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Idiopathic granulomatous mastitis (IGM) is a rare, benign, inflammatory breast disease that primarily affects parous women within a period of five years post-partum. Cystic neutrophilic granulomatous mastitis (CNGM) is clinically identical to IGM, but histopathology demonstrates distinct central lipid vacuoles rimmed by neutrophils with an outer cuff of epithelioid histiocytes/granulomas, with inconsistent presence of Coryneform bacteria within the vacuoles. There is no consensus on the treatment for either IGM or CNGM, which may be managed surgically with wide local excision or mastectomy or medically with antibiotics, steroids, and steroid-sparing immunosuppressive agents. We present a 30-year-old woman with plaque psoriasis and CNGM whose breast symptoms resolved after treatment with the tumor necrosis factor alpha (TNF-α) inhibitor adalimumab, which has not previously been described as a treatment option for CNGM.

Background: Small round cell tumors (SRCTs) are a broad category of diverse malignant tumors composed of monotonous undifferentiated cells. Involvement of serous fluids by SRCT is rare; however, the identification of exfoliated malignant cells is a crucial component of management and has significant implications for treatment and prognosis. The most common effusion tumors with SRCT morphology include Ewing sarcoma, synovial sarcoma, rhabdomyosarcoma (RMS), small-cell neuroendocrine carcinoma (SCNC), and desmoplastic SRCT, and the cytomorphologic distinction between these tumors is challenging. The purpose of this article is to describe the morphologic features of the most common SRCT in fluids and propose helpful ancillary testing. Summary: Effusion SRCTs display similar primitive and undifferentiated morphologic features although each has subtle variations. Ewing sarcoma is a mesenchymal neoplasm and harbors characteristic translocations t(11;22) (EWSR1-FLI1) or t(21;22) (EWSR1-ERG). In fluids, Ewing sarcoma shows poorly differentiated cells of variable size with round to oval nuclei, prominent nucleoli, and scant cytoplasm. In contrast, synovial sarcoma typically involves extremities and expresses a fusion transcript in t(X;18) (SS18-SSX). This soft tissue neoplasm demonstrates uniform cells with irregular nuclear contours, characteristic nuclear folding, and scant cytoplasm. RMS is a neoplasm arising from skeletal muscle, and the alveolar subtype demonstrates a translocation in t(2;13) (PAX3-FOXO1). The malignant cells show a spectrum of small round cells and pleomorphic large cells with rhabdoid morphology. RMS cells characteristically express myogenin and MyoD1, markers of skeletal muscle differentiation. Although SCNC is not a classic SRCT, the morphology is similar. SCNC demonstrates tight clusters of malignant cells with nuclear molding and salt-and-pepper chromatin. This tumor classically has neuroendocrine differentiation and is positive for synaptophysin and chromogranin on immunohistochemistry. And last, desmoplastic SRCT typically presents as an intra-abdominal mass in young men and characteristically harbors the translocation t(11;22) (p13;q12) (EWSR1-WT1). Cytomorphologically, the tumor shows small monomorphic cells occasionally arranged as rosette-like structures. Key Message: The diagnosis of SRCT can be made in effusion samples and is best achieved with a combination of morphologic features, clinical history, and ancillary testing.

Urinary cytology (UC) is one of the primary diagnostic modalities used for the screening and surveillance of urothelial carcinoma. Despite its widespread use, UC has suffered from a lack of standardized or reproducible criteria and wide interobserver variability, particularly of the designation of atypical urothelial cells. The Paris System for Reporting Urinary Cytology (TPS), published in 2016, aimed to provide a standardized approach for evaluating UC by creating diagnostic categories with specific cytomorphologic criteria. Recent studies have primarily investigated the application of TPS on lower urinary tract specimens and have mostly shown that TPS implementation has improved the performance of UC specimens. Only a few studies have reported the impact of TPS on upper urinary tract (UUT) cytology. Additionally, there is uncertainty as to which cytological features are most predictive of high-grade urothelial carcinoma (HGUC) in the UUT. This review summarizes the literature regarding the utility and performance of UUT cytology and highlights findings before and after the implementation of TPS.

