring 2018

Electronic learning introduces a teaching device for deeper and more efficient learning. A study was conducted by the Pathology Department of Tehran University of Medical Sciences, Tehran, Iran. The topic of practical pathology was selected earlier based on the curriculum. High-quality digital images of the slides were presented in the form of an e-file. The medical students were asked to register for participation in conventional or virtual groups. The first group underwent traditional education and members of the virtual group were given the website address to click into the website where the materials were uploaded. At the end of the semester, both groups were scientifically evaluated. The mean final pathology exam grade in the virtual group was higher than that of the control group; however, the difference between groups was not statistically significant (P=0.658). In conclusion, it was observed that in teaching practical pathology, virtual education may be as effective as conventional method.

Hepatitis C virus (HCV) is responsible for a vast majority of liver failure cases. HCV is a kind of blood disease appraised to chronically infect 3% of the worlds’ population causing significant morbidity and mortality. Therefore, a complete knowledge of humoral responses against HCV, resulting antibodies, and virus-receptor and virus-antibody interactions, are essential to design a vaccine. HCV epitopes or full sequence of HCV proteins can induce HCV specific immune responses. In fact, structural proteins are usually the main target of humoral responses and non-structural proteins are usually the main target of cellular responses. Hence, various vaccines based on distinct antigenic combinations are developed to prevent HCV infection and the current study tried to summarize them.

Thyroid cancer is a frequent endocrine related malignancy with continuous increasing incidence. There has been moving development in understanding its molecular pathogenesis recently mainly through the explanation of the original role of several key signaling pathways and related molecular distributors. Central to these mechanisms are the genetic and epigenetic alterations in these pathways, such as mutation and DNA rearrangements. That does not mean, however, that all the somatic abnormalities here in a cancer genome have been involved in development of the cancer and just driver mutations are concerned in tumor initiation. By way of illustrations, MAPK pathway which is motivated by BRAFV600E and RAS and RET / PTC rearrangements are suggesting driver genetic alterations in follicular derived thyroid cancers which are considered in this review.

Pneumocystis pneumonia (PCP) is responsible for pulmonary infection in immunocompromised patients. This study aimed to investigating the frequency of Pneumocystis colonization in patients hospitalized in the intensive care unit (ICU) and evaluating the relationship between PCP and Pneumocystis coloniza­tion.
In the current cross sectional study bronchoalveolar lavage (BAL)fluids of 100 patients were collected from surgery and neurosurgery ICUs with different underlying corticosteroid therapy conditions. Patients were divided into 2 groups (patients who received corticosteroids and not received corticosteroids). Direct examination on BAL fluids was performed by the Gomori methenamine silver andGiemsa staining techniques. Additionally, 2 filtered air samples of the 2 above mentioned units were collected. A nested-PCR targeted mtLSUrRNA gene and sequencing were used to identify Pneumocystis spp.
In direct microscopy, 31 out of 100 hospitalized patients (31%) showed positive results. Twenty-three (46%) of smear positive patients were from the group of patients who received corticosteroid, the other 8(16%) were from the group of patients who didn’t receive corticosteroids (P= 0.001). Pneumocystis jirovecii DNA was detected in 77 out of 100 BAL samples by nested-PCR (77%) in which 40(52%) and 37(48%) samples were obtained from the patients who received and not received corticosteroids, respectively. Pneumocystis genome was found in 1 of the 2 filtered air samples.
A significant number of patients who received corticosteroids were also colonized by P. jirovecii that may predispose to PCP or be transmitted to susceptible patients. A significant relationship was observed between the mean hospital stay and detection rate.

