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Primary cutaneous marginal zone lymphomas (PCMZL) have a wide range of morphology from tumors with monocytoid B cells to those composed entirely of plasma cells and the T-cell rich variants. We report a 60-year-old male with a PCMZL rich in plasma cells of the foot with a lymphoepithelioid-like pattern of dissemination to the lymph nodes posing problems in the diagnosis. The patient had a lesion on the dorsum of the foot which histologically revealed dense perivascular collections of lymphoid cells and plasma cells amidst fibrous tissue. Though the plasma cells did show light chain restriction, CD20 and CD3 did not reveal an overwhelming B/T-cell population and hence a diagnosis of a reactive process was offered. Subsequently the patient developed inguinal nodes with diffuse loss of architecture and replacement by epithelioid histiocytes and reactive T cells with few large B cells (lymphoepithelioid-like pattern). On pathology review it was realized that the two lesions may be related and clonality studies were asked for. The skin lesion showed clonally rearranged IgH receptor while the T-cell receptor rearrangement was negative. The patient developed disseminated disease and received six cycles of chemotherapy with partial response and 6 years after the initial presentation was alive with nonprogressive disease. Thus, the polymorphous background in PCMZL is evolving and an immunocytoma-like tumor can show a T-cell rich or Lennert′s like growth pattern of spread and early recognition these odd patterns may aid in appropriate management of patients.

Abstract 2690 Background: Aggressive biology, tumor re-growth on treatment and poor tolerance to chemotherapy, are the factors responsible for dismal outcomes in patients with AIDS- related PBL. Treatment with CHOP, CHOP-like regimens or more intensive protocols (HyperCVAD, CODOX-M/IVAC) has failed to improve median survival beyond 15 months. To overcome the problems of tumor re-growth secondary to cancer cell resistance and treatment related toxicity, we devised a regimen in which drugs with proven anti-lymphoma activity were given in fractionated and continuous manner. Continuous daily dosing of oral etoposide for 2–3 weeks provides an effective concentration of drug for extended time periods. Anthracyclines were omitted to reduce the incidence of myelosuppression and mucositis. This regimen was tested prospectively to assess the efficacy and tolerability Methods: Between August 2007 to February 2011, consecutive patients with untreated AIDS-related PBL and age >18 years were counseled for treatment with the proposed regimen at our center. Diagnosis of PBL required absent or weak expression of CD20, expression of MUM-1 or CD 38 or CD138 to suggest plasma cell differentiation. Paraffin blocks were evaluated for expression of EBER, HHV-8 and Ki-67. All patients who were willing for treatment and follow up and did not have CNS involvement or concurrent infections were enrolled. Anti-retroviral therapy (ART) was started concurrently with chemotherapy if not received before. The 3-weekly regimen included cyclophosphamide 375 mg/m2 and vinblastine 4mg/m2 intravenously on day 1 and 8, oral etoposide 50 mg daily for 2 weeks and prednisolone 40 mg/m2//day for the first week of each cycle. Ten weekly doses of intrathecal methotrexate were given as CNS prophylaxis. Radiation was given to the bulky and extranodal sites. Mid and end of therapy responses were evaluated clinically and radiologically (CT or PET-CT). Results: Eighteen patients (males-11, females-7) with median age of 37.5 years (range, 22–51 years) were treated with the above mentioned regimen. Two-thirds of patients were not on ART at diagnosis. Ten patients had tuberculosis as an AIDS-defining illness. Median CD4 count at diagnosis was 175/μL (range 75–407/μL). Significant proportion of patients had adverse prognostic features like B symptoms (9/18), performance status (ECOG) ≥2 (11/18), stage III/IV disease (14/18), bulky disease (15/18), multiple extranodal sites (6/18), raised serum LDH (9/18). Extranodal disease was seen in 17/18 patients commonest being bone followed by anal canal. All except one patient received treatment with chemotherapy (median cycles-6, range 4–8). This patient did not follow up after the initial staging evaluation. Complete responses were seen in 15/17 patients after chemotherapy and 2 patients had partial response. Sixteen patients received radiation. All patients except one had complete response after RT. Patient who continued to have partial response at the end of radiation progressed after 7 months and died. At median follow up of 19 months (range, 3–48 months) both overall survival and event free survival are 87.7%. Median overall survival has not yet been achieved. Treatment was well tolerated with 6 episode of febrile neutropenia which were managed on outpatient basis. One patient was hospitalized for pneumonitis for 7 days. There were no treatment related deaths. On paraffin blocks expression of EBER was seen in 55%. None of them were positive for HHV-8. Six patients had Ki-67 of >90%. Conclusion: This is the first reported series from a single center which has shown improved response rates and survival for AIDS related PBL with a novel regimen as compared to available data till date. However the study has limitations of small size and short follow up. Disclosures: No relevant conflicts of interest to declare.