Urothelial carcinomas of the upper urinary tract (UUT) are uncommon. Cytological examination of voided urine or washings from the UUT has been part of the standard workup for upper tract urothelial carcinoma (UTUC); however, its value remains controversial. The lack of uniform terminology and specific diagnostic criteria could also have contributed to the inferior performance of urinary cytology for detecting UTUC. The Paris System for Reporting Urinary Cytology (TPS) has provided a standardized reporting system for urinary cytology specimens with clearly defined cytomorphologic diagnostic criteria and found acceptance on an international level after its implementation in 2016. Recent studies have shown that TPS has led to improved diagnostic performance of urinary cytology; however, most of these studies had focused on the evaluation of lower urinary tract cytology specimens. Only a limited number of new research studies have analyzed the effect of TPS when applied to UUT cytology specimens. In the present report, we have summarized the current understanding and utility of UTUC, including its molecular biology, and reviewed the current literature.

Author(s): Greenland, Nancy Y; Wolsky, Rebecca J; Darragh, Teresa M; Vohra, Poonam | Abstract: IntroductionGastric-type endocervical adenocarcinoma (GAS) is an uncommon type of endocervical adenocarcinoma that is not associated with human papillomavirus infection. This diagnosis is relatively rare and may portend a worse prognosis than usual-type endocervical adenocarcinoma. Subtle morphological features make it an under-recognised diagnostic challenge. Study of the cytological features of individual cases is valuable in order to increase awareness of this entity.MethodsThe pathology database of our institution was searched for the diagnosis of GAS and all cytological and surgical specimens for each patient were reviewed. The original cytological interpretation was compared to a retrospective central review interpretation. Clinical history and follow-up results were obtained from the electronic medical record.ResultsFour cases of GAS were identified. The findings on initial cervical cytology varied, with GAS found in both patients with negative cervical cytology and those with atypical glandular cells. Cytological findings included endocervical cells arranged in three-dimensional clusters and honeycomb sheets with abundant vacuolar cytoplasm, and in two patients, moderate nuclear atypia with irregular nuclear membranes, coarse chromatin, hyperchromatic nuclei, and prominent nucleoli. In one patient, GAS was incidentally discovered via thorough sampling of a cystic lesion in the superior portion of the endocervical canal.ConclusionsGAS is an aggressive human papillomavirus-independent type of endocervical adenocarcinoma with subtle morphological features and, as our study shows, varying clinical presentation. Given the aggressive nature of GAS and the difficulties in initial diagnosis, increased awareness of this entity among pathologists is crucial.

BACKGROUND The Paris System for Reporting Urinary Cytology (TPS) published in 2016 provides a standardized approach to evaluating urine cytology. In the authors' practice, a TPS-like approach was adopted in 2012 using similarly defined cytologic criteria and correlating cystoscopic findings, and they also began incorporating the use of cell block (CB) material. The objective of the current study was to assess whether this TPS-like approach with the use of CB, as well as direct implementation of TPS, improved the diagnostic value of urine cytology. METHODS In total, 188 consecutive urine cytology specimens from 2010 through 2016 that had concurrent or subsequent histologic specimens available were retrospectively analyzed for diagnostic correlation. Urine cytology performance was compared between the periods 2010 to 2012 (pre-TPS-like), 2013 to 2016 (TPS-like), and after TPS reclassification, including blind review by a cytopathologist. The contribution of available CB material to final diagnoses also was assessed. RESULTS Both the TPS-like approach and TPS reclassification resulted in significantly lowering the rate of atypical urothelial cells (AUC) diagnosis from 48%, to 21%, to 9% (from pre-TPS, to TPS-like, to after TPS reclassification, respectively; P < 0.01) while increasing the positive predictive value of an AUC diagnosis for high-grade urothelial carcinoma from 21%, to 43%, to 83%, respectively. The use of CBs contributed to a definitive final diagnosis in 24 of 36 cases (66.7%). CONCLUSIONS In support of the new TPS recommendations, the application of stringent "TPS-like" and TPS criteria improves the value of an AUC diagnosis for clinicians and patients by lowering the AUC rate and increasing the positive predictive value of AUC for high-grade urothelial carcinoma. CBs can be used to help resolve problematic cases for more definitive diagnostic categorization.