Acinetobacter baumannii is an opportunistic pathogen with high pathogenic and antibiotic-resistance potential and is also considered as one of the main nosocomial agents, specifically in the intensive care units (ICUs). It is highly important to use molecular biology methods in the epidemiological studies, determine the source of infection, and understand the relationships and distributional patterns of pathogens. Therefore, the current study aimed to determining the similar molecular types in the A. baumannii species isolated from patients in Tehran, Iran, by the repetitive element PCR fingerprinting (REP-PCR) method.
A total of 350 clinical samples were collected from patients admitted to different hospital in Tehran, assessed to identify Acinetobacter spp., based on the special culture media and biochemical test results. The resistance of isolates was evaluated against 11 different antibiotics. The cefepime and ceftazidime were assessed by the minimum inhibitory concentration (MIC) method, based on serial dilutions. The genome of isolated strains was extracted using the modified boiling method and amplified in REP-PCR technique using specific primers.
In the current study, out of 120 isolates of Acinetobacter spp., 100 (76.9%) were identified as A. baumannii, mostly from ICUs and infectious diseases wards. The isolates of A. baumannii in the current study mostly showed antimicrobial resistance against cefepime and ceftazidime, and had the highest sensitivity to polymyxin B. About 70% of A. baumannii isolates in the current study were resistant to 3 or more antibiotics. According to dendrogram analyses, the patterns were classified to A- I with the maximum population (36%) of group A. All genotypes of Acinetobacter spp. in the current study showed resistance against carbapenems and aminoglycosides.
High similarities between the isolates in the current study indicated the high distribution of A. baumannii species in the hospitals of Tehran.

papillary thyroid cancer is the most common cancer of thyroid accounting for 75%-85% of all thyroid malignancies. Recently, β-catenin has been determined to play a role in clinical course of human epithelial cancers. This study was designed to reveal the association of β-catenin marker and papillary thyroid carcinoma behavior.
63 paraffin blocks of papillary thyroid carcinoma were stained with ready to use monoclonal β-catenin antibody according to manufacturer’s instructions. Memberanous, cytoplasmic and nuclear staining was scored according to intensity of immunoreactivity. β-catenin immunostaining association with clinical parameters like number of recurrences and cumulative dose of radioiodine therapy were analyzed using SPSS version 15. Histopathologic parameters like tumor stage, grade, capsular invasion, lymphovascular invasion, lymph node involvement, distant metastasis and other variables were also evaluated for association with β-catenin immunoreactivity
77.8% of papillay thyroid carcinoma were well differentiated and the remaining were poorly differentiated. Loss of β-catenin membrane immunostaining depicted correlation with number of recurrences (p=0.023% , Pearson correlation= -0.285). Its loss of memberanous staining correlated similarly with cumulative dose of radioiodine (p= 0.046, Pearson correlation = -0.253). Loss of membranous β-catenin was significantly associated with some histopathologic findings like nodal involvement (p Loss of β-catenin membranous staining and its cytoplasmic accumulation were associated with aggressive clinicopathologic behavior. The exact effect of radioiodine exposure on β-catenin pathway remained to be determined in future.

Many biochemical features of sulfur mustard (SM) intoxication remained unknown. So far, the direct association between biochemical parameter changes and ocular problems in patients exposed to SM is not evaluated.The current study aimed at evaluating the associations between the ocular findings in patients with SM intoxication and the changes of serum and blood biochemical parameters.
In the current study, 372 patients exposed to SM and 128 matched controls were compared concerning the association between their ocular problems and biochemical parameters. Ocular problems include photophobia, ocular surface discomfort (OSD), etc. Biochemical parameters include uric acid, creatinine (Cr), hematocrit (HCT), total, direct and indirect bilirubin, high-density lipoproteins (HDL), alanine aminotransferase (ALT), calcium (Ca), fasting blood sugar (FBS), mean corpuscular hemoglobin concentration (MCHC), etc.
The SM-exposed group with photophobia, OSD, tearing, blurred vision, abnormal tear status, and slit-lamp findings had significantly higher mean serum and blood levels of uric acid, Cr, HCT, and total and indirect bilirubin than the controls. The SM-exposed group with photophobia, tearing, ocular pain, blurred vision, bulbar conjunctival and limbal abnormalities had significantly higher mean serum and blood levels of HDL, ALT, Ca, FBS, MCHC, and HDL, indirect and total bilirubin, compared to the control group.
The association of photophobia with uric acid, OSD and tearing with Cr, photophobia with HDL, ocular pain with Ca, and blurred vision with FBS may be explained for their known ocular effects in the SM-exposed subjects. SM-induced biochemical changes may intensify the ocular problems induced by the direct effects of SM.

