Iranian Journal of Pathology

Abstract Lung cancer is the leading cause of cancer-related death around the globe. It is generally divided into small-cell and non-small-cell lung carcinomas. Small-cell lung cancer (SCLC) is a malignant tumor characterized by rapid growth, high metastatic potential, and a frequent rate of relapse after chemotherapy. All the features may worsen the aggressiveness of this cancer and increase the possibility of unsuccessful therapeutic attempts. Notch1 signaling is a crucial molecular pathway in the regulation of many cellular functions, including cell-cell communication and gene regulation. Moreover, it was proposed previously that Notch1 might be oncogenic in various types of cancer, but the question arises as to why many SCLC cell lines do not express this pathway. This review aims to explore the role of this complex pathway in SCLC in both vitro and vivo studies and whether it has a tumor-promoting or suppressive effect. After an extensive literature review, it was found that the expression of Notch1 signaling in SCLC reduces
 its proliferative ability while promoting increased cell apoptosis . Furthermore, it reduces cell motility, invasion, and metastatic ability and enhances cell-cell adhesion by inhibiting epithelial-mesenchymal transition (EMT). Furthermore, it contributes to cell chemo-resistance by altering multidrug resistance-associated protein-1 (MRP-1), demonstrating an overall tumor-suppressive effect. Given these findings, induction of Notch1 using histone deacetylase inhibitor (HDACi) may be a potential future therapeutic strategy for SCLC management. Nevertheless, the effect of such a sophisticated signaling pathway in tumor carcinogenesis can’t be generalized to all human cancers, and further studies are needed to better tailor therapeutic plans based on the specific cellular context.

Abstract Background & Objective: Atypical squamous cells (ASC) are the most common epithelial abnormalities found in cervical cytology reports. The clinical significance of ASC and atypical glandular cells (AGC) varies, making clinical management and follow-up challenges.
Methods: All women diagnosed with ASC or AGC in the past 4 years and referred to a tertiary hospital were included. The study evaluated regression, persistence, or progression to significant abnormalities over a two-year follow-up period.
Results: Out of 22,386 cervical cytology smears, 208 (4.8%) patients were diagnosed with ASC (ASC-US: 3%, ASC-H: 1.8%) or AGC (0.25%). Among ASC-US patients with documented follow-up, 11 (46%) showed significant abnormalities, while 13 (54%) showed insignificant abnormalities. In the ASC-H group, with available follow-up, 20 (72%) showed significant abnormalities, and 8 (28%) showed insignificant abnormalities. When considering ASC-US and cervical intraepithelial neoplasia 1 (CIN 1) as low-grade lesions, 19 (31%) patients with ASC-H had low-grade, and 13 (69%) had high-grade abnormalities. In the ASC-US group, 10 (99%) patients had low-grade lesions, while only 1 (1%) had high-grade lesions. Among AGC, not otherwise specified (NOS) patients with follow-up, 17 (65%) had significant lesions, and 9 (35%) had insignificant lesions. All 13 patients with AGC, favor neoplastic (FN)/adenocarcinoma in situ (AIS), showed significant lesions.
Conclusion: While patients diagnosed with ASC-H and AGC are at a higher risk for significant lesions, ASC-US patients may also develop significant lesions. Thus, ASC-US is clinically significant, and these patients should be closely monitored.

Abstract Background & Objective: Cervical intraepithelial squamous lesions (SIL) are the first step toward developing most cervical cancers. Moreover, most of the previous studies focusing on a reliable predictive factor of cervical cancer progression have been reported as inconclusive. Recently, immunophenotyping of squamocolumnar junction cells with CK7 has been introduced as a novel SIL detection and risk evaluation method. Therefore, we aimed to investigate the value of CK7 positivity and its pattern in predicting the progression of LSIL to high-grade counterparts.
Methods: This retrospective study was conducted in Yas Complex Hospital from 2016 to 2018 among patients of the clinic of colonoscopy. Patients with low-grade lesions were included in one group, and patients with high-grade lesions were considered as a control group. The immunoreactivity of CK7 by immunohistochemical staining pattern was interpreted in both groups.
Results: CK7 immunoreactivity was negative in 29.5% of the precancerous lesions and positive in 70.5%. The relationship between grade and CK7 staining was significant (P = 0.040). A significant relationship between the progression status of the disease and CK7 staining was obtained (P=0.001). CK7 staining showed a sensitivity of 82.35%, specificity of 81.82%, positive predictive value of 87.5%, negative predictive value of 75%, and diagnostic accuracy of 82.14% in predicting the progression of the SILs.
Conclusion: Our data and previous studies support the correlation of CK7 expression with a higher chance of progression of low-grade intraepithelial lesions.