Epstein-Barr Virus-associated smooth muscle tumor (EBV-SMT) is a rare mesenchymal tumor typically seen in immunocompromised patients. Here, we report a case of EBV-SMT and associated granulomatous inflammation in the liver of a 32-year-old man with history of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). To our knowledge, an association of these two lesions has not been previously reported. We review the literature and discuss pathogenesis, differential diagnosis and immunohistochemical (IHC) stains helpful for the diagnosis of this rare entity. Finally, we consider possible explanations for the concomitant presence of these lesions.

Background: This retrospective study evaluated and compared the diagnostic accuracy and suitability of tissue specimens for advanced molecular diagnostic testing obtained via 2 different techniques for percutaneous biopsy of primary and metastatic liver tumors. Patients and Methods: Samples from 137 patients with liver masses who underwent concurrent fine-needle aspiration biopsy with cell block (FNAB-CB) and core needle biopsy (CNB) at 2 hospitals were assessed for diagnostic accuracy, tumor fraction, and tumor cellularity. A subset of FNAB-CBs, that were deemed to have less or equal tumor cellularity compared with CNBs, had level sections performed and were reassessed for tumor cellularity. Results: Diagnostic accuracy was 96% for FNAB and 93% for CNB (P=.267). In FNAB-CBs, tumor fraction was significantly higher than in CNB samples (67% vs 36%; PPP=.003). Additionally, in 44% of cases, FNAB-CB tumor cellularity was equal to or greater than that of the concurrent CNB. Conclusions: In the current age of personalized medicine, a minimally invasive, safe approach to obtaining adequate tissue for myriad molecular testing is paramount. We have shown that FNAB sampling is diagnostically accurate and produces higher tumor fractions than CNB. Thus, FNAB should be strongly considered as an initial sampling modality, especially for patients in whom molecular tests will determine management.

Background: Low back pain (LBP) is a condition that will affect 60-80% of the population at some stage in their life. Epidemiological studies have shown that simple backache has point prevalence and a 1-month prevalence of 15-30% and 30-40% respectively. Studies that have been performed state that LBP is a self-limiting condition, but many people who have suffered from LBP will experience recurring episodes, which could lead to the development of chronic LBP. The objective of the study was to assess the role of MRI and USG in evaluating degenerative changes in multifidus muscle in chronic low back pain patients. Methods: A Cross-sectional Observational study was done in 30 patients. Adult patients of either sex who presented with low back pain for 6 weeks or more and Grade 1 and grade 2 degenerative intervertebral disc changes as seen on plain skiagrams of L-S spine, A-P and lateral views were subjected to MRI and Ultrasound. Results: Multifidus and paraspinal muscle atrophy and fatty degeneration should be considered in association with the clinical presentation and other abnormalities seen in MRI examination. Conclusions: Whether LBP duration, severity and associated functional disability affect the degree of paraspinal muscle degenerative changes remains unclear. Possible reasons underlying the discrepant findings include variations among the age and symptoms of duration of the studied populations and small sample size.

Background: Infertility is defined as one year of unprotected intercourse without pregnancy. Female factor is responsible for 40-50% of cases of infertility. Uterine pathologies are the cause of infertility in as many as 15% of couples seeking treatment. The objective of this study was to evaluate the accuracy of trans-vaginal sonography (TVS) and saline infusion sonography (SIS) for detection of uterine cavity abnormalities in patients of infertility taking hysteroscopy as gold standard. Methods: A prospective comparative study was done in 60 patients of infertility. Patients were selected from gynaecology OPD of a tertiary care hospital. Patient selected underwent TVS and SIS followed by hysteroscopy for presence of uterine cavity abnormalities. The presence of uterine cavity abnormality and its type (endometrial polyp, submucous myoma, intrauterine synechiae or any other) was noted. The results of TVS and SIS were compared with hysteroscopy. Results: In 60 infertile patients, hysteroscopy revealed intrauterine pathology in 22 patients (36.7%). Among them eight had endometrial polyp and another eight patients had intrauterine synechiae. Submucous myoma was detected in five patients and one patient had thin endometrium. SIS detected eight out of 22 uterine cavity abnormalities indicating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 36.4%, 100%, 100% and 73.1% respectively. In comparison TVS showed abnormalities in six patients only and thus had sensitivity, specificity, PPV and NPV of 27.35%, 100%, 100% and 70.4 % respectively. Sensitivity of SIS for specific lesion was least for intrauterine synechiae (12.5%) and maximum for submucous myoma (60%). Conclusions: The sensitivity of both TVS and SIS for detection of uterine cavity abnormalities in patients of infertility was low in the present study and they cannot be recommended as replacement for hysteroscopy.

