Presentation on theme: "Gen Path Lab MHD Normal Pictures are from internets"— Presentation transcript:
1 Gen Path Lab 10-16-08 MHD Normal Pictures are from internets Pathology Pictures are from RobbinsOther stuff was on MHD WebsiteJackie Kuziej
2 General Pathology Concepts, Case 1 Infarct Necrosis 70 year-old male with right costovertebral angle pain and hematuria, two days after being admitted to the hospital for acute MI.Costovertebral pain—back pain right under rib cage, (over the kidneys)Hematuria—blood in the urineWhat is the organ?Kidney, gross—see light colored (pale) parts, kind of wedge-shaped=think necrosisAlso see a clot up above the necrotic area indicating ischemiaKidney, histology—see some blood (vascular congestion) around the light colored pale parts on virtual microscopyDon’t forget to identify glomerulus and neighboring tubuleIn area of infarct Glomerulus have lost nuclei---nuclei are ghostsYou do see some nuclei—those cells are neutrophils (leukocytes)Been called b/c the cells are dying—the cytoplasm leak initiates the acute responseCharacteristic Structural Changes?Ghost like remnants of glomeruli and tubules—cell outlines remain but cell details are lost.Inflammatory process at interface of infarct and normal tissueVessels dilated with RBCPathologic Process? Ischemic or Infarct NecrosisWhy? Due to embolism—mural (wall) thrombosis after MI. See “ghost-like” cells and inflammation
3 Renal infarction: gross specimen. The kidney is cut in half along its longitudinal axis, exposing the cortex (A)the medulla (B)) and a minor calyx (C).The pyramidal shaped infarct is pale as compared to the adjacent normal cortex.Why?The arrow points to a line of hyperemia that represents the interface between normaland necrotic tissue.
4 Thick arrow points to glomerulus in an area of coagulation (ischemic) necrosis. Thin arrow points to a glomerulus which is in the interface between necroticand normal kidney.
5 Normal Kidney Glomerulus Note cells have nuclei!
7 General Pathology Concepts, Case 2 Hemorrhagic Necrosis 70 year-old male complained of chest pain with inspiration. He developed hemoptysis and dyspnea.Pain w/inspiration?Infarct extends to the pleura, pleural irritationInflammatory responseHemoptysisCoughing up the blood that is in his alveolus from the other circulationHe has metastatic colon cancer and a swollen left leg.Swollen leg makes us think DVT to the lungRemember cancer patients are hypercoagulableAlso immobility will cause clots to form
8 Case 2On virtual histology you see lots of blood in the alveolar spacesNote you can tell arteries b/c they have more thick wallsThere are some pulmonary artery thrombiWhen you look on the walls of the thrombi you see strands, it is starting to setThis is a Hemorrhagic Necrosis (infarct)Why? The lung has a dual blood supplyOne blood supply is infarcted, and the other blood supply bleeds into itWhat other organs have dual blood supply?Small intestine (celiac, mesenterics, arcades)liver
9 Lungs removed en-bloc during autopsy The arrow points to an embolus extending through the branches of a pulmonary artery.
10 Pulmonary Infarct (arrow)—WEDGE shaped Lung looks more “spongy” than the kidneyIt looks like there is a clot in this vessel. Remember the lung has dual blood supplies: pulmonary artery and bronchiole blood supply (from aorta)Pulmonary Infarct (arrow)—WEDGE shapedPulmonary infarcts are typically pyramidal with base at the pleuraOnly about 10% of pulmonary emboli actually cause infarction.Why?In patients with adequate cardiovascular function, the bronchial arterial supplycan often sustain the lung parenchyma despite obstructionof the pulmonary arterial system..