Abstract Background & Objective: COVID-19 is a global pandemic that has caused an increase in hospitalization rates and high mortality. Secondary bacterial infections in hospitalized patients are one of the common complications of this viral disease. Due to the increased prevalence of antibiotic resistance, treating these patients is challenging. Therefore, this study aimed to evaluate the secondary bacterial infection and antimicrobial sensitivity test in hospitalized patients with COVID-19 in a tertiary hospital.
Methods: In this retrospective descriptive study, all patients with COVID-19 who were admitted to Shahid Modares Hospital (Tehran-Iran) from October 2020 to March 2021 with positive culture results for bacterial infections, were assessed. The significance level was lower than 0.05.
Results: Ninety-seven patients with a mean age of 65.23 ± 16.72 years were assessed. The male patients accounted for 58.8% of the patients, while 41.2% were female. The ICU admitted patients with critical COVID-19 severity accounted for 59.8%, while 40.2% were hospitalized in the ward with a severe form of the disease. Age, length of hospitalization, and mortality rate were significantly higher in patients with ICU admission (all P-values<0.05). The most antibiotic-resistant bacteria were Klebsiella pneumoniae (32.98%). ICU admission showed a significantly higher rate in patients who were resistant to Cefotaxime, Ceftriaxone, Gentamicin, and Co-trimoxazole compared to the patients who were hospitalized in the ward (all P-values<0.05).
Conclusion: Secondary bacterial infection in hospitalized patients with COVID-19 may lead to high mortality.

Abstract Background & Objective: Breast cancer is the leading cause of cancer deaths among women worldwide. Fine needle aspiration cytology (FNAC) and breast sonography have played a pivotal role in the characterization of a breast lump. The main objective of this study was to analyze the correlation between the International Academy of Cytology (IAC) Yokohama for Reporting Breast Fine Needle Aspiration Biopsies (FNAB) and breast imaging reporting and data system (BIRADS) for sonography along with histopathological correlation.
Methods: A total of 135 FNAC specimens were categorized according to the IAC Yokohama system and BIRADS reporting system and their correlation with histopathology wherever possible to calculate the risk of malignancy (ROM).
Results: According to IAC Yokohama categorization, the cases in categories I, II, III, IV, and V were 1,78,8,6 and 42, respectively. Akin to cytology, most of the cases were assigned BIRADS score two followed by score 6, with the Pearson’s correlation coefficient between the IAC Yokohama system for reporting breast cytology and BIRADS scoring system of 1.957 with a P-value < 0.001 (strong correlation). The sensitivity, specificity, PPV, NPV, and DA of FNAC with category III assumed as malignant were 98.9%, 85%, 76.1%, 99.3%, and 89.5%, respectively. Histopathological correlation was available for 90 cases. The ROM for categories II, III, IV, and V was 5.6%,37.5%,100%, and 100%, respectively.
Conclusion: IAC Yokohama system of reporting breast cytopathology and BIRADS serves as a common language of communication between pathologists and clinicians and aid in better stratification of the lesions. Both FNAC (minimally invasive) and ultrasound (non-invasive imaging technique) are diagnostic tools that complement each other for patient diagnosis and management.