With the easy availability, portability and durability of ultrasound, rapid improvement in bedside and Radiologist-performed ultrasound is seeing increasing use in rural, underdeveloped parts of the world. Physicians, and medical officers have demonstrated the ability to perform and interpret a large variety of ultrasound exams, and a growing body of literature supports the use of point-of-care ultrasound in developing nations. We review, by countries, the existing literature in support of ultrasound use in the countries with low and middle income group and training guidelines currently in use, and highlight indications for emergency ultrasound.

Background: Diagnostic imaging plays an important role in the evaluation of abdominal masses. Many imaging modalities are available ranging from conventional modalities to the cross-sectional modalities like USG, CT and MRI. The main principles of imaging are to determine the origin of mass, its measurement, extent, characterisation and assessment of its effect on contiguous organs. In the past, the mainstay was conventional imaging modalities like plain radiograph, Gastrointestinal contrast studies and I.V.U. Modern imaging modalities allow an early and accurate pre-operative diagnosis resulting in a higher rate of surgical resection and improvement of survival.Methods: A Cross-sectional observational study was done in 30 patients. Patients of either sex of any age group who had presented with involvement of retroperitoneal organs detected by routine ultrasound and postoperative patients with recurrence were included in our study.Results: Ultrasound is the initial imaging modality of choice since it is inexpensive, easy to perform and no radiation exposure. On USG, the retroperitoneal masses are classified as solid or cystic or mixed. Since most of the retroperitoneal masses have hetroechoic/mixed pattern, they cannot be characterized by ultrasound alone and hence need further evaluation.Conclusions: Multidetector computed tomography is the imaging modality of choice for further evaluation and characterization. CT protocol for evaluation of the retroperitoneum consisted of both non-enhanced and contrast-enhanced scans for localisation and characterisation of the masses. Multiplanar reconstructions allowed the images to be viewed in any plane chosen including a curved plane thus helping in defining the exact location and extent of the lesion. With MIP and volume rendered images, the relationship of the vessels with the mass lesions was clearly visualized.

This chapter encompasses four uncommon types of triple negative breast cancer, which include adenoid cystic carcinoma (ACC), apocrine carcinoma, metaplastic carcinoma, and medullary carcinoma. Also included in the discussion for differential diagnosis are three additional rare subtypes: acinic cell carcinoma, oncocytic carcinoma, and mucoepidermoid carcinoma. Most of these tumors are “basal-like cancers,” as defined by gene expression analysis. Although sharing the triple negative and basal-like phenotype, these tumors demonstrate remarkably different clinical behaviors, which range along a spectrum from indolent to aggressive, emphasizing the notion that triple negative or basal-like breast cancer comprises a heterogeneous group of diseases. While ACC has well-defined histopathologic features and unique molecular alterations, metaplastic carcinomas represent a morphologically and genetically diverse group of tumors. Furthermore, uniform agreement on diagnostic criteria is lacking for medullary carcinoma and apocrine carcinoma. Accordingly, diagnosis of these uncommon lesions can be challenging, especially in core needle biopsy (CNB) specimens.

Background: Due to rapid pace in development of imaging techniques and increasing number of investigations being done, more number of renal masses are discovered incidentally during evaluation of unrelated or unspecific symptoms. Hence it is vital to differentiate neoplastic and non-neoplastic masses. Among the neoplastic masses, there is a need to differentiate benign and malignant masses so that appropriate treatment strategies like nephron sparing surgery, radio frequency ablation etc. can be planned at an early stage and avoiding unnecessary radical treatments for improved patients survival.Methods: A Cross-sectional Observational study was done in 35 patients. Patients of either sex in any age group who had presented with suspected renal mass by clinical signs and symptoms (palpable renal angle mass, renal angle pain, hematuria) confirmed on USG examination or an incidental Renal mass diagnosed on USG/CT examination were included in our study.Results: Ultrasound is the initial imaging modality of choice since it is inexpensive, easy to perform and no radiation exposure. On USG, the renal lesions are classified as solid or cystic. Anechoic, thin walled cyst without any septations or solid components is usually Bosniak I cyst (simple cyst) and does not need any further evaluation. Rest of the cystic and solid lesions cannot be characterized by ultrasound and hence need further evaluation.Conclusions: Multidetector Computed Tomography is the imaging modality of choice for further evaluation and characterization. CT is done in four phases viz., unenhanced, corticomedullary, nephrographic and excretory phase especially in cases of malignancy while in benign conditions like angiomyolipoma and abscess, evaluation with unenhanced and single phase post contrast in portovenous phase is sufficient.