KRAS mutations are reported in many types of cancers including pancreas, lung, colon, breast, and gastric (GC). High frequency of KRAS mutation is observed in the pancreas, colon, and lung cancers; they commonly arise in codon 12 and 13 of exon 2. Due to the lack of information about the frequency of KRAS mutations in the Northeast of Iran, the current study aimed at evaluating KRAS frequency in cases with GC in this region.
A total of120 formalin-fixed, paraffin-embedded blocks of patients with GC were assessed. The assays to detect KRAS in codon 12 and 13 were obtained through the peptide nucleic acid (PNA)-clamp.
Totally 87 male and 33 female patients were analyzed in the current study. The mean age of the subjects was 55 years. The most common tumoral fragment was located on the body with 48 cases (40%) and the less frequent was related to fondues with six cases (5%). Of the 120 GC samples, 16 (13.3%) cases had codon 12 KRAS mutation, and 16.7% had codon 13 mutations. There were no significant relationships between gender, age, and KRAS mutations in the studied specimens.
In conclusion, the overall frequency of KRAS codon 12 and 13 mutations in GC was 30% in the current study population. Frequency of KRAS codon 12 and 13 mutations had significant correlation with tumors location. Different pathogenic mechanisms are suggested for GC according to tumor location. The current study results may be an important diagnostic tool for physicians managing atrophic gastritis.

Each laboratory should determine the type of errors and turnaround time (TAT), especially in the preanalytical phase to report quality and timeliness of the test results. The current study aimed at investigating the common causes of preanalytical errors in biochemistry and hematology laboratories and evaluating the preanalytical TAT for outpatient samples.
Data of rejected samples in the laboratory information system from September 2014 to September 2015 were retrospectively reviewed. Also, the preanalytical TAT of the outpatient samples was evaluated over the period of three months from June to August 2015. Preanalytical TAT was calculated from order entry to barcode scanning in the autoanalyzer.
With respect to the ratios of blood sample transfers, 1% of samples (2305 out of 225,563) in the hematology laboratory and 0.6% (1467 out of 255,943) in the biochemistry laboratory were rejected. The most common cause of rejection in the hematology and biochemistry laboratories was insufficient volume (48.8%) and hemolyzed sample (74.1%), respectively. The average preanalytical TAT for the outpatient samples was 62.3 minutes.The preanalytical TAT accounted for 10.8% (order entry-sample collection), 49% (sample collection-sample receipt), and 40.2% (sample receipt-barcode scanning in the autoanalyzer), respectively.
Of all the samples received in the biochemistry and hematology laboratories, the overall percentage of rejections were 0.6% and 1%, respectively. The main target to improve preanalytical TAT was determined as the transportation (sample collection-sample receipt) step.

Fine needle aspiration cytology (FNAC) is an easy, rapid, and less hazardous tool to diagnose the intra-abdominal lesions with various imaging modalities adding to its sensitivity and accuracy. However, sometimes it does not yield adequate information for precise diagnosis and the risk of false-negative and indeterminate diagnosis is always present. Cellblock preparations may be particularly helpful in such problematic cases.
The current study aimed at evaluating and comparing the cytological as well as histopathological features of different intra-abdominal mass lesions.
Image-guided FNAC followed by cell block were performed on 167 patients from June 2012 to May 2013. Histologically correlated 111 cases were evaluated. Results of conventional smear, cell block, and combination of FNAC with cell block were compared with histopathological findings regarding diagnostic sensitivity, specificity, and accuracy of diagnosis.
Cell block was more specific to diagnose these lesions than FNAC (95.49% versus 90.09%). Combined application of cell block with FNAC was more specific (96.39%) than cell block alone with 100% diagnostic accuracy.
Application of a combination of cell block with FNAC was more useful to diagnose intra-abdominal mass lesions.