Abstract Background & Objective: Evidence-based medicine has shown that patients with similar risk factors, stages, and therapy often have different clinical outcomes, highlighting the heterogeneity of breast cancer. In a quest for a better, cost-effective approach, researchers proposed the selection of surrogate IHC markers such as cyclin D1 and claudin-1 for the prognosis of breast cancer patients, supplementing the traditional ER, PR, and HER2/neu receptor.
Methods: This retrospective study was conducted in a tertiary care hospital in northern India and included 50 cases of invasive breast carcinoma obtained from mastectomies, wide local excisions, and biopsies diagnosed over 4 years. In addition to ER, PR, and Her2/neu, claudin-1 and cyclin D1 IHC expression was assessed.
Results: Cyclin D1 expression exhibited a statistically significant correlation with nodal status involvement (P=0.011) and with luminal-type breast carcinoma (P=0.023). Though there was no significant statistical correlation between claudin-1 and various clinic pathological features, it was seen to be positive in both luminal and HER2/neu-positive tumors.
Conclusion: Our findings advocated the expression of IHC, namely, cyclin D1 and claudin-1, in cases of breast cancer. Cyclin D1 positivity may show a significant association with better prognostic determinants, while claudin-1 negative tumors may tend to be more often triple negative. Thus, IHC can be used in resource-constraint settings to substitute expensive molecular techniques.

Abstract Background & Objective: Esophageal squamous cell carcinoma (ESCC) is one of the world's deadliest cancer diseases. Deregulation of developmental signaling pathways such as Wnt/β-catenin is frequently implicated in a wide range of human cancers. The present study was designed to analyze the expression of the Pygopus2 (PYGO2) protein, the main co-activator of the Wnt/β-catenin signaling pathway, in ESCC tissues and evaluate its probable correlation with clinicopathological features of patients.
Methods: In this study, PYGO2 protein expression was assessed in tumors and margin normal tissues from 50 ESCC patients using immunohistochemical analysis, and its clinicopathological relevance in the patients was evaluated.  
Results: A significant PYGO2 overexpression was observed in %32 of the tumor cells. Interestingly, PYGO2 expression was significantly correlated with the depth of tumor invasion (P= 0.021).
Conclusion: PYGO2 protein may be highly expressed in ESCC in correlation with the invasiveness of the disease. Therefore, it may be used as a biomarker for the diagnosis of invasive ESCC and a putative therapeutic target to inhibit ESCC invasiveness.

Abstract Background & Objective: Multiple myeloma (MM) drug resistance is thought to be caused by the development of protective autophagy. This work aimed to assess the non-coding RNA (ncRNA) autophagy-related alterations in drug-resistant (DR) myeloma cells.
Methods: DR Plasma cells were extracted from the bone marrow of DR patients referred to Baghai 2 Hospital in Ahvaz, Iran. The cells were grown in RPMI-1640 media containing 10% FBS and 1% Pen/Strep and incubated at 37˚C and 5% CO₂. After six passages, the plasma cells were precisely isolated and utilized as DR cells. The U266B1 cell line (IBRC C10148) was grown in the RPMI-1640 media containing 10% FBS and 1% Pen/Strep and utilized as drug-sensitive (DS) cells. The relative expression of the genes was determined using the Real-time PCR method. Statistical analysis of the data was performed using GraphPad Prism 8 software.  
Results: When the DR cells were compared to the DS cells, there was a notable increase in the expression of ULK1 and LC3B. However, expression of P62 in the DR plasma cells showed a significant decrease compared to the DS plasma cells. The miR-1297 level was considerably higher in the DR cells than in the DS cells. Although, there was no statistically significant difference in the expression of miR-26a-5p between the DS and DR cells. The DR cells exhibited a statistically significant increase in the expression of MALAT1 and SNHG6.
Conclusion: Drug resistance in MM cells may result from overexpression of non-coding RNAs involved in autophagy.

Abstract Background & Objective: Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide, which can lead to virus-related cancers. This study aimed to investigate the frequency of HPV genotypes in women with genital warts referred to available laboratories in Tehran by molecular hybridization method.
Methods: This cross-sectional descriptive study was conducted on the genital warts of 67 women aged 20-50, who were referred to the clinics of Afshar, Namad, Mani, and Al-Mohammed in Tehran province. Viral DNA was extracted using Add prep genomic DNA extraction kit, and genotyping was studied using HPV Direct Flow CHIP Kit.  Data were analyzed by GraphPad Prism software.  
Results: HPV was reported to be positive in all cases. The most common low-risk genotype involved was type 6, with 30 cases (44.77%), and the most common high-risk genotype involved was type 16, with 4 cases (5.97%) in the total population. Among the patients examined, there were 16 cases with multiple infections.
Conclusion: The results of this study showed that low-risk genotypes may be responsible for majority of the genital warts. High-risk genotypes and simultaneous infection with several genotypes could also be common in genital wart samples. Therefore, controlling HPV infection is important, especially in patients with high-risk genotypes. HPV genotyping should be considered in diagnosis and prevention of  HPV-related cancers. 