Accurate diagnosis of dysplasia and adenocarcinoma in patients with Barrett esophagus is critical for clinical decision-making and patient management. IMP3 is an oncofetal protein and has been demonstrated to be associated with aggressive tumor behavior. The aim of this study was to establish the expression pattern and diagnostic value of IMP3 in Barrett esophagus, dysplasia, and carcinoma. A total of 217 cases (resection, n=56; biopsy, n=161) with 302 lesions (invasive esophageal adenocarcinoma, n=147; metastatic esophageal adenocarcinoma, n=14; high-grade dysplasia of the esophagus, n=52; low-grade dysplasia of the esophagus gland, n=21; and Barrett esophagus, n=68) were examined by immunohistochemistry for IMP3 expression. IMP3 showed strong cytoplasmic granular staining in 138 of 147 (94%) of invasive esophageal adenocarcinomas, 13 of 14 (93%) of metastatic esophageal adenocarcinomas, and 49 of 52 (94%) of high-grade dysplasias. In contrast, 3/21 (14%) of low-grade dysplasia and 5/68 (7%) Barrett esophagus were positive for IMP3. Expression of IMP3 was not found in adjacent benign squamous and glandular mucosa. Our findings indicate that IMP3 is a highly sensitive and specific biomarker for the diagnosis of invasive esophageal adenocarcinoma and high-grade dysplasia. The data also suggest that IMP3, an oncofetal protein, may play an important role in malignant transformation in esophageal adenocarcinoma.

Background: Diffuse lung diseases describe a heterogeneous group of disorders of the lower respiratory tract characterized by inflammation and derangement of the interstitium and loss of functional alveolar units. The disease is not restricted to the interstitium only, as it involves epithelial, endothelial and mesenchymal cells with the disease process extending into the alveoli, acini and bronchioles. Thus, the entire pulmonary parenchyma is involved. The objective of the study was to evaluate diffuse lung diseases by high resolution computed tomography of chest.Methods: A cross-sectional observational study was done in 30 patients. Adult patients of either sex of age group 18 and above showing reticular opacities on chest X-ray and those patients who were incidentally diagnosed as cases of diffuse lung diseases on HRCT chest were included in present study.Results: Reticular opacities were the most common roentgenographic finding followed by reticulonodular opacities. On HRCT, intra and interlobular septal thickening was the most common finding in Idiopathic interstitial pneumonia (usual interstitial pneumonia).Conclusions: High resolution computed tomography (HRCT) is superior to the plain chest X-ray for early detection and confirmation of suspected diffuse lung diseases. In addition, HRCT allows better assessment of the extent and distribution of disease, and it is especially useful in the investigation of patients with a normal chest radiograph. Coexisting disease is often best recognized on HRCT scanning.