Liquid-based cytology (LBC) is an emerging pathological method for better establishment of the diagnosis in almost all the organs of the body. It is currently used both for the gynecological and non-gynecological (fine-needle aspirates (FNAs)/fluid) specimens in most of the developed and few developing countries. The current study aimed at assessing and illustrating the cytological morphology on SurePath® LBC technique when used on FNAs from head and neck lesions, compared to the conventional smears (CS).
In the current prospective study, a total of 1000 FNAs obtained from swellings of head and neck region were simultaneously processed both by the standard conventional and SurePath® LBC techniques. Both of these preparations were studied, compared witha semi-quantitative scoring system, and statistically analyzed. Pvalue LBC smears were better, compared to CS ones, due to the presence of evenly dispersed cells (P ≤0.001), clearance of obscuring elements / background debris (P≤0.001), and better cellular details (P≤0.001). However, these abilities of LBC often became its own nemesis and made the interpretation difficult.
LBC, though costly, is an acceptable, simple, and valuable technique. However, CS still cannot be considered inferior to it, and it is recommended that in most of the cases LBC, along with CS, should be reported before reaching a final diagnosis. This is beneficial especially in the developing countries such as India where most of the centers are devoid of LBC technique and hence, are not familiar with many cytomorphological features and potential diagnostic pitfalls unique to it.

Primary pleural neoplasms are rare entities compared with the pleural involvement by metastatic carcinoma.
The current study aimed at investigating the complete spectrum of pleural neoplasms and differentiating between them with the aid of immunohistochemistry (IHC).
Consecutive pleural biopsy specimens positive for a neoplasm, both primary and metastatic, were included in the study. Diagnosis or a differential diagnosis was suggested on histopathology confirmed by a panel of IHC markers such ascytokeratin (AE1/AE3), epithelial membrane antigen (EMA), vimentin, calretinin, CD34, CD99, SMA, bcl2, S100, CK7,CK20,TTF1,GCDFP, HMB45, LCA, synaptophysin, chromogranin, and naspsin.
A total of 35 cases of pleural neoplasms included 15 (42.9%) primary pleural neoplasms and 20 (57.1%) metastatic carcinoma. Synovial sarcoma, malignant mesothelioma (MM), and solitary fibrous tumor (SFT) accounted for 14.2%, 11.4%, and 8.5% of metastatic cases, respectively. Epithelioid sarcoma (ES), neuroendocrine carcinoma, and inflammatory myofibroblastic tumor were less common, each contributing to 2.9% of pleural neoplasms. Among the 20 cases of metastatic carcinoma, 13 were from the lung and 7 from the breast. Lung neoplasms metastasizing to the pleura were adenocarcinoma (n=12) and atypical carcinoid (n=1).
Analysis of histopathological pattern along with a panel of appropriate IHC markers distinguished the rare entities of pleural neoplasms essential to determine the prognosis and treatment modality.

Micro-vascular proliferation is an important histological feature of brain glioma with more vascular proliferation is present in higher grades of glioma. CD 105 is expressed in new actively proliferating and immature endothelial cells in tumor environment and appears to be capable to distinguish between malignant neo-vasculature and normal vessels.
This study was designed to evaluate the Micro-Vessel Density(MVD) in different grades of brain glioma based on CD 105 expression by Immunohistochemistry method to determine whether it can be a helpful marker for rumor grading or not.
Paraffin blocks of formalin fixed samples of brain astrocytic glioma were retrieved and IHC was performed using anti-CD105 monoclonal mouse antibody.
Total number of 48cases of low and high grade astrocytic gliomas were evaluated.We noted that there was a positive correlation between MVD evaluated by CD105 and tumor grade, meaning that expression was significantly greater in tumors with higher grade (P=0.019).
We concluded that MVD quantified by CD 105 has positive correlation with tumor grade. Also we think that expression of CD 105 specially in low-grade glioma can serve as a basis for selective treatment option in combination with current standard care .

Increase in intra- and extracellular glucose levels can cause oxidative stress, and the prolonged imbalance between prooxidants and antioxidantscan lead to cell damage and the associated complications in patients with diabetes. Vitamin D acts as a strong antioxidant in the body and several studies emphasized on its important role to prevent oxidative stress in prediabetic and diabetic subjects. The current study aimed at determining and comparing the total antioxidant capacity (TAC) in individuals with hemoglobin A1c (HbA1c) below and above 6.5%, and its correlation with vitamin D levels.
The current cross sectional study was conducted on a total of 107 patients with diabetes (HbA1c >6.5%) and 107 non-diabetic subjects (HbA1c Age and body mass index (BMI)were significantly higher in patients with diabetes, compared with the serum levels of vitamin D and TAC (P The low serum levels of TAC and vitamin D in patients with diabetes could be indicative of oxidative stress in the presence of high blood glucose levels. Supplementation of vitamin D in patients with diabetes might be effective to control the negative impacts of the disease and decrease cells’ exposure to oxidative environment in prediabetes.

