Journal of Pathology of Nepal

Artificial intelligence in surgical pathology

Gopi Aryal — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23444

Artificial intelligence (AI) is machine intelligence that mimics human cognitive function. It denotes the intelligence presented by some artificial entities including computers and robots. In supervised learning, a machine is trained with data that contain pairs of inputs and outputs. In unsupervised learning, machines are given data inputs that are not explicitly programmed.1 Machine learning refines a model that predicts outputs using sample inputs (features) and a feedback loop. It relies heavily on extracting or selecting salient features, which is a combination of art and science (“feature engineering”). A subset of feature learning is deep learning, which harnesses neural networks modeled after the biological nervous system of animals. Deep learning discovers the features from the raw data provided during training. Hidden layers in the artificial neural network represent increasingly more complex features in the data. Convolutional neural network is a type of deep learning commonly used for image analysis.

Keywords: Artificial Intelligence

Histopathological spectrum of skin diseases in a tertiary skin health and referral centre

Ram Chandra Adhikari — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23172

Background: Skin diseases are very much prevalent in the developing countries. The pattern of skin diseases varies from country to country and even region to region within a country. The histological diagnosis is used by clinicians to aid in the management of patients & most appropriate clinical interventions.

Materials and methods: The study included a total of 1040 skin biopsies from January 2016 to December 2018 in the department of pathology, DI skin health and referral centre, Kathmandu, Nepal.

Results: The majority of the patients were in the age group of 31-40 years. The most common skin disease is non-infectious vesicobullous and vesicopustular disease (28.6%), followed by non-infectious erythematous papular and squamous disease (25.9%). The most common vesicobullous disease is spongiotic dermatitis (84.8%). Erythema dyschromicum perstans (31.8%) is the commonest non-infectious erythematous papular and squamous disease. The most common microbial disease is fungal infection, followed by leprosy. Among the neoplastic diseases of skin, tumors of epidermis are commonest diseases and the most common epidermal tumor is basal cell carcinoma. The commonest tumor of skin is melanocytic nevus. The most frequent site is upper extremities.

Conclusions: Eczema is predominating non-infectious vesicobullous and vesicopustular disease. A relatively higher, prevalence of fungal infections was observed. Basal cell carcinoma is the commonest epidermal tumor and melanocytic nevus is commonest of all skin tumors.

Keywords: Dermatitis; Papular; Spongiosis; Squamous lesion; Vesicobullous

Diagnostic role of bronchoalveolar lavage: A cytohistopathological correlation

Prabesh Kumar Choudhary — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23173

Background: Tumors of lung are common in Nepal. The risk of malignancy has to be judged prior to surgery for which bronchoscopy is often done. Brocho-alveolar lavage and bronchial biopsy are routine procedure done for diagnosis of lung cancer during bronchoscopy. This study was done to correlate the cytology of broncho-alveolar lavage specimen with histopathology in malignant tumors of the lug in our setup.

Materials and methods: This study was conducted at department of pathology, Nobel Medical College from August 2017 to December 2018. Histopathology reports with malignancy were compared to their cytological diagnosis.

Results: A total of 141 cases were included in the study. Among the study population, Bronchogenic carcinoma was found more prevalent in female. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of broncho-alveolar lavage in the diagnosis of lung cancer were 88.1%, 97.98%, 94.7%, 95.1% and 95.03% respectively.

Conclusions: Brochoalveolar lavage cytology has a greater accuracy for the diagnosis of lung cancer; however, benign cases need regular follow up as there are false negative cases.

Keywords: Adenocarcinoma; Brochoalveolar lavage; Bronchogenic; Carcinoma; Lung

Histopathological subtypes and demographic profile of cystic jaw lesions - A hospital based study

Arnab Ghosh — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23152

Background: Odontogenic cysts are defined as the epithelial cysts which arise from odontogenic epithelium and occur in tooth bearing regions of jaws. The objective of the present study was to analyze different histopathological types of cystic jaw lesions and to determine the distribution of their relative frequency according to site, sex, size and age group.

