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Doctor of Medicine(BRANCH-III) DISSERTATION on METASTATIC STATUS OF LYMPHNODES FROM RADICAL SURGICAL RESECTIONS - ROLE OF CYTOKERATIN AS AN ADJUVANT TO STANDARD STAINING METHOD submitted in partial fulfillment of the requirements for the degree of Doctor of Medicine(BRANCH-III) M.D. PATHOLOGY Register No.:201713301 THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI TIRUNELVELI MEDICAL COLLEGE TIRUNELVELI MAY 2020 CERTIFICATE This is to certify that the dissertation titled “METASTATIC STATUS OF LYMPHNODES FROM RADICAL SURGICAL RESECTIONS-ROLE OF CYTOKERATIN AS AN ADJUVANT TO STANDARD STAINING METHOD” is a bonafide work done by Dr.S.AISWARYA NIVEDHITHA, Post Graduate Student, Department of Pathology, Tirunelveli Medical College, Tirunelveli – 627011, in partial fulfilment of the university rules and regulations for the award of MD DEGREE in PATHOLOGY BRANCH-III, under my guidance and supervision, during the academic period from 2017 to 2020. DR. S.M.KANNAN, MS .MCh (Uro)., Dean, Tirunelveli Medical College, Tirunelveli-627011. CERTIFICATE I hereby certify that this dissertation entitled “METASTATIC STATUS OF LYMPHNODES FROM RADICAL SURGICAL RESECTIONS-ROLE OF CYTOKERATIN AS AN ADJUVANT TO STANDARD STAINING METHOD” is a record of work done by Dr.S.AISWARYA NIVEDHITHA, in the Department of Pathology, Tirunelveli Medical College, Tirunelveli, during her postgraduate degree course period from 2017- 2020. This work has not formed the basis for previous award of any degree. Prof.DR.K.SWAMINATHAN. MD, Department of Pathology, Tirunelveli Medical College, Tirunelveli- 627011 Prof.DR.K. SHANTARAMAN.MD, Professor and Head, Department of Pathology, Tirunelveli Medical College Tirunelveli- 627011. DECLARATION I solemnly declare that the dissertation titled “METASTATIC STATUS OF LYMPHNODES FROM RADICAL SURGICAL RESECTIONS-ROLE OF CYTOKERATIN AS AN ADJUVANT TO STANDARD STAINING METHOD” was done by me at Tirunelveli Medical College, Tirunelveli– 627011, during the period September 2017 to august 2019 under the guidance and supervision of Prof.DR.K.SWAMINATHAN, MD, to be submitted to The Tamil Nadu Dr. M.G.R. Medical University towards the partial fulfilment of requirements for the award of MD DEGREE in PATHOLOGY BRANCH-III. Place : Tirunelveli Date : Dr.S.AISWARYA NIVEDHITHA, Register No: 201713301 Post Graduate Student, Department of Pathology Tirunelveli Medical College, Tirunelveli – 627011. ACKNOWLEDGEMENT I thank Professor Dr.S.M.KANNAN, M.S MCh, Dean, Tirunelveli Medical College, for having permitted me to conduct the study and use the hospital resources in the study. I express my heartfelt gratitude to Professor Dr. SHANTARAMAN. K. MD, Professor and Head, Department of Pathology, for his inspiration, advice and guidance in making this work complete. I am extremely thankful to Professors DR. SWAMINATHAN .K. M.D., DR.SURESH DURAI. J. M.D., DR.ARASI RAJESH, M.D, DR.VASUKI, M.D, my Associate Professors DR.V.BHAGYALAKSHMI, M.D, DR.J.JOHNSY MERLA, MD, Department of Pathology, for guiding me during the period of study. I am extremely thankful to Assistant Professors Dr.Hidhaya Fathima M.D, Dr.Sindhuja M.D, Dr.Mahalakshmi M.D, Dr.Dina Mary MD, Dr. Dharma Saranya MD, Dr.Chandhru Mari MD, Department of Pathology, for guiding me academically and professionally during the period of study. I also thank all the lab technicians and my fellow postgraduates for their cooperation which enormously helped me in the study. Without their humble cooperation, this study would not have been possible. I thank GOD AND MY FAMILY, for blessing me not only in this study, but in all endeavours of my life. CERTIFICATE – II This is certify that this dissertation work title “METASTATIC STATUS OF LYMPHNODES FROM RADICAL SURGICAL RESECTIONS-ROLE OF CYTOKERATIN AS AN ADJUVANT TO STANDARD STAINING METHOD” of the candidate Dr.S.AISWARYA NIVEDHITHA with registration Number 201713301 for the award of M.D. Degree in the branch of PATHOLOGY (III). I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion page and result shows 16 percentage of plagiarism in the dissertation. Guide & Supervisor sign with Seal. TABLE OF CONTENTS Sl.No. CONTENT Page No. 1. INTRODUCTION 1 2. AIM & OBJECTIVES OF THE STUDY 3 3. REVIEW OF LITERATURE 4 4. METHODOLOGY 53 5. OBSERVATION AND RESULTS 59 6. DISCUSSION 85 7. CONCLUSION 89 8. BIBLIOGRAPHY 9. ANNEXURE MASTER CHART LIST OF ABBREVIATIONS USED IN THIS STUDY ACB ADENOCARCINOMA BLADDER ACE ADENOCARCINOMA ENDOMETRIUM ALCL ANAPLASTIC LARGE CELL LYMPHOMA AMC ATYPICAL MEDULLARY CARCINOMA DAB DIAMINO BENZIDINE ENE EXTRA NODAL EXTENSION FNAC FINE NEEDLE ASPIRATION CYTOLOGY H&E HEMATOXYLIN AND EOSIN HEV HIGH ENDOTHELIAL VENULE IDC INVASIVE DUCTAL CARCINOMA IDLC INVASIVE DUCTO LOBULAR CARCINOMA IHC IMMUNOHISTOCHEMISTRY ILC INVASIVE LOBULAR