Fine needle aspiration cytology (FNAC) of salivary gland lesions is an accepted and useful diagnostic tool to differentiate between benign and malignant lesions. Majority of the neoplasms are benign, and specific diagnosis on cytology can be made in most of the cases. However, the utility is limited by the overlapping and heterogeneous morphological features of benign and malignant neoplasms. The current study aimed at investigating the cytomorphological features of salivary gland lesions with histopathological correlation and performing risk based stratification of these lesions using the recommended Milan system for reporting of salivary gland cytopathology (MSRSGC).
The current study was conducted on 192 retrospective and prospective cases of salivary gland lesions over a period of three years from October 2014 to September 2017. Cytohistopathological correlation was observed in 62 cases. Subsequently, cytomorphological features were further revaluated, classified according to MSRSGC into six groups, and correlated with clinico-histopathological features.
Diagnostic sensitivity and specificity of FNAC for salivary gland lesions was 63.16% and 97.62%, respectively. The positive predictive value was 92.31% and negative predictive value was 85.42%. The diagnostic accuracy to differentiate between benign and malignant lesions was 86.88%.The number of cases in each diagnostic category and the risk of malignancy (ROM) were as follows: nondiagnostic – three cases (ROM – 33.33%), nonneoplastic – 14 cases (ROM – 7.14%), atypical – one case (ROM – 100%), benign – 28 cases (ROM – 7.14%), NUMP – one case (ROM – 100%), suspicious – one case (ROM -100%), and malignant – 13 cases (ROM – 92.30%).
Risk based stratification scheme as recommended by MSRSGC can provide a standard method to analyse the results and help to plan the management of salivary gland lesions.

The current study aimed at assessing the relationship between gastritis and peptic ulcer susceptibility and inflammation-related gene polymorphisms in Iranian patients. Gastritis and peptic ulcer are common medical complications with serious outcomes on the quality of life. Inflammatory responses of gastric mucosa are associated with helicobacter pylori, but most infected patients remain asymptomatic. There is strong evidence that inflammatory response is a major part of its etiology.
The current case-control study aimed at examining genetic polymorphisms in inflammatory cytokines interleukin (IL)-4, and IL-10 using polymerase chain reaction-variable number tandem reaped (PCR-VNTR) and PCR-restriction fragment length polymorphism (RFLP) methods, respectively in 603 genotyped patients admitted to Mohammadi Hospital in Bandar Abbas, Iran (198 patients with gastritis, 84 with peptic ulcer, and 321 patients as controls).
No significant associations were detected in genotype and allele frequencies of IL-10 and IL-4 between the case (with gastritis and peptic ulcer) and control groups.
In conclusion, the results of the analyses suggested that these polymorphisms may not predispose the carriers to gastritis and peptic ulcer development.

Globally, breast cancer is the most common malignancy among females. Prohibition (PHB)-I, a homologous protein, was initially introduced as a suppressor gene for amplification process. Further, the protein has a key role in the cell cycle and is capable of inhibiting DNA transcription in many cell types. Therefore, its possible role in different types of human malignancies is of interest.
The current study aimed at examining the relationship between the tissue distribution of PHB-I and prognostic factors of breast cancer.
Paraffin-embedded tissue specimens of 33 patients diagnosed with breast cancer at Omid teaching Hospital, Mashhad, Iran were studied and a commercial monoclonal antibody was used to perform immunohistochemistry (IHC). The relationship between PHB-I tissue expression with age, disease stage, tumor grade and size, as well as hormone receptor status including estrogen (ER) and progesterone (PR) receptors, and Her-2 receptor were evaluated.
The Immunohistochemical analysis showed a relative increase in PHB-I tissue expression along with higher tumor grade (P=0.057). In addition, higher expression of ER and PR were observed (P=0.027 and 0.009, respectively). The age of patients and other prognostic factors including Her-2 receptor status and disease stage did not statistically correlate with PHB-I expression.
An increased expression of PHB-I was observed in the breast cancer tumors of the current study patients compared with the anatomically healthy margin. Its coloration with some prognostic factors such as disease grade and expression of ER and PR might indicate the PHB-I potential application for diagnostic and patient management purposes.