Abstract Background & Objective: Since early detection increases survival rates, colorectal carcinoma (CRC) is a major concern for researchers. CD10 is a cell membrane-bound metalloproteinase involved in carcinogenesis. Studies have associated it with the progression of CRC to advanced stages, metastasis, and venous invasions. We aimed to evaluate the immunohistochemical expression of CD10 in the tumor and stromal cells of colorectal adenoma and CRC and its correlation with the pathological prognostic factors.
Methods: This cross-sectional study was conducted on radical resection specimens of CRC and polypectomy specimens of the colorectal adenomas received for routine histopathological evaluation in the Department of Pathology, Ramaiah Medical College and Hospitals, Bengaluru, from March 2021 to October 2022. Tumor morphology was examined by light microscopy, and CD10 expression was evaluated by immunohistochemistry. Descriptive statistics in terms of percentage and Chi-square test/ Fisher exact tests were used for the statistical analysis.  
Results: The study includes 46 cases of adenomas and CRCs each. Stromal CD10 expression was significantly higher in the carcinomas (63.4%) than in the adenomas (41.3%). Proliferative CRCs showed a significantly higher tumoral CD10 expression. The increase in the stromal CD10 expression in CRCs with increasing grades was found to be statistically significant. No significant association was seen between CD10 expression and other factors.
Conclusion: The results indicate a potential role of CD10 in the adenoma-carcinoma sequence. The significant increase in proliferating and high-grade CRCs suggests that CD10 could prove to be a potential biomarker for aggressiveness and also a therapeutic target in CRCs. 

Abstract Background & Objective: Thyroid lymphomas are predominantly secondary to lymphoma at other sites, and primary follicular lymphoma of the thyroid is a very rare entity.  
Case Presentation: Here, we report a case of a 62-year-old female who presented with swelling in the front of her neck for one month. The clinical diagnosis was a multinodular goiter. Fine needle aspiration cytology was done and reported as nodular colloid goiter with lymphocytic thyroiditis. The system examination was unremarkable. Histopathological assessments of the right hemithyroidectomy specimen revealed the effacement of thyroid architecture by abnormal and extensive lymphoid follicles. Immunohistochemistry revealed CD20, CD10, BCL2, and BCL6 positivity in the lymphoid follicles. FDG-PT CT scan demonstrated no evidence of lymphoma elsewhere. So, a e final diagnosis of  follicular lymphoma of the thyroid was made.
Conclusion: Due to the rarity and low prevalence of primary follicular lymphoma of the thyroid and challenging in its differentiation from Hashimoto's thyroiditis with dense lymphoplasmacytic infiltration and formation of lymphoid follicles, histopathologic diagnosis should be confirmed by immunohistochemical studies.

Abstract Wolffian adnexal tumors (FATWOs) originate from the mesonephric duct remnants. FATWOs are extremely rare, and 100 incidental FATWOs have been reported in English literature. Most FATWOs have a low potential for malignancy, but aggressive behavior, including recurrence and metastasis, has been described in a few cases; There is no standard protocol for optimal treatment of FATWOs. The case described here is a 35-year-old female who presented with a right-side ovarian mass via abdominal ultrasound. She had a history of left salpingo-oophorectomy due to an abdominal mass, which both histopathologic and immunohistochemical study’s findings were consistent with  Wolffian tumor. Later, she underwent total abdominal hysterectomy with tumor debulking because of the probable malignant behavior of the tumor. FATWO has a heterogeneous histologic pattern,which may make its diagnosis challenging. No specific immunohistochemical markers have yet been recognized for FATWO and pathogenesis or molecular alterations are not definitive.  Therefore, there is no comprehensive recommendation for optimal clinical management of FATWO or its recurrence.