Mucosal alterations of the fallopian tube are generally thought to represent alterations of the native tubal mucosal epithelium, whether benign or malignant. The current paradigm implicating the fallopian tube fimbriae as the origin of most pelvic high-grade serous carcinomas (HGSCs) is based on the premise that HGSC growing within the tubal mucosa originated there. This has fueled proposals to redefine classification rules for assigning the primary site of origin on the basis of the presence or absence of HGSC in the tubal mucosa. The corollary is that it is unlikely for metastatic carcinoma to grow within fallopian tube mucosa. Evidence to support or refute this corollary is minimal, in part because the fallopian tubes historically have been ignored. This study reports the pattern and topography of 100 nongynecologic cancers that metastasized to the fallopian tubes. Most tumors were adenocarcinoma (87%), and the remainder included lymphomas, neuroendocrine tumors, and mesotheliomas. The most common primary origins of tumor were the colon (35%) and breast (15%). Gross evidence of a tubal nodule or mass was only seen in 35% of cases. Ovarian metastases were present in 95% of cases, although 23% did not exhibit gross evidence of metastasis. Tumor involved the fimbriae in 49% of cases, including 10% of cases in which the tumor was restricted to the fimbriae without involving the nonfimbriated portion of the tube. The anatomic distribution of metastases included the tubal mucosa (29%), submucosa (43%), muscularis (54%), serosa (76%), lymphovascular spaces (38%), intraluminal space (16%), and mesonephric remnants (39%). The most common architectural pattern of mucosal growth was a flat layer (22/29 cases), followed by varying degrees of stratification, tufting, and papillary growth. High-grade atypia was present in 18/29 cases of mucosal growth, resulting in patterns that resembled primary tubal HGSC. Accompanying growth in the tubal submucosa frequently produced a pseudoinvasive pattern mimicking invasive tubal HGSC. Immunohistochemical expression of p53 by 8/18 high-grade mucosal metastases further contributed to the resemblance to primary tubal HGSC. Bland cytology was present in 11/29 cases of mucosal growth, some of which also exhibited mucinous features, resulting in patterns that resembled either tubal mucinous metaplasia or nonmucinous tubal hyperplasia. Although uncommon, it is possible for metastases of nongynecologic cancers to grow within the mucosa of the fallopian tube and create a potential diagnostic pitfall. Intramucosal growth of a tumor in the fallopian tube is not pathognomonic of a primary tubal origin of the tumor. These findings may carry implications for proposed criteria using the status of the fallopian tube mucosa to assign primary origin of a gynecologic cancer.

GATA3 is implicated in mammary epithelial development and breast cancer progression and is an evolving immunohistochemical marker in breast cancer. Often associated with estrogen receptor (ER) signaling, GATA3 expression has been reported in ER-negative breast cancers, but systematic evaluation of GATA3 expression in a large set of triple-negative breast cancers (TNBC) is lacking. Given low sensitivities of mammaglobin (MGB) and GCDFP15 in metastatic TNBC, additional markers for site of origin identification would be useful in this context. We examined immunohistochemical expression of GATA3 in a large group of treatment-naive TNBC (n = 111) and ER-positive (n = 39) and HER2-positive (n = 31) breast cancers with commonly used antibody clones, HG3-31 (GATA3-H) and L50-823 (GATA3-L), and compared GATA3, MGB, and GCDFP15. Respectively, GATA3-L and GATA3-H were positive in 66% and 44% of TNBC (P = .002), 93% and 79% of ER-/HER2+ tumors (P = .596), and 100% of ER+/HER2- and ER+/HER2+ tumors (P = 1.00 each). GATA3-L was technically and diagnostically more sensitive than GATA3-H in TNBC and was technically more sensitive in other subtypes. MGB (26%) and GCDFP15 (16%) were less sensitive for TNBC than other subtypes (P.001). Notably, 56% and 36% of MGB-/GCDFP15- TNBC were positive with GATA3-L and GATA3-H, respectively (P = .027). Seventy percent of TNBC were positive for GATA3-L, MGB, or GCDFP15 compared with 49% using GATA3-H in the panel. GATA3 is a diagnostically useful marker for TNBC and is more sensitive than MGB and GCDFP15 combined. GATA3-L is more sensitive for TNBC than GATA3-H, and an immunopanel of GATA3-L, MGB, and GCDFP15 provides optimal diagnostic sensitivity for TNBC.

To evaluate the accuracy of transvaginal sonography (TVS) and saline infusion sonohysterography (SIS) for detection of uterine cavity abnormalities in patients with abnormal uterine bleeding (AUB) taking hysteroscopy as the gold standard.This was a prospective study done in the department of Obstetrics and Gynecology of a tertiary care academic hospital. Sixty premenopausal and postmenopausal women who presented with AUB underwent TVS, SIS, and hysteroscopy. The presence of focal abnormality and the type of abnormality, i.e., polyp, submucous myoma, and endometrial hyperplasia, were noted. The results of TVS and SIS were compared with hysteroscopy.On hysteroscopy, 76.67 % (n = 46) patients were diagnosed with intra cavity abnormalities. SIS showed sensitivity, specificity, PPV, and NPV of 89.1, 100, 100, and 73.7 %, respectively. In comparison, TVS showed sensitivity, specificity, PPV, and NPV of 43.48, 78.57, 86.96, and 29.73 %, respectively.SIS was found to be more sensitive and specific than TVS in detection of intra cavity abnormalities.