Most patients with papillary carcinoma of the thyroid gland (PTC) have favorable outcome, but since it has severe capability to invade the nearby tissues, there is a great risk of regional and distal lymph-nodes (LNs) metastases related to poor prognostic parameters, early recurrences, and distant metastasis that lead to bad patient outcome. Discovering other prognostic biomarkers for this cancer helps to detect early recurrences, invasion, expecting patient outcome, and possible use as therapeutic-targets for it. The fork-head-box-E-1 (FOX-E-1), with the alternative name of thyroid-transcription- factor-2 (TTF-2), is one of the transcription factors families that is huge and contains a special fork-head-domain. It has a significant role in the differentiation and maturation of thyroid-follicular cells. Stress-induced phosphor-protein-1 (STIP-1), with the alternative name of heat-shock-protein-(HSP)-organizing protein, is a 62.6-kD protein, with three parts of tetra-trico-peptide repeats (TPR), and is capable of interaction with heat-shock proteins forming structures that have plethora of roles in variable cellular processes; e.g., cell cycles regulations, transcriptions, and RNA splicing.
The current study aimed at exploring the relationship between FOXE-1 and STIP-1 expressions, the clinicopathological parameters, prognosis, and survival of patients with PTC.
The current study explored FOXE-1 and STIP-1 expressions by the immunohistochemical methods in 36 paraffin blocks retrieved from 36 patients of PTC, analyzed the relationships between their levels of expression, clinicopathological parameters, prognosis, and survival of patients.
The high expression levels for both FOXE-1 and STIP-1 in PTC were associated with larger size of the tumor, extra-thyroidal extension, vessels invasion, LNs spread (P Patients with advanced PTC and unfavorable prognosis had high levels of both FOXE-1 and STIP-1 expressions.

In sepsis, enhanced fibrin formation, impaired fibrin degradation, and intravascular fibrin deposition lead to a prothrombotic state. The current study aimed at measuring various coagulation parameters to predict an early marker for disseminated intravascular coagulation (DIC).
The current prospective study was conducted from January 2012 to April 2013 on 50 children aged 1-10 years with clinically suspected sepsis referred to the Department of Pediatrics of a tertiary care center in New Delhi, India. Patients were evaluated in accordance with criteria for acute infection (i e, symptoms less than seven days) confirmed in all patients in the laboratory. Patients receiving antibiotics 24-48 hours preceding the admission were excluded from study. Prothrombin time, activated partial thromboplastin time, plasma fibrinogen, and D-dimer were measured at the time of admission in 50 patients and 50 controls.
D-dimer was positive in 36 (72%) patients and negative in all controls. The difference was statistically significant (P Though none of the current study patients developed overt disseminated intravascular coagulation, the high positivity for D-dimer suggested that it should be measured in children with sepsis for early identification of DIC. This can aid better management as additional coagulation based therapy such as recombinant anti-thrombin and thrombomodulin may help to improve prognosis.