11 Hemorrhage intoinfarcted lungalveoliInfarcted alveolar septa(note no nuclei—are “ghost like”)
15 Normal Lung Remember to look for areas that look more normal on pathology slides first!
16 General Pathology Concepts, Case 4 Acute Inflammation 15 year-old female with right lower quadrant abdominal pain and vomiting.Appendicitis, grosslySee fibrinous exudate (do not write “pus” in patient charts)See normal pink on left hand side, then see dark purple areaAppendicitis, virtual histologysee neutrophils—look for their segmented nucleusThey are filling the lumen along with the purulent exudateCells with orange granules—eosinophilsMononuclear cells are probably lymphocytesLook at serosal surface (the outside)—see pink strands w/lymphocytes, that is the fibrinous exudate (white) that we saw grossly on the surfaceLook at mucosal surface—is partially necrotic
17 MucosalnecrosisBe sure to compareacutely inflamedappendix with normalappendixInflammation throughout all layers of appendix
21 General Pathology Concepts, Case 5 Chronic Inflammation 90 year-old female with diverticulum of esophagus.Grossly w/esophagus, looks like “white snake”—see little puffy thing, is pink, is diverticulumFood retention, multiple episodes of infectionTags on body parts-A for autopsy; S for Surgical resectionNote that inflammation of prolonged duration—active inflammation, tissue destruction, attempts at repair are proceeding simultaneouslyPresence of Mononuclear cells: Macrophage, Lymphocytes and Plasma CellsHealing will be by fibrosis
22 EsophagealmucosaSubmucosal chronic inflammation—see ink-drop looking cellsWhich are lymphocytes (don’t see multi-segmented cells)Remember plasma cells have nucleus on side and “tail” of cytoplasm along it
25 General Pathology Concepts, Case 6 Tuberculosis: Caseous Necrosis 54 year-old male with low-grade fever, cough and weight loss for 2 monthsMan has come from Mexico after living there for 18 months
26 Pulmonary Tuberculosis Ghon Complex—means that caseous necrosis is on the lung and in the lymphThe cut surface of the lung reveals a subpleural granuloma (arrow).The subcarinal lymph nodes contain caseating necrosis (*).
28 What’s a Granuloma?A granuloma is a nodule consisting mainly of epithelioid macrophages (special activated macrophages with abundant pink cytoplasm) and other inflammatory and immune cells as well as extracellular matrix. They are often surrounded by a lymphocyte cuff or fibrosis.Epithelioid-Activated-- Mphages can fuse together ---they are seen in chronic inflammationGranulomas form when the immune system fends off and isolates an antigen but is unable to completely destroy it. (Frustrated TMMI)The antigen is most often an infectious pathogen or a foreign body, but in many cases the offending antigen is not apparent (as in autoimmune disorders).Granulomas are seen in a variety of diseases, infectious and non-infectious.Infections that are characterized by the presence of granulomas include tuberculosis, leprosy, histoplasmosis, cryptococcosis, blastomycosis, coccidioidomycosis and syphilis.The major non-infectious granulomatous diseases are sarcoidosis, Crohn's disease, berylliosis, Wegener's granulomatosis, Churg-Strauss syndrome, pulmonary rheumatoid nodules and aspiration of food and other particulate material into the lung.An important feature of granulomas is whether they contain necrosis or not. A related term, "caseation" (literally: turning to cheese) refers to a form of necrosis that, to the unaided eye, appears cheese-like, and is typically (but not uniquely) a feature of the granulomas of tuberculosis.
29 (A) Center of granuloma showing caseating necrosis (amorphous debris). (B) Periphery of granuloma containing activated macrophages, lymphocytesand a giant cell (arrow).
33 General Pathology Concepts, Case 10: Metaplasia 45 year-old female with white plaques in the endocervix. She has had 5 children with no complications. Her previous pap smear showed inflammatory changes.
34 Virtual HistologyCervix should only have a simple columnar epithelium, glands come to surface in endocervixThis cervix has a huge lining to it—metaplasiaStratified squamous insteadMetaplasia just means one mature type of cell is replaced by another mature typeNote that the lung goes from columnar to squamous when there is smokingWhy does this happen?Infection, Adaptation to stress
35 Stratified squamous epithelium replaced the normal, simple columnar epithelium of the endocervix and endocervical glands. Note that the gland is partiallylined by simple columnar epithelium (arrow).