Materials and methods: This study was a cross sectional hospital based observational study conducted in the Department of Pathology, Manipal Teaching Hospital. All cases with cystic jaw lesions on histopathology during the study period from January 2014 to December 2018 were included in the study.

Results: Thirty-two cases of cystic jaw lesions were reported during the study period. Females were more commonly affected in our study with a male: female ratio of 1:1.9. The age range in the study was 9 to 71 years with a mean age of 33.3 years. The most frequent type was radicular cysts followed by dentigerous cysts, odontogenic keratocysts and cystic ameloblastoma. Radicular cysts showed the most female predilection with a ratio of 1:4.3. and a mean age of 35.6 years. Majority of dentigerous cysts were seen in patients below 30 years. Both radicular cysts and dentigerous cysts showed more involvement of maxilla but odontogenic keratocysts were more common in mandible

Conclusions: The present study corroborate with other similar literature with respect to the frequency percentage of different types of jaw cysts.However, female predilection was seen in radicular and dentigerous cysts. Maxilla was the more common site except in odontogenic keratocysts.

Keywords: Cyst; Dentigerous; Jaw; Keratocyst; Odontogenic; Radicular

Antibiotic sensitivity pattern in culture positive typhoid fever cases isolated at Patan hospital

Sanjay Kumar Shrestha — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23348

Background: Enteric fever is one of the most common systemic infections of developing countries like Nepal. The changing trend of antibiotic susceptibility and increasing rate of resistance to the commonly used antibiotics has been of great concern in the proper treatment and prevention of this disease. This study aims to investigate the current antibiotic susceptibility pattern of Salmonella typhi and paratyphi A and B.

Materials and Methods: This study was carried out at Patan hospital of Lalitpur, Nepal from ____ to -------. Blood culture sample were collected from suspected patients presenting to different departments of the hospital and tested microbiologically by standard procedure. Antibiotic susceptibility test was performed by Kirby Bauer Disc Diffusion method and results were interpreted by National Committee for Clinical Laboratory (NCCLS) guidelines.

Results: Out of the total sample of 212, 40(18.8%) cases were isolated as Salmonella species. Out of these, 29(72.5%) cases were S typhi and 11(27.5%) were S paratyphi. Isolates were mainly from adult age group. Regarding the antibiotic susceptibility pattern, the sensitivity to chloramphenicol was 95% and to cotrimoxazole 97% whereas the sensitivity to ciprofloxacin was 52.5% and 27.5% for Ofloxacin. Nalidixic Acid Resistance Salmonella typhi strain was 60.0 percent. Sensitivity to ceftriaxone, meropenem and colistin was found to be 100 percent.

Conclusions: A high degree of variability is seen in antimicrobial sensitivity pattern with very high degree of sensitivity to the historically used antibiotics like chloramphenicol and cotrimoxazole. Unfortunately, sensitivity to quinolones was seen to be very low, which were used widely in the last two decades.

Keywords: Antimicrobial Sensitivity Test; Chloramphenicol; Ciprofloxacin, Ceftriaxone; Enteric fever

Interpretation on coexistence or association of thrombocytopenia with malaria

Niraj Nepal — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23442

Background: Malaria is a major health problem especially in developing countries. It is a major causeof morbidity and mortality especially in the tropics. There are several hematological changes in thisparticular disease, which includes thrombocytopenia, anemia , atypical lymphocytosis and infrequentlyintravascular coagulation. The aim of the study is to detect and compare the severity of varioushematological changes, especially thrombocytopenia in the particular type of malaria.
Materials and Methods: This was an observational study done on the patients attending the outpatientand inpatient departments clinically suspected for malaria in Nobel Medical College, Biratnagar, Nepal.Thick and thin slides were made and stained with Leishman’s stain for malarial parasites and also antigentests were included wherever necessary. Other tests included were, complete blood counts.
Results: Amongst the included 800 patients with suspicion of malaria, 135 (17%) patients demonstratedmalarial parasites on peripheral blood film. Male predominance in male to female predominance of 3.5:1was observed. Total number of 120 out of 135 had thrombocytopenia. Thrombocytopenia was observedhigher in P. Vivax (79.3%) followed by Mixed infection (17%) and P. falciparum (3.7%) respectively.
Conclusion: Anemia with mainly thrombocytopenia was mainly seen in P. Vivax type followed by P.Falciparum. Since thrombocytopenia is associated with malaria, which is demonstrated in our study,treating physicians should keep malaria as one of the differential diagnosis in patients with fever and lowplatelets.