Squamous cell differentiation (SCD) may occur in papillary thyroid carcinoma (PTC) only at metastatic sites.
We have studied cytokeratin CK5/6 and P63 along with TTF1 (thyroid transcription factor 1) and B-Raf (V-Raf murine sarcoma viral oncogene homolog B1) immunohistochemical expression in neck lymph node metastases of thyroid PTC showing SCD.
The patient (21-years) presented with a neck mass. The check-up revealed bilateral thyroid nodules. Total thyroidectomy and neck lymph node dissection were performed. The diagnosis was that of bilateral PTC with lymph node metastases (pT1N1Mx). The metastases were peculiar by the presence of cystic change and of SCD. The thyroid PTC expressed P63 focally and, TTF1 and B-Raf diffusely. Cytokeratin 5/6 was expressed only in the lymph node metastases, in the metastatic cyst lining and in the SCD foci. The P63 cells outnumbered those CK5/6. TTF1 expression was faint in SCD. Metastatic, both classical PTC- and SCD-epithelia expressed B-Raf.
The expression patterns of CK5/6, P63, TTF1 suggest a luminal/central-to-abluminal/peripheral direction for SCD development from PTC-epithelia in lymph node metastases. Whether this metaplasia type may reflect a regression to a less aggressive morphotype or a progression-switch to squamous cell carcinoma-type differentiation in a composite tumor remains matter of debate.

Multiple Myeloma is a neoplasm of B cell lineage characterized by excessive proliferation of abnormal plasma cells. It is characterized by a clinical pentad of 1) anemia, 2) a monoclonal protein in the serum or the urine or both, 3) bone leisons and or bone pain, 4) hypercalcemia >11.5g/dl and 5) renal insufficiency. Non secretory multiple myeloma is a rare variant of the classic form of multiple myeloma and accounts for 1% to 5 % of all cases of multiple myeloma. The clinical presentation and radiographic findings of non-secretory multiple myeloma and multiple myeloma are the same. The diagnosis of multiple myeloma requires the demonstration of monoclonal gammopathy in the serum or urine. In non-secretory multiple myeloma, however no such gammopathy can be demonstrated, making the diagnosis more difficult. We describe a 60 year old woman who initially presented with back pain which when further investigated by complete blood count revealed hemoglobin of 13g/dl, Total Leukocyte Count of 10,890 and platelet count of 1.5 lac/cmm. Viral markers revealed HCV positive. Hypercalcemia with a serum calcium level of 12.5g/dl was also demonstrated. MRI revealed multiple lytic bony lesions. No monoclonal gammopathy was found in the serum or urine and bone marrow biopsy showed marked plasmacytosis of > 45%. We present a case of Non Secretory multiple myeloma because of its illusive nature and rare entity.

Verrucous carcinoma (VC) is a rare variant of well differentiated squamous cell carcinoma (SCC) which is usually found in oral cavity mucosa. Cutaneous verrucous carcinoma is a rare entity and in this paper we report a 43 years old man with VC superimposed on chronically inflamed skin of ileostomy site. Previously, he was operated to treat rectal adenocarcinoma and has had ileostomy for six months. The skin lesion was resected totally during surgical operation for ileostomy closure. Histopathologic examination confirmed the diagnosis of cutaneous verrucous carcinoma. Post-operative follow up shows no evidence of recurrence after six months. We suggest patient’s training for follow up visits in order to early detection of osteomy site complications including neoplastic changes.

Hepatoid variant of yolk sac tumor of ovary is an unusual tumor with an aggressive behavior. It is usually observed in young females, presents with abdominal complaints and is associated with raised α-fetoprotein (AFP) levels. It should be differentiated from other hepatoid tumors involving the ovary. A complete patient evaluation with gross, microscopy, and immunohistochemistry can identify the site of origin to administer appropriate treatment.
The current study reported the case of a 30-year-old married parous female presenting with abdominal distention and pain of two months duration. She had regular menstrual cycles. Based on lab investigations her serum AFP level was markedly raised to 34,244 ng/mL (normal range: 0-9 ng/mL). Computerized tomography (CT) scan showed large lobulated heterogeneous mass in both ovaries and omental, gall bladder, and lung metastasis. A CT guided biopsy of the ovarian mass was done. On histopathology, a differential diagnosis of hepatoid variant of yolk sac tumor, hepatoid carcinoma of ovary and hepatoid tumor arising from gall bladder metastasizing to the ovary were observed. Patient underwent surgery. Per operatively gross ascites with bilateral ovarian mass, extensive omental, pelvic, and gall bladder deposits were observed. Bilateral salpingo-oophorectomy with omental deposit biopsy was conducted. Histopathology along with immunohistochemistry confirmed a diagnosis of hepatoid variant of yolk sac tumor in both ovaries with widespread intra-abdominal metastasis.