146 Background: Ductal carcinoma in situ (DCIS) identified by screening mammography accounts for 20% of breast cancer diagnoses, and microinvasion (DCIS-M) is found in 5%-10%. There are no defined treatment guidelines for palpable DCIS or DCIS-M. In the developing world wherein screening mammography is controversial due to a predominantly premenopausal population, most women with DCIS present with a palpable lump in the breast. The objective of this study was to evaluate whether disease in these patients with palpable DCIS have been treated differently from screen detected DCIS. Methods: Annually we register 3,000 new cases of breast cancer of which DCIS constitute a small fraction. Over a period of 12 years (1998-2010) we registered 71 cases of DCIS for treatment. A retrospective analysis of these was performed. Results: Of the 71 patients reviewed, 35 (49.2%) had foci of microinvasion. The median age of presentation was 49 years and mean tumor size was 2.3 cm; all presented with palpable breast lumps. Of the 36 women with DCIS alone Tsize was > 2 cm in 26 (72.2%), 14 (38.9%) had presence of comedo necrosis and 1 (2.7%) had positive lymph nodes on histopathology. Adjuvant chemotherapy was given to 4 (11.11%). Of the 35 women with DCIS-M Tsize was > 2 cm in 23 (66%), 10 (29%) had comedo necrosis (compared to 38.9% in pure DCIS p=0.45), 3 (8.5%) had positive lymph nodes, and 17 (48.6%) received chemotherapy. We compared this data to that of women treated for invasive ductal carcinoma with pTsize Conclusions: DCIS presenting in these palpable lesions poses a clinical dilemma for the use of adjuvant therapy. Over 49.2% of the palpable DCIS showed evidence of microinvasion. We thus need to consider the role of adjuvant chemotherapy when treating women with palpable DCIS.