Abstract Background & Objective: Sezary Syndrome is an uncommon leukemic variant of Cutaneous T-cell Lymphoma (CTCL), comprising only 5% of all CTCL cases. The rarity of this syndrome emphasizes the critical need to comprehend its distinct clinical presentation, diagnosis, and treatment.  
Case Presentation:  A 51-year-old man was admitted with itchy, persistent, and extensive erythematous patches, ulcers, lumps, lymphadenopathy, alopecia, and nail dystrophy that had been present for eight months. Laboratory findings showed elevated LDH and 𝛽2-microglobulin. Peripheral blood smear analysis confirmed the presence of Sezary cells, while imaging revealed multiple lymph node enlargements. Skin biopsy and immunohistochemistry suggested cutaneous T-cell lymphoma (CTCL), while immunophenotyping verified a diagnosis of  Sezary syndrome . The patient underwent fluid therapy, systemic antibiotics, topical antibiotics, phototherapy, and chemotherapy. Tenofovir was given due to the hepatitis B co-infection. Despite the improvement when discharged from the hospital, the patient's health eventually deteriorated, which led to death at home.
Conclusion: This patient presented with Sezary Syndrome, exhibiting atypical dermatologic manifestations that must be differentiated from other causes of erythroderma. This case highlights the importance of a comprehensive diagnostic approach, including clinical evaluation, laboratory tests, imaging, and biopsies. Sezary Syndrome is an inherently aggressive malignancy, characterized by a poor response to treatment and a low 5-year survival rate. 

Abstract Hemiscorpius lepturus is a deadly scorpion species found in the tropical regions of the Middle East. Its venom consists of a complex mixture of peptides and enzymes, including the protease toxin hemiscorpius crolysin, the analgesic peptide, and the cytotoxic agent which attacks vascular low-body weight patients, and especially young patients, are prone to systemic complications such as nephrotoxicity, hemolysis, hepatotoxicity, and even death.
In this case report, we present a 7-year-old boy from city of Ahwaz in southwestern Iran, who was bitten by Gadeem (H. lepturus) and developed hemolytic uremic syndrome. After being stung, the patient developed hemolytic anemia, thrombocytopenia, and uremia in the subsequent days. The patient received supportive treatment, hemodialysis, and plasma exchange, and was discharged after 30 days of hospitalization.

Abstract Dear Editor,
 
We have read the recent paper published in the Iranian Journal of Pathology entitled "Formalin Induced Micronucleus Formation in the Buccal Mucosa of Pathology Laboratory Workers"(1). The authors found a significant increase in the percentage of oral micronucleated cells in the pathology laboratory workers when compared to the non-exposed group. Nevertheless, some concepts and guidelines for properly evaluating the paper are presented.
The objectives of the evaluation are based on some guidelines for the use of the micronucleus assay in oral exfoliated cells, as described in detail by the Human Micronucleus Assay Expert Group (2). Of particular importance, it is strongly recommended that a minimum of 2,000 cells per individual be analyzed with a DNA-specific stain in oral mucosal cells. This approach is critical for a high-quality assessment, as such parameters are considered important confounders. In this study, the authors noted that "Papanicolaou staining was used to evaluate the cells containing micronucleus after fixation procedure using the Pathofix spray (PADTAN TEB Co, Tehran, Iran) and drying at room temperature" and "A total of 500 cells were counted for each sample and presence of the cells with micronucleus was reported in percentages" (1). It is important to note that Papanicolaou is not suitable for micronucleus testing in oral mucosal cells because the dye is not reliable for identifying nucleic acids specifically. This is a complicating factor because the identification of micronuclei in this case is very complicated due to the presence of some structures inside the epithelial cells that are equal to micronuclei, such as cytoplasmic granules, leukocytes, or microorganisms (bacteria) (3). This leads to false positives. In addition, the study analyzed only 500 cells per individual. Surely, the total number of cells evaluated is considered very low, considering the results found. 
In the results, the authors were able to present all data in terms of the total number of micronuclei and the percentage of micronucleated cells. Statistical differences were found only for the percentage of micronuclei. How can this be explained? The authors in the manuscript did not elucidate such a discrepancy.
In the Discussion, it was stated that "This discrepancy could be due to the presence of other genotoxic factors, such as air pollution (presence of NO2) and exposure to ionizing radiation, both of which have the potential to increase the frequency of micronucleus. Although these genotoxic factors may influence our results, it was impossible to evaluate them in the current research" (1). This statement does not make sense since the control group was also exposed to air pollution. How is it possible that ionizing radiation can induce genotoxicity in the buccal mucosa (inside the mouth)?
Finally, it is very important to argue the relationship between cytotoxicity and genotoxicity. It is important to remark that Tolbert et al. (4) reported several metanuclear changes indicatory of cytotoxicity (apoptosis and necrosis) for the micronucleus assay in exfoliated cells, such as karyolysis, karyorrhexis, and pyknosis. This approach is very important because cytotoxicity is a potential source of bias in the micronucleus assay. When cytotoxicity is elevated, micronucleus frequency reduces because micronucleated cells are missing as a result of cell death. In this study, the authors were not able to evaluate cytotoxicity assessment in oral mucosal cells.  This certainly helps to clarify the absence of evidence for a statistically significant difference in the total number of micronuclei between groups.
We believe these commentaries are useful for better understanding this important article on the evaluation of genomic damage in pathology laboratory workers chronically exposed to formalin.
Acknowledgments
None.
 