Keywords: Fever; Malaria; Thrombocytopenia

Pattern of hematological malignancy in a tertiary level hospital in Kathmandu

Amar Narayan Shrestha — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23355

Background: Hematological malignancies involve the blood elements, marrow, lymph and lymphatic elements and are among the common malignancies afflicting the human race. They tend to involve the extremes of the ages- the young and the elderly.

Materials and Methods: A hospital register based retrospective study was conducted including the data of five years duration. The confirmation of diagnosis was done with blood smear examination, bone marrow examination and flow-cytometry. The epidemiological parameters were then calculated using Microsoft Excel and SPSS.

Results: Among the total number of cases, 60.7% were males and 39.3% were females. Age group of 50 to 59 years was most commonly involved. Lymphoma (including Hodgkin’s and non-Hodgkin’s) was the most common hematological malignancy.

Conclusions: Males are more afflicted by hematological malignancies and lymphoma was the commonest hematological malignancy.

Keywords: Hematology; Lymphoma; Leukemia; Malignancy

Clinicopathological study of breast diseases: A hospital-based study

Ramesh Chavan — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.21991

Background: Breast diseases are more common in women than men. Breasts undergo perpetual physical and physiological transition from puberty till death, which are related to menstruation, pregnancy, and menopause. The aim of this was to classify different types of the breast lesions, and conduct its clinicopathological study.

Materials and Methods: Breast lesion tissue specimens were collected either as needle biopsy, lumpectomy, or mastectomy. For specimens fixation, 10% formal saline was used. Tissue was processed into paraffin blocks and stained using hematoxylin and eosin. Data were entered into Microsoft Excel spreadsheets and analyzed using percentages.

Results: Out of 150 patients, 97.3% were female and 2.7% were male. Nonneoplastic lesions and neoplastic lesions accounted for 11% and 89% of the cases in patients, respectively. Among the nonneoplastic lesions, chronic mastitis (47%) was most common. Fibroadenoma (76%) and invasive ductal carcinoma (91%) was the highest encountered benign and malignant neoplasm, respectively. Maximum (43%) of benign neoplasm incidence was encountered in the age-group 20–30 years; whereas in malignant neoplasm, it was 40–50 years (38%). Out of 150 patients, 55% were diagnosed with Nottingham grading system grade 2 of breast cancer.

Conclusions: Occurrence of neoplastic lesions in the breasts is comparatively higher than nonneoplastic lesions. Differentiating between benign and malignant lesions would be useful in the management and treatment of patients.

Keywords: Benign breast lesion; Carcinoma; fibroadenoma; Neoplastic; Nonneoplastic

Evaluation of intrathoracic lesions by image guided fine needle aspiration cytology

Manisha Shrestha — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23363

Background: Fine needle aspiration cytology has become an indispensable tool for diagnosis of intrathoracic lesions. The purpose of this study was to evaluate the spectrum of intrathoracic lesions by image guided fine needle aspiration cytology.

Materials and Methods: This was a prospective study of 100 patients, who underwent image guided fine needle aspiration cytology of intrathoracic lesions from December 2015 to November 2016 in the Department of Pathology, Institute of Medicine, Tribhuwan University Teaching Hospital.