Abstract 4615 Diagnosis and subtyping of mature B cell Non-Hodgkin's lymphoma (NHL) in the bone marrow (BM) and peripheral blood in a leukemic phase may be challenging due to overlapping cell morphology and immunophenotypic features. This study aims to investigate the utility of CD200 and CD43 co-expression on lymphoid cells in differential diagnosis of mature B cell Non-Hodgkin's lymphoma by flow cytometry (FCM). CD200, known as OX-2 protein was first purified in 1982 as a type I membrane glycoprotein membrane of the Ig superfamily is postulated to play an immunoregulatory role in tumors. A prospective study of staging and diagnostic BM aspirates or peripheral blood samples for immunophenotyping from all consecutive cases of suspected Lymphomas referred to our center over a period of 3 months was done. Co-expression was determined by 3 color FCM. An additional tube with Fluorescein Isothiocyanate conjugated anti CD43, Phycoerythrin conjugated anti CD200 and Phycoerythrin cyanine5 conjugated CD19 was added to the routine panel of antibodies used for immunophenotyping in all the samples. Diagnostic utility of CD200 and CD43 co-expression was determined by comparison with Gold standard diagnosis made out of a combination of clinical features, morphology of tissue biopsies, FCM, immunohistochemistry and cytogenetics using Fluorescent insitu Hybridisation (FISH) for translocations involving IgH gene. Total 116 patients of suspected cases of Lymphomas were referred to our laboratory during the period of study. In addition to Bone marrow and peripheral blood FCM evaluation was done in ascitic fluid (n=1) and pleural fluid (n=3) and FNAC of lymph node (n=1) and retro-orbital mass FNAC (n=1). Out of these, 60 patients showed involvement by mature B cell NHL. Age range of the patients was 26 years to 86 years (Male:Female = 48:12). Chronic Lymphocytic Leukemia (CLL) was the commonest subtype (43.3%, 26/60) followed by follicular lymphoma (16.6%, 10/60), Diffuse Large B-cell Lymphoma (DLBCL) (13.3%, 8/60), Mantle cell lymphoma (MCL) (8.3%, 5/60), Splenic Marginal Zone Lymphoma (SMZL) (5.0%, 3/60), Hairy cell leukemia variant (HCLv) and Waldenstrom's Macroglobulinemia (3.3%, 2/60 each), one patient each (3.3%, 1/60) of Chronic Lymphocytic Leukemia/Prolymphocytic leukemia (CLL/PL), Prolymphocytic leukemia (PL) and Burkitt's Lymphoma. One patient was of unclassifiable low grade B-cell NHL presenting with splenomegaly and pancytopenia with bone marrow involvement and no lymphadenopathy and absence of any trans locations involving IgH gene.This patient had the immunophenotype of CD19, CD22, CD23, CD25, CD79b, CD200 and Kappa positive, with CD20 dim+ and CD5, CD11c, CD103, CD123 and CD43 negative. Annexin A1 was negative in the bone marrow biopsy. The detailed distribution of expression of CD200 and CD43 is given in Table 1.Table 1DiagnosisCD200 pos CD43 posCD200 pos CD43 negCD200 neg CD43 negCD200 neg CD43 posTOTALCLL2600026CLL/PL10001Follicular Lymphoma027110Splenic Marginal Zone Lymphoma02103Hairy cell leukemia variant00202Diffuse large B Cell Lymphoma12328Burkitts Lymphoma00101Small cell/Low grade B Cell Non-Hodgkins Lymphoma01001Mantle Cell Lymphoma00415Prolymphocytic Lymphoma10001Waldenstrom's macroglobulinemia02002Total29918460 Amongst all, CD200 and CD43 co-expression was noted in all cases of CLL, CLL/PL, PLL and only one case of DLBCL. This case of DLBCL was negative for CD5. The truth table for same is given in Table 2.Table 2CD43 and CD200CLL and related NHLNon CLL NHLTotalCoexpression present28129Coexpression absent03131Total283260 The sensitivity specificity data is given in Table 3.Table 3Specificity96.88%Sensitivity100%Positive predictive value96.55%Negative predictive value100% Conclusion: 1. Absence of CD200 and CD43 co-expression strongly rules out a diagnosis of chronic lymphocytic leukemia and related neoplasms. 2. In the differential diagnosis CD5 positive NHL, CD200 positivity strongly suggests the diagnosis of CLL/PLL or PLL. Disclosures: No relevant conflicts of interest to declare.

Adenosarcoma like tumor of the seminal vesicle is reported herein. A 35-year-old male presented with mass in the pelvis between bladder and rectum, involving the seminal vesicle and prostate. Mass recurred after enucleation in four years. Histologically, the tumor was multicystic with bland ciliated lining epithelium and sarcomatous stroma. A wide excision was performed followed with chemotherapy and radiotherapy. Adenosarcomas have a low grade recurrent malignant potential and should be recognized.