Hydrotherapy is the use of water in the treatment of diseases. It is an effective method of detoxification. It was formerly called hydropathy. Water comprises from 75% body weight in infants to 55% in elderly and is essential for cellular homeostasis and life. The use of water for therapy has been around for hundreds of years. The theory behind it is that water has many properties that give it the ability to heal:water can store and carry heat and energy. Though water fasting offers the quickest detox and strongest therapeutic effect, it is no doubt the most challenging fast to perform in the first few days.

Contrast-enhanced ultrasound (CEUS) is the application of ultrasound contrast medium to traditional medical sonography. Ultrasound contrast agents rely on the different ways in which sound waves are reflected from interfaces between substances. This may be the surface of a small air bubble or a more complex structure. Commercially available contrast media are gas-filled microbubbles that are administered intravenously to the systemic circulation. Microbubbles have a high degree of echogenicity (the ability of an object to reflect ultrasound waves). There is a great difference in echogenicity between the gas in the microbubbles and the soft tissue surroundings of the body. Thus, ultrasonic imaging using microbubble contrast agents enhances the ultrasound backscatter, (reflection) of the ultrasound waves, to produce a sonogram with increased contrast due to the high echogenicity difference. CEUS can be used to image blood perfusion in organs, measure blood flow rate in the heart and other organs, and for other applications.

Paget's disease is an uncommon manifestation of breast carcinoma occurring in 1-2% of female patients with breast cancer. Here, we present a case of Paget's disease of the breast, which was initially interpreted as squamous cell carcinoma on cytology. This case report raises two issues. First, histological and cytological specimens of Paget's disease show a mixed population of epithelial cells including squamous cells with reactive changes and malignant glandular cells. In the current case, a mixed population of atypical keratinizing and nonkeratinizing epithelial cells was initially interpreted as squamous cell carcinoma of cutaneous origin. The marked reactive changes in the squamous epithelium involved by Paget's disease should be recognized. Second, this case is an unusual clinical presentation for Paget's disease of the breast as the nipple-areolar complex and underlying breast tissue were surgically absent at the time of diagnosis. Clinical suspicion, along with an awareness of the cytologic features and clinical presentation of Paget's disease, can help in reaching the correct diagnosis in a timely fashion.

Gemistocytic astrocytoma still continues to be enigmatic; both in terms of definition and prognostic implications. The major issue of contention has been the clinical relevance of this pathological entity. The currently accepted definition of gemistocytic astrocytoma requires 20% or more gemistocytes, and considers the neoplasm as a diffuse astrocytoma, which is a WHO grade II tumor. Some suggest that gemistocytic morphology should be considered as evidence of a higher grade astrocytoma. However, there is no consensus on the percentage of gemistocytes associated with a worse prognosis than otherwise expected. Given the reported cases and series, it is not clear that this morphology portends a more aggressive biology when all else is equal. There is still a need for studies with sufficient numbers of well-matched gemistocytic and non-gemistocytic astrocytic neoplasms to decide whether upgrading a tumor with 'significant' number of gemistocytes is justifiable. This article presents a critical review of the existing studies and a brief mention of our experience from a pathological perspective.

Objective: Determination of Bone Mineral Density (BMD) in children with idiopathic musculoskeletal pain (IMSP) and associated risk factors Methods: This cross sectional hospital based study investigated bone mineral density in 45 children with IMSP between 5-16 years of age and equal number of healthy matched controls. Characteristics of IMSP, associated disabilities, and dietary pattern were recorded. Serum calcium, Phosphrous, Alkaline Phosphatase and Vitamin D levels were measured. Bone Mineral Density was measured with dual energy X-ray absorptiometry. Results: Eighty seven percent of the subjects with idiopathic musculoskeletal pain had pain lasting for more than 3 months. Most common location of pain was the lower limbs (93.3%). Pain during exercise was the most common disability (36%).The mean (±SD) levels of BMD of whole body (WB), Total body less head ( TBLH) and distal radius (DR) in cases was significantly lower compared to controls (p=0.041,p=0.002 and p