Results: Of the 100 cases, diagnostic material was obtained in 86 cases, which included 69 cases (80.23%) from lung, 7 cases (8.13%) from pleura and 10 cases (11.62%) from mediastinum. Lung lesions constituted of 61 neoplastic lesions (88.40%), 3 cases (4.34%) suspicious of malignancy, 3 cases (4.34%) negative for malignancy and 2 non- neoplastic lesions (2.89%). Squamous cell carcinoma was the most common lesion of the lung. Pleural lesions consisted of 5 neoplastic cases (71.42%), 1 non- neoplastic case (14.28%) and 1 negative for malignancy (14.28%). Mediastinal lesions consisted of 7 neoplastic lesions (70.00%) and 3 non- neoplastic lesions (30.00%). Biopsy for histopathological examination was available in 30 cases. The concordance of diagnosis of lung lesions by fine needle aspiration cytology and histopathology was 90.90%. Image guided FNAC had sensitivity of 95.83% and specificity of 50.33% in diagnosing intrathoracic lesions. The positive predictive value of image guided FNAC in diagnosis of intrathoracic lesions was 92.00% and negative predictive value of 66.67 percent.

Conclusions: Image guided fine needle aspiration cytology of intrathoracic lesions permits categorization and distinction between non- neoplastic and neoplastic lesions.

Keywords: Image guided fine needle aspiration cytology; Intrathoracic lesions; Intrathoracic FNAC; Lung; Pleura

A comparison of two techniques of cell block preparation

Anita Kasichhwa — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23370

Background: Cell block technique is a method of preparing cytological material so that it can be processed, sectioned, stained, and viewed as a histology section. The study compared two methods of cell block preparation, plasma-thromboplastin method and collodion bag technique of cell block preparation.

Materials and Methods: Samples were randomly processed by plasma-thromboplastin technique or by collodion bag technique. Hematoxylin/Eosin stained cell block sections were examined and scored scaling from 1 to 3 for cellularity, clarity, nuclear features, cytoplasm, use of ancillary test and recovery of cell-cluster and fragments. Mann-Whitney U test was used for comparing two methods and establishing statistical significance.

Results: The median cellularity score was 2.0 for plasma-thromboplastin and 1.0 for collodion bag. The median morphological preservation score and use of ancillary test score were 2.0 for both of the method while median score for recovery of cell cluster and fragments was 2.0 for collodion bag and 1.0 for plasma-thromboplastin. Statistically, both of the methods had similar results in cell block quality.

The median total score for plasma-thromboplastin and collodion bag were 10.0 and 11.0 respectively. Diagnostic cell blocks were obtained in 46.51% of cell block by plasma-thromboplastin method and 60.52% of cell block by collodion bag method improving the diagnosis over conventional smear in 76.74% and 81.57% respectively.

Conclusions: Cell block by plasma-thromboplastin and collodion bag method are cost effective, useful adjunct to FNA for diagnosis of mass lesion. Both techniques has no significant difference in quality of cell block produced.

Keywords: Cell block; Collodion bag; FNAC; Plasma-thromboplastin

Cytohistological correlation of conventional Papanicolaou smears in cervical neoplasia at a tertiary care hospital of Nepal

Anuj Poudel — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23372

Background: Conventional Cervical Cytology is the most widely used cervical cancer screening test. The incidence of cervical carcinoma is incredibly high in developing countries due to lack of proper knowledge. The extensive use of cervical screening with Papanicolau smears had considerably increased the detection of precancerous and cancerous lesion of uterine cervix. Study was conducted to evaluate cytohistological correlation and to calculate concordance and discordance of Pap smear in detection of precancerous and cancerous lesions of uterine cervix.

Materials and Methods: A total of 54 samples reported in Pap smear as cervical intraepithelial lesions and suspicious for invasive malignancies were selected and correlated with corresponding histopathological findings. It was an observational study done for a period of 18 months from November 2016 to May 2018 at UCMS-TH. All the statistical evaluation was done by using SPSS version 20.

Results: During the study period 54 cases were evaluated. Atypical Squamous Cell of Undetermined Significance was the common abnormal findings in the Pap smear with frequency of 26 (48.1%). Out of total 54 cases of Pap smears, 30 (55.55%) were concordant while discrepancies occurred in 24(44.44%) cases with cervical biopsy.

Conclusions: The study revealed a good correlation between cervical cytology and cervical biopsy. We also concluded that conventional Pap smear is a cost effective test for the early detection of precancerous and cancerous cervical lesions.