Conflict of Interest
None.

Abstract Dear Editor,
 
Mucosal melanoma of the head and neck (MMHN) region accounts for ~1.3% of all melanomas affecting the body (1). The conjunctiva is most frequently involved, followed by the upper aerodigestive tract. The oral and nasal cavities share almost 48% and 44% of the melanomas occurring in the upper aerodigestive tract. Paranasal sinuses harbor the bulk of the remainder of cases. Rarely are the pharynx and larynx involved (2). Nearly 80-90% of oral mucosal melanomas (OMM) arise from the keratinizing mucosa of the hard palate and maxillary gingiva.  Buccal mucosa, mandibular gingiva, and the floor of the mouth are rather unusual sites (3). The amelanotic version of melanoma constitutes ~13% of all MMHN, which is more than its cutaneous incidence of 1.8-8.1% (4).
Case 1
The 42-year-old lady presented with an irregular blackish mucosal patch involving the inner surface of the upper lip (Figure 1A). Any pain or tenderness was absent. Only mere discomfort to the part led to its self-localization. Palpably, the mucosa appeared slightly thickened. Clinically, hemangioma and malignant melanoma surfaced as possible differentials. On histopathology: The thinned-out mucosa overlying diffuse sweeps of heavily pigmented tumor cells (Fig. 1B). These epithelioid tumor cells contained abundant cytoplasm, flocked with dense pigment granules that eventually obliterated their cellular details. Nuclei appeared vesicular with prominent nucleoli. Histomorphologically, the diagnosis of malignant melanoma was evident. Simultaneous positron emission tomography (PET) negated any further dissemination of the melanoma. Postoperatively, after a regimen of radiotherapy and chemotherapy the patient was followed up at 6 months interval without any relapse or recurrence.
Case 2
A 56-year-old man attended the otorhinolaryngology outpatient clinic with a rapidly enlarging left paranasal mass on his face. Computed tomography (CT) delineated a homogeneous solid tumor arising from the maxillary sinus, encroaching and compressing onto the nasal cavity (Fig. 1C). With a primary suspicion of sinonasal carcinoma or lymphoma, a punch biopsy was taken from the mass. Histologically, undifferentiated tumor cells appeared in diffuse sweeps undermining the ulcerated mucosa (Figure 1C, 1D). The polygonal tumor cells bore grossly irregular large nuclei, marked nuclear pleomorphism, frequent intranuclear cytoplasmic pseudoinclusions, vesicular chromatin, prominent nucleoli, and abundant pale eosinophilic cytoplasm (Fig. 1E). From such a dubious histomorphology sinonasal undifferentiated carcinoma, poorly differentiated squamous cell carcinoma (SCC), large B-cell lymphoma and amelanotic form of malignant melanoma posed as closest differentials. To their discrimination, a battery of immunohistochemical (IHC) markers were exercised. Cytokeratin (CK) 5/6, CD 45, and S100 were applied in the primary panel. The tumor cells expressed strong nucleocytoplasmic reactivity with S100, indicative of malignant melanoma (Figure 1F). While the other two reagents stained negatively (Figure 1I, 1J). HMB 45 was applied for confirmation. Tumor cells expressed strong cytoplasmic granular positivity, affirming it as amelanotic melanoma (Figure 1J). PET scan detected widespread dissemination to cervical lymph nodes, brain and lungs. The patient was immediately subjected to combination therapy. Despite this, he died of the disease after 4 months.