CARCINOMA MDACCo MODERATEDLY DIFFERENTIATED ADENOCARCINOMA COLON MDACCx MODERATED LY DIFFERENTIATED ADENOCARCINOMA CERVIX MDACS MODERATEDLY DIFFERENTIATED ADENOCARCINOMA STOMACH MDSCCBM MODERATEDLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA BUCCAL MUCOSA MDSCCL MODERATEDLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA MDSCCT MODERATEDLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA TONGUE MuADCS MUCINOUS ADENOCARCINOMA STOMACH NOS NOT OTHERWISE SPECIFIED PANCK PAN CYTOKERATIN PapCA/PTC PAPILLARY THYROID CARCINOMA PDACS POORLY DIFFERENTIATED ADENOCARCINOMA STOMACH PET POSITRON EMISSION TOMOGRAPHY SPAC SEROUS PAPILLARY CYSTADENOCARCINOMA SPECT SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY VEGF VASCULAR ENDOTHELIAL GROWTH FACTOR WDACCx WELL DIFFERENTIATED ADENOCARCINOMA CERVIX WDACE WELL DIFFERENTIATED ADENOCARCINOMA ENDOMETRIUM WDACI WELL DIFFERENTIATED ADENOCARCINOMA ILEUM WDACS WELL DIFFERENTIATED ADENOCARCINOMA STOMACH WDEACOv WELL DIFFERENTIATED ENDOMETRIOID ADENOCARCINOMA OVARY WDSCCA MODERATEDLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA ALVEOLUS WDSCCBM WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA BUCCAL MUCOSA WDSCCF MODERATEDLY DIFFERENTIATED SQUAMOUS CELL CARCINOMA FOOT INTRODUCTION Cancer metastasis is a complex, multistep process that involves dissemination of cancer cells from the primary site to distant organs. Lymph nodes are initial sites for metastasis in many solid tumours[1]. Metastasis, the spread of a tumour cells from its primary lymph node (LN) to distant organs, is the most fearsome aspect of cancer. Patients presenting with metastatic disease or those developing metastases after successful management of primary tumour carry a universally grave prognosis. Metastasis is the cause of 90% of cancer deaths. Tumour cell invade either the blood or the lymphatic vessels to access the general circulation and then establish in other (visceral) tissues. Hence, nodal status is a significant predictor for survival of patients with malignant tumours[2]. Though surgical resection done early, some patients get recurrence and die of cancer. So it is our thought that those with an early stage of malignancy and died, might have got occult metastasis in their nodes at the time of initial diagnosis. Those occult metastasis can be identified by evaluating deeper levels of blocks by or IHC with epithelial markers such as cytokeratin[3]. Cytokeratin is a family of water insoluble intracytoplasmic structural proteins that are the dominant intermediate filament protein of epithelial and hair forming cell, also present in epithelial tumours, within a cell, form a dense network radiating from the nucleus to the plasma membrane which helps cells 1 to resist mechanic stress. Pan cytokeratin immunohistochemical stain that reacts to a wide range of keratins includes AE1/AE3, MNF116. AE-3 is a broad spectrum anti pan-cytokeratin antibody cocktail, which differentiates epithelial tumours from non epithelial tumours. The pan cytokeratin antibody cocktail is a well-known broad spectrum immune histochemical epithelial marker for screening for epithelial differentiation in tumour and their metastases. Positive pan cytokeratin staining with the antibody in the lymph node or bone marrow can be useful for identification of metastasis[4]. Hence the present study is carried out with the aim to establish the utility and expression of immunohistochemistry marker (pan cytokeratin) in identifying occult metastasis in lymph nodes. 2 AIM To determine the effectiveness of immunohistochemistry (Pan cytokeratin) as an adjuvant in detecting occult metastasis in lymph nodes OBJECTIVES: 1. To Establish the role of cytokeratin in detecting occult metastases in lymph nodes which are missed in routine H-E staining. 2. To understand their aid in accurate staging of the disease, thereby determining further treatment plan of such patients. Thus, improving the prognosis and survival of patients with malignancies. 3 REVIEW OF LITERATURE LYMPHNODES - FUNCTION AND THEIR DISTRIBUTION: The lymph node is one of the important anatomic components of the immune system[5, 6]. They are encapsulated and act as centres of antigen presentation, lymphocyte activation, differentiation and proliferation. These are facilitated by complex trafficking of cells and lymphatic flow via the structure [7]. They generate mature, antigen-primed B and T cells, filter particles, including microbes, from the lymph by the action of macrophages. Normal young adult body has up to 450 lymph nodes, of which 60–70 are found in the head and neck, 100 in the thorax and as many as 250 in the pelvis and abdomen. They are especially numerous in the neck, mediastinum, posterior abdominal wall, abdominal mesenteries, pelvis and proximal regions
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