Keywords: Cervix; Intraepithelial neoplasm; Pap Smear, Squamous Intraepithelial Lesion

Study of serum lipase level in pregnant woman presenting with nausea and vomiting

Arun Dhungana — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23374

Background: Hyperemesis gravidarum is a complex condition characterized by excessive nausea and vomiting during pregnancy. It presents with various symptoms which include disturbed nutrition, electrolyte imbalance, ketosis and extreme weight loss. The objective of this study is to compare serum lipase, amylase and glucose in Hyperemesis gravidarum with non-pregnant women.

Materials and methods: A total of 100 subjects among which 50 were nonpregnant women as controls and 50 were women with hyperemesis gravidarum as cases were enrolled in the study. Serum lipase, amylase and glucose levels were estimated in all the subjects.

Results: The levels of mean serum lipase were lesser in cases (23.55 ± 4.91U/L) compared to that in controls (25.45 ± 5.97U/L) with p=0.086. However, the levels of mean serum amylase were higher in cases (76.40 ± 33.86 U/L) compared to that in controls (69.66 ± 16.45U/L) with p= 0.210. Serum amylase activity was raised in 8% of the patients whereas the activity of pancreatic lipase was within normal range. Serum glucose levels were lower in cases (84.72 ± 11.28 mg/dl) than that in controls (87.04 ± 10.65 mg/dl) with p=0.293.

Conclusions: From this study we conclude that lipase activity was statistically insignificant in hyperemesis gravidarum. Therefore, pancreatic activities were less affected by hyperemesis gravidarum. So, this condition needs further exploration regarding biochemical basis to minimize the risk associated with it.

Keywords: Acetone; Amylase; Gravidarum; Hyperemesis; Lipase

Evaluation of Prostate specific antigen levels and its correlation with histopathological findings

Sujata Pudasaini — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23376

Background: Prostate specific antigen is a tumor marker though is expressed by both normal and neoplastic prostate tissue. The absolute value of Prostate specific antigen is useful for determining the extent of prostate cancer and its treatment. Prostate specific antigen also increases in cases like Benign Prostatic Hyperplasia and prostatitis. The availability of Prostate specific antigen as a marker has encouraged its use to diagnose both cancer and cancer recurrences.

Materials and methods: This is a cross sectional study conducted in a tertiary hospital over a period of two years. Cases of prostatic disease undergoing surgery during the study period were taken. Prostate specific antigen level of all these cases were correlated with clinical and histopathological findings.

Results: A total of 51 cases of prostatic disease underwent surgery during the study period with the mean age of 66.57 ± 10.68 years. On histopathological examination, 70.6% had benign prostatic hyperplasia and 17.6% had prostatic adenocarcinoma. Prostate specific antigen level was <4 ng/ml in 45.1% cases and >20.1ng/ml in 15.7%. In case of carcinoma prostate, 88.9% had prostate specific antigen level > 20.1ng/ml and 11.1% had prostate specific antigen level in a range of 10.1- 20 ng/ml. In case of chronic prostatitis, 66.7% had prostate specific antigen level in a range of 4.1-10 ng/ml. However, in case of high grade prostatic intraepithelial neoplasia (HGPIN), 66.7% had PSA level <4 ng/ml.

Conclusions: Strong correlation of prostate specific antigen levels of > 20.1 ng/ml with carcinoma prostate was seen.

Keywords: Benign prostatic hyperplasia; Carcinoma; Prostate; Prostate specific antigen; Prostatitis

Histopathology of important fungal infections – A summary

Arnab Ghosh — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23377

Fungal infections due to pathogenic or opportunistic fungi may be superficial, cutaneous, subcutaneous and systemic. With the upsurge of at risk population systemic fungal infections are increasingly common. Diagnosis of fungal infections may include several modalities including histopathology of affected tissue which reveal the morphology of fungi and tissue reaction. Fungi can be in yeast and / or hyphae forms and tissue reactions may range from minimal to acute or chronic granulomatous inflammation. Different fungi should be differentiated from each other as well as bacteria on the basis of morphology and also clinical correlation. Special stains like GMS and PAS are helpful to identify fungi in tissue sections.