39 General Pathology Concepts, Case 11: Lipoma 40 year-old female with subcutaneous nodule in outer thigh.Was non-tender, soft, movableNodule was excised, and the cut surface was yellow and lobulatedLooks encapsulated, is well-circumscribedEncapsulated is usually benign
40 Why does it matter if nodule is movable or slowly growing? “If it is movable, it is removable”Those things generally mean benign neoplasmOn virtual histology note the capsule on the edgesThe fat cells are not trying to penetrate the capsuleFat cells just look like spacesWell differentiated adipocytes with no evidence of atypia
42 General Pathology Concepts, Case 12 Malignant Neoplasm-Fibrosarcoma 44 year-old female presented with weight loss and lower back pain.On examination both her legs were swollen.CT scan revealed a large retroperitoneal mass encasing the inferior vena cava and right ureter.
43 What’s retroperitoneal? A useful mnemonic to aid recollection of the abdominal retroperitoneal viscera is SAD PUCKER:S = Suprarenal glands (aka the adrenal glands)A = Aorta/IVCD = Duodenum (except for its first portion)P = Pancreas (the head and neck of the pancreas (but not the tail)U = UretersC = Colon (only the ascending and descending branches, but not the transverse or sigmoid )K = KidneysE = EsophagusR = RectumAlso- What’s Love Got to do, Got to do with it?
44 Mass encasing inferior vena cava and the right ureter? Inf vena cava—probably cause of swollen legsRight ureter—increased pressure to kidney (hydronephrosis)Retroperitoneal massMalignant neoplasm, such as a fibrosarcoma, will infiltrate adjacent tissue, encasing or destroying organs. It is surrounding and encasing the IVC and RU.Neoplasm is interlacing bundles of malignant fibrocytesThey are infiltrating the fat and are highly atypical (pleomorphic)See mitotic figures on virtual histologyThis is not good—you usually see mitotic figures in malignancyNo capsule—it is infiltrating things—look at interfaceThe cells do not look like normal cells, they are atypic
46 mitosisThe neoplastic cells are highly atypical, pleomorphic and havelarge, hyperchromatic nuclei
47 General Pathology Basics, Case 13 Benign Fibroadenoma of Breast This 35 year-old female found a nodule in her left breast on self-examination. It was non-tender and firm but not attached to the skin or chest wall. On resection, it was found to be well-circumscribed , with a white, rubbery cut surface.Well-circumscribed and movable---generally benign—probably encapsulatedEncapsulated tissue is compressed by the slowly expanding tumorWhen tumors are going to infiltrate or if they don’t have a capsule, they STICK DOWN
48 The neoplasm is well circumscribed, grey-white and multilobated. Fibroadenoma - BreastDescription: The surgical specimen consists of a bisected fibroadenoma.The neoplasm is well circumscribed, grey-white and multilobated.
49 Adipose tissue“Capsule” and compressed breast tissueStromal componentEpithelial component
50 Stroma with well differentiated cells which lack atypia Epithelial cells, lack atypia (are uniform, do not vary in size or shape)
55 Basic Pathology Concepts Case 14: malignant epithelium neoplasm--Carcinoma This 58 year-old male smoker presented to the clinic with swelling and pain of the floor of the mouth.Ulcerated tumor involving floor of mouth and tongue: Neoplasm infiltrating oral structures—characteristics consistent with a malignant neoplasmTumors have a tendency to ulcerate because it outgrows it’s blood supply and the middle part caves in.On examination he had an ulcerated tumor involving the floor of the mouth and tongue. Wide local excision was done.
56 The neoplasm infiltrates skeletal muscle. There is no capsule. Remember skeletal muscle cells have many nuclei that are pushed to the sides
57 They are the ONLY type of cell that does this. Malignancy. Also squamous cells form “intracellular bridges” which look like a ladder.They are the ONLY type of cell that does this. Malignancy.Large and small nests of squamous cells.Keratin pearlMalignant squamous cells trying to re-capitulate and mimic normal squamous mucosaby forming keratin pearl
58 Intracell bridgesMitosisNests of atypical, pleomorphicsquamous cells
59 Goljan Review Says…Leukoplakia literally means "white patch" (Fig. 17-3).Lesion does not wipe off.Erythroplakia is a red patch.Both lesions are due to squamous hyperplasia of the epidermis.Increased risk for squamous dysplasia or invasive squamous cancerCausesChronic irritation (e.g., dentures)All forms of tobacco use, alcohol abuse, human papillomavirus (HPV)LocationsVermilion border lower lip (most common site)Buccal mucosa, hard and soft palates, floor of the mouth