Background: Angioimmunoblastic T-cell lymphoma (AITL), a subtype of peripheral T-cell lymphoma (PTCL), is characterized by unique clinical and biological features. Its diagnosis remains a challenge as clinical presentation as well as pathologic findings are frequently misleading. Material and Methods: We retrospectively analyzed the clinical, morphological and immunophenotypic spectrum of 17 cases of histologically proven AITL. Result: The mean age was 54 years and male to female ratio was 2.4. Common clinical features included generalized lymphadenopathy (60%), hepatomegaly (70%), splenomegaly (50%), anemia (80%) and polyclonal hypergammaglobulinemia (100%). Microscopically, three architectural patterns; pattern I (6%), pattern II (41%) and pattern III (53%) were observed. Bone marrow infiltration was seen in 60% cases and 30% cases revealed plasmacytosis. Absence of follicles, polymorphous infiltrate, extra-follicular follicular dendritic cell (FDC) proliferation, high endothelial venules (HEV) prominence and neoplastic T-cells were the diagnostic features of AITL. CD10 positivity (47%), clear cells in the background (59%) admixture with large size CD20+ B-immunoblasts (35%) and bone marrow plasmacytosis (50%) were common observations. Conclusion: Awareness of various morphological and immunophenotypic complexities of AITL and distinction from reactive adenopathies and other types of lymphomas that mimic AITL is underscored in this study.

This study was carried out to observe the trend in hormone receptors over the last 8 years in a tertiary cancer center in India. A total of 11,780 tumors analyzed for hormone receptors over the last 7 years were compared with the results of hormone receptor expression in a prior published study on 798 cases of breast cancer from the same institute. The patient′s ages ranged from 18 to 102 years, Sixty percent of the patients were in the age group of 31-50 years. Seventy percent of the tumors were grade III tumors. The percentage of hormone receptor expression in breast cancer in the last 8 years varied from 52 to 57%. The overall receptor expression in the last 8 years shifted within a 5% range, confirming that the hormone receptor expression in Indian patients with breast cancer is low. However, there was redistribution within the pattern of estrogen receptor (ER) and progesterone receptor (PR) expression among tumors showing hormone receptor expression. Breast cancers showing only PR expression reduced dramatically from 21% in the year 1999 to in the year 2006, with a parallel increase in breast cancers showing combined ER and PR positivity (from 25 to 41.8%) and only ER expression (from 7.4 to 10.6%). The hormone receptor expression in breast cancers in India is and continues to be low but the high incidence of only PR-positive tumors in our population reported earlier was misrepresented.

Synovial sarcoma is a well defined morphologic entity extensively researched in literature. Synovial sarcoma displays a wide spectrum of clinical presentations and histologic appearances that may give rise to diagnostic dilemmas. One such unusual site in the head and neck area is the tongue. We report a case of monophasic synovial sarcoma of the tongue in a 22-year-old male. Microscopically, this tumor mimicked a poorly differentiated carcinoma which is more common at this site though the patient was young for this type of tumor. On immunohistochemistry, neoplastic cells were positive for cytokeratin, vimentin, calponin, CD99 and bcl2. Molecular studies--viz. reverse transcriptase polymerase chain reaction revealed a SYT-SSX translocation clinching the diagnosis. This paper highlights the immunohistochemistry profile and SYT-SSX translocation which helped arrive at an accurate diagnosis only because the index of suspicion for a monophasic synovial sarcoma is high.

11593 Background: Taxanes have been shown to induce high pathologic response rates in patients with early breast cancer. We studied the use of single agent weekly paclitaxel as anterior chemotherapy in large operable (tumour size >5 cm) breast cancer (LOBC) and locally advanced breast cancer (LABC). Methods: In this prospective study, we enrolled women above 18 years with T3–4 any N and N2- 3 any T with nonmetastatic disease. Patients with inadequate organ function were excluded. Tumor size was documented at baseline and after completion of neoadjuvant chemotherapy. After diagnostic biopsy, patients were given paclitaxel (100 mg/m2) weekly for 8 weeks. This was followed by breast conservative surgery or mastectomy (as per surgeon’s discretion) and adjuvant chemotherapy with 4 cycles of FEC (5-fluorouracil 500 mg/m2, epirubicin 90 mg/m2, cyclophosphamide 500 mg/m2), radiotherapy and hormone therapy (if indicated). The primary objectives included assessment of clinical and pathologic response after primary ...