Keywords: Fungus; Mycosis; Opportunistic; Systemic

Pseudomembranous colitis

Devish Pyakurel — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23378

Pseudomembranous colitis is an inflammatory condition of the colon that is most often a manifestation of Clostridium difficile infection. If laboratory testing and endoscopic finding for Clostridium difficile infection is negative, then other less common etiologies should be sought for to identify the correct diagnosis. Ischemic colitis, inflammatory bowel disease, medications, chemicals, vasculitis, and multiple infectious pathogens are responsible for non-clostridium difficile Pseudomembranous colitis. Exposure history, chronic medical problems and a current medication list will aid in narrowing the differential diagnosis. Histology varies significantly with underlying etiology and can establish the diagnosis. Treatment is specific to the underlying etiology. The purpose of this review article is to aware clinicians and other healthcare professionals about various etiologies of pseudo membranous colitis along with its histological finding and treatment.

Keywords: Clostridium difficile; Infection; Pseudomembranous colitis

Adrenal involvement in Histoplasmosis

Nisha Sharma — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23381

Histoplasmosis is a fungal infection caused by a dimorphic, saprophytic fungus Histoplasma capsulatum with primary predilection for the lungs and disseminated infections occurring rarely. Our case illustrates the case of disseminated adrenal histoplasmosis in an immunocompromised 42-year-old diabetic man. Radiological diagnosis suggested bilateral malignant adrenal mass, most likely metastasis. FNAC yielded blood only. Excisional biopsy from left adrenal gland, Hematoxylin & Eosin staining along with special stains as Periodic Acid Schiff and Grocott’s Methenamine Silver were performed to yield the concluding diagnosis of histoplasmosis.

Keywords: Adrenal; Diabetes; Immunocompromise; Histoplasmosis

Borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis: A rare association

Palzum Sherpa — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23382

Tuberculosis and leprosy are chronic mycobacterial infections that elicit granulomatous inflammation. The incidence of co-existence of pulmonary tuberculosis and leprosy has ranged from 2.5%-13.4%.¹ Cutaneous tuberculosis is a variant of extrapulmonary tuberculosis and its simultaneous occurrence with leprosy is uncommon. The concomitant presence of leprosy, pulmonary as well as cutaneous tuberculosis is rare.

We report a case of borderline tuberculoid leprosy, lupus vulgaris and pulmonary tuberculosis in a 45 years male who presented to the dermatology outpatient department with three morphologically distinct skin lesions over the posterior aspect of right leg. Ours is presumably the first case reported from Nepal, a country where both of these mycobacterial infections are endemic.

Keywords: Leprosy; Lupus vulgaris; Tuberculosis

Malignant melanoma arising within ovarian mature cystic teratoma

Aasiya Rajbhanari — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23383

Mature cystic teratomas are frequently encountered neoplasms of the ovary that comprise of tissues derived from all three germ layers. They are benign neoplasms with malignant transformation noted rarely in around 0.1 to 3% cases. Among the various transformations, malignant melanoma is one of the least commonly encountered. Here, we report a case of 41 years old female with malignant melanoma arising within mature cystic teratoma.

Keywords: Dermoid cyst; Malignant melanoma; Mature cystic teratoma; Ovarian melanoma

Cutaneous granular cell tumor: A case report

Deliya Paudel — 2019-05-29

DOI: https://doi.org/10.3126/jpn.v9i1.23384

Granular cell tumor is a rare benign neoplasm of the skin that accounts for 0.5% of all soft-tissue tumors. Granular cell tumor can affect both sexes and in any age, although it is most common in females. The common locations are the head and neck, the tongue is affected in 25% of cases but any internal organs can be affected such as soft tissue, bronchus, stomach, rectum, anus, biliary ducts. Here, we report a 58-year-old female patient who presented with a 4-year history of a slowly growing mass, with a dimension of 5 × 4 cm on her left waist, diagnosed as a Granular cell tumor at histopathological examination.

Keywords: FNAC; Granular cell tumor; Neoplasm; Skin