We have had a recent spurt in cases of AIDS-related lymphoma (ARL) at our centre. Most of these cases are aggressive mature B cell lymphomas, mainly plasmablastic lymphoma (PBL) and diffuse large B-cell lymphoma (DLBCL). Most of the PBL are extranodal in location and are mucosa-based. We reviewed the morphological features of 34 cases of PBL. Diagnosis was based on morphology, immunohistochemistry, proliferation index, HIV positive status and its preference to extranodal sites (mostly mucosa based). We classified PBL into three morphological subtypes (immunoblastic - 25, Burkitt's - 7, plasmacytic - 2). Tumor cells expressed as leucocyte common antigen (LCA) in 60%, CD138 in 100%, EMA in 45% and light chain restriction in 86% cases. CD20 was negative in all cases. Pathologists need to be aware of PBL and its various morphological subtypes as the identification of this entity from its close differentials carries major therapeutic implications.

Clear cell sarcoma of soft parts is a rare tumor in children and it requires a high index of suspicion for accurate diagnosis. Early diagnosis leads to radical surgical excision and limits the aggressive behavior of this tumor. We report a case of a 12-year-old boy with a recurrent soft-tissue tumor in the scalp, misdiagnosed on three occasions as epitheloid sarcoma owing to the poorly differentiated appearance of cells. In spite of focal S-100 expression, this tumor was not recognized as a tumor of melanocytic origin till melanosomes were demonstrated on electron microscopy (EM). Detection of melanosomes on electron microscopy helped in clinching the histology diagnosis, reiterating the definite role of EM in diagnosing these tumors. Failure to accurately diagnose this tumor resulted in institution of preoperative chemotherapy, delayed surgical excision, tumor progression and death of patient within a year and half of presentation.

Primary thyroid lymphomas (PTL) are extremely uncommon neoplasms accounting for 5% of all thyroid malignancies. There are very few small series and occasional case reports of fine needle aspiration cytology (FNAC) of PTL in literature. We present an interesting and rare case of PTL diagnosed on FNAC. FNAC is an important tool in the diagnosis of thyroid lymphoma.

10661 Purpose: The aim of the study is to evaluate the safety and feasibility of radical brachytherapy for accelerated partial breast irradiation (APBI) and to study the outcome with respect to local control and survival. Materials and Methods: During May 2000 to December 2004, 115 women participated in the ongoing prospective study of APBI using interstitial brachytherapy as the sole modality of radiation for early breast cancer. Women with age > 40 years, single tumour up to 3 cm without diffuse microcalcification and clinically negative axilla were considered suitable. Brachytherapy was done either intraoperatively during the breast conserving surgery or postoperatively using 2–4 planes. Tumor bed demarcation was done with radiopaque clips placed during surgery, CT scans, ultrasonography and/or fluoroscopy. Cavity with 1cm margin was treated based on orthogonal pair of X rays to a dose of 34 Gy in 10 fractions over 1 week with twice daily fractionation using high dose rate iridium source. Results: Implant was done postoperatively in 35 patients while in remaining patients it was done intraoperatively. Implant procedure was tolerated well by all the patients. In 8 patients only 3 or 4 fractions of HDR Brachytherapy were delivered and this was followed by 45 Gy/25 # whole breast radiation therapy for following reasons: positive nodes (4), EIC positive (3) and poor implant coverage (1). At a median follow up of 23 months, the actuarial local control rate is 100%. Three year actuarial disease free survival is 93% while the overall survival is 100%. Complications included fat necrosis in 5 and wound gape in 4 patients. Cosmesis was good to excellent in 60% of the patients. Conclusion: In this ongoing prospective study, APBI using radical interstitial implant was well tolerated and appears to be safe and feasible in appropriately selected patients. Further follow up is needed for confirm the long term safety of the procedure. No significant financial relationships to disclose.

Summary Myoepithelial carcinomas are not as rare as is generally believed, but they are simply not well recognized. Those arising in the oral cavity and exhibiting pure spindle cell morphology are often difficult to diagnose primarily and are likely to be misinterpreted as other more common spindle cell lesions of the oral cavity. Use of ancillary studies like Electron microscopy (EM) and immunohistochemistry (IHC) is very much essential for confirmation of diagnosis. Here we present two such cases of spindle cell myoepithelial carcinoma, which were initially misinterpreted as nerve sheath tumours after IHC and later presented with multiple recurrences and lymph node metastasis.